Sunday, January 30, 2011

Sunday's Best

Thirty plus miles on the road today: gas and mileage $15.00

Three hours of my time: (this is tough, just guessing) $60.00

Hearing him say, "I feel great, thank you so much for taking me to church today.": PRICELESS

Needless to say, I wasn't enthusiastic about getting out at 9:30 on Sunday morning to drive up to my Dad's, pick him up, drive to church, participate in the service, drive him home and then drive myself home. But, I did it and my conscience feels squeaky clean today. Plus, it was pretty nice once I got underway. No rain, temperatures in the low forties, no wind, a hint of sunshine every now and again. There service was lovely; great choral and organ performances.

Dad was pretty weak on his feet today; even with the walker he is less and less confident of his steps. No falls or near misses; just a long walk around from the side entrance of the church where we parked to the seat he likes on the far side of the church. He was quite winded both ways of the journey and felt he'd had his exercise for the day.

He's almost 94; we'll be celebrating his birthday this week instead of next because of family schedules. His mind is sharp and his observations about people and things still make me laugh. It was my pleasure today Dad, entirely my pleasure!

Saturday, January 29, 2011

Stability is Sucess

Things I remember saying to patients this week......

"You've grown a lot of different bugs in your urine at various times; look here....I'm seeing Klebsiella, E. coli, Enterococcus, Staph coagulase negative, Serratia. You're an equal opportunity hostess."

"Your kidney function is better this time; not exactly sure why but we don't ask questions when things improve. We just take it."

"Your kidney function is relatively stable, some wobble in the lab results visit to visit but overall stable. Stability is success." **

"Yep, you've got me today. I know you weren't expecting to see me on a Monday but one of our colleagues is out sick and they called me in.'ve got me!"

"I don't think you've got polycystic kidney disease but we need to do a few additional tests to find out for sure."

"Do you have obstructive sleep apnea?"  (the answer was almost always, affirmative....what an epidemic of people with sleep disordered breathing)

"You've got 35 percent kidney function; that sounds awful but I wouldn't expect you to have symptoms at that level. Your kidneys are doing a pretty decent job of regulating your electrolyte, acid-base balance, and fluid balance. But...."

"You use mostly sea salt?  That's basically salt."  (sigh)

"Your kidneys are scarred from diabetes and high blood pressure. Like a scar anywhere on the body it's going to be there forever. We can only hope to slow the process down and prevent further scarring."

"You've got overactive parathyroid glands; that happens to almost everyone with chronic renal failure. Parathyroid glands are in your neck but they have nothing to do with the thyroid which is also in your neck."

"Your dialysis fistula is beautiful, just beautiful."

"We really need to get that tunneled chest catheter out before it gets infected."

"I know you aren't keen on adding any more medication but your blood pressure is dangerously high."

"It's all gravity driven. Totally. During the day your swelling collects in your lower legs as you are upright. At night it layers out in your back and buttocks (or butt, depending on the patient) and your ankles look good when you wake up. The swelling hasn't really gone away, it's just redistributed."

"Do you think you can cut back on your dietary salt intake?  Any room for improvement?"

All in a week's work. Over and over and over again. With twists thrown in at the oddest times, lots of laughs, and empathetic acknowledgments.

** My favorite phrase when I talk to patients with chronic kidney disease who are not yet on dialysis. When their kidney function remains roughly the same, I count that as a win. They always hope for improvement and sometimes we get that but gradually many are accepting what I say about stability being success.

Friday, January 28, 2011

January 28, 1986

I remember.

Twenty five years ago today the space shuttle Challenger exploded after lift-off. Where were you that day?  Do you remember?

I was 31, a young physician assigned to the hospital wards, responsible for teaching medical students, interns, and residents for the month of January 1986. In my eighth month of pregnancy, I was looking forward to the birth of our first child in February and the exciting opportunity to put medicine aside for awhile and open the door to motherhood. Chris was due in mid February and from a physical standpoint, I wasn't exactly waddling but I felt full, my back hurt, and I remember saying to anyone who would listen that the last 6 weeks of pregnancy were not physiologic as much as they were pathologic.

The days on duty were crazy busy. An older, terminally ill man was transferred to our service from M.D. Anderson Hospital, desperately ill with cancer, sepsis, liver and renal failure requiring dialysis. His family was the biggest problem; they were all of the mindset that everything and all needed to be done to save his life and nothing less than success was acceptable. There was no sense of reality, they were needy, almost hysterical, unwilling to accept that their loved one would inevitably succumb and that no amount of intervention would save him. Every morning, one or more members of this family would approach me the moment I stepped off the elevator, wanting an update and my daily plan of action before I had an opportunity to see him. In their minds, he was my only patient and despite the assistance of my team, I became the source for any and all information. Updates were expected multiple times a day. Their questions and needs were endless. Their grief and anguish were palpable. This went on for days and as he became sicker, the tension escalated. I grew weary of their unrealistic expectations. They likely grew dissatisfied and frustrated with me, sensing my distance and maybe my honest feelings filtered through my calm, cool, and collected facade (I was much better with this early on in my career). Tough situation. In retrospect, in all my years I don't recall a family as intensely invested in saving a loved one despite the futility. I was young, desirous of pleasing, comforting, and probably promising things I could never deliver. Meanwhile, he got sicker and sicker.

The morning the Challenger blew up high above the ocean off the Florida coast, I watched the unfolding and recounting of the tragedy over and over on the television on the hospital ward. We stood in groups, shocked, disbelieving, watching and feeling the sorrow spread like an eerie anguish. I still can't bear to watch a film clip of the explosion, especially the view of spectators, including Christa McAuliffe's father watching the sky in confusion; he must have wondered if all that smoke was "normal" while knowing deep inside that something was terribly wrong. Awful.

Within the hour, the wife of my sickest patient pulled me aside and literally chewed me out, criticizing my decision making, the overall care of her husband, and proceeded to pin his deteriorating status and imminent death on me. I held my cool. Professional. Listen more, speak less; everything we're trained to do but which took every ounce of  my strength to quell the impulse to lash out, curse and scream in my defense.

After the tongue lashing, I took a time-out and retreated to my office but was barely thirty feet removed from the scene when the tears started welling up, uncontrollably. I felt scoured, humiliated, rubbed to raw with no (professional) way to respond other than to "take it". Lo and behold, I had my weekly checkup with my OB doc that same morning. As I blotted my puffy face with tissues and pulled myself together for the appointment, she was perceptive enough to ask, "What's wrong? Have you been crying?". That's when flood gates opened all over again and I spilled it all out; the stress of the hospital wards and this patient's wife jumping all over me. She was appalled, picked up the phone, called my boss and said, "Kate has to go home. Right now. She needs a break. She needs to rest."

And so, I did. For two days I lay in bed and watched TV, re-witnessing the explosion of the Challenger over and over and over again.

Then I went back to work but by that time there was only one more day, January 31st, and my ward duty was over. When I returned, my very ill patient had died and his wife/family were no longer around.

Thursday, January 27, 2011

The Carb Slippy-Slide


I have to remember that gurus of change remind mere mortals that "if at first you don't succeed, try, try again". When you steer off course, when you fall off the wagon, when you mess up.....forgive yourself and get back on track.  So, I did and didn't feel too bad about screwing up this Day 5 of my low(er) carb diet. 

Today I scrimped on breakfast because after eating eggs every day (there's nothing else on the menu for the first 2 weeks), the appeal wears off. So, I downed a glass of tomato juice and a mozzarella cheese stick on the way out the door. Halfway to work I started feeling jittery and weak, sort of hypoglycemic.An overwhelming hunger, deep down in my bones begged for begged for carbs. Feeling tired and dizzy, my climb up a flight of stairs to the office left my legs wobbly and my lungs winded. Jeeeez. That's bad. 

I rationalized that something had to be done quickly, "main-lined" to get the job done, to pump me up for the ten patients on my morning schedule. Rocket fuel, please.

This little devil  (and several more of the same) were in the bottom drawer of my desk. I downed those 4 vanilla cookies in less than a minute and it wasn't more than 15 minutes before I felt considerably better. Calm, cool, collected.....and guilty. But, not guilty enough.

The problem with a slip is the overwhelming temptation to slip again because, well....hell, the day is trashed anyway. That was me when the clinic served up an enormous chocolate cake, a tasty goodbye treat to honor a colleague who was leaving. That was right around noon. No control at all. Gone. And, oh my God, that cake tasted damn good. My only regret was inhaling rather than savoring the delicious blast of raw sugar heaven.

So what? I'll get back on track. Things are going well overall and I'm determined to quell my carb frenzy with healthier foods. A week ago, I'd have been eating this kind of stuff every day, all day.

Monday, January 24, 2011

Resisting the Cravings of the Mind

It's Day 2 of the South Beach Diet and I'm functional but not feeling too great.Cravings abound and I'm pouting about my state of deprivation.

Background: In my early fifties, I got disgusted with the extra pounds that insidiously crept up on me. I rarely get on the scale but back then, I succumbed and was floored when I weighed what I was in my 9th month of pregnancy! I wanted to get that weight OFF and thought South Beach might work for me; not as radical (and meaty) as Atkins and more liberal with regard to (good) carbs after the first two weeks.  Good (and bad) carb addict that I am, I'm convinced my body goes into major spasm, shock, and disbelief when the bread, rice, pasta...not to mention the cookies and chocolate, vanish. GONE!

My first experience with this diet lasted about a month; the first two weeks I was very strict and the last two less so but basically trying to be "good". I lost the pounds, shed them like weight taking a run for the hills. Sounds like I'm bragging but this one really WORKED. Even off the diet, but exercising, I maintained myself pretty well.....

Until....this past year when...slothful inactivity, ice cream, and late night snacking got me into the same trouble. Again.

My clothes started feeling tight once again and I noticed that the feel of my "fat jeans" was oh-so-comfortable. Those were the jeans that I refused to throw out and banished to the top of my closet shelf. the last time I lost this weight. The scale was the next sobering step and the results weren't at all to my liking. Guess I had to pay up for all that ice cream.  I had to face facts. Damn!.

I'm five or so years down the line from my first go-round with the South Beach routine. I decided to try my luck a second time, hoping my metabolism hasn't shifted into new and more resistant territory. At the end of  DAY 2 and feeling oh-so-deprived of my crackers and toast (not even bad stuff like chips), I'm also deliriously craving something sweet. Anything that's real. The sugar free jello just isn't cutting it. But, I'll persist.

I have to remind myself that sometimes, every once in awhile, deprivation stimulates those endorphin receptors. I'll take it and hopefully it's only a few more days away. Who doesn't love a 'natural high'?

Time for another piece of cheese and a handful of almonds.

Sunday, January 23, 2011

It's a Disease

I'm concluding that my lapse in posting this month is a direct result of a more intense schedule at work. Kicking it up from 0.6 to 0.8 full time equivalent is apparently a bigger incremental increase in time than I'd predicted. It feels like a lot more and for all practical purposes is a full time proposition by the time the hours add up; well over 40/wk for sure. I shouldn't whine; at least I'm gainfully employed and valued by those who pay my salary. Plus, I have great colleagues.

I find myself perpetually connected to my work. I find it impossible to stay away from my computer link to work on days off, weekends. I rationalize by telling myself that I'm just getting "ahead of the wave" of work that will stack into deeper piles if I don't whack it back. Instead of batching my work and taking a chunk of time during my work day to tackle it, I am irresistibly  tempted to just do it now so I won't have to do it later. True: my inbox is manageable but only because I'm constantly sweeping it. Curiously, the inbox is less of a physical entity, although it is that too. The inbox is all the stuff I can knock off from home on a laptop wired into my office. Mixed blessing, this.

With discipline, I suppose I could keep myself from logging on but to not do so makes me ANXIOUS and what do we do when we are ANXIOUS?  We do what needs to be done to ease the feeling.

It's this whole "ahead of the wave" business. My blog does not carry the title on a whim. It's's how I deal with so much in my life (but not all; some weird exceptions) Seriously. I hate surprises, curve balls, stuffed in-boxes, and disasters that might have been averted had I only been connected.  T'is a disease. Truly. One I can see but feel powerless to tackle. Not sure I even want to change my modus operandi.  My methods work....until I hit the wall at 100 miles an hour. Having been through that once 5 years ago, I need to learn from past experiences.

Saturday, January 22, 2011

The Way it Work

Several months back we four kidney docs decided that for sanity's sake, we would upend the way we've traditionally divided our "work" (that would mean the clinical load: outpatients and inpatients). For years we operated a practice that had each of us following patients in the hospital as well as putting in a full day's work in the clinic seeing outpatients.

The system worked well with the hospital and downtown clinic rolled into one, large self-contained unit. Fortunately, our practice has never required us to jump in the car and drive to other hospitals to round/consult on  inpatients. However, several years ago, our practice model fragmented as all of us took on responsibilities at satellite clinics around town.  We kept the one hospital model but traveling far afield became the norm. One of my colleagues flies on a (teeny tiny) plane to a site on the Olympic Peninsula several times a month. Glad that's not me (sigh). The rest of of have a more civilized ride on the freeway to one of several free standing clinics. Our patients are delighted to see us at a facility with FREE PARKING and closer to home. Good for all. Probably.

What happened was that the combined hospital/clinic work inherent in the downtown practice became insanely heavy. Urgent hospital issues would disrupt the flow of clinic appointments as we struggled to be in two, even three places at once. We'd find ourselves hopelessly behind, covering our duties in both clinic and hospital. After several years of escalating tension around this annoying issues, we re-booted the entire system.

We now have one doctor assigned to  hospital duties and the other three are here, there and everywhere: they could be enjoying a much needed vacation or, more likely are seeing outpatients in any one of our four locations. The only problem is: we have to have at least two of these three docs in the downtown location. Why? Because volumes are highest downtown and the acuity/complexity scale is often ramped up to the max. Patients with a recent kidney and/or pancreas transplant require detailed review and can wind up back in the hospital in nothing flat.

There-in lies the problem. With docs scattered to outpatient locations separate from what we call the "mother-ship", satisfying the two doc rule and simultaneously allowing for an occasional day off or a vacation is challenging. Whereas we used to decide on a vacation a few months ahead of time, now we need to get vacation dates on the calendar 6 or more months in advance. Case in point: I just asked for the day after Thanksgiving off last far down the road is that?

So, while our new model of care has some advantages, we've also learned that we need another doctor. Desperately and yesterday. We're recruiting but it takes a long time to find the proper fit: someone who will bring clinical expertise and commitment and yet have a bomb sense of humor and ability to play well with others. So until then, we work long days and feel like we're never finished. I speak for myself, I suppose although I do hear my colleagues making similar comments.
Medicine is a harsh mistress.

I'm still savoring my Monday's off. As the only one of the four who is "part-time", I've managed to keep a grip, although slipping some, on a life.

Friday, January 21, 2011

Why I Might be Tired this Week

Yesterday a patient said to me, "Doc, I feel like I've got one foot in the grave and the other on a banana peel".
We laughed together but then got serious.

The sad thing is, most every patient I've seen this week could have said the same. It's been a long, soul-draining journey through these last four days. I'm weary.

Thank goodness for the weekend.

Tuesday, January 18, 2011

A Lull

Not sure what is going on with me and this blog just now. I feel a pull to write but then when I open up the blank page, nothing comes to me. Dry. But why?

I'm busier at work for sure. But still, usually I have plenty of ideas and thoughts swimming around in my head.

Not so just now. Everything is just fine. I'm just spending my spare time reading, watching TV, playing with the cat, visiting my Dad, and going to work. I'm hoping this is just a temporary hiccup in my devotion to the written word.

I'll be back...could be very soon. A lull.

Wednesday, January 12, 2011

Lazy Brain

I'm going through a very dry spell creatively.

However, I do have my nose in Jonathan Franzen's new book, Freedom and am spellbound. Between a good read, back episodes of Weeds Season 5, Californication, and In Treatment, all I want to do after work is vegetate, read or watch the tube.

Sigh. Till later.

One of these days, I need to get to a yoga class and start a run/walk program. Right now I'm still dreaming of goals and accomplishments but savoring the inertia of the moment.

Sunday, January 9, 2011

Catching Up after a Week on Call

I last posted over a week ago. No surprise. I've been on the hospital service for the last week and today is my last day; seven in a row.  I'm more than ready to hand the baton to the next one in line. The week actually wasn't too bad but couple the generalized out-of-control feeling of being on call with a cold that just wouldn't quit and you've got a tired me. I'm so ready for 2 days off. Finally, a Monday to lie in bed and listen to the sound of city workers pick up my trash and yard waste bins and know that the day (for the most part) is mine.

I didn't make it to to see my Dad at all this week until yesterday and today.He was pleased to see me but, as usual there's little to say. We review things that we've reviewed dozens of times before and go over the plans for the coming weeks. This appointment, that visit or outing. He wants for nothing; I ask every time I see him, "Can I bring you anything.". What he needs/wants is a visit from me and yet....I leave feeling like I've done so little but maybe that's not actually so. He doesn't seem to mind that I don't stay long as long as I tell when I think I'll be back. "Tomorrow, Dad," I say.

The holidays are over, the new year well underway. Our Christmas tree is still up although we've not had the lights turned on in over a week. There are miscellaneous decorations from the holidays scattered about the house that need to be put away. The house looks cluttered with paper and dusty. Always more that could be done to make the place look better. I know what I'll be doing over the next few days.

I've nothing particularly enlightening to say. Reverb10 is over; no more prompts. I'll need to scour my mind for subjects. Sleep needs to knit up my raveled sleeve of care. Till later.

Saturday, January 1, 2011

Highlights of the Holidays

Happy New Year!

Those busy days between Thanksgiving and January 1st passed in flash. We didn't get our Christmas tree decorated until late in the season and never did get those lights strung outside. Nonetheless, the weeks were full, fun and loaded with all variety of family gatherings, tasty food and music.

Here's a look back in pictures from December 2010 and today, the start of a brand new year.

33rd Wedding Anniversary with 1982 Cabernet

Dressed up for Handel's Messiah at Benaroya Hall

Chris and Heather before lunch at Palomino

Laura enjoys mashed potatoes on Christmas Eve

Santa left gold and silver balloons

Christmas morning

Boxing Day; Earl and Mary Margaret

Dad and his three children on Boxing Day

Dad enjoys Christmas pudding with foamy sauce

2 days at the beach at Ocean Shores, WA

Chris grills the sockeye salmon New Years Day

Tina and Wayne enjoy New Year's Dinner

Salmon, Mashed Potato, Black Eyed Peas, Collard Greens
We're off to a good start to 2011. Blessings to All!