Wednesday, December 31, 2008
I made it through year 1! Unbelievable.
Hubby made it to Spokane on Christmas morning. He left Portland by train at 4:45pm, but the train was held up for 4 hours after it left the station--not due to weather, as was anticipated, but by commercial freight trains (Amtrak does not own its tracks, so it has to cede the right of way to the freightlines that own the tracks) which were presumably held up themselves by the storms of the previous several days. He finally made it to Spokane at 5am, and took a taxi as far as he could to our house, but ended up having to walk part of the way. Poor guy got to our house at 6am. We slept for a bit as the snow continued to fall, and spent the rest of the day overeating and watching movies. It was pretty nice, all in all.
Between him having to work overtime for 2 weekends, and then the weather preventing travel, we were separated for a whole month before Christmas Day. Not really something I recommend to anyone. Hopefully this won't happen again. We are hoping he finds some work in Spokane...
On Monday, we both took the train back to Portland. Our 2:45am departure was delayed to 10:20am, and we arrived in Portland around 6:30pm. It snowed here quite a bit, but by the time we arrived it had pretty much melted, except for some dirty piles beside the roads. Which meant that yesterday, for the first time in 2 weeks, I was able to go run. It really did more for me mentally than physically, even though it was great to move. I was going to go run today also..but didn't...so will head out tomorrow again. And probably every day I am still in Portland. Spokane isn't going to be run-worthy for a while. The snowfall for December was 62" the last time I checked. Most of the sidewalks are not shovelled, so there's nowhere to run but in the street, which is pretty unsafe with vehicles unable to brake. So...it looks like I need to find a gym again. Suck!
Last year I went through this process of trying to find a gym. I settled for the Y in Spokane Valley, but the hoardes of screaming children in the locker room make me want to avoid that this time. I am thinking of just joining my university gym. Gonzaga's facility seems pretty nice, and it's $150 for a semester (Jan to May) for graduate students. There are no gyms in walking distance of my home anyway, and pretty much all of the gyms in Spokane are lame.
I'll be joining millions of Americans tomorrow by vowing to lose weight, although it's not a New Year's Resolution, but the continuation of my plan for the past several months. I'm looking to lose about 12 more pounds and I don't have a timetable for it. I gained some weight during my time being snowed in over Christmas (9 days total), but nothing terrible. Considering that I couldn't exercise and had all these goodies baked that I was going to give as Christmas gifts (but never was able to see my family), it could have been worse, and shouldn't be hard to get rid of.
Happy New Year everyone.
Wednesday, December 24, 2008
Today I spent the day scanning some old photos, and watching movies, and cooking. My hubby has been trying to get to Spokane for a week now. The weather has foiled us at every turn. Finally, he got a train ticket for the 24th that wasn't cancelled. He got on...there was a 4 hour delay after the train left the station, but they are on their way. He should be here around 5am.
Like a lot of people this year, all of our normal Christmas plans have been cancelled. We already decided that we couldn't afford presents this year. Or, rather, giving gifts just didn't seem worth the cost. We already have everything we really need, we don't really want anything that you can get as a gift. And money is tight, as it is for everyone this year. My being an unemployed full-time graduate student doesn't help that situation any. So it made no sense to do the gift thing this year. We plan on doing something nice for each other later--whether it is exchanging gifts or planning a little weekend away or something, we haven't decided. I had planned on making gifts for my family, and we were going to see them--we planned to stay at my brother's house from the 24th to the 26th. But then the snow started, and soon it became apparent that we would not be getting to that side of the state under any circumstances.
So for me, Christmas this year is all about seeing my husband. We've been separated, not by our choice, for a month now. Getting him out here has been the number one priority. I will go back to Portland with him this weekend, but we really wanted to spend the holiday together here in Spokane. And it is very much a white Christmas...
It's actually really a relief not fussing over presents this year. First we asked everyone if we could either agree to not buy gifts for each other (of course we would for my nephews), or choose names out of a hat and buy for just one person, like a lot of families do. No dice. So we asked everyone to not buy us gifts, and I think everyone except my mom agreed to that. Next year, I'm going to ask everyone who can't stand to not buy us presents to donate money to charity for us. I know a lot of people do this already. But my family just doesn't seem to "get" the idea of not exchanging gifts, even though most of them agree with me that we don't really need stuff and the gifts we exchange are never really things that we wanted or needed. I think because we don't see each other that much, having that exchange means a lot to some of them. But I kind of convinced my mom tonight on the phone when she was talking about an animal rescue that she volunteers for, that she could donate to that in our names next year. She kind of warmed up to that idea a bit better...so hopefully I can make some headway by next year. We are very blessed, and we have what we need. I hate bringing home stuff that we don't need, and feeling guilty about it because I know my family gives it to us because they care. A present-free Christmas is actually pretty nice.
We'll have a low-key holiday by ourselves. I've made some of our favorite traditional Christmas foods, and we'll watch some movies and probably go for a walk in the snow. Hubby will get here so late (or early) that we'll definitely sleep in. I think it will be nice! But this is the first year I can recall that I won't spend with any of my family. That is pretty sad, especially after losing my grandparents this year. I'd really like to spend time with them. And they won't be seeing each other, although they all live within 50 miles of each other. The roads are just in no condition for that kind of travel right now. (Western Washington is not prepared for major snow like other areas that usually get it. When they get snow like they've gotten over the past week, things shut down, because there just aren't that many plows and there is no organized response, like there is in Spokane or other towns that usually get snow.)
Being stuck in the house with holiday food and no real prospects of exercise hasn't been good for my weight AT ALL. I can't wait until I can get back to some kind of exercise! Aack, it's driving me bonkers. But right now there's truly not much I can do about it.
Merry Christmas to everyone. May your holidays be as low-stress and low-guilt as possible, filled with love and family.
Monday, December 22, 2008
This is Day 6 since the Big Snow started to fall. We have somewhere between 2 and 3 feet on the ground, but the plows have been through most places, and the roads look ok, so I thought I would go venture out and pick up my glasses at Costco. It seemed like a good outing, entirely on major arterials once I got out of my neighborhood. I just had to dig my car out first.
I went out with a shovel, determined to get the car out of its snowy cocoon. I put my keys on the garbage can so that I wouldn't drop them, and dug and shoveled for about 15 minutes until the back was pretty well cleared, enough that I could start the car and not get carbon monoxide poisoning. Then I went to clear the driver's side so I could start the car and let it warm up and thaw. I grabbed my keys and shoveled once, twice...
...and dropped the keys.
The snow was all shoveled so there was no obvious hole where they went. I looked under the car and couldn't see them...looked beside the car...then started going through the piles of snow beside the car. It's perhaps worse than looking for a needle in a haystack, with that much snow to look through.
I didn't find them, though I looked for over an hour, and had help from my neighbor. The keyring held 4 keys: my car key, which I have no copy of (it's electronic, I lost my other one down an elevator shaft 4 years ago), my house key, which I have no copy of, my apartment key to the Portland place, and the key to our classroom at the hospital. My landlord came over and let me into my apartment and will get me another copy tomorrow. My car I'm just going to have to have rekeyed. All told, that will end up costing a few hundred dollars, and won't get done for at least a week--which is fine, I don't really need to drive anywhere for at least that long. But what an asshat thing to do.
Once I got inside and took a hot shower to thaw out (and looked to make sure that I really don't have another car key), I had to just let it go. What can you do? You really can't unlose your keys. They might turn up one of these times, when the snow melts in..April? May? I'll look again tomorrow morning, but the keys seem to have fallen into a black hole. It's not the end of the world, just a little annoying, and I'm lucky that I don't have to go to work this week and I'm in walking distance of the grocery store, which is all I really need while I'm on winter break. I can take a taxi to the train station, or could even walk if it got that bad. It's a little expensive and inconvenient, but it could be much worse.
So, I'll be confined to about a 1 mile radius for at least another week. Sweet!
Saturday, December 20, 2008
I've posted about a lot of random things lately...evidence that I've been able to dedicate some thought to things other than school, finally. WLS blogs are funny things. We all seem to go through a similar process: first, we have this huge goal of weight loss, a scary prospect of major surgery to achieve it, and we start a blog to help ourselves, and hopefully others, through the process. We spend a year or more navel-gazing about our "Journey" and blogging about the smallest details of the process. Then something changes--we lose weight, we start to widen our view and our blogs change a bit. Some of us regain, and stop posting out of embarrassment. Others settle into regular life and post about everything but weight loss, because--guess what?--it's happened, and other things seem more interesting.
Major weight loss is a puzzle about life, and whether we have surgery or not, our Herculean task is to solve the puzzle. Over time, we come to realize that most of it is more dependent on us solving the riddle for ourselves than on the surgical procedure. And with a wider view afforded by achieving our goal (even partially), we come to see that the riddle applies to our whole lives, not just the number on our scale.
I'm not apologizing any longer for my blog not really being just about WLS anymore. If you are a reader who is doing research on WLS, I'd like to suggest that you see WLS blogs that shift focus after reaching goal or coming close as a sign of success. The success is not only losing weight or being thinner (or whatever the original goal was), but in sorting out our priorities and figuring out how to see ourselves in a greater context than our dress size. I'll always talk about the process somewhat, and I'll probably always have some health, fitness or weight-loss goal that I am working toward, just like everyone else. But thank goodness that I am no longer singularly obsessed with my lap band. I wish everyone the same success.
My Patients Are Dying...And I've Never Been Prouder.
This is a really well-written piece about the importance of planning for end-of-life care in the hospital, and the better-late-than-never shift of focus from "The Patient Must Never Die!" to a discussion of the viable options and possible shift of focus from "doing everything" to making the patient and family comfortable. We all die, sooner or later, and not many of us want to do it in the ICU, especially if there is no real hope for a positive outcome.
The one thing I would like to see more of is a focus on the nurses' role in palliative care. This doctor talks a lot about all the physicians he has worked with who have advanced the issue of end-of-life care, and mentions the multidiciplinary Palliative Care Team he works with. He mentions the social worker by name, but then refers to the "PCT-trained nurses" as a group, and never talks about the bedside nurses that not only carry out orders, but coordinate the efforts with the patient and family, and create the environment that families need and remember later. Nurses really make palliative care possible. Certainly the doctors who make the major treatment decisions are important, but there are a million intangibles that cannot occur without an educated, compassionate and willing nurse caring for the patient and family.
I am still childless, both by choice and not by choice. I think our lives are like big Jenga puzzles--you don't know which piece can be removed without making the rest fall down. I have wanted to be a mom since I was a teenager. That being said, I also decided as a teenager that I shouldn't marry before I was 30, and I assumed that meant I wouldn't have kids before then, either.
Despite that, I married for the first time when I was 24, and my plans were that I would have a baby around age 26. I had just finished nursing school and started my career as a trauma nurse. I thought 26 would be a great age to have a kid. Unfortunately, my marriage ended before I got there, partly because my husband decided really didn't want kids, after all. I usually blame my currently childless state on my ex-husband, because it's more fun to blame the ex than myself. The real truth is a lot more complex than that. I should have known that he wasn't really on-board with my desires for children, although he told me he had changed his mind and really did want them when we did get married. I wanted to believe that, and I didn't want to face the difficulties of ending that relationship, which was 5 years old by the time we married. So instead of having a baby at 26, I had a divorce.
What happened after that was just life, and I had about as much control over its flow as anyone else does. It's easy for me to look back now and guess at which Jenga pieces I could have taken out that would change my circumstances now, but less easy to decide if I really want my circumstances changed at all. I lost weight, gained it, lost it, regained it...who knows if that would have affected my ability to have kids between ages 26 and 35, because I wasn't in a position to try. I dated for many years, mostly not very seriously. I didn't want to get married again. I didn't really want to be a single mom either, but I never lost my desire to be a mom. I just didn't know how to realize it.
When I was almost 31, I met my current husband. We knew right away that we would get married. We married when I was almost 33. (Actually it was 2 years exactly after our first date.) By this time, I was fast becoming burned out in my career as a critical care nurse, and I knew I wanted to go to grad school and become a CRNA. We had some decisions to make--buy a house or not, go to grad school or not, have a baby or not. I decided that having a baby then would push out grad school too far for me to tolerate, and we both decided that I should pursue graduate school--which also meant not buying a house yet (a great decision, I think, given current circumstances). We both continue to second-guess these decisions, because the path we chose is not easy. I'm in grad school, pursuing a career that I'm excited about--but I'm also 400 miles away from my husband most of the time, which is very hard on both of us. At this time of year, travel between Spokane and Portland is very difficult. As I write this, I haven't seen my husband since the end of November, and he's trying to make arrangements to get here this weekend. The road conditions in the desolate areas of southeastern Washington and the central Columbia Gorge area mean that we are separated a lot more than we want to be. And of course, now I am 35 and my biological clock ticks louder each day.
The good news is that I am healthier than ever before, and I have no reason besides statistics to think I won't be able to have a child in a year and a half. I've already pretty much decided that extensive fertility treatments are not for me--if I find that I cannot become pregnant by the time I am finished with school, I MIGHT try some fertility drugs, but would not do anything more invasive unless for some reason I couldn't adopt. IVF and all those things are fine in certain circumstances and for other people, but to me, my point is to be a parent, not just to have my own genetic child. If I'm going to spend that kind of money, I may as well spend it on adopting a baby, and not risk my health so much. That's my personal philosophy, and I'm sure it's subject to change if I ran into unforseen difficulties along the way.
It's sad that people are so judgmental of others in the area of having children. At my age, people who meet me assume I must have children, and when I tell them I don't they tend to ask questions that aren't really their business or assume that I don't want them. It's a subject that is very emotional and uncertain for me, and I don't really want to talk to strangers about it. Then I get the comments about all the things I can't possibly understand because I'm not a parent. Whether that is true or not, it hurts to have it put in my face all the time. And it happens every day. The emotional part of me wants to tell the world that it's not my fault I am not a parent right now. That's how it feels, but of course it's as much because of my choices as it is because of circumstances beyond my control. And I'm usually able to see that my life would be very different right now, and not necessarily better, if I had kids. If I had kids right now, which things in my life wouldn't have happened? Would I have met my husband, traveled around the country? Would I be in grad school right now? For the most part, I am happy with where I am right now, but this one area of uncertainty does cause a lot of anxiety and sadness for me.
I was having breakfast this morning and thinking about this as I listened to Ani Difranco's latest album, Red Letter Year. One of the things I love about music is that moment when you are listening to a new album and it goes from being something unfamiliar to somethng that you really connect with and relate to. It's sort of a magical thing that happens with music. I've listened to Ani since I was about 21--which for those who are keeping track is kind of a long time--and have seen her career and her music change a lot over the years. (That's another thing I love about music, watching how artists change through the years and how their music changes with them. That drives a lot of fans crazy, but I enjoy it.) Ani has gone from being this almost militant young teenaged folksinger to a sort of artistic patron in her hometown of Buffalo, NY (she writes a lot of music about Buffalo, and has provided some jobs at her own record label that she founded as a teen, Righteous Babe Records, and recently refurbished an old church into a concert hall in the downtown area) to a new mom. Her latest album contains a lot of songs about being a new mom, and about love--topics a lot less political than her early work, but still with her unique perspective and voice. Ani is 2 years older than I am, and the fact that she had her daughter at my age now gives me a lot of hope--as do all of my friends my age who are having kids now. In this album she sings about having this incredible insecurity and self-loathing that a lot of women have and having to revisit that when she sees that her child looks so much like her and is beautiful. This is in the song "Present/Infant" ("so I'm beginning to see some problems with the ongoing work of my mind/and I've got myself a new motto/it says don't forget to have a good time/don't let the sellers of stuff have power enough to rob you of your grace/love is all over the place/there's nothing wrong with your face"). In "Landing Gear" she sings of her pregnancy and the arrival of her daughter with a tenderness and cheerful beauty that fits the topic perfectly. Her unique view of labor and birth in this song both lightens and elevates the moment: "the candles are burning down, the music is fading/your pinata is torn/it's time to be born...you're gonna love this world if it's the last thing I do/the whole extravagant joke topped in bitter sweet chocolate goo/for someone who ain't even here yet look how much the world loves you."
I don't often quote lyrics in postings, but the topics covered in this album have the potential to bring a whole new set of listeners to this incredible artist. Of course, there are still some controversial politics on this album, too, and she's definitely a liberal--it's not for everyone, but it's worth checking out. Listening makes me feel a little better about my place in the Mommy Wars--even if I'm not sure if I'm an insurgent or a casualty.
Friday, December 19, 2008
(Note: I'm going to talk in detail about facial injury and disfigurement, and about the process of organ donation, in this post. I also talk about patients who are burned, and those who attempt suicide via gunshot. If this is too emotional for anyone, I suggest skipping this post. It's not really graphic, but it can certainly be emotional.)
I have worked with many patients who were severely disfigured by surgery, burns and trauma, who are the usually talked-about potential recipients of face transplantation. The idea that this surgery is not medically necessary is a lofty one for those who don't have to live with the consequences of having a devastated face. Take burns, for example. There is a lot of research going on to determine the best ways to prevent disfiguring scarring after burn grafting (especially to the face) and how to treat disfiguring scarring when it does occur. Scars continue to grow months or even years after a graft has healed. Some new specialized laser surgeries do offer some hope to people with horrific hypertrophic scars (like keloids) over their burn wounds, but these people live for years with a face that humans naturally recoil from, even if they have the best of intentions not to. And to lose what was once a normal face to a burn accident or trauma can be so devastating to a patient, they often withdraw from society altogether, unable to take the ongoing trauma of interacting with people.
I've also had many patients who disfigured themselves in attempting suicide. (Side note: gunshot to the head is not a surefire way to commit suicide.) I've had a few patients who blew off their whole face but left their brains competely intact. Imagine being so depressed that you try to commit suicide by putting a gun in your mouth, only to wake up in an ICU, on a ventilator, still depressed and now you have no face. (Aim too low, and you can blow off the top of your spinal cord, leaving you a quadriplegic with an intact brain.) Many people tend to blame these patients for bringing this on themselves. But depression is a disease, and the consequences they face after something like this happens are devastating.
The people who do research on treating facial disfigurement (I think the term deformity refers more to structural problems that tend to be congenital) see facial transplantation as a very viable treatment option to problems that our other surgical techniques just can't solve. The obvious downsides include the following: you have to take high-dose antirejection drugs for the rest of your life, which often cause cancer; the liklihood of a facial transplant being rejected over time is higher than for most solid organs; if the transplant is rejected, there is no second chance, and the patient is left with a face that will probably be worse than what they started with. In short, if it fails, the patient--who already could not bear to live with their original disfigurement--may not wish to live with the consequences.
All of this is, I am certain, covered in extreme, minute detail when the surgeon discusses this option with a patient. Unlike a lot of mainstream journalists opining on this subject, plastic reconstructive surgeons who consider this option for a patient think every day about the consequences of extreme facial disfigurement for their patients. Humans have a strong attachment to faces, and it's not just societal norms that cause people to recoil from disfigured faces--it's a very basic part of human nature. That's not to say that people should not make every attempt to counteract this instinct when interacting with someone who is severely disfigured. But look at the dance that occurs between that patient and one stranger with whom they are interacting: the stranger trying to treat the patient normally, being compassionate but trying not to make the patient feel bad, and the patient feeling the stress of knowing that their face is difficult to look at. And this is with people who are trying not to be cruel--some don't even try. Imagine having to do this dance with every single person you interact with for the rest of your life, and it's easy to see why doctors and patients consider taking all these risks to repair extreme damage to a face.
The donors are another matter. Some of the articles that quote Art Caplan, the bioethicist (whom I've seen on a number of forensics shows before, and who I think is kind of a tool) talk about this new world of organ donation, wondering if families get a choice in having their loved one's face transplanted when they agree to organ donation, or if we need to change the whole process so that people can make sure their loved one doesn't have to have a closed casket when they agree to organ donation. I think this is a bit of silliness that reflects a lack of research into the organ donation process. In my experience with numerous organ donors in several states (at least Washington, Oregon, Arizona and Illinois, the states I have worked with organ donors in), just having "organ donor" on your driver's license doesn't mean that you are obliged to donate your face when you have a devastating accident. (Or any other organ.) The declaration on your driver's license carries no legal weight, and at this point only serves to inform the organ procurement agency (OPA) of your wishes so that they can convey this to your family. Your family makes all of the decisions about organ donation--not your driver's license. This includes specifying what organs are transplanted.
Here's what happens after a patient is determined to be a possible candidate for organ donation. A donation coordinator from the OPA approaches the family and discusses the option of donation. This conversation happens very delicately and focuses on what the family wants and what they think their loved one wanted. If they sound like they want to pursue the option of donation, the coordinator lets the family know what kind of donation appears possible--i.e. full organ donation (heart, lungs, kidneys, liver, pancreas, plus tissues such as bone, tendons, corneas), donation after cardiac death (kidneys and pancreas only, plus tissues), or tissue donation only. The OPAs are very sensitive to the needs of their donor families, and of course to the possibility of being sued by a donor family, so they would never "slip" a facial donation into that process without being extremely clear about it. With all of the OPAs I have worked with, I am confident in saying that at least about those organizations. OPAs are not going to say to a family, "You consented to organ donation, so you don't get any say about what we take." With all the emotional weight that a face has, no one is going to use a donor's face without explicit and detailed consent from the donor's family. I think this is really a non-issue based on what I've seen. There is a choice. The consent process doesn't need to be changed at this early stage.
In all of the articles I have read about this issue, one thing that always comes up is the idea that this surgery isn't really "necessary" for life. This really bothers me. I think bariatric surgery patients can relate to this to a lesser degree. How often have people told us we didn't really "need" our surgery? These are people who haven't had to live the life we lived as morbidly obese people. They don't have to face all the social problems that the MO do. For candidates for facial transplantation, this is much more extreme because they don't also have the systemic health risks of morbid obesity, but their psychological necessity is even greater. The idea that a person's life should be fine as long as their heart is beating and they are able to feed themselves and get around is so simplistic. How can you say that transplanting a kidney is more medically necessary than transplanting a face? (After all, you can live a surprisingly long time on dialysis.) Transplanting solid organs is a fairly uncontroversial topic these days, since people aren't as emotionally attached to a liver or a heart as they are to a face. But I defy any of these journalists who say that this surgery isn't worth risking a patient's life for to tell that to a patient who can't eat or breathe normally, who is missing entire parts of their face and cannot go out in public without being stared at in horror.
I don't know if my readers find this topic as interesting as I do. But again, I think we all can relate to other people determining what is really "necessary" for us. For people who may be wishing that medical science hadn't been able to save their life at all, now that they have to live with the consequences of an otherwise healthy body and a horribly disfigured face, this can be the only hope for a reasonably normal life. The ethical dilemmas are real--I'm skipping entirely the question of offering assisted suicide--but they are best left for the patient and the physician to determine.
Snowshoeing, for anyone who hasn't tried it but wants to, is really just walking. If the snow is a little bit packed, the snowshoes will keep you from sinking much, but in the loose powder, forget it. The snowshoes I bought have much nicer bindings than the ones we rented last winter, and that makes a big difference since you don't want to have to take off your gloves to adjust the snowshoes when it's so cold out. These work well with big, clumsy gloved fingers, and they stay on much better than the rentals. I'll post a few pictures sometime today.
Thursday, December 18, 2008
We were supposed to have a year-end school brunch today, which was cancelled. OR tomorrow was also cancelled for us. As it stands, the hospital has cancelled all elective surgeries anyway so there wouldn't be much for us to do. Spokane is a city that is accustomed to snow, but this is an emergency even here. But as opposed to places I have lived closer to the coast, where people freak out and act a fool (like Seattle and Portland), in Spokane people just enjoy the snow. If it's an emergency, like this particular snowfall, they stay home and do snow things. Most people here have trucks or SUVs with 4wd (I do not, I have a Jetta and don't even have snow tires) so they are a little bolder about getting around. I am bound to the house for now, since I have the little car with no traction, but I am in walking distance to the hospital and the grocery store, so I'm doing okay. Just a bit bored.
I don't care for the cold too much, so it's hard to convince myself that I should get out my snowshoes and go up to the park. I know I should. I haven't been able to run since Friday. And I will...I'll go snowshoe and get some exercise. Lord knows there is enough snow for it. When the sidewalks are shoveled, and it stops snowing, we'll be left with packed snow and ice and I can run again, or so I hear. There are two ways I have heard of to get traction on your tennis shoes for running on snow and ice. One, buy YakTraks, which go on your shoes somehow (I've never seen them but many people swear by them). Two, buy a bunch of 1/2" screws and screw them into the soles of your running shoes. They are short enough that they won't go all the way through but they give you some "studs" to grip the snow. They come out, but they are dirt cheap. So I am sure sometime this winter I'll be trying these things out. I'm not really made for the snow and cold, though.
It will soon be time to try to tackle the last 10 pounds. I've been waiting for this semester to end. Here are some things I was thinking of doing when the new year arrives:
Food: Try the plateau-busting diet that Sandy R developed. (I would post it, but I'm not sure it's okay with her, so for now I won't.) That is 2 weeks max. It's basically the same as the liver shrinking diet that many surgeons put their patients on pre-op.
Then, see how my restriction is (like actually pay attention) and go in to see the surgeon and determine if I need a fill.
Eating is always about going back to the rules and the basics, which I haven't been sticking to very well this semester. Using FitDay again will help me out with that.
Exercise: My running is good, but I need to get back to something in addition to that. I haven't decided if it will be weight training again, or yoga, or both. If I have time next semester, both would be good. I'd love to do a weekly or twice-weekly yoga class, but weight training might be better for me. I haven't decided about that yet.
It's nothing earth-shattering, by any means. It's just a cluster of things to focus on again to see if I can lose 10 more pounds. But what is interesting to me is that right now I have maintained the same weight for 6 months. And that weight is exactly how much weight my surgeon initially told me he thought I would lose. Of course, it's about 70% of my excess weight (that's what they always predict) and I want to lose more than that. But I'm not going for 100%, I don't think that would actually work well for me and it would be extremely hard for me to maintain even if I could get there. I guess the lesson here is that on-going weight loss is not a mystery with the band. It's still calories in, calories out, more or less, no matter if there's WLS involved or not. If these things don't work, then I either need to regroup with my surgeon, or maybe just be okay with this weight. I'll keep ya posted.
Wednesday, December 17, 2008
So, I am sorry that I have not blogged. It's not that I've fallen off the wagon or anything. I've just been studying for the pharmacology final ever since I got back from Thanksgiving break.
The pharm final is the big hurdle for the first year of my program. We have lots of midterms and exams through this big first year, when we do the bulk of the classroom work for the 28 month nurse anesthesia program. But this pharm final is a really big deal. It covers all the pharmacology that we have learned in our first 3 semesters of school. I realize that if you haven't had to study pharmacology, a lot of this is Greek, but I'll share with you anyway. The topics include:
Basic pharmacology concepts
Inhalation anesthetic agents
Anesthesia induction agents (paralytic medications, hypnotics used for "induction")
Opioids and benzodiazepines
Autonomic nervous system agonists and antagonists
Cardiovascular drugs: vasopressors, catecholamines, antihypertensives, drugs for congestive heart failure, diuretics, etc...
Antiemetics, prokinetic (GI) drugs
Antipsychotics and antidepressants
I might be missing something there. Anyway, that's hundreds of drugs to know what they do, what receptors they work on or what their cellular mechanism of action is, what are the drug interactions, how are they metabolized, how are they cleared, etc. etc....so that's why I've been MIA.
The final was today. Our instructor said he is spending the day correcting the exams and plans on giving us our grades tonight by email (there are only 8 of us in our class). I'm really anxious to hear how I did...the way he tests, it's very difficult to know. There are a total of 295 points possible in the class, and the final is 200 of them. The other 95 are everything else we did in the last 2 semesters (the first semester was graded separately, we get the same grade for summer and fall semesters): that includes 5 midterms, 6 or 7 quizzes and our big teaching project/presentation that we each did a few weeks ago. It's kind of unfair that so much is riding on this one exam, but that's how it goes. At least we are forced to go back through all the material and make sure that we know it (or relearn it, as we tend to forget everything after the exam). Then we'll have to do it again when we take our boards in 18 months. Each time you go back through the material, of course, you learn it a little better. That's the reason we do the big giant painful final.
So...sometime soon I'll find out if I passed. I'll try to blog more now that I'm on break. It's snowing like crazy here in Spokane. Hubby has been stuck in Portland for weeks because of overtime and weather. I'll be glad when we don't have to be so far apart.
Wednesday, November 26, 2008
But today I'm feeling super-productive. I got up at 7:30, spent an hour relaxing then chatted for a while with bro-in-law, which was really nice. I went and had coffee and breakfast, organized my pharmacology notes, cooked half of Thanksgiving dinner (everything that could easily be made ahead), got a second giant binder for my pharm notes (they FILL two 3" binders), ran 4 miles, and now am out studying pharm. It's only just now 6pm. Feeling pretty good...
My new fave place to study in Portland is Staccato Gelato in Sellwood. The original Laurelwood location was my favorite gelato place in Portland (there are a few). This location opened in the last 6 months, and is only a few minutes from our apartment--conveniently just a block away from our favorite sushi restaurant. This one serves lunch and really good coffee, and the gelato is served in little tiny scoops, so I can have a scoop without feeling too guilty. Gelato is made with milk, as opposed to ice cream which is made with cream, and it has less fat than ice cream, plus it's so delicious. So, getting a tiny scoop of gelato is a pretty low-impact guilty pleasure. They also have free wi-fi here, and it's not very busy and quite spacious, so it's a great place to study.
When I'm adequately caffeinated and wishing to avoid buying something (or being tempted by delicious food that I don't need), I go to Reed College to study. It's also nearby, and the library is big and quiet and filled with studious Reedies, which helps me concentrate. The wi-fi is free there too, of course, and it has a sufficiently collegiate feel to keep me on task. But this week they are on limited hours because of the holiday, so I am at Staccato Gelato.
I am slowly getting my running miles back to where they were before the accident and subsequent curtailing of my running schedule. It feels good to be back on track (even if the weight loss still isn't happening--at least I'm not gaining). If anyone is considering taking up running, I'd like to encourage you in your interest. I always thought I was too heavy to run, and I felt like if I couldn't run a mile straight through, I shouldn't even bother. But here are some great reasons to take up running:
- It's free, except for shoes. Of course, you CAN spend lots of money on specialized running gear: clothes made of high-tech wicking fabrics, heart rate monitors, MP3 player, Nike + iPod sport kit, etc. And those things can make running more enjoyable--but are totally optional. All you really need are running shoes that work for your feet and gait and fit well. I swear by my Asics 2130s. Get fitted at a quality running store, it's worth it.
- You can do it just about anywhere. No membership required.
- You don't have to be able to run a mile, a half mile or even a block all the way. You can start out the Couch-to-5K way (many people start running using this method, and it works great): run 15 seconds and walk 45-60 seconds, repeat for up to 20 minutes.
- You don't have to be at or near goal weight. You should get clearance from your doctor, of course. You may have bad knees if you've been overweight for a long time, and that's one of many good reasons to check with a doctor first. But many, many people start running when they are significantly overweight, and most of them have nothing but positive results--as long as they don't overdo it. The key is not advancing too quickly (speed, distance, or intensity), and not outrunning your fitness level. (I highly recommend reading Jeff Galloway's Running: Getting Started. Also check out his website, jeffgalloway.com.)
- Runner's high is real. You won't believe how great you feel when the endorphins start kicking in. Plus, the sense of accomplishment and pride in actually being able to call yourself a runner--especially when you're like me, starting out morbidly obese, and having no experience running since junior high--will make you a believer.
- It doesn't take much time to have a great fitness effect. I get way more fitness benefit from running than an equal amount of time spent in almost any other cardio activity (the only exception that I've actually done lately is swimming laps). Run for 20 minutes (or walk/run) and ditch your 45-60 minute elliptical routine.
I know there are lots more reasons--which can be supplied by my running friends She Smiles, Thinspiration, Angie, and others. If you're thinking about it, I say go for it. You just might become one of those crazy runners, too.
Saturday, November 22, 2008
This week was very busy. We all gave presentations on Tuesday and Wednesday. (Let me tell you, listening to powerpoint presentations for 6 hours is a bit much.) I had 2 presentations to give: one a case study presentation on multiple sclerosis and anesthesia implications, and one in pharmacology about the anticonvulsant (antiepileptic) drugs. That was about 30 minutes, about the cellular pathophysiology of seizures, and many of the drugs used to treat them, mainly about their pharmacology, drug interactions, and anesthesia implications. If you hadn't thought about it before, anesthesia has interactions with many drugs that people take routinely, and many underlying conditions that people have. So those presentations were big deals. Then we had a pharmacology midterm (on antibiotics) and got back out test on central line placement, so now we can place central lines--woot! (With direct supervision, of course, while we are students.)
I placed my second spinal block yesterday, too. That is a very satisfying thing to do--getting the needle placed correctly and getting that CSF back just feels like you've really done something, and then when the block works and the patient tolerates the surgery with just a little sedation--that is super cool.
I was reading in one of the other blogs about the idea that you can defeat your band by drinking while you are eating. This is the main basis for the no-drinking-with-meals rule--you'll render your band ineffective, basically, and eat way too much. But I have discovered that if I drink after I eat (and usually I don't) I actually get more full. Especially if what I have eaten is something that can swell with moisture, but it seems to happen with most things. I avoid drinking with meals now mainly to avoid overfilling my pouch and stretching it. There are times, though, mainly when I take a break from clinicals in the morning, and I want to eat my breakfast AND I MUST get some coffee in...and the coffee is too hot, but I only have 15 minutes...I drink the coffee after I eat. You know, it seems I don't get hungry any sooner than when I don't drink. (Ha, you thought a bandster couldn't eat in 15 minutes? You never met a bandster anesthetist!) I think many people can "wash the food through" their pouch with drinking, and I am not recommending trying it. I'm just noticing for myself, it doesn't seem to work that way. But then again, I never get food stuck or PB, and I still seem to have restriction. So it seems some of the usual band things don't apply to mine.
Okay, time to get my day going...
Monday, November 17, 2008
Of course, pit bulls aren't bad dogs, it's the bad owners, right? That sounds like the argument for another thing we regulate (a little) in the US--guns. Which got me thinking: Why don't we have similar regulations for owning breeds of dogs like pit bulls who are known to be dangerous, especially when improperly handled and trained? I don't think pit bulls are inherantly "bad" dogs. But I don't see why we can't have a law that requires potential owners to attend a safety course, have a background check, basically some of the same things we require of people who want to own a deadly weapon. You have to have a trigger lock and a lock box if you own a gun in a home with a small child--why is it fine to have your family pit bull hanging out with your baby, when we know that small children might be harmed if they pull the dog's tail or even just start crying and startle the dog? The arguement goes round and round about how these dogs are fine if they are properly handled and trained--but we as a society do nothing to ensure that the dogs are owned and handled by people who are responsible and educated in how to handle a dog like this. It's not okay to have a lion in your house with your baby--why a pit bull?
That's what I'd do, if I was Queen of Everything.
People who don't want to regulate things like that have similar arguments against helmet laws--both for bicyclists and motorcyclists. But as a former trauma nurse, I saw the public health implications of people who don't wear helmets, or seat belts in cars. They become a burden to the taxpayer. We can be all for personal freedoms and say it's our own business if we don't want to wear a helmet when riding a bike or a motorcycle. But when you get that head injury that you don't recover from, that you end up in a nursing home on a feeding tube instead of back out working at your job and being a productive member of society--all because you wanted the "personal freedom" not to wear a $40 bike helmet--that is a public health issue. I'd better stop there, because I can really get going on helmets! If it just affects you--do what you want. When it starts becoming a burden to taxpayers (to ME), or when it involves not protecting the weakest members of our societies (the very young and the very old), that is when we need to regulate. That's my opinion.
Ok, off to run now. Lost 3 of the 4 lbs...slowly getting there. Everything is slow. This is Hell Week for the semester--lots of stuff due in the next 2 days, tests and presentations and papers. I spent the whole weekend at the library, and I'll be going back once I finish my run.
Thursday, November 13, 2008
But today, finally, I ran again, and felt better. It's harder now that it's getting dark so quickly. I'm putting together strategies for how I can run on days that seem impossible. Some days ARE impossible: I leave before dark, I get home after dark, and I still have hours of homework to do before going to bed for a few hours of sleep. But others aren't quite as bad, like today, and I could get in a nice 5 miler before the sun set at 4:30. I can't run in my neighborhood after dark, not because I'm afraid of being mugged, but because there are no streetlights and my neighborhood has dangerously cracked sidewalks. I'm pretty sure I'll end up with a newly flattened nose if I try to brave the roads in the dark. So I either have to find a lighted running path somewhere, or find a way to run during the daytime, or run indoors, which is my LAST resort, and which I'll eventually have to start doing anyway, when it gets too snowy and icy to safely run.
I really liked that article that I posted below because I think all of us who have gotten close to goal weight and stayed there long enough to know people who didn't know us when we were MO have had these experiences. It's so weird for people to assume that they can talk smack about fat people because you aren't fat. It's really bad in health care, because you can get badly hurt taking care of the morbidly obese, so a lot of providers have a hostility toward fat people. It's sad, because of course we all deserve dignity and to be treated as a patient who deserves good care, not a liability or a burden. But people are people, even if they are doctors and nurses. It's going to be more of a problem, and I hope that my fellow health care professionals learn how to do their jobs without getting hurt and without treating patients poorly as the population grows more obese and needs more health care. (Of course, I hope the trend towards rising obesity rates starts to reverse. But it hasn't yet.) But even just among friends, it is weird when you overhear someone talking amongst their thin friends or coworkers and realize that you are hearing things you never would have heard when you were MO. People would make sure not to say them in your earshot. (Or sometimes they wouldn't...ouch.) At first it's exhilirating to be thought of as someone who was never obese. But then it's sickening, to realize the way many thin people think of fat people. I know that just because I was MO didn't mean I was lazy, or refused to exercise (I exercised more than most normal-weight people), or ate buckets of greasy junk food (I ate a sensible, vegetarian diet, much like I do now...just with more cookies and ice cream). And people who knew me wouldn't have thought those things either, I don't think, but people who didn't know me probably did.
My Secret History
I may be thin now, but that doesn't mean I share your opinions about fat people.
By Megan Northrup Newsweek Web Exclusive
Dec 6, 2007
It's almost surreal how I find myself privy to the hushed conversations thin people have among themselves. I'm part of this insider group, but I carry a secret identity that renders me an impostor to some degree. I spent most of my childhood and the entirety of my adolescence overweight, and eventually morbidly obese (a very difficult health category to own up to). My core identity was once tied to being an outsider to this camaraderie of thin people. But my identity shifted rapidly in February of last year, when I underwent the kind of "medical intervention" that Star Jones recently acknowledged was the reason for her own weight loss. People I've met in the last year don't know me as I knew myself before I underwent gastric bypass surgery. They take for granted that my physical presence—I am now 130 pounds, having dropped 135 pounds after my operation—has always been this way, and I let them believe this myth because I see now, more than ever, how much judgment is directed toward the overweight and obese.
My best friend Bea places nannies in elite homes in Los Angeles, and more than once she has been explicitly asked not to send overweight applicants, no matter what their qualifications. Recently she had a candidate of the highest qualifications and glowing references, but this particular candidate wore size 16 jeans. When she found the courage to share this last detail with the client, the client immediately justified her prejudice by explaining that there were a lot of expensive antiques in her home, and narrow hallways. Fat, this woman believed, was simply unacceptable. If I had been there, I'm sure I would have simply nodded in quiet acquiescence.
I did as much recently when I went on a date with a young doctor. As I batted my eyelashes and enjoyed my newfound attractiveness, he recalled his morning spent helping in the delivery of a baby. "The woman was morbidly obese," he leaned over and whispered. Who, he wondered, would have wanted to have sex with that nine months ago? I said nothing and just let him buy into the illusion of me as someone who has only ever known a normal, healthy weight range.
I survived the day-to-day humiliations of obesity, the looks of pity and the "you have such a pretty face" compliments. In a moment I consider emblematic in the story of my struggles, I was once even stuck inside a dangling car tire six feet off the ground. I was 19 years old, participating in a ropes course retreat with my collegiate peer group. Somehow my assigned "bonding" group managed to hoist my 265-pound body up and into the challenge element (goal: get entire group through car tire) where my hips promptly announced themselves to be larger than the tire's opening. Bea (thankfully present for this ordeal) pushed from behind. The strongest male pulled from the front. Nothing. I was completely stuck. After a few more minutes of audibly difficult pushing and pulling by the group, I was free. Weeks later I still had the bruising around my hips to remind me of this embarrassment.
Two years ago Bea was also thankfully present when a nurse in the hospital yelled across the nurses' station, in reference to my need for a chair, "Has anyone seen the extrawide wheelchair? You know, the really big one?" Under her breath, Bea responded to her with, "Has anyone seen my friend's dignity?" We like to re-enact this moment from time to time, overexaggerating the extent of the nurse's yelling and complete lack of consideration for me as a human being. It's funny and we laugh, but we both know that this day, the day of my medical intervention, was the most difficult day of my life.
I've had nothing but success, healthwise, from the decision to have gastric bypass surgery. I've even run a half-marathon since then (not a superhuman feat by any means, but one almost unimaginable to that girl dangling in that tire). But every day I struggle with who I am and what this new membership to the normal-weight group means to me.
When you take on a new identity, and you've let others believe that this is your one true identity, it's easy to find yourself completely disowning your previous self. Recently my mother and I were going through old pictures of me—all those years of photographs and truths that I've hidden from new people in my life—and, picture by picture, my expressions of disdain and disgust grew louder. Fully acculturated to the thin insider group, it took my mother's tears to shake me out of my judgment. With wet eyes she said gently, "Be careful what you say about that girl. I loved her very much." And although my words could never carry the power of my mother's quiet admonishment, the next time someone leans over to me in the assumption of shared judgment, I can only hope that I will not remain silent.
Northrup lives in Charlottesville, Va.
Thursday, November 6, 2008
While I'm getting caught up (instead of writing a paper, naughty me!) on all your blogs, I was checking out Thinspiration's latest pics--girlfriend is over 100 lbs lost! And looking so fantastic. So I just wanted to give her a shout-out over here...
...and also to my friend, who had RNY about 4 years ago, and finally got her tummy tuck and looks like a million bucks. She was quite thin, but had extra skin that was making her feel bad, so she went out and did something about it for herself. Self-esteem is just as important an outcome of WLS as improved health is. I won't give you away here, but you know who you are. She looks so beautiful. Congrats to you, lady!
But I've been giving some thought to the filibuster-proof majority that didn't happen for the Democratic Party. That, plus listening/reading some of the chatter about Republican rebuilding. I am glad the Republican Party's reign of terror, er, power is over. But I am also glad that the supermajority did not happen in the Senate. The parties need each other. Absolute power corrupts absolutely, and all that.
Let me be clear here: I may be left-of-center, but I don't trust or like either of the parties. I'm not a loyal Democrat, but their ideals usually fit mine better than the Republican ones. Not always. I personally think that most politicians, when placed under just a little pressure, turn out to pretty much be the same. I realize that is a very cynical viewpoint, but I don't think I am alone. I hope we've just elected an exception to this rule.
What I WOULD like to see is a new focus on public service, as has been promised by Obama's campaign. I think we could do a lot in this country if we just organized people's natural desires to be involved in the community and the world. Our citizens are our greatest natural resource, and most of them have been alienated by politics and policies of the past 20 or so years, at least. That's the change I'd like to see.
How about this WLS stuff? Well, weight is still hanging in that same 3 lb range that it has been sitting in. After taking a few days off, I ran again today. I haven't felt up to it--a little depressed, maybe--but today I just got sick of my own laziness and excuses and got off my butt. It felt a lot better to do something good for myself.
We need each other in this WLS arena, too. I get a lot of inspiration reading all of your blogs about your own journeys, at all different points along the way. Some are newbies, some long-time bandsters, some are just starting the pre-op process. And some aren't having surgery at all. I haven't really been frequenting the boards lately--that really fell off my radar once my free time started to disappear. But reading my sistas' blogs--including Achieving Me (She Smiles), Laura (I'm a Pretty Girl Momma), losingjusme, Diz, Angie (Journey to a New Me), Love My Lap Band (Lori), killthefatman (Manatee--right, not a sista, sorry man), Lise the Loser, and Pasta Queen, and Thinspiration (I'm sure I'm forgetting someone here, sorry! see sidebar for all my peeps)--you guys keep me inspired and moving along. I'm starting to formulate a bit of a plan in my brain to lose the last 10 after this semester is over. I'll let you know if I come up with anything concrete, but I think I'll be in the thinking phase for a bit here. Thanks everyone, for keeping it real.
Wednesday, November 5, 2008
I arrived around 9 pm. She was not conscious, and her breathing was halting and irregular. I wanted to remove the oxygen that was still being delivered to her, to avoid prolonging the inevitable unnecessarily. But I knew that the facility she was in couldn't do that without the doctor's permission (or at least hospice's okay), and I didn't want to put them in a bad position by doing it myself--plus the rest of my family might not have seen it the same way I did. At any rate, I don't think it mattered much. I held her hand and sang to her a little bit, told her I loved her and told her it was okay to go when she was ready. I left around 10pm, and she died a few hours later, in the early hours of Election Day.
My grandmother was a staunch Republican, for whom even Sarah Palin was not conservative enough. Oregon is an exclusively vote-by-mail state, and she made sure to vote while she was still able. That remained important to her even as she knew she was dying. I'm actually not certain if her vote was legal if she died on Election Day, but I'm certain it was counted nonetheless. She was resigned to the fact that John McCain was not going to win the election, though.
But my politics were very different from both of my grandparents. I have nothing but tremendous hope and pride in my country for our historic participation in democracy, and in our ability to elect one I feel is a transformational leader, Barack Obama. The only way this could happen in America was for people who really believed they could make a difference to get out and vote, and for people to really consider the man and his arguments rather than his race. Here on the "Left Coast" I think people take for granted the kind of advancements that the country has made in the last 50 years, and in doing that I think we tend to believe that we have advanced further than a realistic look at race relations in all of America actually reveals. There is still a great deal of oppression, more covert than in years past, and we have taken one step forward in this election--even people who did not think Obama was the best candidate seem to recognize this achievement. And I for one was really touched by McCain's classy concession speech, which seemed like a return to the John McCain we knew before the campaign really got heated. (I understand that there are politics in play with any concession speech, but I felt he meant what he said.)
All in all, I was proud of this country yesterday, and today. I hope that we can all come together to face the challenges of today and tomorrow. I think my grandmother would have recognized this if she had lived to see it, even if the person she voted for didn't win. For all her conservative politics and fundamentalist Christian beliefs, she had many surprises for us all. I remember growing up believing that she and my grandfather were racist, and perhaps they were--but in the last 10 years they both proved to me that this was either untrue or that their views had changed. This is a remarkable thing to happen so late in life, by people who lived in an insular farming town where ethnic diversity was composed entirely of Mexican migrant workers showing up on their farm for day labor.
My grandmother had a long career as a special education teacher, in addition to raising 3 kids and being a farmer's wife, which is itself a full time job. She received her master's degree around the time that my aunt, her middle child, graduated high school, and contemplated pursuing her doctorate but decided against it--this was still very rare in the 1960s, much less in a rural farming town. She was educated in the natural sciences as well, and had a zeal for learning and for teaching that influenced everyone around her. Even this year, she was mentoring teenagers at her church who she felt had the promise and ability to go to college but no one to encourage them in their abilities. She was the kind of Christian woman who sought out the holy books of every religion and sect and read them to better understand what they all were about. Her bookshelf had her well-worn and annotated Bible sitting next to copies of the Torah and the Book of Mormon, and numerous other religious books that she read for the sake of education. This was also unusual for a farmer's wife, but my grandmother was an unusual woman. Her intense curiosity must have been part of the impetus for my grandparents' globetrotting--they visited almost every continent after their retirement, and travelled extensively within North America. (They decided to retire from international travel when my grandfather was 90--it was becoming too difficult to make connecting flights and navigate complex itineraries, and keep up with their tour groups.)
My grandmother also played a significant role in the rearing of every one of her eight grandchildren. Three of them grew up on the family farm, which my aunt and uncle farmed. Their house was across the driveway from the stately farmhouse that my great-grandfather built, where my grandfather was born and lived his entire 92-year life. Two others lived at least part of their childhoods with my grandparents, and the rest of us spent summers and weekends and holidays there. Grandma definitely helped raise us all. She also taught my cousins how to read, long before they started elementary school, and provided extensive pre-school education to them, because teaching was as natural to her as breathing. In addition to the eight grandchildren, they had nine great-grandchildren and one great-great-grandchild.
One remarkable thing about both of my grandparents was that they were not sentimental about old things or old times, and always strived for progress. My grandfather always sought out the latest and best methods and equipment to run his farm, which he took great pride in growing as a profitable business as well as a physically beautiful place. My grandmother was similarly minded about embracing progress, and not the least sentimental. She cleaned out the farmhouse of all but the most cherished antique things, and donated them to the county historical society, where she worked for many years in her retirement. She then redecorated and remodelled the place, and fought to keep the house off the historical register so that they wouldn't have to have every change they wanted to make to their home approved by the county. I would like to think that these ways of thinking contributed to their growing acceptance of the more diverse world as times changed, and that even though they feared rising taxes and other signs of impending liberalism, they would have seen the good in what happened in yesterday's election.
Sunday, November 2, 2008
I decided today that if I plan on not becoming tremendously fat again soon, I ought to start cooking again. I've been sort of getting by on things I can throw together quickly, which don't tend to be the best for you, of course. So I pulled out some favorite cookbooks and got started. The first thing I made was a "hot dish" type of casserole that is traditionally laden with sour cream and cheese, but I made it healthier (and more protein) by using nonfat greek yogurt instead of sour cream, and adding Morningstar Farms fake ground beef for a little more protein. It's quite yummy and not as sinful as the original by far. Later I plan on making some Wasabi Mashed Sweet Potatoes. Doesn't that sound strange and yummy? Decent nutritional profile too, though I'll have to dream up a way to get some more protein in them.
My grandmother is doing worse than before, and I need to evaluate tomorrow whether I ought to come back to Salem to see her before she dies. Everything in me longs to just go see her now, but I at least need to get through clinicals tomorrow first, and I want to call my aunt and uncle to see if she is alert enough to know if I am there. But either way, I'm torn on what I should do. I feel like I should try to get as much school in as possible, since it's so easy to get behind and so hard to catch up. But this is my grandma, probably my favorite person in my whole family (maybe just my favorite person, besides my hubby). And it's hard for me to concentrate on my schoolwork when I know she is dying. It's so hard to make these kinds of decisions. If I was still working I wouldn't be able to take this much time off at all--but then, if I was still working I'd be in Portland, and I'd be able to see her within a 45 minute drive, and I never worked more than 3 days in a row as an ICU nurse so I probably would have been able to see her more even if I couldn't take much time off. Not that it matters. My grandma is just a wonderful person, and I'm so lucky that I've had her in my life for over 35 years. It's hard to let go.
Monday, October 27, 2008
10. Portland's beautiful neighborhoods.
9. Customized, do-it-yourself bikes, and their wacky owners. And all the weird bike culture in Portland. And bike paths.
8. Trains that arrive and leave at reasonable hours.
7. Drinking fountains and public trash cans on the streets.
6. Mild winters that don't require snow tires.
5. Free public Wi-Fi clouds.
4. Coffee--a Stumptown would be heavenly. While we're dreaming, we could export my all-time favorite Portland coffee house, Albina Press.
3. Saburo's Sushi
2. My band surgeon, Emma Patterson.
1.My friends. Not just the ones from Portland, though. You know who you are!
Sunday, October 26, 2008
On my trip back to Portland on Friday, I listened to Tippet’s two part exploration of the faith life of both the left and right wings of the American political system. Both parts were extremely interesting; in fact, I found myself identifying more with the conservative commentator (Rod Dreyer) than the liberal one (Amy Sullivan). Mainly I think this series illustrated to me the main reason that I have ceased identifying as a religious person, as well as my reluctance to declare my political stance to even myself, much less to the world. The conversation on Tippet’s program basically addressed all the people caught in the gray no man’s land in the midst of this country’s two party system: liberals who are evangelical Christians, for example, and conservatives who have values that have traditionally been held as “liberal” views, such as eating sustainably grown food. There was a lot of conversation about the modern American impasse when discussing abortion, and the need for a different kind of dialogue about it so that some sort of progress may be made. They also discussed, in both segments, the idea that Christianity is exclusively the realm of Republicans, and that Republicans are by default, evangelical Christians.
I guess the thing that really resonated for me was the reason that we have a two party political system in American: our thoughts in this country about issues of culture, policy and faith are black and white. The US has a history of trying with all of its might to erase the gray in all issues. Things are one way or another. One of the unfortunate results of this is that many Americans are alienated by this because we do not fit neatly into one of the two boxes. In fact, I would argue that MOST Americans do not fit into the boxes the way we are “supposed” to. And this perception is passed on to the rest of the world, because we perpetuate it. The world perceives us as either super-conservative, uneducated religious fanatics who are rude and self centered, or passive, bleeding-heart activists who are filled with self-loathing over our citizenship. There are very few people who actually fit into these gross stereotypes, of course, but we allow this perception to be perpetuated. Our political system aptly illustrates it, and is part of the machinery that foments anti-American sentiment.
I have said on this blog before that intellect is under attack these days in American politics. I think this is part of the loss of nuance in political discussions. I also think that the attempts of the Republican party to associate themselves in the minds of Americans with evangelical Christianity has driven many more liberal people away from Christianity. It certainly happened that way for me—I have to admit that despite knowing some loving Christian people who do believe in social justice and equality for humans, as a whole I shy away from that faith because of the history and the association that I make with conservative politics.
For those people who wish to see more in-depth discussion of all the aspects of the issues we care about, rather than the sound-bite parsing of the conversation that happens today (yes, I am speaking of the dreaded “MSM” but more of the convenient way that we allow this to occur in our daily lives), I recommend checking out this podcast. Go to www.speakingoffaith.org.
Wednesday, October 22, 2008
I think on Saturday we realized that two things were happening: one, his memory was fading and his mental status was decreasing, and he was beginning to become uncomfortable with the immobility and being on a ventilator. At the same time, perhaps paradoxically, he was starting to realize that he wasn't going to get better or go home. For my grandfather, who was born in the house that he lived in his entire life, and who farmed the same land--with one arm--that entire time, this was unacceptable. The staff were beginning to talk about placing him in a nursing home. After all, his heart was starting to become irritable, but he was showing no signs of dying imminently. The only nursing home that could manage a paralyzed patient on a ventilator was in Vancouver, WA, which is about an hour from the nearest family members. We all realized that this was not a viable option for him.
So Saturday night we were all thinking about the same thing: my grandfather was not able to make his own decisions reliably any more, and continuing treatment would only delay the inevitable. No one wanted to have to decide to withdraw support, though (turn off the ventilator). Sunday morning, the neurosurgeon had a talk with my grandfather, and he told her that he wanted the ventilator turned off.
We all gathered at the hospital--his 3 kids, 4 of his 8 grandchildren, and all the spouses, plus a great-grandson. My grandmother couldn't be there, as she was still pretty ill and at another hospital. We met with the neurosurgeon and the trauma surgeon and went over what he had said and what the situation looked like for Grandpa. They told us how withdrawal of support would occur--he would be medicated with enough morphine that he was asleep, and then the ventilator would be disconnected from the trach. Everyone was comfortable enough with this to proceed.
As an ICU RN, I have withdrawn support on more patients than I can count. It is surprisingly frequent that we reach a point in our advanced medical treatment that continuing treatment only prolongs the inevitable. I have come to see this as a loving choice that families can make to end their loved ones' suffering, without actually causing death. (It is very different from euthanasia, although both are aimed at ending the suffering. Withdrawing support just means that the artificial interventions, or "life support", that are the only way the patient is not dying a natural death, are removed. This is called "comfort care" sometimes because medications are used to help the patient be as comfortable as possible.) I've always considered it a great honor to be present at this time in a patient's life. As a family member, I was actually prepared for this step when I first learned the nature of my grandfather's injury. I knew that 92 year old men do not live long as C1 quadriplegics, even with the most advanced treatment available. I also knew that his advance directive stated he did not want to be maintained on life support.
What happened next was really beautiful. We all gathered in his room by his bed, and one by one we told him that we loved him and that the family would be okay. He got to talk to us a bit as well, although it was hard to read his lips and he couldn't really "talk" with the trach. Then he got some IV morphine, and went to sleep. The ventilator was taken off, and he took some very tiny breaths, but couldn't do much because of how high his spinal cord injury was. I stroked his forehead as he had fewer breaths and turned a little dusky. Within 4 minutes he was gone.
My grandfather was a great man. He was well known and loved in his community. He lived his whole life in a farming town with a population of about 60. He lost his left arm in a farming accident when he was 18, but you never met a harder working man, and no one who knew him ever thought of him as handicapped by his injury. With little exception, he didn't sit still for long, which was why at 92 he still only looked about 70. He raised 3 kids and helped raise most of his grandkids as well. He had 9 great-grandchildren, and lived to become a great-great-grandfather, as well. He loved little kids, who were invariably fascinated by his hook instead of a hand. He had a special weakness for his granddaughters and great-granddaughters, and this would exasperate my grandmother at times. But he taught us all the value of honesty and hard work.
My grandmother won't be able to make his funeral this weekend. She is too weakend by her severe, end-stage heart disease and her injuries from the accident. She was just discharged yesterday to a home where she will be on hospice; she couldn't return to their home, either, because she can't go up any steps without severe chest pain, and needs assistance to even get to the restroom. We don't know how much longer we will have her with us, so I'm trying to see her as much as I can.
I came back to school yesterday, but it's hard for me to concentrate or get back into the swing of things. I have a lot of studying to do, but don't seem to be able to stay on task for very long. I did get a nice 5 mile run in today; running has been sporadic these past 2 weeks. And I am so sick of fast food, after grabbing whatever I can get between one hospital and the other. I have gone up and down a couple pounds, but have basically stayed about where I was when this all began. But all of this will sort itself out with time, I'm sure.
At 92 and 88 years old, my grandparents were prepared for death. They had advance directives and powers of attorney, wills and trusts all drawn up, and prepaid and prearranged their funerals. It was all neatly laid out in well-labeled file folders where my aunt could easily find everything. They didn't want to live forever. And I didn't want them to, either; as much as I've seen of life and death as a nurse, I know there are worse things than dying after a long, happy, healthy life. But this is not the end that I ever wanted or envisioned for them. At that age, you should get to die in your sleep, not deal with this kind of pain and suffering. And as much as they tried to prevent us from having to make difficult decisions about them, with their advance directive, the paperwork didn't really cover this sort of situation, so we were left with shades of gray to navigate. Trying to decide the right thing to do is not easy in a situation like this--and what one family member thinks is right might not be what another one is comfortable with.
I'm just grateful for the time I was able to spend with my family, and especially with my grandparents. I'm glad I was able to help my family navigate the health care system somewhat, and understand a bit more about the injuries they sustained. Being on the other end of the trauma system--the family end, instead of the provider end--is not something I recommend for anyone. But I am grateful that both of my grandparents received excellent nursing and medical care.
Thursday, October 16, 2008
Go to www.google.com/reader and set yours up! I know there are other feed readers and whatnot but this is just so simple and easy to use, I love it.
I don't think this idea applies just to women. We had an interesting discussion the other day while waiting to talk to my grandmother's cardiologist at the hospital. It turns out every one of my grandparents' kids has a profound sweet tooth--their sons maybe even more than their daughter. It's been passed on to many, but not all of us grandkids. How much is genetic vs. learned behavior is hard to say.
The Pleasure Factor
Using milkshakes and brain scans, researchers find that some women are genetically predisposed to get less enjoyment from eating and may overeat to compensate.
By Sarah Kliff NEWSWEEK
Published Oct 16, 2008
It was a difficult question for obesity researchers: do some people overeat because they find eating more pleasurable or gratifying than others? Logically, that makes a lot of sense—it's a time-tested principle of psychology: if a behavior feels good, we'll keep doing it. But a new study published today in the journal Science adds to a growing body of research suggesting the opposite: that women who derive less pleasure from eating may eat more to compensate, putting them at higher risk for weight gain and obesity. The research also discovered a particular genetic trait that, when present, is associated with an even stronger relationship between low sense of reward and overeating.
"If you ask overweight individuals if they crave food, I really think they are legitimately thinking it's more rewarding," says study author Eric Stice, a senior scientist at the Oregon Research Institute. "They'll say they're really sensitive to the rewards. But when you look at the brain scans you get a different picture."
Previous brain imaging studies have looked at what happens when we look at pictures of food. In those cases, obese individuals tend to anticipate a higher level of satisfaction of eating the pictured food than lean individuals do, supporting the idea that the people who overeat are the ones who find it more rewarding. But the Science study was the first to do those same fMRI scans while participants were actually eating—or, in this case, drinking a chocolate milkshake.
"Nobody had ever administered food to people in a brain scanner and looked at what happens in the brain while you're eating," says Stice. "Now we have evidence that, when you give an obese individual a chocolate milkshake, there's less of a response going on."
What they found had a lot to do with dopamine, a neurotransmitter typically released in response to a pleasurable experience. Using an fMRI machine, the researchers measured the activity in an area of the brain that tends to be a hub for dopamine, called the dorsal striatum, when women had either a pleasurable food (the chocolate milkshake) or a control food (a tasteless solution). Obese women showed less activity in that region of the brain when they drank the milkshake compared to their leaner counterparts. And when researchers followed up with their participants a year later, they found those with decreased activity were also more likely to have gained weight. The more an individual overeats, the less potent the rewards from eating become and that creates a pattern of overeating. "The new bit is that once you start down that obesity track, it's hard to get back off," says Stice.
That risk was particularly pronounced among individuals with a particular genetic variation known as the Taq1A1 allele, suggesting a genetic disposition for weight gain—what other researchers call the most significant finding of this study. "What this research does to move things forward is identify a genetic component to brain functioning in obese people," says Gene-Jack Wang, a scientist with the Brookhaven National Laboratory. "This is a gene that can go any direction and these people are potentially more vulnerable [to having lower levels of dopamine]."
The study results reinforce the notion of obesity as similar to drug addiction, a comparison that researchers have been toying around with for the past few years. Dopamine has played a critical role in addiction research, where researchers have seen a similar pattern. "This research follows what we have seen in addictive people," says Nora Volkow, director of the National Institute on Drug Abuse. "At first we thought they were more sensitive to pleasurable responses. But research has shown exactly the opposite, that they have a blunted response to drugs and release much less dopamine. With obesity, it took everyone by surprise."
Researchers know that these findings of a genetic basis for low-reward overeating are important, but there's still a lingering question: how this research can best translate into obesity-prevention efforts. "A lot of things come out of this, a lot about future applications, possible drug treatments," says Wang. "It provides answers, but is also a bit of another Pandora's box." Wang and others know genetics is definitely not everything—rates of obesity have skyrocketed in the past century, far too quickly to be attributable to genetic variation alone—and that our nutritional environment plays an extremely significant role.
Still, if doctors can pinpoint genetic risk factors for obesity, it could reshape treatment: by, for example, identifying high-risk individuals early on or using pharmacologic interventions that could counterbalance low dopamine levels. Stice says he's not an advocate of genotyping, which he says would be "infeasible." Instead, he sees the main message of his study as a public-health warning, a strong reminder of why it's important to avoid overeating in the first place. "The more you eat, the less reward you get and the worse the problem is going to get," says Stice. Talk about a no-win situation.
Before that was able to happen, I had a day and a half of clinicals. On Thursday I was scheduled to provide anesthesia for a patient undergoing an aortic stent-graft, which was supposed to treat his aortic aneurysm. It is inserted through a large artery in the leg. The patient looked fairly ill, with fairly severe vascular, lung, and kidney disease. He had had some teeth removed a few months before to prepare for this surgery, and during that case he had dropped his blood pressure to an extremely low level, requiring more than one medication to keep it up. So we knew that it would be a risky procedure for this patient, and we prepared all the medications we thought we might need, and planned to do it with him deeply sedated rather than as a general anesthetic. (It's not unusual to do this procedure under deep sedation, but more common to do a GA.)
As we were preparing the patient in the OR, we gave him a tiny bit of sedation and a tiny bit of pain medicine. As I went around to place an arterial line in his wrist, my preceptor gave him a tiny bit more medicine because what I had given hadn't affected him yet. Then the patient complained of feeling "funny", turned purple and stopped breathing. We checked for a pulse and found none--started CPR. The code continued for about an hour and a half until we were finally able to transfer him to the ICU.
That was Thursday.
Friday I had a half day of clinicals so I could start driving to Portland early and get there in time for the networking reception downtown. While I was at the reception, my father called and left the same message he always leaves me when he calls: "It's Dad. Call me." I got the message around 8, and planned on calling him the next morning.
Saturday I went to the conference, which was very good. I turned off my ringer out of courtesy to the speakers, but towards the end of the day heard a few calls vibrating on my phone. On my way out of the auditorium, I listened to the voicemails, one from Dad and one from my brother. Just seeing that they had both called, I knew something was wrong. It turns out that my grandparents were in a bad car accident on Friday evening. My grandfather, who is 92, was driving my 88 year old grandmother somewhere. There's a 2 lane highway near their small farming town in Oregon, and my grandfather was trying to cross the highway and was hit by another car. Both of them were taken to different hospitals about 40 miles apart. The occupants of the other car had minor injuries.
(I'll interject here that our family has been trying to get Grandpa to stop driving for years. It is nearly impossible to get an independent, elderly adult to stop driving in this country, despite all the evidence in the world that the driver is no longer safe. Ironically he had actually tried to get his own mother to stop driving when she was in her 90s, and was unsuccessful, but that didn't help him see that he shouldn't be driving, either. Grandma used to drive instead until her heart attack last year, and now she can't. Not that she should be, either. But she would have been safer.)
My grandmother has bruising on her lungs and heart, and a broken rib. In a healthy person this would be a relatively minor injury and would heal without any problems. But my grandmother has bad cardiovascular disease, and has been intolerant of exercise since she had a heart attack about a year ago. Now, she was having constant chest pain and signs on her EKG that her heart was not getting enough oxygen--which is what causes heart attacks, ultimately. The accident was on Friday, she was in the ICU until Sunday and they moved her to the step down unit. She was still having severe chest pain the whole time, and they decided to do an angiogram to see if there was something they could treat to relieve the pain--even though they knew her heart disease was severe, and she was not a candidate for bypass surgery. What they found was that her heart disease is even worse than they thought, that she had had another heart attack, that all of her major vessels are blocked, and that she is expected to live no more than a few weeks. The plan is to discharge her from the hospital to hospice once her chest pain is under better control.
My grandfather was brought to another hospital about 40 miles south. He was not breathing initially, and his heart stopped a few times between the accident and the hospital. The reason he wasn't breathing is because he sustained a very high spinal cord injury in the accident--essentially the same injury Christopher Reeve had. He is unable to move his arms or legs, or breathe without a ventilator. For the first 24 hours, he was unresponsive. The family gathered and brought in their advance directive, which said basically that he didn't want artificial life support. Then, he woke up. A few more days were spent examining his situation and determining that he can actually respond by blinking and sticking out his tongue to yes/no questions, and that he seems to understand what is explained to him. Because of this, his advance directive is not effective until he is no longer responsive, and he has indicated that he wants to continue treatment. But remember, he is 92 years old. A healthy young person with this injury has a life expectancy of 2-5 years. Christopher Reeve survived 9 years with the best care money could buy--and he still died from complications related to his immobility. Even if my grandfather wishes to be sent to a nursing home on a ventilator, and despite his excellent health for a 92 year old man, he will not live long this way.
So this is why I haven't been blogging. I am taking a temporary leave from school while we deal with all of this. I don't know how long any of this is going to last. Both of my grandparents remain alert and able to interact; my grandmother is just as funny and smart as ever, but she knows that both of their conditions are grave. It is unlikely that they will see each other before they die. They are the hub of our family; they have been farming the family farm their whole lives, living in the house in which my grandfather was born. They now have a 5 generation family--they became great-great grandparents 2 years ago. I remained in Oregon until yesterday, when I finally had to get back to Spokane since I was only packed for 2 days, and I hadn't planned on anyone looking in on my cat. I'll head back either today or tomorrow morning and see what the weekend brings.