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Monday, October 27, 2008

Top 10 Wishlist: Exports to Spokane

Top 10 Things I Would Like to Export from Portland to Spokane:

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

Right or Left?

I listen to a lot of podcasts, mainly because I drive a lot between Spokane and Portland (a 400 mile trip) and like to have intellectually stimulating things to listen to. One podcast that I enjoy is Speaking of Faith, by Krista Tippet and American Public Media. I do not particularly consider myself a religious person, for many reasons. But I enjoy these podcasts, which Tippet describes as “public radio’s conversation about religion, meaning, ethics and ideas.” They cover a great variety of religions and personalities within the world of faith, and speak of them in a particularly informed, nuanced way.

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

Kenneth 1915-2008

My grandfather spent about one week in the ICU. After a few days, they placed a tracheostomy and a feeding tube, in hopes that he would be able to communicate better and would be more comfortable. It was very difficult to tell if he was mentally intact or not, but he was answering questions appropriately and asking some of his own, mainly about my grandmother and asking to be shaved. However, despite being completely paralyzed from the neck down and remaining in bed on a ventilator for many days, with a cervical collar on, he appeared comfortable until Saturday.

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

Google Reader

I have not kept up on my sistas' blogs. First it was school, now it's family...I feel so behind. But today I set up a Google Reader page and put all my blogs on it. It's so easy, and they're all in one place so I can hunker down and get all caught up. I don't have a TV in Spokane but this is just as good.

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.

Article: Why Food Is Addictive For Some Women

I'm posting this now because I think it's relevent and interesting, and because reading it gave me something to think about other than what is happening with my grandparents.

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.
© 2008

Hiatus: Bad Week

This past weekend was supposed to be all about networking: I planned to go back to Portland for OHSU's Anesthesia Conference, where I would have a chance to meet Oregon CRNAs and scope out the job market.

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.

Wednesday, October 8, 2008


Sorry and a shout out to Diz, to start. I meant to "publish" your comment on the last post but accidentally hit "reject" and it was lost to the abyss. I don't know if Blogger notifies people when their comments are deleted or not. But if you are wondering what was so offensive about your comment that I didn't publish, the answer is, Nothing. I just fat-fingered it.

It's Hump Day, and we had our first pharmacology exam of the semester today, which I think went well. I won't find out for at least another week, though. Tomorrow I have clinicals, and I am doing a big vascular day--a couple of carotid endarterectomies (cutting out plaque from the carotid artery) and an aortic stent. These are big, involved cases that can lose a bit of blood and, more often, can be very difficult to manage blood pressure, as they are done on people with a lot of vascular disease. Should be busy.

I made an appointment for next week to see Dr. Pennings, the band doc. I will try to persuade him to schedule a fluoro to make sure my band looks good before we do any more fills. He doesn't like to do them if one is asymptomatic. But band slips can happen without symptoms, as can esophageal dilation, and I want to be sure. So I'll let you all know how it goes. I'm still gaining and losing the same 4 lbs, which is frustrating. It's okay if I don't lose ground, but I want to make at least a little more progress before the end of the year.

The good thing is that the running is going fine, although with the evenings getting dark so early now I'm going to have to figure out something other than running after school or clinical pretty soon. I'm doing about 13 miles per week, which is only a bit more than I've done most of the summer, but it's about all I have time for now. Perhaps I'll get in an extra mini-run this week to bump it up a bit. It's getting cold too--I've heard rumors of snow this weekend. I'm putting off turning on the heat as long as possible--this old house has no insulation, so getting enough heat to make a dent in the temp inside means pouring money out the walls. I'm using the space heater when I have to, but I'm resisting the baseboards as long as possible.

Blah blah blah, that's enough. Have a good week all!

Sunday, October 5, 2008

Sweet talker, Betty Crocker...

Well, I should probably write a Dear John letter to brownies, too. We had a picnic this weekend to welcome the soon-to-be new students in our program (they start in January), and I made brownies and got stuck taking most of them back home. I sent most of them to Oregon with hubby today, but certainly ate more than my surgeon, or my scale, would approve of. These brownies I made are from a recipe that my mom made when I was growing up, and I had to buy 4 vintage, used Farm Journal cookbooks before I finally found that recipe--and they are good. But, no es bueno for my weight loss.

To atone for my dietary sins, I did run 5 miles today, and totalled almost 14 miles last week--something I havent't done in a long time. So, I feel pretty good about that.

I'm not moved to get all political on the blog at this time, but I appreciate everyone's comments about the idea. I'm sure I will at some point, but right now, nah. I am really enjoying SNL's Tina Fey/Palin skits, though. The Palin/Biden one this weekend was hilarious--good zingers on both candidates, and on Gwen Ifill, too. It's funny how both sides are claiming that they "won" the debate--but in the grand scheme, the VP debate really means nothing. They each have a lot more to lose than to gain--they can definitely screw things up for their campaigns, but they can't really gain any ground. And the format was about as soft-pedal as it gets.

This week: test on Weds, a paper due. OR 3 days. Hope everyone has a good week.

Wednesday, October 1, 2008

Dear Apple Pie...

Dear Apple Pie,
I love you. You are one of my favorite foods, and I know how to make you about as well as anyone else I've found. In fact, making you is one of my baking specialties.

However, you are bad for my thighs. You tease me, making me think I'll have just one little piece, but you know that once I taste you I won't be able to resist you until you are gone from my presence. And since I'm trying to lose weight--and I'm not supposed to have you at all, since I've been banded--having as much of you as I desire is the wrong thing to do.

It's fall, and I thought I could make you without eating all of you. But you seduced me, and I've had more of you than I should have. It's not fair, but I'm going to have to say goodbye to you. I can have you in public, with other people that I can share you with, but I can't be trusted alone with you.

I hope you understand.