Saturday, July 25, 2015

Shifting Focus to a New Book...

As a family physician, I've had an amazing range of experiences. I've seen so many different people, with so many life circumstances.

For the past 17 years, I have been honored to serve the transgender community - with my patients ranging in age from 8 to 80!

I am currently writing, "Where's MY Book?" A Guide for Transgender and Gender Non-Conforming Youth, Their Parents, & Everyone Else.

Look for it around Halloween! I guarantee you, it won't be boring!

Take care,
Linda Gromko, MD
www.QueenAnneMedicalAssociates.com

Sunday, February 22, 2015

Dori Schatell Introduces Practical New Tool for Dialysis Choices at 2015 ADC Conference

When my husband Steve was first diagnosed with End Stage Renal Failure, we attended the "Choices Class" at the NW Kidney Centers.

It was an honest representation of the options available, but Steve and I quickly labeled it the No Good Choices Class. Simply, the choices were 1) Kidney transplant (not an option in the short run), 2) Dialysis (in-Center Hemodialysis, Home Hemodialysis, and Home Peritoneal Dialysis), and 3) No treatment.

Steve quickly dubbed the last option as "Door Number Three," i.e., certain death in about two weeks with no treatment at all.

Medical Education Institute Staff at the Annual Dialysis Conference
in New Orleans, February 2015

Dori Schatell, Director of the Medical Education Institute and co-author of "Help! I Need Dialysis," introduced a new model for presenting dialysis choices at the ADC Conference. I think it has great merit.

As all dialysis choices can sound overwhelming at first, Dori devised a tool that helps kidney patients identify what's important to them, i.e., flexibility, NOT having medical responsibility, dietary freedom, etc.

Then, after completing an on-line personal survey - with immediate personal results, an individual is better able to identify what method of dialysis would best fit with their own priorities and lifestyle.

It focuses on a patient's life, rather than on a mix of choices that all sound burdensome at the outset.

I like the fact that this tool feels empowering. When a patient is feeling overwhelmed and out of control, this tool brings a bit of control back to the patient. Win/win!

Check this out at www.HomeDialysisCentral.org.

Linda Gromko, MD

Saturday, January 31, 2015

Learning from my Japan Visit: Part 2

It's amazing that I had the opportunity to go to Japan to talk about home dialysis. And it's particularly poignant because Steve spent years working in Japan - and had his health permitted, we would likely have traveled there together. I guess he really did take me there, at least indirectly!

Linda giving a bookstore talk, with
Steve's image on the PowerPoint slide
After speaking at Shizuoka, I traveled to Kyoto on the Shinkansen - the "Bullet Train." I saw the manicured Japanese countryside on my way to the University of Kyoto, where I was to speak to a group of medical students, residents, and nephrology fellows. They were impressed by the small size of the NxStage dialysis machine we used. They wanted to know how we kept Steve's spirits up. The answer? Weekly movies and a dinner out, courtesy of Access Bus!


After my talk, the four nephrology fellows (specialists-in-training) shown at left took me to the golden Kinkajui Temple shown behind us. We had a remarkable dinner - with me eating my first-ever raw fish.
Later, I was to have a most informative visit to the Sakai Rumi Clinic in Kobe. Dr. Rumi Sakai is passionate about dialysis; her daughter, Dr. Aya Kita jokes that "more dialysis" is her Mother's religion!

Dr. Sakai tells of having a patient
on dialysis for 40 years!
I mentioned in the previous blogpost that cadaver transplants are not accepted in Japan because of the Japanese observation that brain death occurs when the heart stops. Therefore, harvesting donor kidneys isn't done, except for a small number of living donors.

My observation is that when dialysis is what you do for ESRD, you have to do it very, very well!

For example, the blood flow rate in Japanese hemodialysis is much slower than in the United States. Surely, this must be more gentle on the dialysis access fistula!

In Dr. Sakai's clinic, patients have the option to do hemodialysis every other day: not the Monday, Wednesday, Friday regimen we do in in-Center dialysis. The three-day U.S. routine leaves patients with a long weekend to allow a patient to become volume overloaded, thereby increasing their risk of cardiac events during the break!



Above, Dr. Aya Kita explains another feature of the Sakai Rumi Clinic. Each numbered cubicle allows a patient to dialyze in private overnight! They are monitored by video cameras, blood pressure recordings, and moisture detectors - in the event of an accidental disconnection. Patients are able to shower after their dialysis and go right on to work. To me, this seems like a great solution for people who do NOT wish to dialyze at home. Plus, it would allow for maximal facility utilization!

I am a staunch advocate for the use of home dialysis. But the more options we have, the better!

We're in this together, and we can make it better!
Linda Gromko, MD

Visiting the Japanese Society of HHD Conference, Part 1

In February 2013, I gave two presentations at the Annual Dialysis Conference in Seattle, and sponsored by the University of Missouri.

After hearing my presentation on supporting the caregiver (care partner) in Home Hemodialysis, Dr. Ituko Masakane from Yamagata University asked me if I'd like to come to Japan.

Japan! A lifelong dream. With an invitation formalized by Dr. Noriko Mori of the Department of Nephrology of Shizuoka General Hospital, I left Seattle on April 17, 2014. My topic: "Home Hemodialysis: The Best Gift I Could Give My Husband."

Dr. Masakane, Dr. Gromko, and Dr. Mori after Linda's Talk

What's it like to give a talk in Japan? Considering I speak about three phrases in Japanese - and we weren't planning on formal translation, it could have been rugged! But Dr. Mori was kind enough to translate my slides into Japanese. My audience was very kind and respectful.

Here's the poster that advertised the conference I attended in Shizuoka.
 
We agreed that my late husband Steve, with his Metabolic Syndrome and Diabetic Renal Failure, would have been nicknamed, "Mr. Metabolic Syndrome." In Japanese, of course, that would have been "Metabol-San."


My guides, Keiko and Masaki
Japan's ESRD culture is quite different from what I know in the US. For example, kidney transplantation is extremely rare. With a philosophical stance that does not allow for brain death as a criterion for organ harvesting, transplants are essentially limited to related living donors, not cadaver donors.

For this reason, Japan leads the world in its proportion of hemodialysis. Home hemodialysis, however, occurs much less commonly than in America. There are approximately 400 patients on HHD in the entire country. This is where personal stories - like the story of helping Steve with dialysis at home - may be of help.

Models of sharp and blunt needles -
larger than life, but pretty much how Steve saw them!



It occurred to me that Steve had been told by a nephrologist, "Dialysis is what you do until you get a kidney."

In Japan, dialysis is most likely what you do with End Stage Real Failure, period. From what I saw, though, there are some innovative approaches with tremendous merit.


Check out the next blog post for my experience at the University of Kyoto, and - best of all - my visit to the Sakai Rumi Clinic in Kobe.

We're in this together - and we can make it better!
Linda Gromko, MD

Tuesday, September 30, 2014

Supporting Mom through the Night of her Death had Similarities to Assisting Mothers in Labor

My little Mom died this morning at 5:58 a.m. The night reminded me of my years of attending women in labor. Intense and personal, I think her death "went" as well as it could have gone.

Mom and Dad - married for 50 years.
He died over 20 years ago.

My mother was nearly 97 - healthy up until April when she had two falls resulting in three fractures, and the need for a change in care from Assisted Living to an Adult Family Home. She was hospitalized a couple of months ago with a urinary tract infection - which highlighted the degree of her declining kidney function. (She was admitted with an eGFR of only 11, improving to the high 20's by the time of her discharge - and after considerable rehydration.) We all knew that Mom couldn't sustain this degree of hydration. She hated being in the hospital, pulling out her IV and begging to know, "Why are these women trying to hurt me?"

My sister and I decided to involve the Palliative Care/Hospice Team. They'd provide the care that could be provided in the Adult Family Home, with the intention of delivering comfort - not cure.

 
Mom holding me in 1951, with sister Bonnie looking
"delighted" about my very existence!

 

Mom was treated as an outpaient for another UTI. Then, about 10 days ago, she began to show more confusion - and an ominous loose cough. This was pneumonia. Strong antibiotics, adjusted for her decreased renal capacity, didn't work.

The cough grew more tenacious, and Mom grew weaker. She pushed away the oxygen that was offered, and pursed her lips together when food and fluids were attempted.

On Sunday morning, my mother told me I looked pretty (something she wouldn't typically say). She had sweet visits with my sister, her granddaughter Michelle and great grandson Mason - and, of course, with my son Tim.

Great Grandma Florence gets a visit
from Mason
But early Monday morning, Mom had no more words for me - just a sad straight-ahead gaze. Her focus was locked on the work of breathing.

I moved through my clinic day, seeing patients and checking in with my sister by phone. I arrived at the Adult Family Home at 8 p.m. Mom looked more "serious" than she had that morning: still no eye contact. Everything she had was invested in breathing. I settled in for the night - just as I often did when I was delivering babies.

I delivered hundreds and hundreds of babies over a period of 18 years - and I had been an OB nurse before that. There are observtions I made in those days that seemed to fit last night's process. For example,
  • Birth has its own timetable; there are visual, verbal, and kinetic clues you learn that go beyond knowing the degree of cervical dilation.
  • There is a single-mindedness you see in a laboring woman; there is little attention directed externally.
  • Birth has a rhythm, a pace of its own; except when intentionally stopped, labor pushes ahead.
  • Labor and delivery can be approached by helpers with love and kindness, but it can also be a time of supreme vulnerability.
Last night, I could see and feel the clues; my Mom was in a different type of labor. Her body changed as the process chugged relentlessly on. Her skin became more transparent. There was no external focus. The sounds of her labored breathing reminded me that there was no turning back. We were on the timetable of dying now.

I remember one woman in labor who stood up and announced at five centimeters, "I'm going home, right now. I don't want to do this anymore."

But just as in that situation, turning back wasn't an option. The only way out of this was through it.

The small doses of morphine deposited under Mom's tongue helped settle her breathing. Stroking her fine hair seemed to help, too.

Then I sang some songs: "On Christmas Morn" written by my friend Bob Bost, and "The Moon Keeps Me" (Through the Night)" written by my friend Rebecca Cohen. Finally, an old hymn I remembered from my childhood church choir:

"High o'er the lonely hill, black turns to gray.
Birdsong the valley fills, mist folds away.
Gray wakes to green again.
Beauty is seen again.
Gold and serene again, dawneth the day." (or something like that)

Another half dose of the blessed morphine, and Mom's face relaxed into calm - maybe even a tiny smile. Her breathing shifted again - now soft; not the exhausting, pulling breaths that had forced her tiny upper body into spasmodic contortions.

And then, at 5:58 a.m., it was quiet in the home.

She was beautiful; she was strong. She had gotten through her labor, to some other side. I think we made good choices in advocacy and love.

Take care,
Linda Gromko, MD

Friday, September 19, 2014

Fargo Trip Brings Important Information: Fatal Vascular Access Hemorrhages

I was invited to speak at the 13th Annual Sanford Kidney Services Nephrology, Dialysis & Transplant Symposium September 17. My topic - one of my favorites - was "What My Husband's Kidney Failure Taught Me About My Own Profession."

But I also had a chance to listen to several speakers before returning to Seattle. One was Lynda Ball, MSN, RN, CNN - who spoke about the alarming topic of "Fatal Vascular Access Hemorrhage." Can you imagine?

 

Here are some important take-home points from Lynda's talk:
  • Fatal vascular access hemorrhage accounts for 0.4 to 1.6 percent of all ESRD patient deaths annually (230 episodes annually in US)
  • 75% had access complications within 6 months (meaning there were some warning clues)!
  • The majority of these events occur away from a dialysis facility, e.g. SNF, home, jail.
Lynda stressed the importance of evaluating the patient for access complications such as stenosis, ulceration, infection, and non-fatal hemorrage. She reminded us that it's important to ask the patient, "Have you had any bleeding at your access site since your last dialysis?"

Aneurysms in a fistula can occur from repeated punctures in the same location. The skin can become shiny and smooth, but it is also stretched. The patient is likely to request a puncture at this site because it hurts less - but the skin can become thinned, and can rupture like an inflated balloon!

Any skin breakdown, ulceration, infection, or prolonged scabbing at the puncture site should prompt further evaluation.

Emergency measures in the case of spontaneous access hemorrhage include:
  • Direct pressure
  • Elevation about heart level
  • Calling 911.
Good to know.

When I speak in various locations, I'm impressed with the hard work and sincerity of the people who work in the area of dialysis: people who are clearly trying to make things better for people traveling this tough road of CKD.

Take care,
Linda Gromko MD
PS - Please take a moment to look at my medical practice's updated website: www.QueenAnneMedicalAssociates.com.

Wednesday, August 20, 2014

Acute-on-Chronic Renal Failure Brings Different Questions in a 96-year-old Mom

My little Mom had been blessed with excellent health until age 94 when she began to show some signs of cognitive decline. She was still witty - really delightful. She had only one health problem: hypertension - and that was well-controlled with small doses of beta-blocker and a mild diuretic. She'd never had a surgery, and except for a brief admission for Atrial Fibrillation, she'd been in the hospital only to deliver my sister and me!

Florence Gromko, at left, with daughters Linda Gromko
and Bonnie Gromko Mearns in December 2013

At 94, she moved into an Assisted Living Community, and did reasonably well until she had a fall in April 2014 - sustaining a distal tib-fib (ankle) fracture. About a week later, she fell again, fracturing her pubic ramus. This required hospitalization and about a month in a rehabilitation facility. She then moved to an Adult Family Home with only six residents and more one-on-one care.

Like so many elderly folks, Mom had diminished kidney function, CKD Stage 3. This was likely due to hypertension - or more likely, to being 96-1/2.

A urinary tract infection took her into the hospital in August. She was very dehydrated from vomiting and diarrhea, and on admission, her creatinine had risen to over 3, and her eGFR was only 12. (You start thinking about dialysis with this eGFR - and with an eGFR of 15 in a diabetic.) Of course, this was an acute situation; vigorous volume repletion got her tuned up to an eGFR in the 20s by the time she was ready to return to the Adult Family Home.

But she hated the whole ordeal: pulling out her IV, and begging me to answer, "Why is this woman trying to hurt me?" - as a very sweet nurse tried to start another IV.

The amount of fluid my Mom received by IV was appropriate, but we could see there was no way on earth she'd be able to keep up with it on her own. Another bout of diarrhea, another few episodes of vomiting, and she'd be sliding down again. I figured she'd be in trouble within a month or so.

When my husband's eGFR was 5, and he was started on emergent dialysis via central line in the setting of Acute-on-Chronic Renal Failure, it made so much sense to initiate the "full court press." With a twelve-year-old daughter, he was hopeful for a successful transplant - and willing to pursue home hemodialysis in the interim.

But with a woman as elderly as my Mom - voting with her behavior by removing her IV lines, and declining the amount of fluid that would protect her volume status, it seemed time for palliative care.

She's still happy and glad to see us. Last week, she was saying, "You've got to have goals. I've got to get things done."

I asked her what goals other 96-year-olds had, and she replied instantly, "Oh, they're all dead!"

Different circumstances clearly call for different interventions.

Linda Gromko, MD