Thursday, February 25, 2010

Evaluating Patients: Three Critical Questions

I've been a Family Physician for twenty-three years, and worked as a Registered Nurse and Nurse Practitioner for years before that. I've been doing health care in some capacity for thirty-nine years, and that doesn't count my days as a teenaged Candy Striper!

So, like many others of my vintage, I've seen many, many patients over the years. I've done many evaluations and heard countless stories.

The trick in medicine, I believe, is knowing when to worry. Left to our own devices -- and the Internet -- we can worry about everything, and that's simply not practical!

So, when evaluating a patient situation, I've distilled my approach down to Three Critical Questions, and I've found these to be invaluable time after time. Here they are:

1.  What is the worst condition this could possibly be?

 I rule that one out, and work down the list from there. That's not always straightforward. After all, not all headaches are aneurysms and not all skin lesions are melanomas. So, given a specific set of symptoms, I try to define what is the worst possibility. Then, I try to find the most rational test to rule out the "worst case scenario," providing that the test does not present undue risk to the patient.

2.  I often ask a patient: "Do you feel sick enough to be in the hospital?"

I have found that patients are excellent at self-triage -- in general. When a patient responds immediately with "Oh, of course not!" or "Absolutely not," I feel reassured. On the other had, if a patient says "I'm not certain," or "I have been wondering about that," I am ready to look further. A corollary to this, of course, is "Does the patient LOOK sick enough to be in the hospital?" We make these judgements from across the room sometimes! And with children, the key question is "Are they ACTING normally?"

3.  The third, and most important question in medical decision-making is "What are the facts?"

Sometimes a patient and I will simply list the facts we know -- separating the worry out from the facts of the case. For example, a patient may complain of chest symptoms but be capable of doing an hour of high-speed cycling. Does that rule out the possibility of cardiovascular disease? No, but the fact that the patient has excellent exercise tolerance is greatly reassuring. The fact that a patient's work is not impacted by symptoms, the fact that a patient is not awakened by symptoms, the fact that a headache is easily relieved by a Tylenol tablet -- are all reassuring to me. And, of course, we have the facts of the objective data we gather, e.g. laboratory tests and medical imaging studies.

In medicine, there are no guarantees: it's medicine, not accounting!

But I've found great assistance in a quick review of my three critical questions: 1) What's the worst possible case?, 2) Does the patient judge himself to be sick, and 3) What are the facts? After all, a little logic never hurt. Common sense, we know, can be UNCOMMON in medicine!

Take care. Linda Gromko, MD

Saturday, February 20, 2010

What is "Metabolic Syndrome" and Why Should we Care?

Metabolic Syndrome is a collection of conditions that run together -- and increase a person's risk of having  heart disease, stroke, and /or diabetes.

I think this is critical to review from time to time, because it certainly is a "theme" in my medical practice and probably in MOST medical practices.

While definitions vary, I've paraphrased the definition given by the American Heart Association and the National Heart. Lung, and Blood Institute below:

They define "Metabolic Syndrome" as having three of the following criteria:
  • Elevated waist circumference (men greater than or equal to 40" and women greater than or equal to 35"). This is also known as "visceral obesity." Do you remember the image of being an "apple" vs a "pear" in body shape? Better to be a pear.
  • Elevated triglyceride levels (fasting level over 150 mg/dL)
  • Low HDL cholesterol: under 40 mg/dL in men and under 50 mg/dL in women. (By the way, I use this memory tool to help patients remember good cholesterol and bad cholesterol: "H is for Healthy; L is for lethal! We want more HDL and less LDL.")
  • Elevated blood pressure, i.e. greater than or equal to 130/85
  • Fasting blood sugar of greater than or equal to 100 mg/dL.
Particularly if an ESRD patient developed renal failure as a result of hypertension or diabetes, there's a good chance they have not just three of these criteria -- but ALL of them!

The bad news with Metabolic Syndrome is that it predisposes a person to diabetes, heart disease, stroke, and certainly CKD (Chronic Kidney Disease).

But the very excellent news is that Metabolic Syndrome can be prevented or even reversed!* How? By doing the following:
  • Becoming physically active: start with walking and move on from there.
  • Controlling body weight: even a 5% loss reduces risk.
  • Treating high blood pressure -- often the above measures, i.e. exercise and weight loss, will be enough to lower BP.
  • Getting diabetes diagnosed and treated early, to limit the damage it can do to both large and small blood vessels in the body.
  • Diagnosing and managing cholesterol properly.
These recommendations, while simple in essence, are tough for people to actually do. Just as with alcohol or overweight, sometimes we have to "hit bottom," have a personal scare, or see a friend suffer irreversable consequences that worry us to the point of changing our own behavior.

But it's interesting that physical activity and weight management can often be pre-emptive or curative. In other words, these two measures can in turn help manage blood pressure, diabetes, and abnormal cholesterol.

So, start with moving your body. Remember: the best exercise for a person is the one they will do! If that's walking, perfect. And like the Nike ad says, "Just do it!"

Metabolic Syndrome is one of the greatest challenges our country faces; we're seeing it in children and adolescents in alarming numbers. But we're not powerless here; we can help improve our own health and the health of our next generation.

And like Steve says, "I'd be happy if we could prevent Metabolic Syndrome in even one person."

And he should know...he's "on the hose" (i.e. dialysis) because of potentially preventable conditions.

Take care. Linda Gromko, MD
*Note: I'm not implying that ESRD is reversable here, unfortunately.

Wednesday, February 17, 2010

Anniversary of a Failed Transplant

Some time ago, I wrote about "Anniversary Phenomenon:" that vague sense of uneasiness that occurs on or about the anniversary of a significant event in our lives.

Today, Steve and I are profoundly aware of Anniversary Phenomenon. Last year, on February 18, Steve had a Living Donor Transplant, courtesy of his lovely niece Teresa. I remember doing what we thought was to be Steve's last Home Hemodialysis Treatment. I remember taking the ferry in the dark early morning to get to University Hospital. I remember the confident hope with which we signed the consent form. We were so excited; we were practically giddy.

After all, the odds of a successful transplant were extremely good--particulary with a healthy related living donor.

But, as we all know, there are no guarantees in medicine. Steve's blood pressure dropped to a systolic of 70 during the surgery; he had a run of bradycardia with a heart rate in the 30's. Ultimately, we were to learn that Steve had suffered a mild heart attack during the surgery.

Two more heart attacks and roughly five weeks later, Steve was still showing poor blood flow to the donor kidney. An interventional arteriogram was attempted. After that procedure, Steve began to bleed into his belly from the site of the disrupted anastomosis (connection). He went to surgery for the third time: this time for the explantation (removal) of the donor kidney.

There have been few nights in my life that have felt as bleak as that one. All of us - from Steve, to Teresa, to the Transplant Surgeons - were heartbroken.

For Steve, there was a protracted recovery: home with a "Wound Vac" packed into his open wound for a period of many weeks. It meant Home Dialysis through a central line again, as Steve's fistula had clotted off during his hypotensive episode. It meant a longer-than-expected absence from my medical practice; Steve was a heavy care post-op patient on Home Dialysis again. And it meant enormous financial sacrifice.

So, what happens next?

Next month, we are hopeful that Steve will pass his Nuclear Medicine heart study. But our optimism is cautious. He may need another stent; he could even require another CABG (Coronary Artery Bypass Graft.) .

But if he does pass the heart study, he'll be back in the ring again with other potential donors stepping up and many more hurdles to clear.

All I can say is this: Transplant is a modern miracle. But it doesn't always go as hoped. While we never expect to be the exception to the rule -- the one with the less fortunate outcome, it can happen.

My deepest respect goes to the man who says "For a kidney--with a fourteen year old daughter? I'd do it again in a minute!"

So, Anniversary Greetings to Steve and to Teresa. You are loved and treasured for your courage.

Take care. Linda Gromko, MD

Monday, February 15, 2010

Thanks to Frank at NxStage

A fistula, for the non-iniated, is a vein that is surgically connected to an artery  -- usually in the forearm. Because the arterial connection forces the vein to grow larger, it allows for the near-daily hook-up to a dialysis machine. One inserts "fistula needles," 15-guage spears that are so large you can actually see down the barrel of each little trochar.

There's no getting around it, a 15-guage needle is impressive no matter which end of the needle you're on!

Experts advocate "Fistula first!" This, I believe, represents the plea to plan ahead for your patient's End Stage Renal Faiilure so that a patient can start their Hemodialysis with a mature fistula. The options of grafts and central lines are more dangerous. Especially with the latter, I've heard, "it's not a question of if they will become infected; it's a question of when."

I suspect Steve has had more problems with his fistula access than the average person, but I certainly don't know that for sure. Maybe everyone really does have three surgeries and at least as many fistulagrams. And I understand that diabetics -- like Steve -- are more likely to have difficulties with their fistulas, as their blood vessels are more tenuous.

Nonetheless, we currently have the best access yet -- and for that I am grateful. Threading the last fistula felt more like threading an IV -- with a 15-guage needle.

Yesterday, as Steve and I were doing his treatment, I was able to puncture without any problems. But the machine was reading pressures that simply didn't make sense.

So I called the Technical Support person at NxStage with my questions. We weren't in any danger, and we weren't "calling from the State of Confusion," mind you. We just wanted to know if there might be something wrong with the machine or the disposable cartrige that contains the "guts" of the dialysis process.

We have talked to a number of Technical Support people over the last two years. And this guy Frank (Frank, I so apologize; I can't remember your last name. Emal me and I'll add it!) was a prince.

Here are some of the factors that made Frank's assistance so commendable:

  • He was cordial and polite.
  • He didn't make the automatic assumption that we had done something wrong!
  • He conveyed the attitude that troubleshooting was a challenge -- maybe even interesting, and that solving the problem would be a triumph for all of us.
  • He said, "If you have the time, I'd like to stay on the phone with you for a few minutes?" (If I have the time? Frank, come on over -- we're not going anywhere!)
  • He was a cheerleader: liberal with praise and encouragement.
  • He was a clear advocate for Home Hemodialysis.
  • Frank conveyed that he liked the work he was doing.
  • We ended the call with a sense of greater understanding of the process and more knowledge about the parameters of the machine -- good information to know.
Now, I want to be careful to point out that almost all of the Technical Support we've received has been very good. But, as in any healthcare experience, there's a range. And Frank got Honors.

It's always struck me that in healthcare, one of the most effective things a helper can do is to simply act polite! Fake it 'til you make it, I don't care. Just sound respectful.

So thanks to Frank for making our day better. We certainly ended our call feeling more clear and less isolated. And when you've hit a snag, every bit helps!

Take care. Linda Gromko, MD

Wednesday, February 10, 2010

Weight Loss May Require "Hitting Bottom"

 I was talking to one of my patients today about her impressive weight loss: 150 pounds in 13 months, now maintained for nearly three years.

How did she do it?

Through the time honored method of good nutrition, portion control, and a new commitment to physical exercise. She did employ a personal trainer, but now uses soccer and weight training as her mainstays.

We talked about readiness for weight loss. There came for her a time when she was simply ready to make the necessary changes. Readiness came on its own timetable. But when she "hit bottom," there was no going back!

I remember my own "hitting bottom" with obesity. Ten years ago, when I was nearly fifty pounds overweight, I tripped on a curb cut--falling with arms outstreached and landing on my knees. Nothing broke, thankfully. But the startling thing to me was that I was standing next to my tiny little Mother, then a mere eighty-two!

Had I landed on her, I would have broken her little body! It occurred to me then how mortified I would have been if I had to confess that my Mom had suffered a hip fracture because I crushed her!

That was my "Come to Jesus" moment!

I signed up for Weight Watchers...again. But this time, I added the critical component of physical exercise. I was astonished that I loved the exercise: working out at the gym, taking spinning classes, and my all-time favorite: rowing--in a 12" by 27' single shell at the Lake Washington Rowing Club.

My patient and I reviewed the important ingredients in our different programs:
  • Taking a realistic view of what has to be done
  • Understanding why we are doing a weight loss program: that might be health reasons, it might be fitting in an airplane seat without an extension, it might be the horror of nearly falling on an osteoporotic mother who surely would have been injured on impact!
  • Supporting ourselves with excellent self-care measures
  • Recognizing that an injury or other circumstance that necessitates a "detour" also requires a mental reset: It's not back to the old way anymore!
  • An understanding that there are a thousand helpful tricks to keep us on track.
  • Excercise is a non-negotiable requirement.
As a doctor, I've seen far too many people lose 30-40 pounds for a prom dress -- only to gain it back if exercise isn't in the mix.
Let's face it, we're not doing this for a prom dress anymore!

So congratulations to my wonderful patient; she'll receive lifelong rewards as she sidesteps the diabetes that runs in her family. What a great example for us all.

Take care. Linda Gromko, MD

Jane McClure and Linda Gromko to present at The International Dialysis Conference in Seattle March 6-9, 2010

The University of Missouri presents the International Dialysis Conference March 6-9, 2010, in Seattle. According to conference organizers, 1900 participants have registered to attend the various sessions covering all aspects of Dialysis.

Jane McClure and I are scheduled to present our session on "Arranging Your Life When Dialysis Comes Home" on Sunday, March 7. We will cover:

  • Examining the impact of Home Dialysis on a couple/family
  • Planning your Home Dialysis Space for comfort, efficiency, and safety
  • Drawing on Designer expertise to create a space that feels like home -- rather than an ICU room
  • Finding storage solutions for dialysis supplies
  • Supporting the ever-important Caregiver by recognizing and preventing Caregiver Burnout.
Jane McClure and I co-authored the book, "Arranging Your Life When Dialysis Comes Home: 'The Underwear Factor.'" Our book is available through our website at, and on in both paperback and Kindle editions.

What we have to offer may not be rocket science. We don't pretend to compete with the "hard science" to be presented in some of the other sessions.

But, we would offer that anything that makes Home Dialysis more user-friendly -- more approachable for patients and families -- represents an important contribution to the Dialysis Community.

We invite Conference participants to join us for some practical solutions for your Home Dialysis challenges.
Hope to see you at the Conference.

Take care. Linda Gromko, MD

Friday, February 5, 2010

Caregiver Burnout Series: Part Four: Supporting the Caregiver

Burnout and the "Giant Breast Syndrome:"

Every mother who has ever nursed a baby knows that to make breastfeeding work, you need two components:
  • Nourishment: food and fluid to make milk, and
  • Plenty of sucking to stimulate milk production!
Most mothers who are faced with Burnout understand the breastfeeding analogy immediately: we seem to get plenty of  "sucking," but few of us get enough nourishment. Translated further, we all have so many demands on us that we may feel we don't have enough nipples! What we lack is the kind of nourishment required to make more milk. And in this case, "nourishment" goes beyond food and fluids.
Another metaphor is to envision your life energy as fluid contained in a bucket -- but, a bucket with a hole in it! You have to keep filling your bucket, or it will soon be empty!

Enough metaphors? Let's get down to business and talk about what we need. You may find some of these tips discussed further as Caregiver Tips elsewhere in this blog.

1.    Move your body; exercise.
2.    Use the "HALT" acronym from AA.
          Don't get too HUNGRY, ANGRY, LONELY, or TIRED!
3.    Eat small meals regularly.
4.    Sleep.
5.    Take little breaks often.
6.    Seek humor!
7.    Listen to music that you like.
8.    Find "creature comforts," e.g. massage.
9.    Buy inexpensive treats that say "hang in!"
10.  Read or knit.
11.  Have a good cry.
12.  Steer clear of people who sap your energy.
13.  Avoid alcohol and other recreational drugs.
14.  Give back to the community somehow.
15.  Attend "Kidney Events."
16.  Learn any prayer that speaks to you.
       Examples:  the AA Serenity Prayer, and "The Four Agreements."
17.  Accept help from others.

A few more thoughts to consider:

In order to ask for help from others, you must know what you need!
I recommend an exercise I call the "Minimum Daily Requirements." What ARE your daily requirements for exercise,  food, touch, intellectual stimulation, etc.?  You are far more likely to get what you need if you know what it IS that you need.

Remember: It could be worse!
Every single day in my medical practice, I see examples of people whose lives are worse than ours -- much worse. In the early days of Steve's kidney failure, we used to say, "At least it's not the burn unit." It was our shorthand way of acknowledging that we have much to be thankful for.

Negative feelings about your partner are normal -- to a point!
Many Caregivers do have negative feelings about their partners from time to time. I know that there have been times when I didn't even LIKE Steve! Now, did that interfere with the quality of his Home Dialysis? No, but we had to agree not to bicker during treatments; it made him feel too vulnerable. Talk to a counselor if you find that negative feelings are beginning to dominate your thinking. You need a safety net; don't take your frustrations out on your partner with that fifteen guage needle!

The Caregiver role is critical to successful Home Dialysis. Yet, Caregivers need care, too. Often, we are so caught up in the seemingly more critical needs of our partner, that we don't get our own needs met. Unless, of course, we make a conscious effort to do so.

Caregivers, take good care of yourselves. You'll be more effective as a helper if there's something left for you.

Take care. Linda Gromko, MD

Thursday, February 4, 2010

Caregiver Burnout Series: Part Three: Treating Depression

In this Blog Series, we've discussed the role and requirements of the Caregiver, and signs and symptoms of Caregiver Burnout. We've noted that burnout and depression have important similarities, the latter usually being more severe and prolonged -- and not responding as easily to breaks and self-care measures.

Today, we will focus on depression and how it can be treated. This is an enormous topic, and cannot be adequately covered in a blog post! But, hopefully, this "Depression in a Nutshell" post will give the reader a brief overview, and a place to start if this is an issue for you.

Depression is characterized by a "down" mood, and other symptoms including low energy, irritability, loss of interest in usual pleasures, a sense of hopelessless, sleep disturbances, involuntary weight change, excessive worry and/or guilt. Depression generally lasts for at least two weeks, and may be accompanied by thoughts of suicide.

So what do you do if you think you may be depressed?

First of all, get some help. Your Primary Care Provider, i.e. family doctor or nurse practitioner, the Social Worker at your Kidney Center are good places to start. Naturally, your local E.R. or Crisis Clinic are appropriate if you feel you may be in danger of self-harm.

Years ago, there was a study that took a group of people with depression and divided them into four subgroups (I do not have the reference for this). The groups received treatment as follows:

1..    Exercise
2.     "Talk Therapy"
3.     Antidepressant Medications
4.     No therapy, i.e. "Control Group"

The important observation was this: the people in each of the first three groups improved; the "Control Group" which received no treatment did not improve.

Let's look at each approach:

You don't have to be a jock to appreciate that simple exercise -- even a short walk -- helps us to feel better. And regular exercise, done several times a week or even daily, is even more powerful. We feel stronger, we work off stress, we feel more capable of dealing with life's challenges. Which exercise is best? In my opinion, the best exercise is the exercise a person will do!

Talk Therapy:
If you've never been to therapy, you might want to give it a try. Think of it this way: appproximately one hour per week, a trained and compassionate person focuses on you and your concerns. A psychiatrist friend of mine used to say, "It's the heathy people who go to therapy!" I'm convinced that he was correct. Remember, we aren't talking about years of psychoanalysis here. We're talking about short term cognitive therapy, lasting a few weeks to months.

We have many antidepressant medications from which to choose, and their risks and side effects have been greatly reduced over the years. That said, it may take a few tries to find the proper antidepressant -- or combination of medictions -- for a particular person. I tell my patientts,

"Antidepressants don't change the facts of your life. But they can change the way you respond."

Here's a good tip: if a close relative of yours is using a specific antidepressant and has had a particularly positive or negative response, tell your Health Care Provider. This information may be useful in selecting the right medication for you. Another important consideration: antidepressants can take two to four weeks to "kick in." So, don't wait until you're at the end of your rope. Get help soon if you see depressive symptoms lingering on.

My favorite approach to depression for patients in my practice? The triple combination of physical exercise, cognitive therapy, and antidepressants!

Depression can be frightening and unpredictable; it feels awful to be depressed. For Caregivers, depression may make us concentrate less effectively and make more errors. Keep in mind also that a severe depression may require hospitalization; this is where we need professional help to sort this out.

What else can you do to help yourself?

1.     Avoid alcohol and other recreational drugs. This is critical, as alcohol is actually works as a depressant! Experts claim that it takes only four drinks per week for a woman and six drinks per week for a man to cancel out the effect of an Antidepressant!

2.     Keep yourself safe. Be attentive to your driving and other activities which place you at risk. Pay attention to your prescription medications; take them correctly and do not combine with alcohol. Remove articles from your home which place you at added risk (e.g. firearms). If you feel you cannot guarantee your own safety, tell someone! Go to the ER or call the Crisis Clinic.

3.     Focus on self-care. Tomorrow's blog will focus on the many Self-Care Tricks that help us nuture ourselves. Please join me tomorrow and examine many of the ways we can help ourselves.

Take care. Linda Gromko, MD     

Wednesday, February 3, 2010

Caregiver Burnout Series: Part Two: What is the Difference Between Burnout and Depression?

In yesterday's post, we noted that the symptoms of Caregiver Burnout are almost identical to the symptoms of depression. So how do you know if you're depressed or if you're experiencing Burnout?

Burnout usually responds to a healthy dose of self-care, and continuing to do the things that help.

Depression -- on the other hand -- lingers on for two or more weeks, not responding as easily to self-care measures and more often linked with serious symptoms like suicidal thinking.

When trying to figure this out with patients in my medical practice, I often ask something like this:
"If we could just give you a week off and a gift certificate to your favorite store, would it make things better?" (As if we could do this!)

For the person who is depressed, a temporary break and a gift certificate would be nice, but it wouldn't really solve anything. But for a person who is experiencing Burnout, a break can make a significant difference -- particularly if a break and some serious self-care are part of an ongoing effort in that direction.

It is critical to get some help if you think you are depressed, or if you simply don't know. Your Primary Care Provider, a Counselor, or the Social Worker at your Kidney Center are great resources.

Important Warning: If you are feeling so down that you are thinking about suicide, you MUST get help! If you can't see your Primary Care Provider immediately, call the Crisis Clinic or go to the nearest Emergency Room for an Evaluation.

Things can get better, but only if you're breathing!

Tomorrow's blog post offers Part Three in this series on Caregiver Burnout: Treating Depression.
Take care. Linda Gromko, MD

Tuesday, February 2, 2010

Caregiver Burnout Series: Part One: Recognizing the Signs of Burnout

The Caregiver is essential to the smooth operation of Home Dialysis. Because the role of the Caregiver is so important -- and because Caregivers can sometimes feel isolated or "lost in the shuffle" of seemingly larger issues, I am starting a four-part post on Caregiver Burnout. The main themes are as follows:

Part One:         Recognizing Signs of Burnout
Part Two:        How is Burnout Different from Depression?
Part Three:     Treating Depression
Part Four:       Supporting the Caregiver

Recognizing Signs of Burnout

The Caregiver in Home Dialysis may experience a variety of emotions. He/she may be reeling from the diagnosis of the partner's illness, with all the uncertainty that entails. There are more demands on the Caregiver's time. Family responsibilities may be unevenly divided, and the day-to-day responsibilities don't stop, even in the face of ESRD!

The Caregiver may find himself/herself consumed with financial worries. The partner's ESRD may have resulted in major changes in a family's income. And anyone who has tried to untangle the intricacies of insurance or medicare knows how difficult that can be.

The Caregiver may grieve for simpler times gone by. There's a loss of spontaneity in day-to-day life. A Caregiver may grieve for the life he or she had imagined; surely it didn't include ESRD!

It's natural for Caregivers to have frustrations and bad days. But sometimes, it goes beyond that, and the Caregiver is at risk for Burnout.

Burnout feels like you can't possibly continue for another day -- you're too worn down and bone tired. This can be uncomfortable and dangerous for the patient and the Caregiver. Our own health can suffer and we make more mistakes.

Be on the lookout for these warning signs:

1.     Fatigue
2.     Irritability
3.     Persistent crying
4.     Inattention to usual grooming
5.     Avoidance of exercise
6.     Inattention to the Caregiver's own health
7.     Poor concentration; difficulty reading
8.     Low energy level
9.     Sleep disturbances
10.   Weight gain or loss without trying
11.   Loss of interest in usual activities
12.   Decreased libido
13.   The sense that nothing will ever get better
14.   Helplessness and/or hopelessness
15.   Excessive worry
15.   Feelings of guilt
16.   Hypervigilence.

These symptoms are important to watch for. If you see these symptoms lingering in yourself, get some help from your Primary Care Health Professional or your Kidney Center Social Worker.

If you've noticed that these symptoms of Burnout resemble the symptoms of Depression, you're correct.

Tomorrow, we will look at "What is the Difference Between Burnout and Depression?"

Hopefully, by knowing what to watch for in ourselves and in others, we can nip problems in the bud before they become major problems.
Take care. Linda Gromko, MD

The Continuum of Dialyzor Activity in Home Hemodialysis

Dori Schatell of Home Dialysis Central and I were e-mailing about the range of dialyzor activity in Home Hemodialysis and Home Dialysis Training. We noted that the span ranges from 0 to 100 percent activity on the part of the dialyzor.

Take Bill Peckham, for instance. He does his own fistula needle insertions, and handles the entire set-up and treatment without assistance from anyone.

But then, there's my husband Steve. He's probably closer to the other extreme. He's not at what he and I call the "Do-Me" method of Hemodialysis, but he's close. Steve takes his vital signs and weight, calculates the amount of fluid he wants removed, tears tape, and helps me troubleshoot problems.

Why? Well, Steve probably has more "co-morbidities," other conditions that impact his health and treatment. In his case, these include severe peripheral neuropathy, deconditioning after his long recovery from last year's kidney transplant and explantation, labile (unpredictable or variable) diabetes, fistula problems which have required several surgeries to arrive at our currently great access, labile hypertension, and angina!

Is Steve "involved" in his own Home Hemodialysis? Of course he is. Even though he's not up to doing the whole treatment for himself, he most assuredly is involved.

It reminds me of the story Steve tells about ham and eggs:

Q: What's the difference between ham and eggs?

A: The chicken is invested, but the pig is committed!

No matter the details of dialysis Steve performs! He's alert, involved, and 100% committed. And he's at the "sharp end of the needle!"

Every Home Hemodialysis patient and partner has to work out what's practical and possible for them. I think the more involvement, the better. Home Dialysis gives us the opportunity to work within the limitations of our own situations, and make the best of what we have.

Take care. Linda Gromko, MD

Monday, February 1, 2010

Caregiver Tip #9: Surround yourself with supportive people, and stay away from people who sap your energy!

If you are a Caregiver for a Home Dialysis Partner -- or a Caregiver in any other capacity, you know you have many demands on your time and energy. Steve and I have been fortunate to have had many people provide support and assistance in a variety of ways.

But as a physician, I've talked to people for years about the experiences they've had as patients and as Caregivers.

Here are some "pet peeves" I've heard over the years, and/or experienced myself:

  • Describing your situation -- whatever the experience -- to someone, only to hear a litany of their own horror stories in return.
  • Well-wishers who imply that something is wrong with the care the patient is receiving. (Example:  "So the transplant didn't work. Did the doctors do something wrong?" My answer: "No, it was a complicated situation.")
  • Sympathizers who encourage lawsuits! ("So, you're suing them, right?" My answer: "No, we're not, and go away!")
  • People who say: "I understand your situation completely. I know exactly how you feel."

Be aware! Anyone who says "I understand completely" probably doesn't. If they did, they wouldn't say it!

I truly believe that some helpful things to say include:
  • "I have no idea what that must be like."
  • "I've never experienced that. I have gone through some difficult experiences, but this sounds rugged."
  • -- or better yet -- "What is this experience like for you?"
The person who "gets it" doesn't say, "Call me if there's EVER anything I can do." They understand that a requirement to orchestrate ANYTHING is yet another demand on your time.

The people who "get it" listen. They allow you to vent. They give you Starbucks cards. They know they don't have to fix it -- because if you could have fixed it yourself, you would have done it already.

Isn't compassion interesting? I believe that people have good intentions for the most part. But as a Caregiver, you need all the support you can get. So, seek out the people who "fill up your bucket," and make less time for those who make you feel worse.

Take care. Linda Gromko, MD