Monday, April 26, 2010

What Price Advocacy? Discomfort!

As my husband Steve completes his seventh week in the hospital following his open heart surgery, it's fair to say that he's come a long way. Truly, by all rights, he should have died -- were it not for the courage of Dr. Joseph Tepley and Dr. Brad Tupper.

But this past week, Steve suffered a setback. For a variety of reasons, he became volume overloaded and suffered several sleepless nights with severe shortness of breath. Fluid was accumulating in his lungs. Because he is essentially bedridden, Steve accumulates edema fluid in his neck and back, and even under his chin -- but less so in the usually dependent areas like the feet.

Concerned that the volume overload would place undue strain on his heart, I approached his health care providers. My concerns were reasonable. Plus, Steve's symptoms of chest constriction and shortness of breath raised concern about other possible diagnoses such as pulmonary embolism and coronary artery ischemia.

Here I am, an MD with a Master of Nursing degree -- and over two years of experience with Home Hemodialysis. And I found it uncomfortable to ask his care providers about these problems!

Would they resent my "intrusion?" Would my comments be charted as "wife insists....?"

Fortunately, Steve's team was gracious. His cardiac enzymes and d-Dimer did not support the worrisome possibilities of bypass graft failure or blood clots in the lungs. His chest X-ray, however, showed classic signs of fluid overload -- signs any second year medical student would have recognized.

I was relieved; we were on the road to correcting the problem. But what would have happened if I hadn't spoken up? Could it have meant a detour back to the ICU -- or worse?

What if I had been elderly (or more elderly than I am)? What if English was a second language? What if I felt truly intimidated, not just uncomfortable?

No doubt about it: there are barriers to being a "mama lion" in the hospital! But I believe, as a wife and caregiver, we have an obligation to overcome our discomfort and step up. Not doing so really could make the difference between recovery and disaster.

Remember: good doctors don't get rattled when you ask them questions. They welcome your input. They don't want a bad outcome either.

Take care. Linda Gromko, MD

Monday, April 19, 2010

Obesity Conference: A Real Eye-Opener

Last week, I attended the Obesity Conference presented by the American Society of Bariatric Physicians. What an eye-opener!

Two thirds of all Americans are now considered overweight or obese! And the problem is "ever-expanding" in that more children are facing challenges with excess weight. At the conference, I learned that it is now predicted that the current generation will not outlive their parents!

How does excess weight impact the "Renal Community?"

Excess weight is directly related to the following conditions. Certainly, Diabetes, Hypertension, and Metabolic Syndrome increase risks for End Stage Renal Failure (CKD-5). But note how much overlap we see between ESRD and the other conditions listed.

  • Type II Diabetes
  • Hypertension
  • Metabolic Syndrome
  • Obstructive Sleep Apnea
  • Coronary Artery Disease
  • Stroke
  • Erectile Dysfunction
  • Abnormal cholesterol
  • Asthma
  • Depression
  • And ON!
I learned that even a 5-10% reduction in weight is medically significant. And -- no surprise -- exercise is essential to keeping weight off on a long-term basis.

The problems of excess weight have become so concerning that we will be offering a Weight Management Program in my Family Practice, Queen Anne Medical Associates, PLLC, beginning in June 2010. I feel we are at a point where it's irresponsible NOT to offer a Weight Management Program of some sort. 

Link to for more information.

And, for our new Weight Loss blog, go to

Take care. Linda Gromko, MD

IMPORTANT ADDENDUM: ESRD patients should attempt a weight reduction program ONLY with the approval of their nephrologist and renal dietician!

Thursday, April 15, 2010

The Inn At Cherry Hill -- Useful Recycling of Old Hospital Space

When I was a medical student at the University of Washington, we rotated through many of the hospitals in the Seattle area. I spent many months at Providence Medical Center, both in medical school and in residency..At the time, it was run by the Sisters of the Charity of Providence. Morning and evening prayers were broadcast over the PA system; there was a crucifix in every room.

Today, Providence has evolved into the "Cherry Hill Campus" of Swedish Medical Center. There's a Starbucks where the gift shop used to be, the chapel appears more "bland" -- even non-denominational, and the crucifixes are gone.

The fifth floor of the old hospital -- with its small private rooms and tiny bathrooms -- was retired from patient use some time ago. Today, it is "The Inn at Cherry Hill" -- with rooms rentable to families of patients at the medical center for a fee that isn't cheap ($70/night), but certainly beats any area hotel rate. The rooms are modest, but clean. Best of all, they are down the hall from your family member. The Inn features a communal washer and dryer, and hospital linen is provided.

For those of us who come a distance, it is a tremendous service. This week, for example, I've been attending a medical conference at the airport. But I still live on Bainbridge Island, and commute to Seattle for work -- and to spend time with Steve at Cherry Hill. Some nights, when there's been too little energy to go around, I've spent the night at the Inn.

I think every hospital should have sleeping rooms for patients' families. And if not full quarters, at least a "USO style" lounge with showers, recliners, desks, and phones. A place to wash up, and a place to calm down.

I applaud Swedish for using these old rooms for such a humane purpose. Undoubtedly, they wouldn't have met newer codes for patient care use. And remodeling would have been too expensive.

But someday, perhaps hospitals will be planned to include such areas for families! Someday, it will be recognized that it's simply the right thing to do.

Take care. Linda Gromko, MD

Friday, April 9, 2010

Fistula First...or Second or Third!

My husband Steve has been in the ICU now since 3/5/2010. He's had an angioplasty, then a major open heart surgery to replace his severely stenotic aortic valve and bypass four coronary vessels. He was so unstable that his chest was left open -- to be closed in a second surgery five days later. I had never even heard of this before! We are so grateful he survived.

Steve's dialysis fistula in his forearm "went down" on the day of his surgery. His cardiac ejection fraction was only fifteen percent (normal is at least over 50 percent), so peripheral blood flow was sluggish. The fistula clotted -- and Steve's condition was so precarious that he required twenty-four-hour-a-day dialysis via an Internal Jugular central line.

Even though Steve has had two prior central lines for Home Hemodialysis, we know that a central line is an infection waiting to happen! They say it's not a matter of if there will be an infection, but rather, when!

(We have been very fortunate with Steve's central lines in the past -- even using them for many months without infections.)

But this time feels more critical. In Steve's already weakened state, we cannot risk a line infection. So, the current plan is to place a new dialysis fistula this coming week. We know it will take weeks to mature to the point where it's usable for dialysis.

All this brings me back to the point of the slogun "Fistula First!" In the best of circumstances, a person with End Stage Renal Failure starts Hemodialysis via a mature fistula, surgically created weeks to months in advance. This is why patients are referred to a vascular surgeon as their renal function nears the point of dialysis (as reflected by the eGFR- or estimated glomerular filtration rate). In general, dialysis would begin with an eGFR of 10, or 15 in a diabetic.

Back in September of 2007, Steve's initial presentation with acute-on-chronic renal failure was so rapid, he didn't have the luxury of getting a fistula placed ahead of time. Even then, he couldn't seem to catch a break. But, even then, he landed on his feet. We're counting on continued strength from this extraordinarily resilient man.

Take care. Linda Gromko, MD