Thursday, March 24, 2011

Hypnotherapy Calms Steve's Breathing and Brings Better Sleep

As a resident physician at the University of Washington, I received basic training in the techniques of hypnotherapy. I went on for more training in this area, and have practiced it intermittently with my patients - as an adjunct to smoking cessation, weight loss, and other significant challenges.

Steve has struggled with poor sleep for years, and medications to help have been met with variable results. Medications which leave him "drugged" or "groggy" don't seem to do him any favors - and we are mindful of  adding anything to his already full pharmaceutical menu.

With the recent respiratory infection Steve encountered, he experienced full-blown wheezing. Even after his hospitalization - and the pulmonary treatments - and the steroids - and the antbiotics, his breathing sounded like a creaky, poorly-oiled machine. As an asthmatic, I understand intimately the discomfort of constricted breathing. It takes so much effort to pull in and force out each wheezy breath.

So, I tried a hypotherapy technique to get Steve to sleep and ease his breathing. It went something like this:

"Steve, as I count down from 5 to 1, you will experience a deepening of relaxation. As you envision a place in the world that is particularly restful to you, I invite you to focus further on your breathing.

Notice that it is becoming more easy - almost effortless - as cool, clear air moves easily in and out. Your breathing slows as you realize that your breathing tubes are opening ever-so-gently to allow for easier entry of life-giving oxygen. Your body deepens further into relaxation.

Take a moment to receive any message, to take care of any matter you need to before you drift easily into sleep"

---------"I love you, Linda Jo," Steve whispered.

"Excellent. Now slowly, gently drift to sleep through the night without waking. Wake in the morning, relaxed, refreshed, and restored."

Steve drifted off and slept soundly through the night: no coughing, no request to be turned. It was a quiet night in spite of its uncomfortable beginning.

Take care,
Linda Gromko, MD

Tuesday, March 22, 2011

Steve Gets a Hospital Tune-up

While Steve's respiratory symptoms quieted after the removal of some extra fluid via Peritoneal Dialysis, his wheezing and cough came back in earnest on Sunday. He was tiring out - and getting a little worried about something more serious like pneumonia.

So, rather than our Sunday date, we took a cabulance to Swedish Hospital.

Our whole family had had respiratory viral infections. But with Critical Illness Myopathy/Polyneuropathy, Steve may have more difficulty clearing out secretions. He did have a flu shot earlier in the year.

Steve spent a couple of nights in the hospital, getting antibiotics, bronchodilators, and a blast of anti-inflammatory steroids.

So whether it was an atypical pneumonia or a viral bronchitis, Steve did need treatment, and he felt better after the tune-up.

Breathing is, after all, non-negotiable.

Now that Steve has been in the hospital many times, he recognizes some of the nursing staff as friends.

A'dree-Rose Hollinger, RN - a Dialysis Nurse who has cared for Steve many times, stopped by to say hello. Steve loved her visit. We have a special place in our hearts for A'dree-Rose. She is one of the few nurses we've come across who knows intimately the process of Home Hemodialysis and Home Peritoneal Dialysis. She knows because she was her Grandfather's Home Dialysis helper while she was a student! We have been frequently surprised at how few health care professionals know that dialysis can be done at home - and with some significant advantages.

Tonight, it's nice to have Steve home again. I don't think he's out of the woods with respect to the respiratory symptoms. But we'll keep a close eye on him.

Take care,
Linda Gromko, MD

Saturday, March 19, 2011

Returning Home to Find Steve Sick Again

I spent one night in San Francisco - one night for a two-day training event. My son Tim was able to spell me for two of Steve's Peritoneal Dialysis treatments. And with a little coaching over the phone, Tim did great.

But when I walked in the door last night, Steve was audibly wheezing!

Our whole family has had colds. But Steve wasn't clearing his secretions well; I could hear him wheezing across the room.

I gave Steve Combivent treatments and started him working on the Incentive Spirometer - trying to encourage deeper breathing and better "pulmonary toilet."

It's hard to read Steve in the best of circumstances. We cannot get proper blood pressures on him in any consistent manner because of his bilateral arm fistulas and his poor lower extremity circulation. We cannot weigh him at home because of the logistics involved in moving him. Of course, Medicare doesn't cover a bed scale. Critical Illness Myopathy/Polyneuropathy hangs on as a formidable foe.

So we're left to assess volume by his subjective symptoms (e.g. degree of thirst, difficulty breathing) and objective observations of Steve's edema. He rarely gets swelling in his feet, of course; he doesn't walk and he spends most of a day reclining or in bed. 

When he is truly volume overloaded, we see extra fluid around the neck area, the backs of his arms. It's tricky, especially without comparative weights and blood pressures. But we've managed reasonably well thus far. It is - by no means - the usual standard for home dialysis. But Steve's circumstances are unusual.

So I asked Steve's nephrologist about taking him in to the ER to be evaluated. After all, I have no idea about his oxygen level or what a chest x-ray might show.

Dr. Thakur suggested a trial of a Peritoneal Dialysis run using a more concentrated dialysate. If Steve is really volume overloaded, the removal of a net 2 liters or so would be helpful in relieving symptoms. It it didn't, the ER would still be there.

And since Steve didn't look like Medic One material to me, it seemed like a reasonable idea.

Now, as I type, Steve is snoozing soundly - breathing much more comfortably after we tried Dr. Thakur's suggestion.

So far, so good. If this continues, we'll have avoided a costly, difficult afternoon for Steve. And, of course, if things change, we'll make a new plan. But for now, it's a great relief.

Take care,
Linda Gromko, MD

Tuesday, March 15, 2011

Going Out of Town Brings New Worries

Most of my professional training requirements can be met in Seattle, I do go out of town once in a while. Thursday and Friday of this week, I make a short trip to San Francisco for a training event related to the Weight Loss portion of my medical practice.

I am Steve's primary caregiver. As I write this, he's snoozing through his Peritoneal Dialysis run. But this evening, he's also been given medications; blood sugar has been checked and insulin's been given. I've turned him in bed, cleaned him, and tended to his skin care.

I realize that San Francisco is two hours away, and I leave Steve in many hands. There's my son Tim, who cares for Steve every weekday and coordinates all of his PT/OT and MD appointments. Tim has also been trained in Peritoneal Dialysis. And, of course, he's got the back-up of the Kidney Center nurses. Then, we'll have several hours of other caregivers' time each day for the more personal care.

Well orchestrated, the trip should come off without a hitch.

But here IS the hitch: the last time I left town for two days, Steve was still in the hospital. I came back to Seattle to find Steve delirious with a temp of 101, right upper quadrant tenderness - acute cholecystitis! Back to the ICU - once again.

I appreciate that Steve's health is tenuous enough that anything could tip his delicate balance at any time. So leaving town is nerve-jangling for me.

But, as before, I'm not in control here! I can orchestrate the things I can, and the rest will have to follow.

Take care,
Linda Gromko, MD