The humble (limping) protege

It was a nice affair. My boss (fifteen years my senior) is a cardiologist, scientist, mother, and today Professor of Medicine. They gave her an endowed chair..... with all of the pomp and circumstance. There was a medal, a big one, that she wore around her neck as she gave her lecture.

The chancellor of the university, dean of medical school, chairman of medicine all said that she is an amazing scientist. They had her mother, father, brother, sister, husband, son and daughter stand up. They all were in the audience. For her introduction, "When a brilliant mind meets excellence in education and enthusiasm for discovery........"

It all-together was surreal. In surroundings familiar, I felt like an outsider.... being away for almost two months. Her accolades seemed to belong to a giant. For a moment seeming more like a coronation than lecture. Today she is the star. Somehow managing to find her way atop a pile of ego-centric, contemptuous, impatient, gender-biased men.

Surreal because I know this woman. I have been known to curse her. When she returns my writing nearly all red with edits, sends me back to the bench feeling my questions were ridiculously stupid, chastises me for spending too much time with patients and casually suggests I should repeat the experiment over the weekend.

But she is also the woman who hand-delivered home cooked meal to my house after my surgery.

What a challenge to be a successful woman. Here I am a critic, sitting in the privileged position to advance under her tutelage. Perhaps it reflects my own struggle. To find the right balance between kick-ass cardiologist, healthy/ fit athlete, and caring thoughtful friend.

A love hate relationship with the Professor. A love hate relationship with myself?

Hip Update

I am reaching the 6 week post-op magical date. This is when I stop taking the medications. Anti-inflammatory to prevent heterotopic bone formation. Aspirin to prevent blood clots. Lexapro because I don't want to take it anymore, and I prescribed it anyway.

Update of wound healing...... this was taken last week.


Compared to POD#5 you can appreciate the improvement!


And the wrist? One year of healing, my scar is white, flat and smooth. Secrets?

• Scar massage, rubbing skin to loosen from connective tissue below.
• Vitamin E/Coca butter lotion, applied daily for first few months.
• The SPF 45 sun-block all summer, if fresh scar is exposed to the sun, it will turn pink or blue
  

Mini Medical School 101

Recently I came across the efforts of Fran Drescher (star the Nanny). She is leading the Cancer Schmancer Movement, with the goal of increasing awareness of gynecological cancers.



Her goal is for all cancers to be diagnosed in stage one, when the disease is most easily and most effectively treated. An advocate for women understanding and taking control of their bodies, I applaud her efforts.

In a recent interview she was speaking about screening tests, in particular the use of vaginal ultrasound for detection of ovarian cancer. She was expressing the concern that it is not covered by insurance and therefore not available to women.

Respectfully I would like to clarify this issue. I believe it to be an important one and will be an excellent topic for my 1st Mini Med School Post.

A screening test is only useful if it:

Is capable of detecting disease
Has more benefit than risk
Makes a difference in the outcome of the disease


In the case of ovarian cancer, vaginal ultrasound is not an effective screening tool. The problem is the frequency of false-positive results. False-positive results are when the test suggests an abnormality when nothing is really wrong.

Doctors believe this because in one study (Jacobs Lancet 1988) 5 cancers were found among 5,489 asymptomatic patients who received 14,356 vaginal ultrasounds. In a second study (Andolf et al Br J ObGyn 1986) one cancer was found in 805 high risk women who were screened by vaginal ultrasound, BUT 38 patients in the study had exploratory surgery to follow-up on false positive test results. These numbers (the frequency of disease in a population and complication rate from screening) are used by physicians to determine if screening tests work.

Sometimes people believe that because a test is available it must be good. This is not always true. The well-informed patient should understand this.

Quiet time

An ice storm outside and husband snowed in in Boston provided the smokerdoodle and I some quality quiet time. Although I am able to be more active, the past two days I have extended my recovery- not too practical to balance on the ice and scrape the car. Before my surgery I had a panicked feeling about my sick leave- how silly I was. It has been the most wonderful month. A few experiences/ surprises discovered that I am grateful for:

Yogurt- cannot beat it, it was what I asked for out of anesthesia, better than ice cream. Packed full of nutrients, calcium, excellent calories. Narcotics and antibiotics can wreak havoc on your GI regularity, gotta love the active cultures

Helplessness (true, not the I'm overwhelmed emotional kind) provides recovery for the type A mind- I actually felt my brain re-setting, in those moments when there was nothing to do, nothing to plan for, nothing to worry about. Looking forward to simple pleasures: hot coffee, someone to turn on the light so I could read, an extra blanket for warmth

PBS (and TiVo)
Jane Austin Collection (all of her stories, one each Sunday night)
Legacy: Being Black in America (high profile black Americans find their mainland African, slave, and surprising white ancestors through public records and DNA profiling)
Local Explore your city shows..... who knew there were live caves beneath the asphalt, special meaning behind statue in my favorite park, new exhibits in the museum worth checking out

NexFlix- In your mailbox every day, oh my!

Public library- online catalog, remote book requests, the library in a century building, weeknight outing to retrieve books, public access computer room, lively with parents online with children, reminding me that the most important things in life: love, family, education are free.... material wealth and the pursuit of it can alienate us from this truth

I am healing

Sitting at the kitchen counter eating my oatmeal with raisins, a searing high pitched tone grabbed my attention. The fire alarm? Cell phone out of batteries? Actually my pager. So funny. I did not recognize the sound. I have been into work twice now. On the second journey I opened up shop so to speak, which included turning my pager back on. There were times on call, especially my first year of cards fellowship when it went off every 20 minutes. Following the beep my laboradoodle Smokey looked at me..... eyes wide open, head tilted slightly, ears raised as if to say what the heck is that.... what have you done!!

I am walking without crutches for short distances. Sitting is more comfortable. The potty chair and shower seat have been sent to the basement. My plastic apparatus for donning socks still is essential. I have PT exercises that I do as frequently as possible, and I can tell my strength is increasing. My hip hurts. Not all of the time, but frequently. It does feel different than before the surgery. Stiffness mostly, but sometimes there will be a pull or cramp when I turn or twist a certain direction.

I also found the courage to get on the scale. My clothes (and bras) don't fit. I have been living in yoga pants for the past month. The damage? Twenty pounds. Ten since November, twenty since I stopped exercising. To my credit when I stare at my naked body in the mirror I do not exactly like what I see, but I seem to have gotten over the loathing. This is kinda huge for me.

Before the infertility, miscarriage, broken wrist, hip problem/surgery there was a sense of control. Focus on success, perfection. Consideration of every move, analysis of each decision as if I held the power, thinking that if I worked hard enough I could make things happen.

This blog is about this experience for me. Now I am healing. I certainly hope the series of terrible events that sent me off track are behind me. But if their purpose was to teach me a lesson, give me a life skill necessary for health and happiness- I get it, finally.

Sat Morning at the Y

Surrounded by polliwogs, starfish and eels.... Saturday morning in the pool at the family YMCA. There was also a Baby & Me class, the best part when they played the hokey poky with 10 laughing babies splashing about.

The crowded conditions forced me to do the unthinkable. Walk in the lap lane. No self-respecting fitness swimmer would ever do that. I am so sorry coach (ravenlou) I am sure you are aghast!

One Month Follow-up

My office visit this week confirmed that everything is on track. The incision looks good (finished my Keflex), I can increase my weight bearing, I can drive a car, I can get in the pool. All good. A month of recovery behind me, it went so fast.

Celebrated by walking around liberally without my crutches. Later experienced ("My butt's on fire!") muscle spasms in my hip that kept me up until 3AM. My husband not knowing I succumbed to two percocet before sunrise thought I was dead in bed the next morning. Went to PT and got instructions on how to approach the next step of recovery- the rational practical approach. Allowed 75% weight bearing for the next week, then try without the crutches.

I got in the pool yesterday and it was wonderful! I walked back and forth, back and forth, back and forth.... you get the picture. I had the company of a 70 something little lady with a twinkle in her eye. I imagined as she walked next to me she was saying, honey you can do it!

My PT reluctantly agreed that I could try to swim. I did 100 yards, 25 at a time. It felt wonderful. Silence of the water, water streaming past my body, force of forward motion, strength of my stroke. I was never much of a kicker- so my limp legs did not make a huge difference.

Going to work this afternoon. Plan is to check out how taxing the walk from the garage to the lab is. Also to help celebrate my lab-mate's birthday.

My brother is flying in to town tonight! I am so excited to see him.

Grazie for not smoking

In January of 2005 indoor smoking was banned in Italy.

Yesterday a group published in Circulation reporting reduced acute coronary events among the citizens of Rome. This accompanied by measurable decrease in indoor air pollution, decreased cigarette and increased nicotine replacement product sales.

The reduction of acute coronary events was greater among men, and those in lower socio-economic groups.

Evidence that smoking bans improve public health.

Indoor smoking bans are in place in many American cities. Still others propose legislation, however it lacks the public support to take hold.

Americans hate to relinquish freedoms. Smoking, over-eating, sedentary activity, lifestyle for many. Criticism of these choices are taking hold, but to take away one's choice to behave as they please is another story. Our economy can only survive with a Universal Health Care system if we contain costs, take advantage of public health measures that may in effect legislate health for the general population.

POD#23

Physical therapy this morning. No more CPM machine. Allowed to flex 90 degrees, which means I may sit in a normal chair. Now I am doing exercises against gravity.

My first post-op visit with the orthropod is next Tuesday, and I am hoping I will be able to bear more weight at that time. Additionally my incision will be healed (infection cleared) by then, so that I may return to the pool. My left leg is strong. I think I will be able to walk. It will be wobbly initially but the majority of the muscles are ready to go. I will also ask when I can bike, I imagine a recumbent stationary bicycle would be the first step.

It has been so long since I have exercised. Months. 2007 was pretty much a wash.

2006 was my best year:
Swam 128,925 yards (78 miles)
Bike 378 miles
Run 282 miles

So this is the time for firsts again. Like yesterday, my first email to my PI (research mentor). Sent off an outline of my grant proposal. Time to start writing.

Next week first day back in the pool.

Maybe the following week back to work. Followed by treadmill, cath lab. All in good time.

Fat Loving Badness Everywhere?

A few posts ago the Bicycling article informed us that conventionally grown food leads to organochlorine (OC) toxicity in our bodies, and when we exercise the harmful chemicals affect our metabolism.

I was disappointed when reviewing their reference, but in that paper however I found the following:
Energy balance and pollution by organochlorines and polychlorinated biphenyls. C. Pelletier, P. Imbeault and A. Tremblay. International Journal of Obesity (2004) 28, 936–939.

This was much more helpful (and scientifically sound). A review:

OSs are proven to be associated with breast cancer, weakening the immune system, decreasing thyroid function and lowering mitochondrial fat metabolism.

OCs are lipophilic (fat loving) therefore are stored in fat. Obese individuals have a larger depot for OCs therefore they have higher total body storage. As the fat is converted to energy (during weight loss) the stored OCs are released into to bloodstream.

Their bottom line- because of this phenomenon, losing weight may not be as good for you as you think it is. Terrific.

Here at this point I need to backtrack and re-group.

Organochlorines are bad for me. But would I recognize an OC if I saw (or tasted it)? Where am I exposed to them? How much can I tolerate? What should I do to avoid them?

The EPA website (http://www.epa.gov/oppfead1/international/pops.htm) includes OCs in a list of the “Dirty Dozen” Persistent Organic Pollutants (POPs). This is news to me. Wasn’t the dirty dozen a movie or something? Anyway from the site a description of POPs

• Certain insecticides, such as DDT and chlordane, which were once commonly used to control pests in agriculture and in building materials, as well as to protect public health, are now considered POPs.
• PCBs, which were used in hundreds of commercial applications, such as in electrical, heat transfer, and hydraulic equipment, and as plasticizers in paints, plastics, and rubber products.
• Certain chemical byproducts, such as dioxins and furans, which are produced unintentionally from most forms of combustion, including municipal and medical waste incinerators, open burning of trash, and industrial processes.

AHA. My friend the architect was trying to convince me the hospital building materials were killing me! Maybe he was right. I certainly have heard of PCBs, and DDT is the insecticide that saves millions of lives from malaria in underdeveloped countries.

Is this stuff in our food (non-organically grown) too? The FDA regulates this, I plan to look into it.

Flabby butt sydrome

It is an epidemic.

"You see your real problem is that your butt muscles are weak," the diagnosis from 4 independent physical therapists! Describing four different butts mind you.

Subject #1. Early 30's. Previous gymnast, excellent swimmer. Serious running and biking. Chronic knee pain, eventual hip pain.

Subject #2. Early 40's. Serious biker for years, leading to hip pain.

Subject #3. Mid 20's. Running, biking, swimming. Back pain.

Subject #4. 33 year old (me). High school volleyball and basketball. College volleyball. Recreational athlete in 20s. Triathlon training in 30s. Running up to 6 miles, biking 100+ miles a week, swimming 5+ miles/week. Hip pain, femoral acetabular impingement, the rest is in the blog.

A coincidence that PT evaluation revealed weak gluts in all of us? Is it the biking? Is it the running? We are in shape, exercising to be/stay healthy.

Is there something else we should we be doing?

POD#20

My husband left town for the week and his mother arrived to stay with me. She is practical, has a relaxed nature and believes in everything in its place (all compliments). She makes hot chocolate with frothed milk and brought a stack of books for me to read. She is the wife of a physician, and I wonder if this has anything to do with the chemistry we seem to have. As a computer tech-y she arranged our wireless so that I can print in the den from my laptop anywhere. Pretty cool. She listens to my observations on life and emotional analysis with eager interest. As a breast cancer survivor and post knee replacement she has an interesting perspective on healing and recovery.

My wound is better. We went to see the doctor yesterday, mainly for peace of mind. Bottom line it will be fine, the antibiotics are working. This is a good thing.

I can do all of my prescribed PT exercises with ease. It feels like my hip is functioning at 30%. My Millenial Crutches are well worth the money- and they are red, which kicks ass. My elevated commode has indeed come in handy. I purchased 6 pairs of TED hose (compression stockings) on ebay. This adds to the two pairs issued to me in the hospital. Netflix has been great, movies come in the mail almost every day. I burned up my first CPM machine, and am at this moment strapped into my second.

Three weeks have passed quickly. I expected to feel frustrated with the convalescence, but feel peace instead.

Digging Organic

Before I dive into my detailed article review, let me start with the conclusion.

In the Bicycling article, the paper Thermogenesis and weight loss in obese individuals: a primary association with organochlorine pollution, Tremblay et.al. (http://www.ncbi.nlm.nih.gov/sites/entrez) was used to support the notion that organochlorines (suggested from conventionally grown foods) are released from fat during exercise and decrease mitochondrial function. I think this particular paper falls short of this assertion. Other papers referenced in this article may have promise however, and I plan to look into them.

I am growing more fascinated in this subject. Vietnam War veterans are compensated for occupational exposure to Agent Orange. They get diabetes. They get cancer. So organochlorines are likely connected to metabolism and certainly cause cancer....... but this doesn't resolve my organic foods question..... stay tuned.


Data in the paper above, was part of a study where the drug fenfluramine was tested. This makes it a secondary study, where the outcomes reported are not what the study was designed to measure. The study was not directed to look at pollution and its effects on the body. Investigators used data from an unrelated study to look for a correlation between pollution and the body’s ability to burn fat. In medical research this is done all of the time. Such research is useful, but is unable to show a cause and effect relationship.

There were 15 obese subjects (average BMI 35.4) who after 12 weeks of dieting had an average BMI of 32. Measurements were taken in these patients before and after their weight loss. Although we know 11 patients received fenfluramine and 4 received placebo, results were lumped together. Incidentally fenfluramine is Fen-Phen, the drug you may have heard on the plaintiff attorney commercials. It was removed from the market in 1997 after patients developed serious irreversible heart disease while taking drug.

Measurements included a sleeping metabolic rate (SMR), reporting calories burned when resting. The expected SMR was determined by measuring it in 86 “normal” people (with BMI 28.7). These people were not obese, not on a diet and not on fenfluramine.

The SMR of patients was recorded before and after weight loss. A predicted SMR was generated for these patients (extrapolated from normal group). Measured SMR and predicted SMR both decreased after weight loss. Before weight loss the measured SMR was much higher than predicted. After weight loss the SMR was slightly higher than predicted. The change (before-after) in SMR was greater for measured results.

The authors wondered why the decrease in SMR was greater in measured than predicted. In my mind obvious reasons (which were not discussed) include #1 because these patients were obese, #2 these patients were on Fen-Phen, #3 these patients were on a diet. All factors were not true of patients used to create generate expected results.

Now for the part we are interested in…. the organochlorine (OC) measurements. The article reviews that OCs are bad, they are in chemicals are used in our home and yards….. but also feared to be present on our food from herbicides and pesticides used by farmers. OCs are stored in fat cells. When fat is lost during weight loss the OCs go into the bloodstream. This has been reported to affect the body’s ability to burn fat efficiently.

The authors measured patient OC levels before and after weight loss. It increased a significant amount. When performing a multivariate analysis they found that the increase in OC concentration predicted the differences in SMR described above.

Organic Fuel: Bicycling Magazine

The March Issue of Bicycling Magazine (page 101) included an article about Organic foods.

They included a list of fruits and vegetables that are more or less important to be purchased organic (from foodnews.org by Environmental Working Group).

Organic please
Bell and hot peppers
Carrots
Celery
Cucumbers
Green Beans
Lettuce
Potatoes
Spinach
Apples
Cherries
Imported Grapes
Nectarines
Peaches
Pears
Raspberries
Strawberries

Conventional Okay
Asparagus
Avocados
Broccoli
Brussels Sprouts
Cabbage
Cauliflower
Eggplant
Onions
Okra
Peas
Mushrooms
Radishes
Sweet Corn
Tomatoes
Bananas
Blueberries
Cantaloupe
Grapefruit
US grown grapes
Honeydew
Kiwi
Papaya
Pineapples
Plums
Lemons
Limes
Mangoes
Oranges

First an admission. I am not a whole foods or organic food shopper. I am committed to eating healthy, but in my lifetime this has been to the extent of dieting and losing weight. It is time for me to investigate this matter, so I plan to do a series of posts on this topic.

This article got me thinking.

In the article mentioned above, the author states that pesticides contain organochlorines (from fertilizer) that collects in our fat cells. Release of these chemicals during exercise affect mitochondrial function [their source Intern J Obesity 2004, will review article]. They explain that by eating organic, "help keep your body and the earth clean and healthy". The list above represents items with more v. less residual pesticides.

My immediate questions are:
What is the evidence of pesticide contamination in conventionally grown foods?
What is the effect of pesticide consumption?
How is organic food regulated?

I am excited to learn more about this.

Big Gulp

I am not a big drinker. Sipper mostly. My favorite beverages with coffee at the top of the list, followed by a nice glass of red wine perhaps. On a long bike ride you should drink a water bottle an hour..... how much do they hold? About 500 mL, I imagine.

The day of my surgery and the night after I was wicked thirsty. Our hospital issues every patient a pitcher for water, with a huge straw that sits on the bedside table. Our heart failure patients have one. Four liters of water. I drank 4L of water in under 8 hours. I think it is the straw. It got me thinking, how much do our patients drink while they are in the hospital?

Water retention is a big problem in heart failure. Decreased pumping function of the heart, decreased blood flow to the kidneys. Kidneys see less blood, and therefore are unable to filter out excess water. At the same time they secrete hormones that increase blood pressure and stimulate thirst.

These measures are the body's way to stay alive. It backfires as the the weak heart is overwhelmed by the excess water. Handfuls of pills are issued to the patient with a failing heart- all to counteract this cascade. When swelling fills the legs and lungs patients are admitted for even more drugs, directly in the veins. An now as I am aware, a large pitcher of water with a mack daddy straw. Interesting what you can learn about medicine from a hospital bed.

POD#16

Yes the wound is infected. Immediately my mind entertained the worst possible outcome. Again because of the complications I have seen in patients during my training. Hundreds of patients are discharged home and live happily ever after. It is the one or two that stay with a bad outcome. Those you have to see every say, with feelings of guilt and frustration that leave the mark in your memory. But at the end of the day the reality (as my husband reminded me) is that it is just a little infection.

So it took 24 hours from my diagnosis of a wound infection until my first dose of antibiotics. In the last picture posted you can see a little redness at the top of the incision. Later that day I noted drainage (determining infection not just inflammation). It was 9PM. I called the SuperNurse early the next morning. I suspect they were in the OR all morning. I emailed with pics of the wound shortly after lunch. At 3PM I called again, to reiterate how concerned I was, and to share the pictures were available. The called me a little after 4. SuperNurse discussed it with the resident (an individual with 6 less years of training than myself) and they called the antibiotics in to the pharmacy. Viola, 4 hours later my husband brought it home.

Okay I realize patients go through this all of the time. I want to to be a good patient, let go of the urge to direct everything, not obsess about the details. I am trying. But waiting for treatment I could have gotten for myself a day earlier, is that the best ultimately?