Thursday, December 23, 2010

DMV doo-doo or do-do?

Mr. Valverde, (State Director of the DMV)

On the morning of November 4, 2010, I arrived at the DMV office on Bidwell St. in Folsom, CA for my appointment. The first sign inside the door reads:

Drive Test



At a glance the sign appeared like a “list” so I stood at the counter and waited for the employee bent at her desk. She looked up and glared. “I have a 9:30 appointment,” I said.

“For a driver’s test?”

“No, for a name change.”

“What does that sign above your head say?” She barked. “Lady, can you read?” Her volume rose with the sneer and a hush fell over the department. “It says driver’s test appointments.”

“I thought it was a list,” I started to explain, “Driving tests and appointments.”

“Read the sign,” she snarled, “You’re in the wrong line.”

“Where is the line I should be in?”

“Over there,” she waved, dismissing me and turning back to her empty desktop.

The customers queued behind me were as wide-eyed as I. Someone pointed to a second overhead sign that read: Appointments.

Let me start with we, the general public, are infrequent visitors to the DMV. Signs that seem to obviously communicate - might not. It is likely the person sitting at that desk, the first station inside, has the unofficial and perhaps unwanted job of traffic cop, directing people to other stations within the DMV office.

Many lessons can be learned from my experience: 1. I undoubtedly misread the sign. 2. The sign might be unclear. 3. There may be need for a traffic cop. 4. The person seated at that desk COULD be the ambassador of the Folsom DMV office, a well of goodwill and assistance.

Few places of business tolerate bad employee behavior. Employees who bark and snipe at customers are a liability. May I suggest posting employee’s names at their workstations, much like bank tellers, such that a nameplate is clearly visible to the public. This minimal form of reckoning can improve behavior.

State workers have long been maligned; incidents like this fuel that fire. The employee’s name seems inconsequential because no one, excepting queued customers, seemed aghast or appalled by a coworker yelling at a customer, as if it is accepted behavior at the Folsom DMV. No one apologized – as often coworkers will – when one of their own acts out. I dare say, my inquiry to obtain her name created more of a stir.

Perhaps this staff needs a refresher in basic courtesy and a reminder that the job IS customer service. Should customers and service be distasteful, they might seek different employ. Lastly, the people of California are their customers and they are expected, nay charged, to treat customers with civility if not care.

Response requested.

Respectfully Submitted,



I delayed mailing this letter for a full 30-days, weighing and evaluating its necessity. But send it I did and recently received a call from Gary, a nice fellow "assigned" to my case. He apologized, "You're right, our job IS customer service. I'm sorry that happened to you. You write well," he continued, "I think you captured the emotions of it pretty well."

Actually, I did not. I'd said nothing of my red-faced agitation that consumed the next hour. I have no tolerance for yelling; zip, zero, nada. It triggers both fight and flight in me, the desire to annihilate then flee.

"That's why I wanted to call,” Gary continued, “Instead of sending a letter. I wanted to apologize and let you know what happens next. I've faxed your letter to the manager at the Folsom DMV. We’ve discussed it. They hold staff meetings every Wednesday. Your letter will be read and will be used as a teachable moment."

"My name and address will be kept confidential?"

"Yes. Thank you for sending your letter, it gives us an opportunity to work with our staff, to better our customer service."

"I didn't know if I should send it. I delayed a full month before sending it."

"I'm glad you did send it. Thank you.”

What did I learn? I learned that in many ways, nothing’s changed. In the face of verbal confrontation, I am a deer in headlights. I silently seethe, I plot, I plan, and I get even. I spared Rebecca however. I did not serve her, trussed like the holiday ham, to her superiors. I could have; I didn’t. Maybe she was having a bad day, maybe her cat was missing, maybe her Dad - lost in Alzheimer’s fuzzy world - had quit eating, maybe… Chalk one up for compassion?

Sunday, November 7, 2010

Z Parade

What I learned curbside, watching the parade - my TENTH patient wean herself from insulin.

1. This project had innocuous beginnings; I didn’t even notice until I shared about Patient-5 and my Kaiser/Landmark colleagues (I call them the Kizermarkians) went wild.

2. When Patient-8 was successfully weaned from insulin, I called seven patients and asked, “Why did you do it?” They universally answered, “No one ever said it could be done.” Clearly, we don’t extend the invitation; we don’t tell patients what’s possible.

3. “I don’t eat that much, I don’t like vegetables, and salads are boring.” I rounded on a post-surgical, open-heart patient last Saturday who weighed 288#.

“About sixty days post-op, I want you to seriously consider doing something drastic with your weight,” I said. “I want you to consider joining Weight Watchers or Over Eaters Anonymous or any such organization and I want you to get some of this weight off.”

“I don’t eat that much,” she said.

…If I had a dime for every time I heard THAT, I could retire in splendor. We have formulas to calculate the number of calories needed to maintain body weight. Do you know how many calories must be consumed to maintain a 300# body? That on an 1800-calorie diet, her insulin requirements were reduced by two-thirds, is telling. ALL ten of my patients dealt with their food intake; there is no magic bullet, no magic pill, no panacea.

4. Who is the likely candidate? Not the skinny guy who is mindful of his food and takes insulin 10 units QID (ten units of insulin four times/day). The successful candidate is one with abdominal adiposity (belly fat), eating typical American fare, willing to try new and different food choices. Studies show we consistently underestimate our intake and overestimate our caloric burn. A surprising finding: exercise recommended but not required.

5. Patients, physicians, and healthcare organizations currently have insufficient support and/or structures to turn this corner. This represents a paradigm shift, a new conversation. And while we tout health maintenance, the bulk of our work is aimed at disease management. Reimbursements are not based on health promotion but disease management. While managing disease effectively does secondarily promote health, disease prevention and reversal is largely not incentivized. Follow the money: no reimbursement, no resources.

Case in point: A recently received email: “URGENT: Looking for PHASE Patients for KP Center for Total Health Exhibit.” (Pause in Think: PHASE is an innovative and successful Kaiser initiative called: Prevent Heart Attack and Stroke Everyday.)

“KP wants to capture a PHASE program patient's story on video,” the email continued, “Asking them questions about their condition and risk factors, how they were introduced to the medication protocol, how they feel about it, and how their health is now. If you have two or three members who you think would be compelling on camera talking about their own story, I would love to speak with them about possibly being a part of this. Please let me know just as soon as possible. Thank you! National Public Relations and Media Consultant”

“I have a patient who is also an employee,” I responded. “She lost 50# this year! We pulled away insulin and oral glycemic agents excepting Metformin. Her last two A1c's have been well below the target of 6.9. She is willing to participate and we would have to coordinate her work schedule.” I sent my story of Patient-8 found here entitled: Sourcing Miracles & Keeping Dreams.

They responded: "Lorin -- thanks, this is an inspiring story. We're looking for folks who were part of the PHASE program, though -- who were on that medication protocol to lower their risk of heart attacks and strokes. Was this person on the protocol?"

ME: "Yes - she is your typical metabolic syndrome Diabetes/PHASE patient who came into Diabetes Care Management and suddenly caught fire. We have decreased all of her meds, stopped insulin, though she remains on low-dose ACE, diuretic, and statin."

They were not interested in her. Of course you’re not, I thought sarcastically. WHO would be interested in patients reversing their disease, driving diabetes into submission, and decreasing medicines?

6. We are so cynical and jaded, patient outcomes beyond the bulge of the bell-curve are inconceivable. Even evidence-based results do not silence naysayers. If WE don’t think it’s possible; it’s not.

“They can’t sustain it,” our Endocrinologists said. Resignation and cynicism are ubiquitous. I vowed to give him a wide berth, to protect the possibility from his cynicism.

Yes, patients fall off the wagon. This is not about being perfect every time. This is about making better choices most of the time, it’s about practice, building the muscle, it’s about coaching them to competence and empowerment.

Driving their diabetes into remission. The first time I used that phrase, a physician friend cautioned, “Those are strong words.” And why not? Suspension of disbelief IS the hurdle.

When people seem uninterested or fail to recognize the impact of this work, the ultimate benefit for patients and healthcare organizations, I dismiss them and label them stupid. My bane, I have little patience for the ignorant AND I hold my profession and colleagues to a different/higher standard. Truth be told, stupid they are not; each has a full plate and nibbles a different piece of this pie.

7. What’s next?

Even the lone wolf is a pack animal. Kaiser stopped their Diabetes Support Group meetings because “the people who attended didn’t need them.” In other words, the patient’s who attended had good blood sugar control and lab values to prove it. Knowing human nature, the truth may have been closer to: their numbers were good because they attended and not vice versa. (That would be easy data to mine from our extensive database.)

As an integrated healthcare system, we at Kaiser Permanente have all the pieces for this pathway to reversing diabetes, heart disease, and erectile dysfunction (collateral damage seldom openly addressed). What we do not have is an established pathway, overseeing provider(s), invitation and follow-up mechanisms.

We COULD; we don’t.

I envision a program utilizing existing resources that shepherds patients from novice to expert, administered by one with prescriptive powers and motivational/empowerment skills (moi’ lest you had doubts).

Perhaps the invitation is extended through a large class format. I envision patient contracts to include participation in the Diabetes Care Management Program and a weight management program of their choosing. Support group meetings held after the basic “Invitation Class” allow prospective participants to observe the next step, the support group.

In that class, we might share food and stories. We could review and practice reading food labels, carb counting, and better restaurant choices. We might critique participant food logs.

To that end, and consistent with “not recreating the wheel,” I am scheduled to visit Kaiser Santa Rosa’s monthly support group meeting in December. I have been in contact with the head of the Wellness Institute at the Cleveland Clinic and am planning a three-day visit in early 2011.

THEN I intend to create a proposal for a pilot program and present it to anyone who will listen. Fortunately, I have generous people with large ears of listening for me.

8. A Larger Parade Marches On:

Study headlines in the last month: “Americans are the Fattest,” “A majority of adults in California are obese or overweight,” “Mediterranean Diet Halves Diabetes.”

None of these headlines surprises me. Halting this parade requires national conversations on many levels and in multiple directions. This surge has more momentum than a simple diet can cure… and a simple diet IS the cure!

Stemming the tide, changing directions, and turning the Titanic requires new, out-loud conversations. It starts in your home, at your table, in your pantry, and with the foods you choose to eat and feed your family.

You COULD start a new conversation around food and health with your family, your friends, your workplace. BE the change.

We are what we eat. Eat Well to Live Well and Be Well.

No problem can be solved from the same level of consciousness that created it. Albert Einstein

Wednesday, September 29, 2010

Fall's Reflections

The straw-like grasses sloping to the creek beyond my fence are burnt and brittle. Water stagnates, piddling and puddling through the creek’s trough, seeping round small stones with nary a trickle. The oppressive heat of summer has been nudged by cooler nights and honking geese overhead. Still, dawn breaks open sunny-side-up with all the fixin’s of an Indian summer.

My heart too is perennial in its heartbreak, rent with sorrow for another summer past, that season of unyielding sunshine and my desire to bathe in it. I’ll clean house during autumnal rains, do dishes after dark, and run or cycle to beat nightfall home. During summer, my life is lived out loud, outside.

As the distractions of summer ceased, something else arose in me. Niggling thoughts sliced deep, filleting my pericardium wide, forcing me to silent introspection.

How will I occupy my remaining years? What good will I do? Where shall I contribute? With and to – whom?

Some would label this mid-life crisis. Crisis it is not, though inferring my life half over, a time for evaluation and assessment is neither unwarranted nor untimely. Most, by virtue of a common pathway – love, marriage, children, grandchildren, great-grandchildren – face a well-trod path. My trajectory is not that; the trail through my jungle as yet unhewed. Work at Kaiser and homeownership lend a certain predictability. After that, it’s up for grabs and mine to create.

Such was my frame of mind departing into the wilds of both Yellowstone and the Grand Tetons. The region’s bears are unusually hungry for a paucity of their natural food sources. Some Ursidae have turned to predation upon Homo sapiens… an encounter heavily favoring brute and brawn. Two have been fatally mauled and three maimed by hungry grizzlies near park boundaries just this year.

Hungry grizzlies had me contemplative, reflective, and introspective, nose-to-nose with mortality. I have no real unfinished business, only unpaid bills. My relationships are rich, my work compelling. I have loved and been loved. I once experienced love at first sight – for my cat Keo – such a heart tumble as it was. I have been blessed with body and mind that work – my vehicle through this life has served me well.

I called and emailed a short list to hold conversations for completion. My close friends have some experience with this though one became agitated and annoyed. “Why would you go?” he emailed.

“There is inherent risk to many of my excursions into the wilds. While I do not intend to perish in the mountains, it is as good a place as any and far better than most. Know that out there – I play passionately and thrive. You?”

I returned unscathed if only less a few pounds. During that first week back, my tenth patient was weaned from insulin and I received that fateful call: That cardiovascular job for Kaiser at Mercy? Ain’t happening. I mourned its loss, my perceived opportunity to practice unfettered. I felt deflated and forlorn. I told few of the tenth patient – the few that seemed to care – and headed to San Francisco for Kaiser’s Cardiovascular Medicine and Surgery (COAST) Conference.

“Around me,” I’ve declared, “People get healthy and fit.” It’s true enough though the mechanics – the why and how of it – escapes me. My masseuse recently lost fourteen pounds with fifty to go. “I am getting back to my tri-athlete weight,” he said, “Because no one will listen to me if I don’t practice what I preach.” Amen Brother! It is a lesson much needed for us in healthcare and into which Kaiser’s new Live Well, Be Well campaign promoting a healthy workforce, points.

At 0750 on Sunday morning, COAST featured Dr. Esselstyn, a retired Cleveland Clinic (can you say: Mecca for cardiovascular care?) heart surgeon outlined his nationally-renown program for reversing heart disease, diabetes, and erectile dysfunction; conditions of gargantuan healthcare dollar proportion and import. I waited to speak with him and sidled up at an opportune time.

“I just weaned my tenth patient from insulin.” The jaw of a nearby cardiologist dropped. “I have another handful of patients who were never on insulin and I’ve pulled away all their glycemic agents excepting Metformin. Some are living in the zone, with hemoglobin A1c’s in the fives (like people without diabetes, having successfully driven their disease into remission). I have a few that have fallen off the wagon but I think my success rate is better than 70%. But I feel like I’m recreating the wheel and I don’t want to do that.” I said nothing of the myriad of friends and colleagues who have altered their eating, lost weight, begun exercising, and corralled their diabetes.

“That’s incredible,” he said, “And it’s a lot of work when it’s done as only one facet of your practice.” We talked a bit; he asked, I answered.

“Let’s do this,” he said abruptly, “You come to Cleveland and stay at my home with my wife and I. You come to the clinic for several days and apprentice with me. If I don’t hire you away from Kaiser, I’ll send you home with everything you need to create a program.”

We exchanged email addresses and I thanked him for his incredibly generous offer. I felt expansive, excited, exploding within my skin. I could hardly wait to get home and email friends including the beeeg kahuna Jack. Instead, I wrote at the Metreon beneath a warm and bright San Francisco sky released from its customary geometry shaped and framed by concrete and fog. Arriving home, I mounted my bicycle and pedaled twenty just to sort myself out.

I’ve spent the week in communication with like-minded practitioners: two cardiologists from Kaiser-Santa Rosa, an internist at Kaiser-Stockton, and an endocrinologist at Kaiser-Sacramento. I’ve been outside daily, my favorite locale for audience with God.

Swirling, sailing, softly crunching, large and leathery Sycamore leaves overwhelm my green waste bin. Fall is a thoughtful season of reflection. I am called to it with every twisting and twirling photosynthetic colony in it’s Newtonian plunge, with every quaking aspen, with every clattering leaf herded before blustering winds, with every reflective headlight off wet streets.

Here’s what I know: I have little interest in a life of mere survival and existence. I am intensely interested in living life inspired. If it is also inspiring? All the better.

“Will you go to Cleveland?” friends ask.

“Absolutely! When the student is ready, the master appears.”

“Will you move to Cleveland?”

“Abso-NOT-ly! Too far from Hawaii.”

I wonder what my life is for? It is for something like this that comes so easily and contributes so much.

Monday, July 5, 2010

Symptom Management

“Well, we will all have to deal with something,” I said, my voice flat with resignation. “Some will deal sooner than others. Fifty feels a little too soon…”

“It IS!” he interjected, so unlike himself.

I shrugged, “It is, what it is.”

We discussed chronic disease, that we had arrived at the decade when those diagnoses were abundantly bestowed, when we meet the thing to manage, the dance with the dragon… from this day forward, ‘til death do us part.

“I love these,” I held up a two-bite pocket, clenched between chopsticks, for his examination. “The outside is pickled bean-curd. The inside is sushi-rice so it’s flavored with rice vinegar and seaweed.” I bit and smiled as spongy bean-curd gave up an extra squirt of vinegar. “Mmm.”

“I’ve sorta come to view my life like symptom management,” I volunteered.

In medicine, we have a term: symptom management. When medicine is not curative, our efforts are palliative, aimed at minimizing symptoms: pain or immobility or breathlessness or any myriad of ails that, if reduced, might add quality versus quantity.

“And the more I look,” I continued, “The more I realize my whole life has been about symptom management. I am always managing symptoms, be they physical or emotional or spiritual. I am always trying to reduce my discomfort at every level. Only now, some of my friends have real disease and their quality of life is affected and their quantity is predictably shortened and…” Tears flooded my eyes and spilled down my cheeks, “And I don’t want to think what life will be like without them.”

“Now you’re worrying about something that hasn’t happened yet,” he offered, his look sympathetic, his voice pleading.

He was, in every way, the picture of beauty and health. He rarely complained and seldom volunteered health information. That we periodically met for lunch satisfied my need to know that, while his disease progressed in relentless fashion, while he circumscribed his schedule to match energy reserves, his outward appearance remained stable.

“I know,” I smiled weakly. “I don’t go there much – until I do.”

I eyed the deep-fried, crab and avo nori-maki on my plate. “Did you try one of these?”

He shook his head, “I can’t have the flour.”

“Bummer man,” I grinned.

To cut expenses, many Eurasian restaurants use wheat in lieu of mochiko, rice flour. Their tempura is notably soggy though undistinguished by undiscerning palates.

“I shouldn’t have deep-fried but I’ll have just one,” I licked my chops and skewered the disk with chopsticks.

“I asked Laird about his Dad recently and he said, I think he’s waiting to die.” Laird is a hiking buddy trying to assist his Dad in West Virginia, from California. I know the feeling. His words: waiting to die, stopped me, dead in my tracks. Do we reach some point when death is indeed anticipated and welcomed? I think we do. What does waiting to die feel like?

“I saw my Uncle Moon Chee; he’s 96, a tiny, little thing with sharp eyes and a sharper mind. He’s like – this tall,” I held my hand up to about four-foot-ten. “And he’s so frail now. Thirty minutes after touchdown in Honolulu, I plopped on the couch and asked, How ya doing Uncle? And he said, Oh, I’m getting old.” I guess! His body is failing on many levels now.

“And then of course, there’s my Dad. Last weekend I had the DNR conversation with Mom. His Advance Directive says DNR but hospitalized, with discussions of burr-holes, his DNR was rescinded. She said, As long as he enjoys his children and grandchildren, I think we should treat him.”

Fair enough. Not a bad measure. When he no longer knows his family, we withhold heroic measures. Meantime, manage his symptoms to minimize physical and emotional dis-ease.

“So all this is kinda in my space,” I said. Our plates were empty.

“I’m going for some hot Chinese,” he rose.

“You mean that greasy, hot food-line over there?”


“Nasty!” I grimaced in disgust.

He turned and sneered, “What-ever!” We burst with laughter.

“A friend recently returned to work after lumpectomy, chemo and rads for breast cancer found on digital mammo.” I started again once we sat before fresh plates of sushi, sashimi, green seaweed salad for me, hot Chinese for he. “Her cancer was detected extremely early; her prognosis is extremely favorable.” All that being said, she was not spared the episodic depression and fatigue embedded in the therapy cascade triggered by that diagnosis. She manages her symptoms and dove back into work and life. What else can you do?

The beautiful boy has a curious method of arranging his hand to chopsticks, an intriguing way of standing them upright beneath his left palm while weaving his right fingers around the slender sticks. He did that beneath my watchful eye as I labored toward the coup de grâce. He knows this about me, that things percolate and simmer and finally boil over into our conversations. He let my lament continue uninterrupted.

“I got a devastating email two nights ago," I said, propping my chopsticks on the edge of my plate. "I haven’t slept since.” Following my lead, he laid his down too. “A physician friend of many, many years, almost twenty. She’s me – slender, athletic, and she’s lived well: never smoked, moderate alcohol. Was in her usual state of health – an asymptomatic walkabout. Felt a lump in her belly on Mother’s Day… metastatic ovarian cancer. They did a huge abdominal surgery... they gutted her," my voice cracked, "Total hyster, partial bowel resection, splenectomy, chole, appy, then stripped and de-bulked everything they could for tumor shed.”

I awoke at 0213 in a tearful sweat, my hands pressed firmly into my abdomen, palpating.

“She started chemo the other day. They’re inserting a peritoneal catheter to mainline chemo directly into her belly. Her prognosis is… poor. She said she’s sad for the things she won’t get to do with her boys.” I dabbed my face, transferring a long, thin trail of tears to my napkin. “None of my friends have died yet; I don’t want her to be the first and I don’t want anyone going before her.” We chuckled at the ridiculousness of my statement. They will manage the symptoms of aggressive treatment and hope for the best.

“We’re at that age,” he said softly. Aye matey, we are that.

“Thank you for letting me dump all this on you.” We rose to leave.

“Of course,” he said. “You should. I want to know because it’s important to you.”

His statement rocked me and I responded slowly. “Thank you for holding what’s important to me as something important to you. I know you don’t like talking about your health but I have come to know that sometimes, just sometimes, I can’t hear a word you say until you tell me how you are, how you feel, and how you are managing symptoms.”

“I know this about you,” his head twitched imperceptibly, as it is wont to do in mild discomfort, “And I include it in our game.”

We hugged; his cheek smooth against my lips. I paused and stored for safekeeping, his every nuance.

How do we live well if we must live sick? We symptom manage. Am I living life fully or waiting to die? How do I give meaning to my remaining moments, ‘til death do us part? And what am I doing today to forward that?

Today my life is all about me and symptom management. Today I manage my grief, my insomnia, my wellbeing and physical health. I’ll write, bike and run - dual workouts and triple play, baby! Today I’ll manage my schedule and purchase a round-trip ticket so that I might see my girlfriend and say, I love you. Symptom management at its finest.

Friday, June 25, 2010

Father of Mine - 3rd in a Series

He fell… again, sustaining a mean forehead gash requiring sutures. The medics were called and they raced to the Kaiser ED in Honolulu at 3 a.m. After suturing, a head CT revealed an intracranial hemorrhage. Guess his daily baby Aspirin will be stopped. The internal medicine doctor admitted him to the hospital and he waited there, on a hard gurney in the ED, twelve hours for a hospital bed.

“That’s not uncommon Mom,” I tried to soothe her with helping her understand. “If the hospital is full, someone must be discharged home before he can have their bed.”

Initially, there were hourly neuro-checks and talk of burr holes to relieve the pressure. Technology is amazing. My sister sent a text message, including a photo of the over-bed monitoring screen, asking for explanation and interpretation. It flew transPac and landed in my iPhone moments after being sent: Dad's heart rate, blood pressure, mean arterial pressure, and respiratory rate.

By nightfall he seemed over the burr-hole hurdle. Then abruptly, his laceration began bleeding again. A nurse stood at the bedside for a long time, applying direct pressure to unsolicited complaints of pain.

“How ya doing Dad?” Someone held a phone to his ear. Sometimes he doesn’t know phone or its use.

“Oh, I’m surviving.” His speech was thick and slow, as if he was drugged. We talked briefly, until he quit.

My sister texted: If his forehead is bleeding, what are the chances he’s still bleeding in his head?

Exactly, but no one wants to perform surgery on a demented old man. And it’s not the dementia, it’s that, in medical vernacular, he’s piss-poor-protoplasm for a surgical procedure. He’s old and he’s bleeding. They cut? He’ll bleed more.

Continued bleeding into his head will cause mental status changes. They will monitor his mental status in an effort to avoid surgery. Barring nocturnal disaster, he’d head for the CT scanner again, next day.

This is his path, I tell myself, get used to it. Did you know that 40% of us will die of diseases related to dementia and frailty? We will fall, break a hip, and die of subsequent, hospital acquired pneumonia. Our interest in food will wane and - wither we will. Our families will command that we eat and force-feed us while our doctors enter a new diagnosis into our electronic medical record: failure to thrive.

“How do we help people live well if they must live sick?” our Palliative Care Chief asked recently.

“He is no longer able to independently create moments of happiness and joy for himself.” During my recent visit, Mom and I discussed giving him the experience of having a life of love. “Those moments must be created with him and for him – by us.”

How does Dad live well while he dies? How do we keep him safe without imprisoning him? How do we prevent falls while preserving dignity in the bathroom? How do we create the best quality for his remaining life and his experience of that? What is it going to take to give him the experience of being loved and cared for and how will we do that?

And how will we take care of self? Where do we renew and rejuvenate? Where is that well of compassion and patience for self and others? Oh, were it a dew pond for daily dipping.

A second head CT scan imaged a stable clot. Dad is now being evaluated for discharge home and safety issues abound.

How do we live well if we must live sick? It’s a powerful question.

Sunday, April 11, 2010

Sourcing Miracles & Keeping Dreams

Kaiser is seeking short stories for possible publication. Here is mine.

EIGHT!!! The subject line of my email streaked out across the Internet through Lotus Notes, screaming at my friends, Kaiser nurses and physicians all. My eighth patient was off insulin.

I recently queried those patients, many of whom lived with diabetes long before working with me. “Why did you do it?” I asked, “What made the difference?”

To which they replied, “No one ever said it was possible and no one ever gave me the steps to make it happen.”

The book Three Law of Performance would call that a change in their occurring world.

In 2008, I joined the Chronic Conditions Department in diabetes care management and invited patients to take-on their disease by learning to count and restrict carbohydrates and get off their insulin. Eight of them did.

“Number Eight (I’ll call her Annie) is an obese, 56 year-old female and a Kaiser Permanente employee,” my email read. “She has been in and out of my care management program twice. When I run at lunch, I pass her walking and we high-five as I yell words of encouragement.”

I encourage patients to get help and seek support.

"You are not reliable to eat for good glucose control and weight loss. If you were, you would have done it. There are many programs available in and out of Kaiser. Pick one and take your cook along. What appeals to you? Do something; do anything." 

Annie did, she attended the Kaiser's Diabetes and Nutrition Class, learning to count and restrict carbohydrates. The impact was startling, stunning, immediate and we regularly and rapidly decreased bedtime insulin in response to hypoglycemia and fasting blood sugars at the low end of the target zone.

Annie was happy with that result and it carried her through the holidays. In January of 2010 she joined Over Eater's Anonymous. Within days we decreased Glipizide due to recurrent hypoglycemia.

On day thirty-seven of her Over Eater’s Anonymous program, she reported a twenty-six pound weight loss and we stopped all glycemic agents but Metformin.

“I can see my toes!” she looked down and pointed. “The aching in my hands and feet is gone,” she stood in the doorway of my office flexing her hands. “I always felt like I had the flu, kind of achy all over; that’s gone. I had no idea how bad I felt.” She hugged me and said, “I love you.”


Annie’s new goal is to run a marathon in her 60th year. I will coach her through lunchtime runs and at least one section of that marathon.

Since then, Patient #9 is off all glycemic agents excepting Metformin and my meager pipeline is working, counting, keeping meticulous records and gunning for their insulin.

I have come to know that I provide an empowering context for these patients; that I am the keeper of this dream. Dreams and goals disappear, they fade in the frenetic pace of every day, they are beaten from us or we abandon them as unattainable. I meet my patients wherever they lie along the continuum of health, acknowledging what they have done. Together we explore small, attainable steps from which they choose.

“I want you to be successful so lets choose something that you know you can stick with. Can you do two five-minute walks every day?”

Most often I direct them into well-established Kaiser or community resources. I never recreate the wheel and it is always our first goal to achieve glycemic control with or without additional medications.

As healthcare providers, when we extend the invitation and provide a pathway toward health, some patients will play for and with their lives.

“In life there are many games we can play,” my email concluded. “We play health and wellness games at Kaiser Permanente. I love and play this game - it brings me to tears and fulfills me in every way. You are the first to know excepting my fabulous pod leader Dr. Huang - who provides a supportive, nurturing environment in which patients and employees can flourish and thrive, including moi’.

BE well and dare I say... THRIVE!”

Lorin Bacon is an Acute Care Nurse Practitioner with Kaiser Permanente in Sacramento, California.

Sunday, April 4, 2010

A Birthday in Yosemite-Part 3

The weather broke on Sunday to clear and sunny skies. The forecast was for more of the same gray soup that had settled over California like tule fog. But Mother Nature is not wont to follow the forecasts of man; the day was unpredictably clear and clear means cold.

I rolled over to peek at the clock and everything about me hurt,

e-v-e-r-y-t-h-i-n-g! Auwe! Plagued with chronic low back pain from a career of hauling patients, I always stretch before leaving my warm cocoon… but this was more than back pain. My quads ached so I pulled my heels up next to my hips and laid my knees on the bed to stretch. Try that bilaterally and simultaneously, that’s a feat! I rolled to my tummy for daily yoga favorites: child, cat, camel and rolled out of bed for warriors one and two. My calves strenuously protested the reach for my toes. My shoulder sockets, jack hammered forward in repeated backward tumbles onto outstretched arms, ached and would ache for weeks.

I dressed and headed for my morning cuppa joe. Deep ruts in the heretofore, muddy service road through camp, were frozen solid. Pea-sized, ice-gravel crunched noisily beneath my boots. The air bit and I coughed with temperatures below freezing. Overhead, snow capped Half Dome shined against an azure sky. A great plume of smoke rose beyond Mother Curry’s Bungalow and the smell of coffee permeated camp, pulling me along like a like a moth to light.

In the lobby, I bumped into the young Russians with whom I’d exchanged cameras at the confluence of trails and trail signs deeply buried in snow. We queued for coffee and chatted of our climb and afternoon departures.

Coffee at the Coffee Corner is self-serve. I purchased a large and filled my insulated Starbuck’s cup that would keep warm for hours. Retracing my steps, I stopped outside Mother Curry’s Bungalow. In her day, the cabins of Camp Curry were called bungalows, those at the Ahwahnee – cottages, while those in Tuolumne Meadows were called cabins. They have not upheld that tradition as all signage and maps currently say: cabins. Too bad, some traditions are quaint and sweet; they honor the Ancients and deserve preservation.

Starting again from outside Mother Curry’s Bungalow, I suddenly remembered it was my birthday. I stopped in my tracks and looked about with new and liquid eyes. The valley pocket remained in shadows, the sun insufficiently high to peer over its shoulders. Overhead, granite gleamed in sunshine, promising a warmer day.

I smiled and sang: Happy Birthday to me. Happy Birthday to me. Happy Birthday dear Lorin. Happy Birthday to me. Why am I going home? I could make spending birthdays in Yosemite a tradition. Yes, I just may do that.

I opened the curtains to watch the sky lighten and plopped onto the bed with my laptop. I’d read and write before packing and checking out. At 11:30 I’d be in the main dining room of the Ahwahnee Hotel for Sunday Brunch, my birthday brunch.

My morning was non-descript. I packed my auto after moving it to warm in the sun. As I ferried satchels to my SUV, Cliff peaked through the window. Cliff was my housekeeper, a resident of Merced who had never visited Yosemite until job loss forced him to seek work far from home. He lived in resident housing and worked four days straight before returning to Merced.

“Waaooww!” I said, imagining how yummy Yosemite living could be, “I’d never want to go home.”

Cliff glared, “It ain’t that great here,” he snarled, “You’d wanna go home, trust me.”

Remember my departing email? “Methinks a winter trip to Yosemite is a good sieve. I will meet people like me. I'll probably LIKE THEM!” Remember that? Exclude Cliff. How one can reside one’s entire snuff-chewin’, teeth losin’ life in the shadow of Half Dome and never visit or appreciate is … oh never mind.

I stopped by the Lodge to retrieve and send a few emails. A fire sputtered and spit in the fireplace though it was 10 a.m. I sank deeply into the same log chair I had occupied twelve-hours prior. I fiddled and figured out how to post to facebook from my iPhone, posting my picture at Columbia Rock, shglicked by George. At the registration desk I checked-out, surrendering the oversized, brass key to my cabin. I arrived at the Ahwahnee ahead of schedule and browsed through their gift shop.

The Ahwahnee Hotel is a stunning amalgam of rustic rock and timber, art deco designs, arts and craft styling, and native Indian motifs. The hotel occupies the meadow beneath the Royal Arches rock formation and the former village site of native Miwok Indians – who called themselves Ahwahneechee.

Designed by architect Gilbert Stanley Underwood, who designed the lodges at Zion, Bryce Canyon and the Grand Canyon’s North Rim, it is in retrospect, his crowning achievement. The site was chosen for maximal sun exposure and its iconic Yosemite Valley views: Glacier Point, Yosemite Falls and Half Dome.

As seen from Glacier Point, the lodge is Y-shaped. It was constructed from 5,000 tons of rough-cut granite, 1,000 tons of steel, and 30,000 feet of timber. Its exterior wood and structural timbers are actually stained concrete poured into wood simulating molds. Construction lasted eleven months and totaled USD 1,225,000 upon completion in July 1927.

Its grand public spaces are rich with tapestries, hand-stenciled timber beams and floors, massive stone hearths, log-beamed ceilings that soar to 30-feet, stone patios and expansive lawns. I’ve sat on those lawns in late summer and watched deer feed. Even in winter, buried beneath snow, the south lawn beckoned.

The dining room is notably Five-Star and dinner is a formal affair, by reservation only. Sunday brunch is casual. I checked-in with the maître d'.

“Ah, yes Ms. Bacon, we have your reservation for,” he paused to reconfirm before looking up, “One?”

“Yes,” I smiled reassuringly. I received many an odd look those three days in Yosemite. You have a reservation for… one? A look of puzzlement shadowed their faces momentarily; we are so unaccustomed to women traveling solo.

The maître d' checked himself and smiled broadly, “Welcome,” he parroted, back on auto-pilot, “We are glad you could dine with us.”

Me too buddy; you have no idea. “Thank you.”

Carol stood at his elbow ready to usher me inside. She was a delightful woman in her forties with an eggplant figure topped and coiffed in pageboy. She wore the black pants and white, long-sleeved, button-down shirt customary in food service. The busboys were similarly clad with an additional long, white, Bistro apron. My busboy was Sally, a decidedly masculine young woman with multiple facial piercings and the never-ending pitcher of fresh-squeezed orange juice – which made her decidedly popular as well.

I was seated in the west-facing alcove originally designed as the porte cochère. Yosemite Falls fell, framed in floor to ceiling glass. At my right elbow, towering over my table, The Royal Arches.

I wandered through the buffet area replete with sushi and egg chefs. A skilled pianist tapped ebony and ivory on the periphery. He looked up from his keys; I smiled and nodded as I passed, pondering a song request. That thought disappeared in the myriad of morsels, trays of truffles, dishes of desserts, bushels of breads and cheese, displays of fruits and vegetables, a panoply of epicurean delights Ahwahneechee-style.

As one whose diet is nearly devoid of meat, a buffet line offers multitudinous opportunities to indulge without discarding all but three of an eight-ounce steak. I conned the prime-rib guy out of two-bites. It’s easily been two years since I last tasted prime rib. YUM!

I ladled up cheese, bacon and collard green grits and three-bites of Cajun catfish. Veeery tasty but too-too salty – my persistent complaint of food prepared by others. I salivated at the sushi station where a chef rolled nori-maki sushi on request. I settled for one rolled disk each of seared-ahi and spicy tuna sushi.

The dining room’s entire south wall is glass, six by twelve foot panes edged by six-foot sliders, and all that completely surrounded by craftsman style windowpanes. Incandescent candelabras stood along the walls, their warm glow pallid against sunlight and snow reflection off the south lawn. On gray days I remembered, the cavernous dining hall could be dark and dreary.

I jotted notes in my journal and listened to the conversations around me. The couple against the west-facing window had broken their carb-free diet for her 61st birthday brunch. The four-top next to me also included a portly and pony-tailed birthday boy. I volunteered that it too was my birthday and that started the patrons of three tables talking.

“What do I have to do to get to the top of that?” Birthday-girl Karen pointed west to Yosemite Falls.

“Walk,” I said.

“That’s my downfall,” she said, “I don’t like to exercise.”

“Do you own an iPod?” They did but were unsure how to load their favorite books into it.

“Have your grandkids help you,” I offered, “They’ll do it in under ten minutes.” They laughed, knowing it was true.

“Then start waking, even if it’s two five-minute walks a day. When you get to two ten-minute walks, combine them into one fifteen-minute walk and increase that by one-minute each day until you are walking forty-five-minutes a day.”

“We’ve both lost forty pounds,” she disclosed, “We’ve got about another fifty to go and we’re gonna do it! We’re back on our diet tomorrow.”

What is it? What always has me at the center of these conversations; as if my forehead blinks neon: Healthy NOW, ask me how! I acknowledged them genuinely and profusely; they beamed slathered in my praise.

Before leaving everyone hugged: the patrons of three-tables-talking, our waitress Carol, our busboy Sally, and promised to attend birthday brunch at the Ahwahnee the following year. Before leaving, EVERYONE HUGGED and I hugged strangers who share my birthday. Do you know how extraordinary that is? For moi’? Curmudgeon-me who does not like to be touched?

“We’ll be a lot thinner,” Karen smiled, waggling a finger between she and her husband.

I wandered to the south patio, to sit in the sun and drink in the Ahwahnee before my departure from the valley. Snow outlined small ridges normally invisible from the ground. My eyes wandered and I imagined the Ancients watching me scour the cliffs in search of their visage – watching me watching them. Clouds rolled in from the west and a cool wind began to blow. I closed my eyes to feel Ahwahneechee and sent a silent prayer of thanks to Heaven (which from Yosemite – is not so far). Climbing into my SUV I meandered through the valley, following the Merced River, stopping at every whim and fancy.

A wolf or coyote protected kill near the roadway. I doubled back for a picture but it ducked before I could center my photo. The Merced flowed low and slow, seeking the riparian trough, exposing alluvial beaches that would disappear with both the thaw and throngs. I shglicked a pic. With nary a ripple and barely a current, tree and beast and rock and sky were eye to eye on its glassy surface. I parked and walked into the meadow - to imbibe its vibe.

Lastly, I returned to the Tunnel View lookout along CA Hwy 41. A brisk wind bit as I marched across the parking lot, mesmerized again by the view that captivated the cavalry two centuries ago. Many photographers littered the sidewalk. Bridal’s Veil fluttered in the wind and dark clouds threatened.

Quietly joyful at my return, I stayed to drink in Yosemite and let her steep, suffusing my cells and etching my memory in her unassuming tea… for later, for me and to honor the Ancients. I watched the gathering gloam until my ears ached and skies cried tears from Heaven (which from Yosemite – is not so far). Only then did I begin the journey home.

E ha’ina ‘ia mai ana kapuana la: This is the end of my story: A Birthday in Yosemite. It was memorable and nurturing in its many moments. It’s valuable methinks, to create moments and memories to treasure.

Mahalo for your readership. This muse was penned merely as a practice and to capture my tale, to be relished, relived and remembered as an Ancient.

May you steep in life's glory, make memorable moments playing in my Heaven and paint on Her canvas. Aloha