The Renal Report - Living Well with Kidney Disease

Meat-Heavy, High-Acid Diet Poses Risk for Those With Kidney Disease: Switching to regimen higher in fruits, veggies might help stave off organ failure, experts say

FRIDAY, Feb. 13, 2015 (HealthDay News) -- Patients struggling with chronic kidney disease who routinely consume meat-rich, highly acidic diets may boost their risk for kidney failure, a new study suggests.

Tanushree Banerjee’s team (University of California, San Francisco) conducted a nutritional analysis of nearly 1,500 kidney disease patients over a roughly 14-year period.

As reported Feb. 12 in the Journal of the American Society of Nephrology, those who consumed high-acid diets appeared to face triple the risk of kidney failure compared with those who consumed low-acid diets. “ The high costs and suboptimal quality of life that dialysis treatments bring may be avoided by adopting a more healthy diet that is rich in fruits and vegetables.”

Some of you learned - only shortly after me - that I was the proud owner of a single and very unhappy kidney. Its discovery is called an “incidental finding” in medicine, found accidentally or coincidentally during testing for something else.

“Absent left kidney” the CT report read, “correlate clinically.” The report was no surprise as I’d scrolled through the actual CT on the computer and noticed the absent kidney bean on the right side of the screen. Whoa! Where’s my kidney? 

I’d been given IV CT contrast dye prior to the test and had the IV remained, we would have infused another liter of normal saline - to flush my kidney. CT dye is hard on kidneys, they have to process it, turning it into urine to be excreted from the body. Impaired kidneys (called insufficient) are overwhelmed and may be damaged by CT dye. They sat me down in the Radiology Dept and would not let me leave until I gulped down a liter of water. “Drink lots of water for the rest of the day,” they instructed.

The nephron is the working unit of the kidney; a kidney doctor is called a Nephrologist. I inquired about seeing one. “Your creatinine looks okay,” my primary care doc (PCP) said, “You’re okay.” That was 2002. I had a bad feeling about it and began research on the internet. 

I did a drive-by-curbside-consult with my favorite Nephrologist, the one who followed our patients on the open heart surgery team. “These kidney tend to fail,” he said, “You need to be followed. I’d be happy to see you.” When my medical benefits returned to Kaiser, I pleaded my case for a Nephrology consult to my new PCP. “Your creatinine looks okay,” she said, “I don’t think you have a problem. But if your nephrologist friend said you should be seen, I’ll send a referral.” That was 2005.

Dr. Patel was the chief of Nephrology and I had to wait an extra month for an appointment on his schedule. My physician friends promised he was worth the wait. Dr. Patel is, to this day, a very lean and soft-spoken man. His medical assistant called and sent me to the lab, where they drew more tubes of blood than I can ever remember having drawn at once.

“I have reviewed your CAT scan,” Dr. Patel said pointing to the picture on his computer screen. “Your kidney is a little larger than normal; we expect that when there is only one because its doing the work of two. Your renal (kidney) artery comes off the aorta four centimeters lower than it should. This affects renal blood flow. Your kidney will be very sensitive to changes in blood pressure. Its important that you keep your blood pressure low. If your blood pressure goes up to 110, we will put you on medication.” His eyes scanned me from head to toe, “I wouldn’t gain any more weight.”

“People can lose a kidney," he continued, "And because kidneys are redundant, they can live well with only one kidney. Kidneys like yours are not perfect, their tubules are not perfectly formed and smooth, they have structural defects and over time, they tend to fail. The way to make kidneys last is to lighten their work. How you do that is by what you eat.” 

We reviewed my lab work - it was whacky. “I’m sending you to the Taking Care of your Kidneys Class. If you follow the diet, over time your lab work will improve. Just one more thing,” he held up one finger, “No NSAIDS (Motrin, Aleve, etc.), no sodas,” he raised a second finger, “No salt,” … third finger, “No chocolate,” …four, “Very little meat,” five.

“No problem,” I said calmly, “I’ve already given up all of that.”

“Why?” he was wide-eyed and clearly stunned.

“Believe it or not doc, I have, at times, said out loud - These things are bad for your kidneys; I’m not doing them.”

A month later, I sat in the very last row of Kaiser's Taking Care of your Kidneys Class - tears streaking my cheeks. “No Cheetos, no gatorade, no artificial orange coloring,” she said. This is so unfair; I don’t belong here. I was initially distraught and I didn’t even know why. My life hadn’t changed one iota except for a new label - renal insufficiency and chronic kidney disease. F them, I thought in a defiant moment later that day while consuming Cheetos and orange Gatorade.

Some think the Renal Diet is too restrictive and difficult to follow. It is comparatively low in protein - my allocation is 45 grams/day - I’m a little person after all. “You can bump that up for backpacking trips if needed,” my dietician said. In truth, my diet changed very little. I discovered that I already followed a renal diet, that I had naturally gravitated in that direction because I felt better when I ate a diet high in raw fruits and vegetables with little or no meat. I learned to count protein grams before consuming them. Cheetos and Gatorade were banned in short order. 

My blood work improved over time and after two years, looked almost normal. Good blood work = happy kidney bean.

Bill, me, John

“I think this kidney will last until you are about 70 years old,” Dr. Patel said three years ago. “But if you want to hike in Nepal; that kind of remote hiking? You should do that sooner than later.” 

I took his warning seriously and began weighing the items of my bucket list. Last fall, I hiked in the Swiss Alps with two of my best buddies. Big CHECK off the bucket list.

I saw Dr. Patel on Monday. “Your lab work is very good; your kidney is very stable. They key to renal longevity is a diet high in vegetables and raw food. If you continue with what you are doing, I can see this kidney lasting another two decades.” Yippeeeeeeeeee!

Its been ten years and I have been the poster child for making the renal diet work. Dr. Patel just doubled my renal prognosis. I am thankful because its doubtful I will ever consent to dialysis (peritoneal or hemo) or transplant. I’ve had a decade to ponder the matter and am unconvinced that life is always worth living at any cost.

But I do want to address how one can live well and thrive with renal insufficiency and chronic kidney disease. Diabetes is epidemic in all western countries and the leading cause of both renal insufficiency and failure. "Chronic kidney disease represents an underestimated public health hazard, affecting at least 26 million Americans," said Dr. Ernesto Molmenti, surgical director at North Shore University Hospital Transplant Center in Manhasset, N.Y. The new study (the one that headlines this blog) "provides us with a nutritional intervention that can be instituted in all people at all levels of society."

Maintaining renal function is directly related to diet and the science is in - in the majority of cases, diabetes type 2 is reversible and renal insufficiency (heart disease, heart attack, stroke) AVOIDABLE. As one who is more interested in life’s quality than quantity, I am acutely interested in avoiding diseases that will curtail my activities or stop me with pain.

So the first things I had to give up were the thoughts: I should be able to eat whatever I want, whenever I want, in any quantity I want.” Second, I had to give up that FDA recommendations and the traditional American diet had any relevance to my current situation. Third, I had to give up that I should be able to eat more than 1100-1200 calories/day. Give it up! It is not serving you.

Fourth, I set up my environment to support me. What does that mean? I purged my home of foods that were not on the renal diet. At the time, I considered Cheetos and popcorn a major food group in and of themselves; they were my binge foods and were summarily banned from my pantry. I could eat Cheetos - but I had to go buy them when the mood struck and I was not allowed to bring them home. Setting up a supportive environment is key. Why? Because "will power" is a limited commodity for us all that wanes with the day. None of us can long withstand the siren's song of chips or ice cream or cookies or popcorn or Cheetos or _____ (insert your favorite snacky food’s name here).

In what other ways do I set up my environment to support me? I ALWAYS bring something that I can eat to potlucks. I ALWAYS travel with food bars. I ALWAYS pack a lunch. I ALWAYS have healthy foods stashed at my desk. In fact, the largest drawer of my office file cabinet is filled with a variety of teas, food bars and low/no salt crackers. One would think I was a foodie and I’ll admit, I do think about food a lot. I am very proactive about meals and am never subject to convenience or fast foods.

“Sounds boring,” one of my friends said. Au contraire! Fresh and raw foods taste amazing once you wean yourself from the salt and sauces hiding their subtle flavors. Over time, my diet has transitioned to include more raw foods just for convenience. Big-box stores like Costco, who sell large bags of super-greens, make it easy.

The kidney makes epoetin (Epogen, you’ve seen the cancer commercials) - an essential building block for red blood cell production. When kidneys are insufficient, they make less epoetin and anemia ensues. A strict vegetarian diet can make keeping up with anemia difficult for those with kidney disease. 

“I wish you would eat a little more meat,” Dr. Patel said after a few years. “Its easier for your body to extract what it needs to make blood from meat than plants.” 

But in the world of restricting all protein (all animal products - yes, even poultry and fish, dairy, beans, and nuts) to 45 grams/day, meat is expensive. 

I made a deal with him, I would eat meat when I dined out. That seems to work. I might have 3-4 oz of meat no more frequently twice/month. With that, I corrected my anemia. I continue to keep it at bay with figs, dark leafy greens and infrequent medallions of meat. It also makes life easier when dining  out and avoids crazy-making for the wait-staff burdened by my peculiar requests.

I’ve learned that protein and fat consumption stave off hunger; that if my foods are strictly rabbit-ish - I am always hungry. So adding a little protein and fat - say a cheese stick, peanut butter, almonds or a little yogurt to breakfast - will hold me until lunch. The formula that seems to work is approximately 10 grams of protein at breakfast and lunch. That translates into feta cheese, nuts or half an avocado on my salad or a black bean burger for lunch. That leaves 20 grams of protein for dinner.

Kidney patients can be very salt sensitive. If we eat too much salt and retain water, we do not efficiently process that water into urine for excretion. Remember, in insufficiency, kidney function is low and slow so water stays in the body to accumulate in the tissues of the feet, ankles, lower legs and lungs until it can be processed and excreted.

I learned this the hard way at Rubios one day. I stopped in for two blackened, mahimahi tacos and (easily less than) 30 salty, tortilla chips. Overnight, I gained eight pounds of retained water. It accumulated around my feet and ankles where the skin was stretched so tight, I ached and itched. My feet could not be stuffed into shoes and I literally felt water “slosh” around my ankles with each step. Auwe! I took a diuretic and learned that flogging a failing kidney with diuretics is like whipping a horse with a broken leg to run faster - it doesn’t work. Over time, I’ve learned that my Bean can process about one pound of excess water/day - that it takes eight days to clear eight pounds of retained fluid.

“No ham, no pastrami, no pepperoni, no corned beef, no preserved meats, no sausage, no salted pork or fish,” Dr. Patel said. I understand and avoid them, unwilling to live with my lower extremities bloated like sausages stuffed in their epithelial casings. Its just not worth it.

Let food be thy medicine and medicine be thy food. Hippocrates 

The human body has tremendous capacity to heal itself. We now know that  type 2 diabetes and heart disease are reversible conditions for many. Some have gone so far as to label those diseases food borne illnesses. As a society, we are suffering the diseases of excess.

Studies show dietary links to autoimmune diseases and autistic spectrum disorders, not as causal agents but in decreasing overall inflammation and the abatement of symptoms and stabilization of disease progression.

Next year, I’ll turn 60 years young. I intend to throw a party. My friends have threatened to speak at that party. YIKES! I’ve started to announce my age more readily just to watch eyes protrude, jaws drop, and dentures shatter when they fall. I am easily one of the oldest members at my yoga studio. I love hanging out with the lithe and lovely bodies that frequent my classes and am inspired by their ease of movement.

“If you continue with what you are doing,” Dr. Patel said on Monday, “I can see this kidney lasting another two decades.” That’s good - coz I have plans. I’d like to see every National Park, maybe even work as a seasonal park ranger in my favorites. I’d like to live in Europe for half a year and experience it from my bicycle. I’d like to do more hiking abroad. I might want to tackle the Pacific Crest Trail in sections. I can’t do any of it from a dialysis chair.

Some say we are spiritual beings having a physical/earthly experience. Spiritual beliefs aside, our bodies are the vehicle through which we experience this life. I desire rich experiences requiring high-performance physicality. I’m not ready to limit myself to paved, flat surfaces. I am unwilling to tolerate one day of avoidable pain and discomfort. For me, the dietary trade-offs are a no brainer.

Tools, Tips and Strategies:

   If you are trying to manage weight, hypertension, diabetes, limit salt or caloric intake, have an autoimmune disease and want to decrease pro-inflammatory foods, these tools, tips and strategies may be helpful.

The first step in managing food is tracking it. This can bring a modicum of consciousness to eating. My favorite food app is one called My Fitness Pal. Their food library is extensive. This allows me to check protein, salt and calories before I eat. It can be found online and is available for mobile devices.
   Start with Meatless Mondays and Fish Fridays. There is a learning curve to increasing plant-based eating and Meatless Mondays and Fish Fridays are an easy way to start.

Cleanse the pantry. Rid your home of tempting foods that derail and are not on your food plan. Its not that I can never have them - I can’t have them in my home. I keep snacks in my home that can’t hurt me = seasonal fruit. “But I can’t …” Excuses keep you stuck.

Ya gotta move. Last year, Kaiser Permanente (Sacramento region) gave every employee who registered, a FitBit. Its a glorified pedometer and my workmates were shocked at their levels of inactivity. Everyone started moving - walks at lunch and more. “But I can’t …” Excuses keep you stuck. There are ways to move, even for those in wheelchairs. Ask me how.

We are the company we keep. Deep-dive into supportive communities. Attend support groups and surround yourself with the like-minded. When dining with others, I make requests. I rarely agree to steak houses (where the menu will offer little I can eat) or places known for gargantuan portions (where my companions and I will be tempted to negate an entire week of stellar food choices in a single meal).

Have go-to strategies. Someone wants to meet for dinner? Couple meals with activity. Take a walk before dinner; a bike ride before brunch.

More on chronic kidney disease at the National Kidney Foundation.

Its not hard; its different. 

Think different ~ Steve Jobs

Swimming Upstream

To date, my blog A Skeptic Dissects z Nursing Strike has received 220+ hits - more than double my normal readership. I’ve received nine (mostly private) comments. Reticence, methinks, points to the caution people feel; I might offend someone. In numerous conversation, physician friends expressed their confusion and dismay with the strike. For some, there is a loss of respect - that nurses would strike for a day of ebola awareness.

They would be further dismayed to know the number of nurses unaware they struck for a day of ebola awareness and nurses who neither worked nor walked but took the days off. I do not require agreement to respect others - but I do seek integrity. I do honor those with courage to stand by their convictions.

However, I explained, if one expects others to march out-of-sync with the masses - first recognize that THAT is a great expectation indeed. And its antecedent would be critical thinking to justify (at least to self) ones oppositional position. Sadly, it is far easier to go with the flow.

It was in this vein that I began examining the repetitive, contrarian conversations of my own life. What follows are pivotal, non-conforming events in my life, the pressures of the cultural discourse and my reactions to them. 

My earliest of such memories was of being labeled a tomboy. I much preferred tree-climbing, touch-football and bike riding to playing with dolls. I’ve given up football. 

In society, there are inherited conversations that exert force. 

Inherited conversations: to get (a personal quality, interest, etc.) because of the influence or example of your parents or other relatives. Inherited conversations lurk in the background.

Discourse: dis·course noun \ˈdis-ˌkȯrs\

: the use of words to exchange thoughts and ideas

: a long talk or piece of writing about a subject (that might span the anthropocene - the epoch of man)

For example - girls of my era wore crinolines, lace and played with dolls. My concession to being female was to wear a bracelet - one I continue even today. I much preferred feminism to feminine, running track in high school and marathons in college. Girls of my era found good husbands, got married, and raised families. The joke was - girls went to college for their MRS degree. College, of course, spans those years when most marry so the MRS degree conflates several forces.

The discourses of a society are often invisible to us. We do not necessarily recognize them and seldom consciously agree to abide by them; they just ARE. Its the way things are; the water in which we swim. The American, societal discourse of athletic females without a man is: something’s wrong and she MUST be gay. 
Ever the rebel, I cared not that people thought me gay and continued on my merry way. It did occasionally give me pause, I found it entertaining, definitely stupid and irrelevant but then - that’s because I had nothing to hide. 

Societal discourse exerts pressure - let me reiterate, it is far easier to go with the flow. And thats why, 40 years later, coming out is still fraught with angst and gay marriage remains outlawed in fourteen states. (Florida capitulated just this week.) As the societal discourse of homosexuality becomes less condemning and more accepting, it allows for freedom of expression - hence the slow change of our laws allowing equality in marriage and spousal benefits.

I was very late to the marriage game and spent the preceding years intermittently unattached and celibate. “Are you gay?” my own family asked, articulating that which hung like low hanging fruit begging to be picked. Athletic female with no man - she MUST be gay.

And so I married. After ample time - say nine-months - a new set of inherited conversations, societal discourses and pressures emerged: Are you pregnant? When are you getting pregnant? Are you trying? Why aren’t you trying? Why aren’t you pregnant; is something wrong? (Note: had I delivered a baby within the requisite nine-months, like Medusa, a different set of inherited conversations would have reared its ugly head.)

Procreation is deeply imbedded in our biology and evolution. It provides for survival of the species and from an evolutionary viewpoint, I’ll concede that I have failed miserably. The pressure of this societal discourse is as ever-present as the tides, constantly pulling. 
If one fails to produce offspring in this era of choice, the common discourse is one of selfishness and egocentrism. I found myself compelled to say, “I was unable to conceive,” to escape criticism. Why do I have to explain? And why is unable better than unwanted? Bless them who choose to resist this societal tsunami in the face of no agreement.

Even now, people assume I have grown children and when they learn the contrary, a shadow crosses their face as they struggle with the anomaly. Procreation is an unrelenting task master that shadows me still.

There is no denying that I have days when I wish for a family. I watch my sister with her grandchildren, my niece marry, my friends welcome their first grandkids. These moments are fleeting but occur with more frequency during the holiday season - a time that is family-centric. 

You could have adopted; why didn’t you adopt? 

PAUSE IN THIMK: Am I the only one who finds this line of questioning extremely offensive? Perhaps I’ve heard it once too often. My reflexive reaction begins with an F and should not be spewed - however tempting. Please do not suggest that people should (have) fix(ed) infertility with adoption. Not now - not EVER. Adoption is a very personal and very different decision, not a solution. Trust me, we know adoption is available.

End Pause in Thimk - sorry for the di-grrr-ession.

You could have adopted; why didn’t you adopt?

Why didn’t you? 

What? Well… because I didn’t have to; I could have my own.

You could have had one less child and adopted one. Why didn’t you adopt?

Oooh - now THIS is interesting; donchya think? It challenges the standard discourse and instantly transports them into my moccasins. I apologize for gloating over the clever trap.

Ever present in this societal discourse is that something’s wrong that should be remedied. Please know that there is nothing wrong and nothing to fix. I am not broken and need no fixing - nor does my circumstance. I have moments of sadness sans familia; people have moments of sadness about their kids. When they do, I don’t advise divestiture of their children. Conversely, I neither welcome nor require instruction to marry someone with kids and grandkids. Should I choose to partner, 95% of the world has kids; do the math.

And so it came to pass that I divorced. Upon hearing the news, people automatically said, “I’m sorry.” Do you hear the common discourse in that? We assume that the end of a marriage is not good. Consider that - it isn’t always.

“Don’t be sorry,” I’d say, “Its the best thing I’ve done in the last 20 years.”

And after ample time - say one year - the discourse about being single emerged: Are you dating? When are you going to start dating? What about him? Why aren’t you dating? Are you in-relationship? What about him? Why aren’t you in-relationship? What about him? You’re too picky. How’s that guy you’re not dating? I guess its okay that you’re not dating. What about him? You should find someone now or you’ll be lonely when you’re old. (As an aside, do you think a man would appreciate being my hedge against the assumed loneliness of old age? Would he knowingly volunteer for that?) You better hurry; you’re not getting any younger. Why don't you want to date? What about him?

As gravity is to earth, so pair bonds are to mankind. So strong is this biologic, evolutionary discourse that we can hardly stand when one does not conform. I have found this conversation unrelenting at every turn. Notice that we do not ask the married-with-children to defend their lifestyle - however contentious or estranged.

I trust this conversation arises from concern for me but you would be shocked at its frequency, even after ten years, leaving me feeling defensive and pestered. Whose business is it anyway? The implication is that I am not whole, am making do, could not possibly be happy or thrive outside a pair bond.

But don’t you miss …? Apparently it is difficult to understand and more so for men. One of, if not THE greatest driver in a man’s life, is the desire for regular sex. The sanctioned avenue to regular sex is through pair bonding. I understand fully - and - I’m not a man.

I recently toured rental homes in Sun City - Lincoln. The talkative tenant paused packing to follow us through the house and jabber. His pallor and belly were vaguely suggestive of liver disease, a subtlety unnoticed by most methinks. 

“I thought that when I moved here, I’d have a line of casseroles to the curb,” he pointed out the front door, “And women wanting relationships. But, they’ve all had relationships. Now they want a beer and pizza and not much more. So either I’m a real jerk or women just don’t want relationships.” He sounded exasperated and confused. Yep, I get it. ‘Tis a brave new world Aldous.

The equally compelling corollary to Gotta find a woman is Gotta find a man. These automatic conversations for coupling are hardwired in our DNA and in them, my own fears of going-it-alone bubble to the surface. Yet, I remain unmoved toward partnership born of fear in lieu of want and love. I am not one to settle for.

Never in the history of womankind, can a woman survive - even thrive - without a man. Our safety, food acquisition and property are no longer solely dependent upon our man or clan. We can now have families and raise them without a partner or husband. Most don’t but it IS possible. We can hold title to property and maintain sole and separate funds. However, the societal discourse around uncoupled women is not kind. She must be gay. She couldn’t find a man. No man would have her. She’s too: tall, athletic, fat, old, angry, smart, strong, sour, dour, yada, yada, yada… as if women have no choice or voice in the matter.

Two friends of mine had children through artificial insemination and are raising families without a known father or man-of-the-house. They have terrific grandparental assistance, love and support. I’ll admit to my initial surprise and carefully avoid any implication of disapproval. I know that digs and off-handed remarks cast aspersions, undermine their decisions and are not supportive. 

This brings me back to my initial premise. That marching to one’s own drumbeat is a very tall order - be it refusing to strike with the masses or bearing children without a husband or coming-out or leaving a marriage, or remaining uncoupled, etc., etc., etc. Inherited conversations and cultural discourses pull for conformity and we are intolerant of them that differ. Further, we are blind to the discourse, like fish blind to the water in which they swim.

Part of the human condition is to look for “what’s wrong”. Throughout evolution, identifying what’s wrong and what’s different has provided a survival benefit. What’s wrong is a human discourse likely spanning the anthropocene. We are blind to the ways in which that lens colors our world. If you seek what’s wrong, you will assuredly find it.

This is why I write, so that you too can see the water in which we swim. Most of us are not childless, have not spent extended periods alone, uncoupled, or celibate in adulthood (actually - a surprising number of marriages are asexual but the societal discourse surrounding that is one of secrecy), will never divorce, bore no children out of wedlock, are not now and never will be gay. Yet we harbor judgements about all of it and our teasing, flippant remarks and advice convey the common discourse and judgements. It can leave people feeling like battered salmon swimming upstream. 

Do I sound defensive? I am - I’m tired of defending my lifestyle to my friends and family, people who are theoretically in my camp. Its exhausting and irritating. I have marched out-of-step and out-of-sync and I am likely to continue. It has been met with resistance and ridicule. I feel like that salmon. I cannot even imagine how my gay friends manage to move through life with such grace.

Obviously, I’ve made the people who tease and pester me wrong - for making me feel wrong - albeit my surety that their pestering rises from care and concern. I am made to feel wrong and I make them wrong for it. It’s all so mediocre and mundane. Can we rise above mediocre and mundane?

I’m sorry you don’t understand me. Your inability to understand does not require an explanation by me or you. Understanding is not required and makes no difference. This is a petition to attend the common, societal discourses and examination of our bias. 

My family would tell you (in a hot nanosecond) that I am equally judgmental and intolerant of those who abuse their bodies with food, substances and sedentism - and they are right. This prejudice is no longer invisible to me and I work to disabuse myself of my righteousness in the matter.

It is a constant struggle to hold on to what connects us. Especially when so many forces -- politics, media, religion -- flood in to demonize our differences, alienate one group of people from another, drown our compassion and leave our very humanity gasping for air. ~LZ Ganderson

Kule Yule Tidings 2014

Melé Kalikimaka e Hau’oli Makahiki Hou! 

My hope is this Holiday Season finds you and yours in good health and spirits. As I write, mana pours from above onto parched westlands. The small creek behind my house has swelled beyond its banks and onto nearby roads. Funny how three years of drought can change ones perspective of minor, local flooding. Let it rain, let it snow, let it snow. 

Bill, John & I - Switzerland

(Click the photo once to enlarge. Click X in upper right corner to return to text.)
LBz 2014: In recent years I’ve had an eye on my Bucket List, adding and reprioritizing. This year I checked off a big one. I spent 5.5, late-summer weeks in Europe hiking with friends. The trip was built around hikes in the Alps and fjords. Huts are sprinkled throughout the Alps along the Swiss Haute Route (haute = hut, pronounced “oat”). They provide hot dinners and breakfasts, cold showers and warm beds; reservations required. We learned the Swiss detest desecration of their land with cleared campsites and fire rings. The hut system allows hikers to travel lighter-faster-farther. To that end, the huts are 8-10 miles apart and shortly after breakfast, off you go toward your next hut. Its a fascinating and well marked trail system supported seasonally throughout many European countries.

We met many wonderful hikers and my pack weighed a fraction of what it did last year in the high Sierra. We’ve never done a “supported” hike before, we had  sherpa/guides, Swiss cheese and chocolate at every break - FUN! We will definitely do another such hike and I have my eye on the Inca Trail in 2016.

Prague @ night

Our route between hikes was sprinkled with old world cities and fishing villages turned Atlantic oil ports: Salzburg, Prague, Oslo, Stäväńger, Haugesund, Bergen, Stockholm, and Amsterdam. We visited UNESCO World Heritage sites in each location. Many of the old cities are tourist traps littered with trinket shops but if one can look beyond the kitsch, the architecture and stories are quite interesting. Prague has the esteemed reputation as a rare, old city spared annihilation during the bombing raids of WWII. Overrun first by the Nazis then the Soviets, they have returned palaces to them that can prove ownership. We toured the Lobkowicz Palace and viewed handwritten scores by Beethoven and Handel! We took guided walking  tours in Stockholm and Amsterdam and learned their secrets and hideaways. I wore a fitbit pedometer during the entire trip. Most days, we walked ten miles.

me @ Preikestolen - 2500' down

The fjords were fantastic, breathtaking and a must return destination. Back onto the Bucket List with Norway! Turns out Norway shares latitude and weather with Anchorage, AK (with which you may remember, I am quite familiar). One of our premiere hikes to Kjerabolten (pronounced Sheerabutn) was rained out with its peak literally in the clouds. Of our hike to Preikestolen - the  pictures say it all.

We toured the palace in Stockholm just days before the opening of parliament. When a parade of plumed horseman and empty carriages passed us, we raced to stand out front, to see the King and royal family depart.

“You saw the KING?” the hostess of our B&B asked with incredulity. “I haven’t even seen the King!” We proudly displayed the photo of her King waving in our  direction.

early Rembrandt self-portrait

The Rijksmuseum (Dutch Master’s museum) in Amsterdam is also back on the Bucket List. There we stood before Van Gogh and Rembrandt self-portraits, Rembrandt’s The Night Watch (which is enormous) and some of his early attempts at playing with light. I am a Vermeer fan and the Kitchen Maid was just exquisite. The museum provided iPhone-ish devices into which one entered a code to hear a brief history of these priceless works. Photos ALLOWED - without flash natch. Amsterdam has several such museums, each requiring at least one full day of exploration. We did visit Rembrandt Square where many of his characters are brought to life in full-scale bronze  sculptures.

The Kitchen Maid - Vermeer

I have two complaints about northern Europe: 1) it IS the land of milk, cheese and meat. They do not suffer vegetarians well. I spent almost 30 days eating Italian food because it was the only way to eat vegetarian. 2) Many of the old cities thrive on the backs of tourists with value added taxes as high as 25% but have made few, if any provisions, for these tourists to pee! I was so annoyed. Even pay toilets are an acceptable alternative to NO toilets.

Their citizens were wonderful. We had many trip-angels help us buy train tickets and head us in the right direction, write a list of things to do in their city, recommend restaurants, help us at the washrei (laundromat) and backrei (bakery).

“I don’t usually help tourists,” the young woman said after walking us to the train kiosk, helping us purchase tickets and sitting with us on the train to Oslo, “But you were so friendly on the plane.” 

“Keep helping tourists!” I called back, waving as we de-trained.

Stävävańger, Norway

“You’ve had a good experience in Norway?” the young man asked as he stuffed his clothes at the washrei. “We’ve been friendly and helpful?” 

“Yes, people have been very friendly and helpful,” I confirmed nodding.

“That’s good,” he nodded once with some finality, “Because we are known to be not so friendly.” He worked for a company that made machine parts for Atlantic oil drillers and spoke of family in Seattle.

We met Sierd Jongstra, a lovely Dutch oilman from Friesland, while prowling the harbor for nighttime pictures. In the end, we traded emails and I sent photos.

Talk to strangers - you will meet the most fascinating people!

Toward the end of our journey, a new Bucket List idea was seeded. That is, to live in Europe for several months post-retirement (which approaches more quickly than I can believe). Take my bicycle outfitted with baskets for food and goods - that way I can assemble my own raw, live, green foods. Live in northern Europe earlier when the weather is moderate and allows for quick excursions north, to the fjords for instance, when the weather forecast is clear. Then move to experience southern Europe and the Mediterranean. European extended holiday now added to the list in addition to visiting every US National Park.

post reconstruction

I finished two major home remodel items this year - the travertine floors and removal of my living room’s back wall. My home backs to a dedicated greenbelt/animal corridor and I envisioned opening it from the moment I stepped inside -  and now, the reality is beautiful and tranquil. My dear friend/gen contractor Wade did exceptional work and captured my vision, turning this small, tract-house into my home.

I finally wrapped my backyard oaks in lights - something I’ve been wanting to do for years. You’ll be happy to know I employed my climbing harness and rope to get 30-feet up. I think it took me longer to remember how to properly tie the figure-8 knot than it did to wrap the trees!

My cul-de-sac and street continue to hold biannual BBQs that promote cohesion and “neighborliness”. I love living on Gardner Court with the Courties!

I continue to work in the Neurology Memory Clinic at Kaiser. It is sad and necessary work to help families understand, then care for persons who’s brains are UN-learning - its counter-intuitive. I do find myself missing the worlds of diabetes and cardiac surgery where patients get better, go home and have an opportunity to reverse disease.

Yoga continues to reign as my preferred sport though tendonitis in my left wrist has curtailed some arm balancing and handstands. I find greater physical challenges by deepening the pose and spiritual connection in its meditative practice.

I continue to blog at http://lorinzmuze.blogspot.com though home construction, disruption and travel seriously slowed my pace in 2014. 

Lael & Darth 9/2014

In news of the family: While I was away, niece Lael married longtime sweetie Darth. Family reports the wedding was magical - and on the beach in Hawaii - natch. My great niece and nephew seem to grow before my eyes and I am thrilled to receive new pictures every few days over our shared iPhoto stream. If you haven’t connected your family in this way - you must! I feel so much more connected, even from 2000 miles away.

On a much sadder note, in a matter of weeks we lost both my Uncle Sonny and Aunt Gert. Theirs was the home in which we gathered every NY eve and day. Uncle Sonny would start strumming his guitar as we scurried for our ukuleles. He called out the chords, we followed and sang Hawaiian songs in kanikapila (Hawaiian jamming). Now and again an aunty or cousins would rise and dance the hula. At midnight, the racket began - strings of ten (or hundred) thousand firecrackers lit in rapid succession to ward off evil spirits in the new year. Wonder why I am always home at new years? I learned the true meaning of aloha in their home and theirs is a devastating loss for our clan. Knowing that he was ill, I flew home for four days in November and we three had a wonderful visit. I am thankful for the foresight and resources allowing those last acknowledging and loving moments with them both. Indelible is their imprint on our hearts.

What’s in store for 2015? 

Mom

Mom & her twin Milly turn 90 in April and we are planning a party for the girls. So my next trip to the islands will be in April.

The annual, national nurse practitioner conference is in New Orleans and I hope to combine that with visiting several friends in the east. Also planning a visit Cancun in September - a European hiking reunion of sorts. There we will tour the Mayan pyramids and lounge on the beach. I am researching the possibility of spending a week in Yosemite as a volunteer with the Yosemite Conservancy. Typically this involves trail restoration of some sort with park employees and other volunteers. It will involve sleeping in a tent at a remote location. Right up my alley! Its a great way to combine volunteerism and a park visit during the summer. They reportedly have many more applicants than spots so keep yer fingers-n-toes crossed for me!

That’s all folks! Would love to hear from you too. Sending you joy and Hau’oli Makahiki Hou!

LAUGH • PLAY • SING • DANCE • LOVE ~ lorin

A Skeptic Dissects z Nursing Strike

This blog is an attempt to distill the communications and issues that lead to the two-day work stoppage across Northern California’s Kaiser Permanente (KP) facilities. In my mind, California Nurse’s Association (CNA) had not built a strong case for strike. Nonetheless, they received a clear mandate from my colleagues. Ever the skeptic, I saved every 2014 communication from both organizations, just knowing I would want to follow the breadcrumbs. 

“The union is a double-edged sword.” If I’ve said that once, I’ve said it a thousand times. I appreciate that my wages and benefits are the spoils of hard fought battles. That nurses can work twenty-plus years for a healthcare system and retire without medical benefits remains the norm. Excepting the state and feds, Kaiser was early to grant healthcare benefits to retirees. The union did that. We affectionately call our pay and pension package the golden handcuffs and I believe nurse retention spares Kaiser the largest expense in any healthcare budget - the hiring and training of nurses. The union did that - that however, is no mandate to heed every word like chiseled tablets from the mountain.

Context is decisive. My context for CNA is not a powerful one. Our last contract was ratified September 1, 2011. Contract negotiations were secreted between CNA and Kaiser arbiters. The rank and file were notified post-hoc and encouraged to ratify. It was a different time, profit margins were thin and Kaiser was anxious to settle the behemoth budgetary item. The contract was bounteous, included raises during a time of high, national unemployment and economic downturn. Generous beyond expectation, we were universally thankful and thrilled.

CNA’s chief arbiter visited each campus to explain the new contract and encourage ratification. I found one phrase unsettling. “They are… scared of us,” he said smugly to the rank and file, “Yeah, scared is a good word.” And not for the first time, I wondered about supporting such an organization. 

That same organization called for a one-day work stoppage twenty-two days into that brand-spanking-new contract to support other, non-KP RNs and KP optical techs in union contract negotiations. A union representative visited each site to encourage nurse participation. I entered the fray brandishing my newly-minted-copy of the Agreement between Kaiser Permanente, Kaiser Foundation Hospitals, the Permanente Medical Group, and CNA dated 9/1/2011 - 8/31/2014.

Page 116 Section I - No Strikes or Lockouts 4023 addressed the issue: There shall be no strikes, lockouts or other stoppages or interruption of work during the life of this Agreement. 

“How do you reconcile a call for a work stoppage with this new contract?” I asked pointedly, after reading the passage aloud.

“We have a past practice,” the union representative said.

“This contract says no strikes, lockouts or other stoppages or interruption of work during the life of this Agreement,” I reiterated. “It does not say except for past practice.” We were diametrically and equally opposed, entrenched and immovable. Some nurses, elated with the new contract, saw heeding CNA’s call-to-action as homage due. Honoring the contract and one’s word seemingly fell upon deaf ears. All told, 23,000 nurses from numerous healthcare systems heard and heeded the call - a CNA flex-of-muscle, described as “the largest-ever strike by nurses.”

That nurses would stage a work stoppage, in direct conflict with our new and very generous contract, and for issues unrelated to Kaiser RNs was unfathomable to me. That CNA would call for such an action was unconscionable. CNA became suspect and the minions who, without question, would do their bidding? I viewed as uninformed and ignorant. I penned a letter of dissent to Sac Bee’s Letters to the Editor that went unpublished. But context is decisive and subsequent calls-to-action by CNA are met with fervent skepticism and scrutiny.

Fast forward to 2014. The Kaiser-CNA contract was set to expire 8/31/2014. 

In April, Dr. Robbie Pearl, Kaiser’s CEO, was filmed at The Permanente Medical Group’s shareholder meeting. “A big threat is that our nurses union has a contract coming up this year that will not get settled. There is no way it gets settled. And so we are looking at strikes inevitably coming up sometime in the latter part of 2014, heading into 2015.” https://www.youtube.com/watch?v=qWLkQJCR5X4

As early as May 2014, CNA emails to membership pointed to the 2014, 21.7 billion dollar profit while care units were short-staffed or shut down. 

With contract negotiations scheduled to begin 7/24, CNA encouraged RNs, on July 20th, to set aside 2% of each paycheck as a Patient Protection Fund and sought a written commitment to do so. A Patient Protection Fund  “for our patients and ourselves if Kaiser fails to work with us…” A strike fund, by any other name, is still a strike fund. Sadly, seemingly both sides were entrenched before negotiations had even begun. Score: 15-love, point-CNA for the pre-emptive strike.

As I walked toward my office on July 23rd, I was asked to sign a petition urging Kaiser to bargain in good faith.

“Isn’t that a given?” I asked. 

“No,” the nurse said, shaking her head.

“I don’t think the best strategy for negotiations is to go in with guns blazing,” I said moving on, “Sorry, I won’t sign that.” Score: love-all, penalty point-CNA for un-sportsman-like conduct.

The first day of bargaining was re-scheduled for July 31st, 2014. CNA reported that Kaiser failed to show, so they marched to Kaiser’s corporate offices in Oakland and read their opening statements in the lobby - which was covered by the national news. Kaiser had been working for weeks to obtain an agreement to meet at a neutral location, at which they waited on the appointed day. Apparently, CNA never agreed to that venue. To their detriment, Kaiser failed to widely broadcast their version. Score: 15-love, point-CNA, everyone loves a David beats Goliath tale.

CNA, framing their demands around patient care and safety, delivered 38 proposals to the bargaining table. As early as August 14th, CNA represented their proposals focused on “working conditions and changes for improved patient care and services” while Kaiser’s rebuttals allegedly cite “cost containment”. (Cost containment will seem ludicrous later with reports of Kaiser’s, record, $12,000,000 daily profit in 2014.) CNA showcased the death of a bay area toddler as proof that services were lacking.  Score: 30-love, point-CNA for strumming the heartstrings. It’s difficult for many to see issues beyond the death of a child.

On August 21st, CNA employed a time-tested-tactic, the old bait and switch. “No takeaways in light of record profits.” With that declaration, a two-pronged attack was launched and the battle subtilely shifted from patient care and safety only, to sharing in the loot. Leaflets addressed corporate profits and CEO salaries. ACE! Score: 40-love, point-CNA, for stirring stinky bait into the pot, muddying the waters and altering the debate.

PAUSE IN THIMK (this was a phrase my university math prof used to indicate a sidebar)

No margin; no mission. Where do new, digital mammogram machines come from? From the margin. Where do new hospitals come from? The margin. Where do newer, designer drugs like expensive insulin pens subsidized by pharmacy programs come from? Yep, you guessed it; from the margin. Where does my very substantial paycheck and pension come from? Righto - the margin. 

As one who has owned a small business, I understand the cost of business, a P&L statement and the margin. While current and historic evidence of income inequality and its deleterious effects on society is well documented, that discussion is for a future blog. Nonetheless, I view CEO pay and corporate profits as a separate issue, unrelated to my own W-2. During my 35 years of nursing, my wages have increased 7-8 fold. Kaiser nurses are well paid, possibly some of the highest paid nurses in the country (uh... = world). When one points to CEO and corporate greed, must one address the three fingers pointing back at self?

End Pause in Thimk

9/11 - CNA reported, “Kaiser informs us that they have no interest in the majority of our proposals.” Did Kaiser actually say this? Unlikely. Counter-proposals are part of the game and do not infer “no interest” - that's what a rejection is for. There is no record of Kaiser rejecting any of the proposals. Kaiser’s accounting of negotiations on 9/11 are collegial and collaborative. They propose extending the contract 60-days and adding numerous bargaining days. Score: 40-15, point-KP for bargaining in good faith.

As negotiations proceeded, nurses were encouraged to attend the bargaining sessions, to witness the process first hand. Carpools were organized across northern California and CNA filled the bargaining venue with chanting RNs. At one point, Kaiser’s negotiating team refused to continue and called for an arbiter to arbitrate the arbitrations on the grounds that they did not feel safe. Excuse me - is this a professional nurse's association or the Teamsters? Score: 30-all, point-KP for professional conduct, penalty point-CNA (and attendant nurses) for behaving like thugs.

On September 30th, CNA proffered its last proposal - one for Ebola preparedness including supplemental insurance in the event that Ebola is contracted at work.

October 8th - Kaiser’s response to the Ebola Proposal included creating a CNA/KP task force to incorporate best practice and ensure all voices/concerns are addressed. CNA scoffed and spun this into: “Kaiser is responding with a proposal with the lowest common denominator. Kaiser is using our patient’s lives as bargaining chips. Kaiser’s lack of preparedness matches how they treat us every day when they fail to prepare for admissions, discharges and sick calls. It is clear they are unwilling to embark on a sufficient Ebola preparedness plan in an effort to limit costs.” 

Here, CNA effectively taps into national nursing outrage that frontline nurses were inadequately protected at Texas Presbyterian, while proper personal protective equipment was available onsite. Undoubtedly, mistakes were made; mistakes for which Texas Pres has apologized and paid. But methinks Texas Pres was a long time ago and far, far away from where we are now. That was then; this is now. Score: 40-30, point-CNA for effectively personalizing the debate and tapping into the outrage required to mobilize the minions.

10/15 - Kaiser is “unwilling to spend any of the $12 Million in daily profits on ensuring adequate relief for nurses.” Score: point and Game-CNA for guerrilla warfare that effectively demonizes Kaiser at every opportunity, tossing in every bone and stirring the pot. Game Score: CNA-1, KP-0.

PAUSE IN THIMK

Burnout: the condition of someone who has become physically and emotionally tired/spent after doing a difficult job for a long time. One symptom of burnout is anger. 

I left the Emergency Department because I was becoming a person I didn’t like. I was angry: angry at patients, angry at home, angry at work, angry at friends, angry with my parents and family. I’ve spent years working on self, finding that which nurtures my soul - returning to myself. “You are more you,” a friend said. Exaaactly. I know many angry nurses; the workplace can be a cauldron, little kindling required to light the fire.

To combat burnout and boost mental health, Kaiser has an Employee Assistance (counseling) Program and an employee wellness program called LiveWellBeWell that is unmatched in the industry. There are processes to escalate concerns of workplace violence, sexual harassment, and unsafe practice, to name just a few. Programs are free too all but employees must actually participate (engage, document, submit) to receive the benefits.

This is not to say that cases of harassment and unsafe practice do not exist; only to say that there are options to anger and strikes.

End Pause in Thimk

Game 2

10/16 - “CNA told Kaiser that we are willing to settle our contract today providing there were NO TAKEAWAYS.”

Regarding the Ebola Proposal: “Kaiser’s refusal to agree to this proposal further solidifies that Kaiser is putting profits before the safety of nurses and our patients.” Note: Kaiser did not refuse but countered. I'm sure CNA knows the difference.

I view this communique as critical. First, while CNA claimed 39 proposals addressed patient care and safety - they are clearly willing to chuck the entire body of work for no takeaways in pay and pension. Really? Didn’t they just commit the exact offense they accused Kaiser of in the next line? Of putting profiteering before the safety of nurses and our patients?

Score: love-15, point-CNA for cleverly/effectively couching double-speak for political gain whipping the nurses into a frenzy.

10/20 - Petition to Authorize Bargaining Team to Call Strike if Necessary 

“We have been bargaining for several months and it is clear that Kaiser is not interested in putting its $12 million per day in profit towards the provision of safe patient care. …Kaiser has the resources to settle our contract …but obviously they have no intention of settling our contract without coming after our benefits.” 

Note: Not agreeing to no takeaways is not the same as proposing takeaways. At this point in the game, Kaiser has deferred financial discussions. Rather, they propose settling most of the 39, non-financial proposals before discussing pay and pension. But notice how CNA framed this as “they are coming after our benefits.”

They may “come after our benefits” but that has not been proposed. I will hardly strike over something I fear Kaiser might do. But fear is a powerful motivator. When my physician friends express confusion with “the issues” its because issues are difficult to discern in the stewing cauldron stirred by CNA. This strike, best I can tell, was not about issues but emotions. Bubble, bubble, toil and trouble. Score: love-30, point-CNA for obvious reasons.

10/30 - Notice Issued for 2 Day Strike

CNA got their mandate from Northern California Kaiser nurses to strike, and in an am-a-a-a-zing coincidence, coordinated Kaiser’s work stoppage to precede a (yet to be declared) National Day of Action by nurses for Ebola preparedness. Ask yourself; does my employer need to be penalized with a day of strikes because their Ebola Policy changes with the evidence? Aren't you glad it does? Score: love-40, point-CNA for coincidental planetary alignment with the moon in the 7th house and Jupiter aligned with Mars. Does anyone feel even remotely manipulated? Think nurses - THINK!

From California to Maine, registered nurses plan to make their voices heard louder on Nov. 12 with a National Day of Action for Ebola Safety Standards.

This comes after hospitals across the country refuse to set proper safety protocols and training with optimal personal protective equipment.

To their detriment, Kaiser all too sparsely leaflets its nurses with position statements and their disappointment in the rhetoric and tactics of CNA. Their information is tempered, a welcome sprinkle on the flames fanned by the frequent CNA communiques. A sprinkle nonetheless - inadequate and infrequent. Kaiser needs a counter-terror blogger, one to call a-spade-a-spade; an impartial voice with an eye for half-truths and spin.

On Novemember 7th, Kaiser's Leadership responded with an email to employees: “The union’s use of Ebola as a rationale for a strike is not justified. We are very disappointed about the nurses union's decision to call for a strike. The reasons it is giving for striking are simply not supported by the facts. To date, CNA leadership has… continued to label KP publicly as unprepared, which is not true and is stoking unnecessary fear.” Score: 15-30, point-KP for stating the obvious - albeit ineffectual.

Buried at the bottom of that 11/7 email, I found this: If you have questions: We understand that you may be hearing conflicting or confusing information from different sources. Please visit For the Record (fortherecord.kp.org), our website that provides updates, answers to frequent questions, and KP’s perspective on bargaining and other important topics. WHAT???

Dear Bleader (blog reader), you know me to be a voracious reader and consumer of information. Trust me when I say, November 7th was the first I’d learned about a Kaiser website for bargaining information. Truth is, it is not solely dedicated to bargaining though bargaining dominates the website at this time. Shame on me and shame on KP. Score: love-30, penalty point-KP for failing Employee Communications 1.0.

November 13th: the day following the strike, Kaiser’s Leadership sent a conciliatory email: “We especially want to express appreciation for the many hundreds of nurses who chose to put their patients first and came to work. On behalf of our patients, we thank you for your dedication and commitment.”  

“With this unfortunate work stoppage behind us, we welcome back those nurses, engineers, and other employees who were not here during the strike. We know you will resume providing excellent care in your departments, your care teams, and at your patients’ bedsides.” Score: 15-30, point-KP for diplomacy and inclusivity.

November 20th: CNA claims victory and responsibility for improvements to the Cal OSHA Ebola policy announced November 14th. Score: 15-40, point-CNA for effectively using circumstance to their advantage.

I spoke of the strike with a non-Kaiser, nursing friend. “Wait a minute,” she cut me off, “Isn’t Kaiser a great place to work?”

Exaaactly.

I wonder - are we better off after a two-day work stoppage? I fear not. I am cautious in speaking with those who supported the strike. I am curious about their view - so different from my own - and  wonder about the decision-points leading to their willingness to strike. 

As the game continues, Kaiser is seemingly outmatched in propaganda and spin. I have spent hours sifting through data for this distillation. Few have the time or want for such a summary; few will read this blog. No matter as my blogs are typically (no exception here) the place to address that which niggles and gnaws and to observe the distillate.

I recently listened to an interview with Arie Kruglanski, an Israeli researcher, psychologist and terrorist expert. He points to the black-and-white, right-and-wrong, rigid versus nuanced thinking of extremism as juvenile, underdeveloped but providing a place for one to become part of a larger whole. He cautions that victims often become as extreme as their oppressors and cites his mother country as an example. Finally, he discussed decreased cognitive complexity as exemplified in one’s inability to digest many points of view and extremism and entrenchment as causal for literally dumbing-down.

I continue to be unmoved by CNA and have been known to call them rabid. It is for me to move forward carefully, that I am not equally rabid from the opposite side of the net and court. Life is not back-and-white, mostly methinks, we inhabit the vast fields of gray.

Rumi said it most eloquently - Out beyond ideas of wrongdoing and rightdoing there is a field. I’ll meet you there.