You know when you are a mood altering drug when:

6 small green pills stare up at me from my hand. One more pill might make the smile they eerily form appear sardonic. They know that when I lift them to my fat scalloped tongue and wash them down my swollen uvuless throat, there is no turning back. The next seven days of my life belong to them! Of course, they start out with enticements like, "You feel great," Anything is possible," and "Everybody loves you." You know they have taken over when voice suddenly at 1:47 P.M. feels like it has raced down a dusty track on a hoarse with no name.
The decadron ride at 5:00, usually blasting rock music while taking corners in the 'Beemer' at 50 miles/hour today is replaced with a Zuma 125 cc powered fuel injected scooter. This bad boy will get up to 50 going down hill hunched over. The negative ions feel great on my face as I split lanes and zip in front of those fat cars.
Of course then comes the 11:00 P.M. hiccups with insomnia provoking me to sit down and write about hiccups and insomnia. My remaining rational thoughts remind me that Friday Night Lights will be dim and Saturday we won't be singing Italian songs in the park.
Contrast Thursdays with impetuous emails promulgating reason to double my weekly work hours (quickly recanted) to Monday morning dressed to go to work, yet drooling on the couch composing a mental e-mail on why I should retire. Aah, fun with Decadron.

I always assume my mood is stable. If my perceived reality changes, it must be all of the other inhabitants of 'me world'. However, occasionally, flaws in the Matrix appear and I am confronted with the possibility that I may be the problem.
When your mood is changed by 6 green pills it appears to yourself that you are still quite normal, status quo, steady. Why then is every one else suddenly annoying?

You know when you are on a mood altering drug when:
  1. Every treats you like you have male PMS.
  2. Your to-do list screams at you so you shred it mercilessly.
  3. You always search for the nearest chair.
  4. You do all of the work and get none of the credit
  5. The bed feels exceptionally comfortable.
  6. You worry more than usual and on Monday felt a brief flash of guilt.
  7. On Sunday you can't find a shovel big enough to stuff food down your throat.
Finally, Wednesday morning returns, green sirens singing of 2.5 more up days. Just swallow me and me and me. The cycle continues. But it is all for a good cause, I think; wait is this Thursday night or Monday morning?
If you want a large loan, see me Wednesday night, I will be in the OR operating late because I offered to cover call for my partner on National Doctors Day. Wednesday is our all-nighter. Line em up!

Kevin

Guided Imagery



Cliffs of insanity

 A few weeks ago I attended the Amyloidosis support group held in Walnut Creek, CA. Early in the meeting I presented an update from Dr Gertz's recent article on treatment for AL Amyloidosis. It was a wonderful review article on the diagnosis, prognosis (via cardiac classifications of 1,2 and 3) and chemotherapy options and their respective results. I highly recommend a review of this article if you have AL amyloidosis and haven't read it.Gertz Abstract
Later in the meeting a woman specializing in guided imagery taught us techniques in self relaxation (This has never been a major issue for me, I was always a generally lazy boy, but driven by lofty goals.) As she described the process, it became apparent that I had been doing this for years. When I needed to psych myself up for a particularly difficult new surgery, I would replay the entire case in my mind while lying in bed. I anticipated problems and pre-resolved them. Another form of guided image, although I didn't call it that, was to go to my 'happy place' while in a painful situation such as dental work or a bone marrow biopsy.
This is a real place in Northern Yosemite. At 13 I was hiking from Stanislaus national Forrest through Northern Yosemite to Touolemme Meadows. On our third day we arrive at the most beautiful spot on earth. I was seated on plush thick grass, dry and slightly warmed from the overhead sun filtering through the pine trees surrounding us, To my immediate left was babbling brook hidden from view between banks made of 12 inch tuft of green grass. The water trickled into the crystal clear blue-silver water expanse before. Golden trout a plenty were jumping to catch the dinner at dusk. A symphony played surrounding us; the light wind through the trees, the ruffling of the grass as we shifted, babbling to the right answered by the snap of the waves in the wind and the trout splashing with there hors Du hourves. Beyond the lake were two mountain peaks that God placed symmetrically to meet at a V on the west end of the lake.The point of the V just resting on the water. And like a ball sliding into a cup, the setting sun silently slid down where the V folded itself, like a fan in a woman's hand.
The most miraculous event took place in the immature mind of a 13 year old boy that actually had the presence of my to be overwhelmed by this singular moment of miraculous beauty. He wrapped it up in a neuron box and store it in a place where important memories reside. Since then, I close my eyes and pull it out when I need it, be it pain, insomnia, test anxiety, or to escape.
The leader then asked if she could take us on an extended guided imagery, We all agreed. We were going to a tropical beach. She then stopped to mention that in a previous class a woman complained of major anxiety as she had once nearly drown at a tropical beach. Three or four people glanced at me, having read my blog on my near drowning in Cabo San Lucas. They waited for me to object; I remained silent.
The imagery began sitting on a warm beach, the waves lapping over your toes. Soon you are in the water up to your waist. The you dive in and become engulfed in a million bubbles swirling around you, you are disoriented....Anxious Memory-I Shift.....Now I could see the Golden trout jumping for dinner as the setting sun silent slithered for the seventy-seventh time in my happy place.  I didn't like the memory of the disorienting bubbles. They are actual quite scary.
Guided imagery is actually quite useful in daily life. I used it today during a vasectomy to distract the patient and they feel less pain and anxiety. You should try it out. (The guide imagery, not the vasectomy)

Kevin

New Beginnings

The last two weeks have seen both culminations and beginnings. A week after I stepped down as chief of the department of Urology, I was called to a new position in church. I now serve as a high councilor, one of twelve men that support the Presidency of the newly formed Lincoln, California Stake. I haven't served in a calling requiring a significant time commitment in years and did not suspect I would as people often worry that my illness might prevent me from fulfilling my duties. Barbie and I both see this as confirmation that God still needs me around for a while. To make it even sweeter, President Perez has assigned me to work with the Spanish Branch. I left the branch 2 and 1/2 years ago when I got sick. It feels as if all that I had lost has now been returned. I feel complete again.
Barbie works so hard to succeed in dental hygiene school. She is doing well despite the impossible pace with which they teach and test her. She is committed to finish school and start a new career.
Rebecca and Jason are ridiculously in love and Rebecca is really establishing herself in her advertising career as junior faculty at BYU
Last week, Caitlin was accepted to BYU in Provo, Utah to begin in August. Yesterday she graduated from Lincoln High School at the top of her class, two months ahead of schedule. Despite being officially done, she will continue to attend AP chemistry to prepare herself for the exam.
Samuel called today to inform us that he was accepted to Penn State to complete a masters of engineering in acoustics. He and Michele now are face with the decision to move east or stay at BYU for the graduate program there. He has done some major work on his Senior Capstone project with John Deere and may have a research grant with Caterpillar.
And finally, Jeremy called on Thursday to inform us that his dream of becoming a doctor will be realized. He was accepted to be a medical student at Midwestern School of Osteopathic Medicine in Glendale, AZ.  It will be exciting to see Jeremy and Alexandria embark on this new phase of their lives. They have waited so long for this day. We are so proud of all of them.
I know this may sound like a Christmas letter, sounding off on all of the accomplishments of our children, but it feels like much more for us. In a two week period, we have witnessed the fulfilment of our childrens' dreams. They will each get to pursue their passions. What more could any parent ask for. One more item to check off on the old 'bucket list'.
President Perez once told me that a parent is only as happy as their saddest child. Just because they are no longer at home, we are still concerned about them.
Barbie and I are very happy right now.

Kevin

I love surgery



Big rocks don't scare me

 There are certain cases I really enjoy doing. In 2008 at the the chief resident graduation, Dr Dana Nanigian gave me a T-shirt with big red letters that said I 'heart' circumcisions. I must have done a lot of those cases with her. Circumcisions are not my favorite surgery, but I do a fine job with them.
If I had to pick a favorite it would be percutaneous nephrostolithotony. Some patients develop large staghorn stones that fill up the entire renal pelvis of the kidney. (The hollow middle of the kidney where urine collects before heading south through the ureter to the bladder.) The goal is to take this hard branched rock measuring 4 to 6 cm out through a straw that is one centimeter in diameter. For many years other urologists have referred theses tough cases to me, and I really love the challenge. Many urologists don't like these cases as they can be fraught with pitfalls. The most common of which is bleeding. To see what you are doing, you irrigate saline through the rigid 8 inch stainless steel nephroscope into the kidney. If the bleeding is faster than your irrigation, you only see red. The trick is to work fast and if you glimpse the stone attack quickly and without mercy. Which brings us to the arsenal. To remove a big stone through a small hole you must crush it. I have used pliers, spark plugs, pneumatic hammers, ultrasonic energy and various lasers. The new weapon of choice is the CYBERWAND. Yes, I have now advanced to wizard level, and like Harry Potter can wave my cyberwand, muttering the incantationn, "Calculo Evapero!!" and the stone will magically disappear. Actually, it is called a cyberwand and is the ingenious combination of two technologies; a jack hammer and an ultrasonic lithotriptor with a hollow core to suck out the debris, (a sonicare hammer vacuum.) Today I took care of a very sweet and very ill elderly woman. Her condition keeps her confined to a bed, and she developed major stones in her left kidney severely damaging the function of that kidney. Worst of all she had a large 3 cm stone down her ureter. Those are very hard to treat. Solid metal rod don't make 90 degree turns very well and ureters are notoriously narrow. As we say in New England, "You just can't get there from here." I knew it would be tough as she might not do well with anesthesia lying prone for two hours.Then, as we began placing tubes in the bladder and kidney, urine did not emerge, but rather a thick foul-smelling white stuff. We gave an extra dose of antibiotics.
Then everything changed. On entering the kidney, there was minimal bleeding and a clear view. Dr Jacobsen, the chief resident, kept inching the scope downward and was soon far down the ureter and at the stone. Fortuitously our access gave us a shallow angle into an uncommonly wide ureter. The years of obstruction had at least one benefit. The magic words were spoken, the cyberwand sprang into action and that stone was dust sucked into a bucket in less than 15 minutes. Dr Lytton at Yale would always remark in a situation like this, "Sometimes a blind squirrel finds a nut." Soon the mid pole and lower pole kidney stones were gone and I the pulled a few tricks from my bag to sneak up into the upper pole and annihilate the invader hiding up there. She was now stone free. It was quite satisfying. All this through an incision in her back measuring a 3/8 of an inch.
I marvel sometimes that I still get to do this. Two and a half years ago today I got a new heart and a new lease on life. I just renewed that lease for another eight years. I hope to honor it.
There are still many more mountains to climb and stones to conquer.

Kevin

Pain Tolerance

My favorite scripture is Luke 9 24-25 "For whosoever will save his life shall lose it: but whosoever will lose his life for my sake, the same shall save it. For what is a man advantaged, if he gain the whole world, and lose himself, or be cast away?" My favorite line from a movie is, “Life is pain, highness, anyone who tells you differently is trying to sell something.”

Lately, I have been thinking about pain tolerance. Recently I had a patient who was generally not tolerant of any inconvenience in his life. He was impatient and angry when I first met him. He contacted me upset that he couldn’t get his CT scan the same day. We found a stone which was not obstructing his kidney and therefore should not have been causing significant pain. His pain, however, had been present for years in a location separate from his kidney. I explained that treating his stone might not resolve his pain. He could not accept this. I scheduled surgery and eventually successfully pulverized the stone with a laser and told him that he would now pass the small pieces. Two days later I got a call from a hysterical patient that had become unhinged (10 times worse than becoming unglued) As I listened to the wailing over the phone I felt bad and arranged for him to come in to be treated for his pain. But I was left to wonder why he had reacted so violently to something that generally is not that painful for most people.

Often, people will exclaim to me that they have a high pain tolerance as they are asking for more narcotics. The degree of their reported pain does not correlate with their clinical presentation. My first reaction is to wonder why some people tolerate pain so differently from others. Over the years I have found a non scientific correlation between certain personality traits and pain tolerance. Those who are impatient, demanding and overly critical often are upset when a solution to their problem cannot be resolved instantaneously. These individuals also don’t tolerate pain well. They cannot abide loss of control in their life. Medical care has its flaws. It is not always immediate. There are many things we cannot fix. Some pain cannot be relieved, even with strong narcotics. Many will suffer despite are best efforts.

What is pain tolerance? I view it as two different responses to a given noxious stimulus. First, it is the way in which we perceive the pain. This is measured in a subjective quantization by our brain relative to the physical injury or insult to our body. Second is how we respond to the perceived pain. To what degree can we suppress the impact of the pain on our consciousness and continue to focus on the task before us. The difficulty is that we can only judge one person with and any true credibility; ourselves. When someone tells me that they are in pain, I always believe them. Who am I to say, “That does not hurt.” However, it is clear that a specific fixed source of pain stimulus will evoke a wide variety of responses from different individuals. One might continue to work while another will be in the hospital on intravenous narcotics.

Yet, how someone will respond to pain is not completely unpredictable based on how they handle others aspects of their life. People who are intolerant, feel entitled or tend to blame others for any problem in their life also tend to blame others for their pain. Our society raises us with the notion that all pain is avoidable and that if we experience pain, someone is culpable and, ergo, owes us recompense. Yet, there are many others that see beyond their pain. They accept it, manage it and work to overcome it. Their positive outlook is more potent than Percocet. They combine faith and science with hope that they might emerge, maybe not pain free, but whole. They accept their new normal and move on.

Some pain is acute and may last for a few seconds or a few weeks. Some suffer pain every day of their life. It never goes away. This is the worst. My heart aches for these.

Some pain is not physical. Emotional pain associated with loss of companionship or isolation, even within a relationship. Spiritual pain associated with guilt and thoughts of worthlessness. Depression deprives so many from enjoying even a little beauty in their day. We feel pain in so many ways. I want so much to alleviate pain from peoples’ lives. As a doctor I can treat the source of their physical ailment. But so much more is needed. Beyond healing the body, I can help heal the soul. First, I must listen, without judgment. Second, I must offer hope.

Last year I had a patient who was very sick. He wanted to die for the last five years since he lost his wife. He argued, “Why should you treat me? Just let me get sicker and die.” He had nothing to live for. As we spoke I knew that the only remedy was for him to lose himself in the service of others if he were to save himself. We spoke of what he could to help other people. Finally he commented. “For all this time I have been preparing to die when I should have been preparing to live.” He smiled and I saw the flicker of hope rekindled.

Life is pain. We can’t always remove it. But we can lose ourselves in the service of others to save ourselves. From Him that suffered all things comes our hope and our tolerance of pain.

Kevin

Looking back at 2010

Mostly what I noticed in 2010 is how a certain normality returned to our lives. Predictable patterns emerged; both in my health and in our daily activities. I cycled my chemotherapy, one month on and one month off in an attempt to prevent rejection. It worked. I did not have any episodes of heart rejection in 2010. Albeit, the cyclophosphamide is progressively the source of more complications with each new cycle. But the alternative month feels so good.
We lost too many people in 2010. Both from the amyloidosis support group and the heart transplant group. The year ended with the passing of Bill. His wife Dina runs the amyloidosis support group. I remember the first time I met Bill. His body had already been ravaged by amyloidosis, yet I gained so much hope as a reflection of his courage. Bill and Dina were strong for all of us. He will be greatly missed.
Last week I went to Santa Clara to get my 4 month heart biopsy. This time felt different; it hurt. I realized that my body's nervous system is now innervating my foreign visitor. The Scarecrow is finally talking to the Tin Man. As I mentioned this, the fellow doing the biopsy, (assuming that I was complaining about the pain) walked around the table to explain. He said, "What you are feeling is the ..." My laugh cut him off as I retorted, "We doctors are all the same." As I looked up I saw a strange look and finished, "You just told me what I am feeling. How can you know that?" How many times have I done the same thing.
A few hours later, sitting in the transplant support group, I heard the same complaint over and over; 'my doctor didn't listen to me'. We all try so hard to fit everyone into a box that we understand and forget how differently we experience things.
2010 was a wonderful year. We went to the Grand Canyon, Paris, Spain, Utah and New York. Barbie finished her prerequisites and was accepted to Dental Hygiene school. Jeremy, Alexandria and Rebecca graduated from college. I never called in sick (although there were days I wanted to.) I love going to work and I love coming home. I am humbled by the extra days that have been gifted to me. As my friends pass from mortality to their eternal home, the words, "There but for the grace of God go I," occasionally pass through my mind. I used to think of this cliched phrase as selfish and unfeeling. Yet now I understand. I may not have passed this year, but it is certain that some day I will. We all will. So much is not in our control. I accept that as I accept God's grace in my continued daily breath. I do not understand why some die and others live. It clearly is not based on merit. My only peace is through the faith in my Saviour.
As I look forward to 2011, I am excited to continue in my relationships with friends and families. I feel really good, physically, mentally emotionally and spiritually. I begin this year with no regrets.

Kevin

Moments and Memories

This is not the way I remember it

How long is a moment? Fifteen seconds? Fifteen minutes? How long is a memory? Forever? I looked out the window to see the sun reflecting off the brilliant green moss on a tree in the backyard. The hills, looking toward the Sierras, were golden as the storm clouds finally broke. I thought, "I will capture this moment with a camera and make it permanent." I walked 20 feet, affixed a lens and back to the door. Maybe 45 seconds had passed and now the tree looked gray as the clouds had again shifted. Somehow I delude myself in thinking a memory is something solid or fixed, or that a moment can be held unchanged with a photo or a video. Yesterday, while sorting through pictures from the last year, I happened on to a photo that I got from my mom's camera. The image showed me in a hospital bed with my brother, Daren, and my sister Leslie standing near the head of the bed wearing full gown and mask. I was shocked to see myself. The picture was taken while I was in septic shock after the bone marrow transplant. My kidneys were not yet working, so that the 5 liters of fluid they used to resuscitate me were still visible in my face. My left eye was bloody from a vessel I burst while vomiting. I attempted a smile, but was quite unconvincing. I looked at the photo and realized that I didn't remember looking like this. Not so much the physical appearance, more so the fatigue I now saw in my countenance. Somehow, my memory had softened the experience as I originally saw it.  I realized that memories can subtly shift as do the hues reflected off the moss covered bark. The tree doesn't change; just the way we see it.

A moment is not defined by time, rather what an experience feels like in the immediate.We grab urgently at dandelions already on the wind exclaiming, "This moment is so precious, I must hold onto to it forever," as I frantically adjust the focus and see it through a viewfinder only to find that the feeling has already passed.
Last night, Caitlin performed with a group that did a Christmas show with dancing and singing. I had no idea that she could dance so well. However, my early Christmas present came on the final number as she stepped forward to sing the solo on "Sing Noel." Her voice was angelic. I didn't even know she had a solo. I sat overcome with emotion as the moment washed over me. I am sure that someone videotaped it and I could watch it again. I know I would enjoy that. But I could never recapture that moment of surprise and wonder; it was enough.

The last year has been wonderful, yet relatively normal with regard to my health. I find myself more and more occupied with the responsibilities at work which consequently occupy more of my thoughts. I actively must remind myself to 'find the beauty in every day'. The memory of what it felt like two years may be changing. But how can I really know that since memory is all we have and it is not static. What I do know is that there are more surprises and wonders that lay before us. New moments and new memories. We must never cease to be amazed. Pause; savor the feeling.

Kevin

Best month ever!

You don't always notice feeling better. It is often not a recognizable moment. Whether you are ill for a week or a year, when we finally have a good day sometimes we are so focused on getting our to-do list done we have failed to notice that we are moving a little faster or with less pain. You can't remember when the sniffles went a way and breathing became easier. However, at some point when there is a lull in the activity we realize, 'Oh, my pain is gone," or the amazing revelation, "Yes, now I remember what normal feels like." Ironically, it is then that the aha moment comes and you feel like the blind person who has just regained their sight. Then you immediately pray, "I hope I feel like this tomorrow." To those who are chronically ill, imagine being healthy so long that you forget what it feels like to be sick. That was November.

For two weeks in Paris and Barcelona I never felt sick and we really didn't even talk about it. There were just too many other things far more interesting. I had been praying for months that I would be healthy enough to travel. Then I prayed that Al Qaeda would not bomb the Metro. Then I prayed that the Parsians would end their strike so that our plane would have fuel. All of my prayers were answered and then came the one I didn't expect, to forget that I was even sick. Truly a Gift from God. I thank Him. I thank my brother Harold and sister-in-law Darlene who invited us and housed us. I thank Dr Shrier and Dr Sardar for both suggesting and giving me an infusion on gamma globulin to boost my immune system. But, of course, I mostly thank Barbie, my reason for living.

But wait! There's more!
Two days after we returned, we left for Park City, Utah to spend Thanksgiving with all of our children, their spouses and Barbie's family. Even in 4 degree weather, the warmth of their company made it a fabulous occasion. We had so much to be thankful for.

On our return, I knew in two days I would begin chemotherapy again. Memory is a funny thing. I thought I knew what to expect. But just as you are surprised when you suddenly recognize you are well. Equally, I forgot how hard chemo can be. It seems like Barbie remembers this better than I do. But as I always say, "No matter how bad I feel today, I will feel better soon." And I always do.
Hope is a marvelous thing.

Kevin