Dialysis Number Nine (#9, #9, #9)


El Milagro: Got here about noon and the place is hopping. On Saturdays staff try to squeeze the last shift (me) in early so they can get off early. It seems the patients like to get done as early as possible too. I like it on Saturdays because it seems the staff are more friendly…. Perhaps because we who are served are also serving them by coming in early.

I don’t want to suggest the staff are unfriendly on Tuesday and Thursday: they actually seem to be very caring, professional, and conscientious all the time. Nurse Phyllis has said this the best place she has worked in the 30 years she’s been a nurse. Spending 12 hours a week here, I am getting to know the staff in a more personal way than I did at Moritz’s office or when I was in the hospital last summer. I’m already finding staff who are good at sticking me, and Tory is my favorite. Today he was standing near my chair but not responsible for it, yet I asked him to stick me (). He agreed and then asked me to tell the other tech (who is responsible for my chair), and they made a small joke about who’s the best sticker.

One of the interesting things about coming here is that it is a perfect opportunity to observe a system almost from outside the box. I am just one of many patients so my impact on the system of staff is probably minimal, allowing me to observe their patterns of interaction, organization, and processes. I am enjoying observing their system rules and structure without asking questions about how they operate. So, that is a mental amusement while I sit there for four hours.

I am a person of habit and I find myself developing a habitual way of spending my time while at dialysis. (Of course this will change when I begin working from the dialysis center). When I arrive and get hooked up, I observe the setting for a few minutes and then start writing a post. Once I’m tired or bored with that, I read whatever materials I’ve brought to read (today it was The New Yorker (April 17th issue) article about Pete Seeger’s life and Bruce Springsteen’s new CD of his songs.) Last Thursday I read an article from The Family Therapy Networker (refusing to call it by it’s new name) on working with Stepfamilies. I counted that one as work time.

After reading, I begin to fidget and decide to watch TV: today it was cooking shows on PBS that featured things I can’t eat but love seeing prepared. Then, before I know it it is time to get unhooked and weighed and out into the sunshine.

Data Notes: I weighed in at 71.6 Kg. and Tory said they’re “pulling off 1.2 Kg. In 4 hours. When I left I weighed out at 70.6 Kg. (1Kg. = 2.2 lbs.).

Later at Home: I got an email from my friend Richard in Utah (who hasn't kept up with my deteriorating kidneys). He looked over my blog and wrote, “Damn, Jack, it's worse than I thought, even if you insist on making it an adventure. …I don't recall your ever being much good at sitting still four hours at a stretch. Still, it's better than the alternative. I'd rather not hear too much about the letting go part of you letting go. it's selfish, but I prefer your being around.”

I wondered if he was taking “letting go” in a different way than I meant, or if he is just being morbidly humorous. And then I started hallucinating that other people might not understand the “letting go” so I wrote back to Richard the following clarification:

Damn, Richard, letting go is not "giving up"! Letting go is about accepting what we can't change and if possible, recognizing it is a necessary part of the total process. As Chou Tun-yi (1017-1073) said long ago "That which has no Pole! And yet it is the Supreme Pole. The Supreme Pole moves and produces motion, the yang. When the movement has reached the limit, rest ensues. Resting, the Supreme Pole produces the yin. When the rest has reached it's limit, there is a return to motion. Motion and rest alternate, each being the root of the other." This quote is from Alan Watts’ Two Hands of God (1963). Jack Kornfield has a whole chapter about this in his book, A Path With Heart but I leant it to someone, so I can't dig up a quote from it right now. Jack.

In this experience, I have to cognitively integrate the new dialytic part of my life with my other learnings and experiences so as to fit it in rationally. Learning is a process of data intake and integration with data that already exists in my fuzzy brain. Back in an NLP training in the 80's I imagined my brain as a floating sphere with compartments on the surface and with electric energy zooming around, zapping new data bits into the compartments they most closely resembled. Once integrated into their compartments another operartion, working through the center of the sphere, developed a data link between the new information and every other possible data bit that it might fit with, such that the whole spheres insides were a system of interlocking connections between the data bits. Some of them organize around ideas to produce new realizations that are more than the sum of the data bits and they become ideas, theories, designs, or creations and are pushed from the interior to the surface of the sphere as new compartments. From the space outside the floating sphere, the compartments resemble polished aluminum library card file drawers. So, my posts are a reflection of my thoughts about how this new experience integrates with the rest of my life experience.


4) Of Mr. Animado & Infiltration


El Milagro: This place isn’t very popular this afternoon… 4 chairs with people in the section I can see. Today I’m in a chair in the back-to-back row separating the two rectangles, so I can see out the windows and watch traffic on the freeway slow to a crawl through the rush hour. This as a background visual is like the opposite of one of those speeded up films of clouds, sky, and sunset.

I had a long conversation with nurse Phyllis about Davita and the other dialysis centers in Austin. She ball-parks that there are about 2500 people on dialysis in Austin. Davita has about four centers in Austin (one in San Marcos) and who knows how many nationwide. Doctors who are medical directors of the units (like Moritz) have the option to buy in as a partner, thus increasing their income from a contracted annual amount to a percenta
ge of the profit. Three of the doctors from Moritz’s practice are medical directors of three of the Davita units. I guess this paragraph is for those of you who are interested in the organizational info.

The place is not empty today because everyone died. I was pleased to hear that. Phyllis reported that the population decrease has to do with a few people being hospitalized for various reasons, a few switching times, and a few of the crowd last time being visitors. And one person on this shift hasn’t shown up yet. As I write this, he walks in. He is a Hispanic guy who always bounds in laughing and saying hello to all the Hispanic patients, going to each of their chairs and giving them a personal greeting and some sort of touch on the knee or shoulder. He is the most cheerful person on my shift. He’s always kidding with the staff and shouting to one of the two other Hispanic guys who are here. All three of them seem to be younger than I, and look to be gritty workers who come in directly from their worksites. Two of them are fairly quiet and seem “sicker”, but Mr. Animado really brightens the place up. Another person I met, Amanda, when we introduced ourselves, said “Sorry to have to meet you this way.” She too, looks younger than me.

There are some folks here that are older than me and generally they look much worse for the wear. A few of them come and go in wheelchairs and a few are slow shufflers. Watching these older fol
ks makes me wonder how they reflect and contemplate on this experience. Do they see it as a necessary labor to stay alive and stave off death? Do they come in here all business and weak looking, but brighten up at home with their families? Have they given up and are just letting their relatives push them along to this necessary life-extending process? Maybe when I get more acclimated into the system here I’ll interview a few of the older people and explore how they perceive this experience.

‘Charlie’ Moritz stopped by this evening, in a black with green hibiscus Hawaiian shirt and matching black pants. He grinned a “Hello, how ya doing?” and I asked him if my insurance was getting charged for a office visit every time he stops by and spends a minute or two checking on me. He answered that it’s more like a hospital rate, where the individual stop-bys don’t count individually. He said I’ll still be coming by the office twice a year and he’ll get my insurance money then. He added that he doesn’t only come to see patients (of which about 4 seem to be his), but also to do ‘director’ work.

Note: It’s two hours into this and my legs are getting fidgety…. I keep readjusting them from cross-legged to straight out to folded right over left to folded left over right to underneath my butt and back to cross-legged. And this cycle occurs about every 4 minutes and I have to do it carefully to ensure I don’t move my left arm*.

*(Added later) I learned on my second visit here that it is not a good idea to move your arm. I
moved it that time and got what they call “infiltrated”. That means the needle coming back into my vein poked through the vein and shoved blood into my arm. Yowzaaa that hurt! I can finally talk rationally about that experience now, 2 weeks later. Fortunately the machine beeped and a tech came to my rescue. Blood shot into my muscle and whatever else is in there that is not the proper place for the blood to shoot for less than a minute. My arm swelled up and the pain was pretty smart. They stopped the dialysis 20 minutes early and taped me up. My “Popeye” arm (named by John) became a topic of interest at our Passover seder the next night. I took a picture of the bruising and will put it up here when I find the connecter from the camera to the computer.

That’s it for tonight. Now I’m gonna watch Survivor.


3) Raccoons & The Urea Reduction Report


It's been a very good two days since my dialysis on Saturday. I've been feeling great and its a good thing because we've had a busy weekend rounding up a family of racoons living in our attic and walls. The mother and four babies are being re-united and taken out south of Smithville to live in the country (see picture of Lizzie with baby racoons).

I'm reporting from the dialysis center. Right now there are, in my section of the room, 10 people receiving dialysis. There are 11 chairs facing inwards arranged in a rectangular circle, all with their dialysis machines beeping and humming beside them and connected to them with red tubes. Above and forward of each chair is a hanging TV that the patients watch and hear with their earphones. When I use my remote (clicker) to change the channel I have a 50% chance of also changing my neighbor's, or anyone else's too. So every once in awhile we hear someone say, "Sorry...".

The section of chairs adjacent to mine, and in the same configurtion, appears emptier, although I know there are a few people over there because the nurses and techs are attending to several chairs.

Today I am up to 4 hours of dialysis, from the 3 hours I had been getting up to now. So, what does that mean? Moving up to 4 hours optimizes my dialysis plan (developed by Dr. Moritz) for removing my toxins. Basically, about 40% of my blood is dialysized, and the fluid weight loss is the same with the increased time. The extra hour will reduce my URR and Kt/V, according to Phyllis. Even though she made it quite clear, my fuzzy brain wasn't able to capture the details so I looked them up later.

URR: Urea Reduction Level ~ The urea reduction ratio (URR) is one way of measuring dialysis adequacy — how much waste is removed by hemodialysis. If you receive hemodialysis three times a week, each treatment should reduce your urea level (also called BUN or blood urea nitrogen) by at least 65%.

Kt/V: K T over V ~ Kt/V ("kay tee over vee"), like URR, is a another measure of dialysis adequacy. Kt/V is a mathematical formula: K (clearance) multiplied by t (time) divided by
V (volume), where:
> K = clearance—the amount of urea your dialyzer can remove (liters/minute)
> t = time—the duration of treatment (minutes)
> V = volume—the amount of body fluid (liters)
For example, if you have 50 L of body fluid and a dialyzer with a clearance of 0.25 L/min,
to get a Kt/V of 1.2, you would need 240 minutes (4 hours) of dialysis per treatment. To clean your blood well, the dialyzer clearance rate (K) multiplied by the time on dialysis (t) should equal a little more than the total volume of fluid in your body (V)that needs to be cleaned.

My experience of sitting there for 4 hours made me a bit fidgety... there is a difference that feels like the syrup hour. I found myself clock-watching until I got wrapped up in NOVA's show on the "Cave of Letters". Then, when I was done at 7:50, I wanted to sit around and finish watching the TV. Some things never change: my focus on TV.


2) The Mind Adventure

Part of me is holding together and part of me is letting go.

Those parts might describe to the reader a duality and yet they are both substantially the same thing; alternate expressions of my core, soul, or said another way: being real (real being?).

When I experience or think about 'holding together' I am aware of the parts of me that really think this kidney adventure is important, physical, and a threat to the entity that is Jack. That part of my consciousness, as I lay on the couch (at home), in the quiet afternoon sun ("resting"), considering 'consciouosness', has no real fear... but continues to internally acknowledge, support (love), and gather together my self... kinda like "circling the wagons". Calling out to all parts and provinces, "Get ready for the battle and then the long-run". On some semi-conscious level the holding together part visualizes green glowing kidneys that operate like we all expect them to.

Can you imagine how out of whack your body gets when your kidneys go haywire? It's an amazing thing how many fuctions they take care of as a part of their essence (more later on the functions of the kidney in the human body).
My 'letting go' self enters softly as I lay in consciousness, whispering "this too shall pass" , or "it's not about the kidneys". Kidneys represent the physical parts we are all over-involved with, afraid of, worried about, attached to, in love with, and trying to control. As I lay there my 'letting go' self knows that my body is simply a body... and is just perfect the way it is in this moment. This part of my self knows that it doesn't really matter what approach I take to my kidney adventure; my chosen American Medicine Way, the eastern herbal and accupuncture way, or any of the myriad other ways to 'deal' with it. The 'letting go' me sees beyond (?) the duality of right and wrong, so any approach choice is simply an approach choice. It is interesting to note that along similar lines of thought, the 'letting go' self isn't really a 'self' at all, but an observation of the relationship between the perceived 'self' and esoteric consciousness.

When I am 'letting go' I am experiencing, visualizing, or meditating on the non-duality; remembering that all the pain and joy in life are expressions of compassion.... remembering that all the 'holding together' and 'letting go' are the dance of being.


My First Time

So, I made sure I had lots of things to finish up at the office, making preparations for tomorrow's training, etc., and finally drove over to El Milagro Dialysis Center, getting there about 10 minutes late. Liz was already talking to the social worker, Marilyn. I was more anxious than I thought I would be.... not about getting stuck or anything....just the anxiety about a new experience that has to force itself in to my life without my inviting it. For the sake of keeping my internal locus of control I found a tag line to introduce myself to the new environment:

"Hi. I'm Jack. I'm a dialysis virgin. Please be gentle with me cause its my first time"

This got a minor reaction from Marilyn social worker, but the nurses and techs loved it! The head nurse, Phyllis, laughed heartily at my tag and was soon telling it to the other workers (about 7 people) when they came to check on me in my chair (amongst the other 30 or so chairs inthe room) and adjust the machine, or check my readouts, or see to my needs.

Liz left and I was left with learning more than enough information bits to ever remember. The whole dialysis machine and what it does is fascinating and I'll describe it in a later posting. The pain was minimal and my fistula was again "ooohed and aaahed" by the staff. I must have a famous fistula and I have enjoyed asking my friends and relations to touch it and watch their surprise as they feel the 'buzz'(more on this for the un-initiated later too). I found out about the machine, how it filters about 40% of my blood, and how they evaluate my balances and toxic drain afterwards. The machine actually warms the blood going back into my system and they can adjust that if I want itwarmer. WOW.

I found out that the important paraphernalia that I must purchase and bring is a universal remote to control my hanging TV. I borrowed one from my neighbor to set a channel to golf. I also was given a workout bag with ear phones, anti-bacterial cleaning solution, a pillow, and a blanket (which I have already traded for one my old cotton Mexican blankets).

So, three hours after walking into "the miracle dialysis center" I walked out a clean-blooded man, thinking this might not be too bad.