More than you want to know – Nancy

Hi Folks,
John writing. Not much new here, as of Saturday morning.
I’m late with this, so this one is just a marker.
I need another hour, and then will post on this simple link below.

February 27th
FIFTH OF UPDATES More than you want to know – Nancy

Tuesday was a blood draw with INR and K both within range.
Getting a plump vein to tap has been a problem. Conversations with others suggest diet and fluid intake need an increase. Looking back, I think she drastically cut Powerade (sports drink) along with total removal of Ensure protein drink (about the highest Vit K item in her diet – still not real high).

As a substitute I’ve been making what I call “blurpies”. If you put fruit, ice cream, and yogurt in a blender the first sound produced sounds like “blurp.” Well, it does to me. She uses Almond Water (COSTCO brand) to dilute coffee, so we also add that to the Blurpy.
So, we are working in this.

Friday at 3:30 we went for the 1st dose of the Pfizer vaccine. We were met in the parking lot and handed a 2-sided survey – filled out in the car. I took those to the greeting table. We were escorted inside and passed off to person #3. We asked for a high chair for Nancy. Most chairs were of the folding metal type, and 10 inches lower. (More of the higher chairs are needed in this world.)
Because Nancy is on a blood thinner (question was on the survey) we were visited by a Nurse (#4), who explained possible bruising from a shot. Nancy showed her a few, and she was satisfied we would not be startled if such happened at the site of the poke. (Without a mirror we can’t see that spot.) The nurse summoned #5 who led us to a table (with a high chair) where #6 was waiting.
We wore short sleeve shirts and warm vests without sleeves; and a warm winter coat. Remove the coat, and there is the bare arm ready for the shot. Next we were off with person #7 to the waiting area. Chest tag had the time 1551 (24 hour clock) at which we could leave. About five minutes into the wait, person #8 arrived with a computer on a high rolling cart. For maybe the forth time we gave names, birth date, address, phone number, e-mail.
Person #9 appeared and we asked to short-circuit the longer exit route, pass through curtains, and exited where we came in, about 30 feet from the car. We thanked all the outside greeters as we passed.

Our 2nd dose was scheduled, but she could not alter the 21 day period. We want to stagger those by 3 days. Some folks can feel a bit off (symptoms vary) as the body’s immune system ramps up after the 2nd dose. It is not likely that both of us would be impacted, but that is possible, and easily prevented. We just have to call the County Health folks and reschedule. I had to call to get us in the same time slot on Friday. The computer system tossed me out when I tried to fill a second slot from my computer.

Saturday morning and into the evening we can feel where the shot was given, only if we put a hand on the arm. Otherwise, it is not noticeable.
That’s it for now.

February 20th
FORTH OF UPDATES More than you want to know – Nancy

We started off the week with a haircut, just around our rural block, from Nancy’s long ago (in EBRG) “find” – – Celia Winingham and husband Bob. He was cleaning snow from the driveway as we arrived. I passed her off to Celia at the door, and then I came back home where a couple of workers were working under the carport. Forth minutes later I went back and picked her up.

Tuesday was the blood draw – INR and Potassium were within range.
Kidney function remains an issue with a high marks for “blood urea Nitrogen” (BUN) and Creatinine. No surprises.

Wednesday, with nice weather and dry roads, we visited with Dr. David Krueger, cardiologist in Yakima (50 miles). He was pleased with the lowering of swelling in feet and legs. We talked about how to ease the pressure on her heart – see the section under the red stars, below, Saturday January 30th. Lots of protein can be an issue, but her intake of meat protein is low, so I don’t see a lot of help via diet. He is also thinking the CPAP (sleep study day is March 10th) apparatus will help. Next visit with him is March 31st, after CPAP or whatever. We also need a new “pulse Oxygen meter” (oximeter). The one we had quite working. $20 for a simple one; $100+ for a recording one, but I haven’t figured out if our WiFi will work (no smart phones here).

General: cast is off unless we are out-&-about. Sling isn’t needed in the recliner, and she has use of her right hand for laptop use. That makes things easier.
An elderly local lady is reported to have had a serious reaction to the 2nd Pfizer Covid dose. I don’t think that means Nancy will have an issue, but on Monday we will ask about this. Our 1st dose shots are scheduled for next Friday.

For now: “That’s all folks!”

Saturday February 13
THIRD OF UPDATES (2nd follows, then 1st at the end)

Not a lot happened on the health front this past week. The Tuesday trip to town allowed her to walk a few hundred steps in the grocery store. Much more exercise would be good.

I had removed the wrap that enclosed her thumb and wrist late last week. Swelling on the back of her hand/thumb/fingers did not increase after that, and maybe went down a bit. Feeling and color were normal, so that is how we left it.
Thursday, after 3 weeks, we did go to Cle Elum for cast removal and a follow-up X-ray. That seems to show normal healing. We were instructed to replace the cast if out & about and, also, take the arm out of the sling a few times a day and do mild exercise of that arm. After 2, days the swelling is now gone, or almost.

I had hoped to get her outside and walk for more general exercise, but the cold air mass seeped into the area – a rare event. Thursday evening we got snow, about 4 inches and a morning temperature of 12 degrees F. The snow and the cold continue. Outside exercise is cancelled.
Neighbor Allen cleared the snow from the driveway. That was the first for this year. He commented that with much more in our forecast he was making sure the equipment {John Deere tractor} was working. As expected, snow continued. He came back just before Noon today and cleared it all again. I need to clean up around the edges.

Drawing blood on January 26th was a left arm affair, and even then had to be from the back of her hand. Both INR and Potassium were in range so we didn’t do them this week. Next week they can go back to the right arm. That’s Tuesday.

On Wednesday (2/17) there is a cardiologist visit in Yakima. Previously an interim meeting (1/20) with his assistant, Buffy Sawyer, provided a “maintenance” status. This will be a more thorough and important exam.

Nancy may add a few notes tomorrow, but that’s all I have for today – 2/13/21.

Saturday, February 6th
SECOND OF UPDATES (1st follows below)

ZOOM to sleep [Tuesday, 2nd]
A consultation with a person at Memorial Sleep Specialists (Yakima) had the expected result. Nancy has to go for a sleep test. This may be later in February, with cast off, but maybe not the sling.
The ZOOM experience was horrendous. Lighting on their end was poor and the audio was worse. We understood enough of the words (2/3) such that we did not have to use another method. A phone call would have been better. An in-person consultation preferred.
The doctor that we dealt with in 2014 has assumed higher level administrative duties so the contact was with Allison Morgan, about whom we know zilch. She read the letter I wrote about Nancy’s non-apnea results from back then. Nancy’s issue is, apparently, hypopnea, or shallow breathing that results in reduced Oxygen in her blood.
However, Nancy – on Dr. Kim’s strong urging – lost weight, enough so that a new test is called for. Something about properly prescribing and calibrating the equipment.
Nancy and I thought her CPAP equipment was less than stellar, and not highly advanced in the sense of being tuneable to a particular situation. Have these things gotten better? We can’t find that they have with respect to Nancy’s needs.
We’ll see.

Moving on to COMPRESSION: I wrote earlier:
“Meanwhile there was significant swelling in the legs, below the knees. Not good.”

I intended to explain our encounter with (think of a mad Badger) compression socks. One soon learns of the lies photos tell. Below is the evidence.
First, nothing so colorful seems to be available in EBRG. We bought the largest size (white) at BiMart. Doc Chelsea showed us how to put these on. She is young, with nimble fingers, and experienced. Still it was difficult. She suggested getting a “sock donner” and that we did. Cost was $45 and a second set of stockings ($10.00); also White. A friend offered a pair of black socks. From “all colors” to no color – great!
Notice the enticing look in the left photo above. Note also the legs are not swollen. Same thing on the right. No swelling. Easy-peasy.
We are now experts at sock donnering. Meaning, with significant effort on my part and great patience on Nancy’s the mad Badger has surrendered – each leg gets donned. The amount of Lasix {LAst SIX hours} is doubled, so Nancy is wearing out the carpet in the hallway.

Next: arm wrap
In this image the cast is in light blue. That is dressed with a Velcro closure elastic wrap; horse owners will recognize this. Also, I bought a dozen rolls and carry a few in my backpack. I took one out over a 10 year period. That was on a trail repair workday at Mt. Rainier. A tourist fell and our best trained crew raided my pack, then went to help. The roll was not used so I still have it. I digressed there.
Note where the hard cast and the wrap end. Well the back of Nancy’s hand, and fingers, became swollen. We’d been keeping Nurse Lacey and Chelsea informed, and on Wednesday (the 3rd) I wanted to either go to the Clinic, or release some of the pressure.
About 10:30 AM, with Lacey having heard my latest concern, and having consulted with Chelsea, we cut the wrap away from the hand and back to the yellow line.
I also realized the hard cast came out to the carpal bones (pisiform bone?) [Yeah, I looked that up.] The cast will have been on for 2 weeks on Thursday the 4th and it immobilizes both elbow and wrist.
We’ve been advised that the cast can be removed for an hour or so if Nancy is a good girl and doesn’t move the elbow much. If we do that, I think I will take about 3 inches of the end – red line above.
Not only has the exposed part of the hand puffed out a bit, but she has complained of it being cold. With slowed circulation out to her fingers, I suppose that’s not a surprise.
We’ll see if we can fix that.
Saturday afternoon we have keep the cast on.

End of 2nd update (1st post follows)

Saturday January 30th

A few years ago the computer place in Ellensburg shut down and we had to create our own domain name. We either lost, or just can’t find the early editions of the writings about Nancy’s health. For any new acquaintances, I will briefly summarize. Skip to the red stars line below if you like.
Nancy, the child, had rheumatic fever. Heart valve damage is a complication. This isn’t a big deal, until it becomes so. For Nancy that started in 2009.
She began that year with a slight persistent cough. No one thought much of that except me. However, either from a dental procedure or bad luck, she contracted “Endocarditis”, a life-threatening inflammation of the inner lining of the heart’s chambers and valves (endocardium). That was taken care of, then followed with a visit to an amazing (we agree on this) cardiologist, in Yakima, WA. Dr. Anatole S. Kim is responsible for Nancy being alive. Next in that sequence is Dr. Baljit Sharma, heart surgeon. But I just jumped ahead.

Early Friday morning, after Thanksgiving Day in 2009, Nancy developed an artery blockage that took us to EBRG Emergency and then on to Yakima and a Cardiac Catheterization unit to remove a blockage in an artery across the front of her heart. From home to removal of the blockage took about 4 hours, enough time for some heart muscle damage. Not good, but not a catastrophe either. Then a sudden calamity. An anticoagulant, unfractionated heparin (UFH), was given to prevent clotting. Most people do not have a problem with Heparin. Nancy was unlucky. By Saturday afternoon she was experiencing a reaction that makes red blood a target of immunological response, resulting in the degradation of platelets, which causes thrombocytopenia. In simple words, her red blood cells were dying. The shorthand for this is HIT, for Heparin-induced thrombocytopenia.
She was sedated and put on life support for 8 days. When I got to the intensive care unit, I was advised that she might not live. She surprised them all.
Over the next few weeks we learned about the intra-aortic balloon pump (IABP), a mechanical device that increases myocardial oxygen perfusion and indirectly increases cardiac output through afterload reduction. A computer-controlled mechanism inflates the balloon with helium and so on. Wow. Look it up. A typical yard-stick leaned against the bed. Among all this high-tech (science fiction like) stuff, a wooden stick was used to make sure the heart and pump controller were at the same height. [Clarke’s third law: “Any sufficiently advanced technology is indistinguishable from magic.” Arthur C. Clarke, Profiles of The Future, 1961]
With a bit of time and prodding by Dr. Kim, the surgical team went to work on December 29th, cut Nancy’s chest open, fixed two arteries, replaced her native Mitral Valve with one from a pig, and used fractionated heparin with low molecular weight to finish the day.
Eleven years later she is using her second implanted cardioverter-defibrillator (ICD). Actually, the ICD is there, but not used. The first was used once, shortly after being implanted when she was, again, ill with Endocarditis. The “pacer” part is almost never used, but it is there too.Late last year (2020) a routine blood exam [Basic Metabolic Panel; BMP] showed a spike in Potassium (K). We cannot identify dietary or other reasons for this, so a few tweaks in medication and dropping Ensure from her diet have followed. (Ensure has K, but not all that much.) One med was dropped, a second was cut by a third, just this week. The test on Tuesday was still high for K, but not as critically high as a few weeks ago.
Meanwhile there was significant swelling in the legs, below the knees. Not good.
We visited, on the 20th, with Buffy Sawyer, the Cardiologist’s assistant and will see Dr. David Krueger in February. Our “doctor” is Chelsea Newman (physician assistant, certified) at the Cle Elum Clinic. Nancy’s favorite drawer of blood (Kim) is in EBRG, where her blood is most often tested. Chelsea’s nurses are Lacey and Summer. A great team – we like all.
A recent echocardiogram (echo) was not a whole lot different than in previous years, although the pulmonary artery pressure was higher, causing swelling of legs (edema), and Tricuspid Regurgitation – backward leakage through an intended one-way valve. Not good.
Images have “exploded” views on the lower left of each heart.
On the left image, blue arrows show flow of blood in open & closed positions. The right side image has a red arrow showing back-flow or regurgitation through a valve that does not completely close.

The hypothesis is that improvement is possible if the cause is Hypoxemia – oxygen deficiency in arterial blood. This can be caused by slow breathing and heart activity while sleeping. This is undesirable because the amount of Oxygen in the blood drops and the organs have an insufficient supply. An exam in a doctor’s office now (for us) includes using a Pulse Oximeter to discover the peripheral capillary oxygen saturation (SpO2). When the heart and lungs do not send sufficient oxygenated hemoglobin to your finger, the rest of your body suffers. A good reading is shown in the image below, along with the pulse.

Low readings, say near 88, are seriously low.
However, when the saturation drops by 3%, say from 97 to 94, that’s not good either.
Nancy used breathing apparatus (continuous positive airway pressure) (CPAP) and an Oximeter for about 4 years but lost a few pounds and seemed not to need it. Now stopped for about 4 years.
Our issue with CPAP was/is that it is designed with stopped breathing [obstructive sleep apnea (OSA)] in mind, rather than shallow breathing – and there was no way to record the SpO2 monitor readings with the rest of the (cumbersome) setup.
Nancy will likely return to the CPAP, maybe with a newer and better technology. Consultation will be by ZOOM, on Tuesday February 2nd.

NEXT (problem):
Nancy goes to Kim (phlebotomist) almost every Tuesday for a blood draw to check clotting time [international normalized ratio (INR)], and now for the Potassium level. When INR is stable she is only tested about once a month. The spike in K changed the routine.

Heading for the medical building, On January 19th, Nancy was turning to get into our Crosstrek and fell. She landed with her right arm between her body and the ground. Ouch!
This resulted in a “closed fracture” with a tiny bit of movement, about where the blue line is in the diagram.
This shows on the X-ray, but we can’t get to that via the medical portal, and Chelsea would have had to use a cell phone camera to send us the image. It was not worth the effort.

She got a modern-day splint, with arm in sling. Photos below are not Nancy.
They put a cotton sleeve on first. The photo does not show the first cotton sleeve.
Then a mixed fiber/plaster (wet first) “splint”, and then wrapped with an outer fabric.

The right photo shows the fiber/plastic that quickly hardens.
Left photo shows the outer wrap, that can be loosened if more swelling (not expected) occurs. Why? Because the fracture happened on Tuesday, we had the visit with cardiologist Buffy Sawyer scheduled on Wednesday, and didn’t get to Chelsea and Racine until Thursday, the 21st.
Because hers is the right arm, and the left shoulder is the one that is bad – the next 8 weeks will be a pain – literally and figuratively.
Chelsea (our “doc”) sees very few fractures, so Racine, who has worked in a special ortho (bone) clinic came to help. She was a pro, so Nancy got all fixed up like a high performance downhill skier. Neither elbow or wrist can move.

They also fitted her with a nondescript black sling, very un-photogenic, unlike in the photo here. I’d add some decorations, but who’s to see?
The restraining cast is due to come off about noon on Tuesday, February 11th. I think Chelsea said the sling should be used for at least a month after that. Maybe Nancy will have enough allowed movement to use the right hand on the keyboard.
The sleep/breathing issue will be addressed starting on the 2nd of February.

Better news:
Nancy has been using a 40 (?) year old recliner, sleeping beside a monitor that sends nightly updates to the ICD folks. It uses the plain old telephone system (POTS). The chair’s lift system died, or the buttons did. We ordered a new chair, but there is a two month wait. So, Korbie, a former student from 16 years ago gave us a very new chair (dog chewed the right side arm and left a hole), used briefly by her father-in-law. I gave her 10 pounds of home grown onions. What a deal! When Nancy’s new one arrives, I’ll move the given one into the converted (new) room.

That’s it for now.
Updates to follow, when things happen.
Such will appear at the top of the page.
Thanks for the good wishes being sent Nancy’s way.
Typing is hard for her, but you can call: