Bring It

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NaBloPoMo 2017: Field Notes from a Life in Medicine

Had my knee MRI yesterday.  I had been looking forward to it for over a week, trying to predict what it would show.  I was thinking a serious meniscal tear, since I have had crackling in my knee for so long and I surely must have arthritis by now, from all the falling on it I did in my youth.  I lay perfectly still and started to get sore where I expected to feel medial meniscus pain.  I could not wait to know the results.  I just wanted to know what I’m dealing with, so I can figure out next steps, get moving.

Since it’s a weekend, I won’t know the radiologist’s report until tomorrow.  Suddenly part of me doesn’t really want to know.  What if it’s really bad and the only option to regain function is surgery?  What if it looks like I’ll be permanently disabled in some way, never able to get back to my previous level of activity?  What if that prognosis totally throws me off and I let myself go, become a sedentary lump, weigh over 300 pounds, and die in five years from heart disease and depression?  Truly, this could end my life, some poisonous voice hisses in the recesses of my mind.

But hubs is the ordering physician and he looked at the images with me tonight.  Lots of fluid/swelling.  Bruises on both bone ends of the joint.  Good news, the menisci are intact and look normal!  Woo hooooo!!  Posterior cruciate ligament also looks normal—thick, uniformly black (swelling and inflammation are light on this image), well-positioned.  Can’t find the ACL.  Huh.  He says 10% of people don’t have one.  That’d be cool, because if I never had one then it couldn’t be torn.  But the bone bruises alone are not enough to explain the swelling and pain.  So either it’s so inflamed that the fluid obliterates it on the MRI, or I have completely ruptured it and the little stumps have retracted out of view.

I had wondered which I would rather have, a serious meniscal or ACL injury.  I had leaned toward the latter, because the ACL can be fixed.  Meniscal tears really don’t heal; the body smooths them over somewhat with time, but the end result is just less cartilage, faster wear, and more tear.  The problem with an ACL injury, however, is that it increases the risk of future meniscal tears.  So either way, the knee will never be the same and now I have to deal with it.

We will wait for the official report, and I may see the sports orthopod.  Here’s what I don’t want from that appointment: For him to tell me, “Cathy, you should stop playing volleyball or anything that requires jumping, sudden movements, or the like.  You’re too old and your knee will just be hurt again.”  I will be polite, but in my mind I will think, “You can’t tell me what to do, I’ll play f*ing volleyball if I want to, and I will do it with or without your help.”  What I would love for him to say is this:

“Cathy, here is what’s going on in your knee.  It’s likely that these factors contributed to the injury (lists possible risk factors that he knows from my history), and also it was a freak accident that can happen to anyone, especially jumping female athletes (which is true).  It’s a good thing you’re pretty healthy to start with, and that you had gotten fit these last few years.  What do you want to do now?”

I’ll tell him that I really want to get back on the court and play.  I’ll tell him I want to keep doing all the training I’ve been doing: elliptical, Kangoo running, TRX, pistols, golf, and Betty Rocker workouts.  I want to take up new things like Orange Theory, kickboxing, martial arts maybe, and who knows what else?  I want to be the most active person I can be, and I want to JUMP.  I’ll tell him that I want to be responsible about it; I’m not going to ignore the risks and be stupid.  I want to know the risks, the evidence as it applies to me as specifically as possible, the 44 year-old mom with lax ligaments and super-flat feet.

Then I hope he tells me, “Okay then here’s the plan.  We gotta rehab the knee really well.  Ya gotta be patient.  Keep up with your trainer, strengthen all the muscles around your knees, continue working on core, posture, and form.  When you start jumping again make sure you know better how to land, train that muscle memory and get it down, own it.  Take your time, and take it easy when you start again.  There are braces you can use when you play that will help keep the knee stable.  And you still might hurt yourself again, there’s no way to predict what will happen. But if that’s what you want to do, I’ll do my best to help you get there.”

Because here’s the deal, my friends:  I own my decisions, but I need help to make them in the most responsible and informed way possible.  I don’t need someone paternalistically telling me what to do, how to live my life.  I need the doctor to explain to me the risks, benefits, and costs of what I may want to try.  Then I need to him to trust that I will make the best decision for myself, based on my own core values and goals.  I understand that nobody can predict the future.  But I also have a clear vision of the future I want.  I want to live a very active life, able to try new things and connect mind with body with spirit, and with other people.  I want to look back in 10, 20, and 30 years and say, “I did what I wanted to do, I made my decisions with the best information I had at the time.”  I may hurt myself again.  I may end up with a knee replacement before age 60, and never run or play volleyball again after that.  But if I get there having thoroughly assessed the risks of my actions, having taken all reasonable steps to proceed safely, and having continued to have fun and enjoy my mobility as long as I could, then hopefully I will regret very little.  I would much rather live this scenario, than get to that age wondering, “What more could I have done?  Did I sell myself short?”

This is how I discuss decision making with my patients, particularly when it comes to screening.  Their decisions must originate from their personal values and health goals, not mine or anyone else’s.  How do they understand the risks, and which worst case scenario of screening or not screening, treating or not treating, will they regret less?  A very athletic yet osteoporotic 65 year-old woman really does not want to take medication.  So we review her daily dietary calcium, vitamin D, protein, and vitamin K intake.  We make sure she continues weight bearing exercise every day.  We pay attention to balance, flexibility, strength, vision, and fall risks.  We reassess her risks and goals every year to make sure that we are still on the path she chooses for herself.  I present her with as much evidence as I can, for efficacy of medication, her personal fracture risk, and potential consequences of fracture.  In the end the decision is hers and hers alone; I serve as consultant and guide.

Meanwhile, knowing what’s likely happening in my knee gives me peace and confidence.  Now I can make a plan.  I’m convinced this is why my knee feels better tonight than it has in days, although the ibuprofen I took this afternoon probably also helps.  I have a new compression sleeve that fits under my dress pants.  I can get back to my workouts, and maybe add on a little every week.  My motivation to eat healthy just got a fierce boost (Betty Rocker really helps with this—I have no financial interests in her business, I just really like what she does and how she does it).  I’ll start physical therapy soon.  No volleyball for likely 6 months.  But I got this.  Bring it.

The Doctor Becomes the Patient

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Grandma Has Hurt Herself.

Tonight at volleyball, I was given the perfect set, my timing was getting better, I sprang and hit the ball over the net… I think it landed in, but I was distracted by the crunching sensation and noise I felt in my left knee, and then breathtaking pain as I landed the jump.  Immediately I went rolling, writhing on the floor, lamaze breathing long and slow (nice how that comes in handy at times like this).

As I sat sidelined, the medical inventory began:  No torsive forces, just a buckle.  No ankle or hip pain, only knee.  It’s the bad knee, had similar pain landing a little jump a few months ago, though not nearly this bad.  Pain primarily posterior, deep, left of center, worse with knee extension and dorsiflexion.  Anteromedial joint line pain with weight bearing.  Immediate but mild swelling/effusion.  Hmmm, maybe medial meniscus, possibly also PCL strain/tear?  When should I get the MRI?  How long before I can start PT?  Where is that knee sleeve I got before?  600mg ibuprofen STAT.

The young people were so loving, gathered around asking me where it hurt, getting ice, helping me up, grabbing blocks to put my leg up, glancing over empathetically as I RICEd.  I felt cared for and also embarrassed.

Not just embarrassed.  I felt guilty, maybe even ashamed.  What had happened?  I’ve been training, I’m a good jumper, what did I do wrong?  Was it karmic payback?  I left home just as my kid was struggling with some homework—but nothing I thought she couldn’t handle.  Or maybe I had been getting too cocky that I could actually do this at my age?  Just yesterday I posted videos of my most recent progress on the TRX—I was openly bragging–“toot-toot!” I wrote gleefully.  Or it was an error in judgment: I have not slept enough this week, and I knew I was tired before I went tonight.  But I wanted to go meet my new friends, I wanted to play and have fun.

The frustration came all at once, and with considerable force.  Thankfully I had a friend nearby with a consoling ear and some crutches to lend.  All athletes get injured, she said.  I didn’t do anything wrong.  Yes, I’ve been training, and I was also weekend warrioring it all these months.  This has been my problem knee for at least 15 years, maybe it was going to happen anyway.  It’s still interesting to watch, almost from outside myself, the emotional lava lamp of fear, regret, anxiety, dread, catatrophization, and sorrow.

Experience and maturity, however, make me optimistic.  It’s a temporary setback, and I have resources available to me for recovery, growth, and even enhancement.  Now I get to learn how to use crutches, and I can relate much better to my patients with knee injuries.  I also get to test my newly formed theory that though we may slow down in general with age, we need not resign ourselves to inevitable and morose decline.  Patients ask me often, what should they expect to be able to do at this age or that, how can they know their limits?  For a long time I had no good answer.  But as I have regained strength, endurance, stability and mobility these last few years (tonight notwithstanding), I now tell them: It depends on what you want and how much you invest.  My 1977 Oldsmobile will not run like my 2012 Highlander.  But if I really want to drive that thing, I can put in all the special care and maintenance required and make it roadworthy.  It’s the same with our bodies.  They are incredibly resilient and adaptive, and also mortal.  So we must Fuel and Train, then Rest and Recover appropriately.

I guess I pushed past my current limits tonight.  Setback acknowledged.  I don’t regret the last five months–I made new friends and played and had fun!  I anticipate a high-learning road to recovery.  And I think I’ll get back before they forget me.

 

 

Aging Rocks.

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My high school friend went tubing with her kids, and her body let her know the next day, it was not happy.  As so many of us do when we realize life milestones, she posted to Facebook, “I must remember that I am closer to 40 than 20.”  Before I could type my, “Amen, sister!” another friend astutely pointed out, “Might I remind you that you are closer to 50 than 20.”  OUCH!  And, true.  We were 38 at the time.

This year I turn 44.  Sigh.  And wooo hoooooooo!!  Aging kinda sucks, and it also freaking rocks.

***

Recently our babysitter invited me to volleyball night at her church.  I played in high school and college; it’s how the hubs and I got together.  We relived those days briefly in 2015 when some local people organized a loose pick-up group.  Like many such groups, the level of play varied, and we had fun, but weren’t challenged much.  I expected the same last week, but nope.  I walked into a small gym filled with people averaging, by appearance and vernacular, about half my age.  I watched wide-eyed as they leapt Michael Jordan high, serving, hitting, blocking, and digging better than any team I had ever played for or against.  AWESOME!!!  I finally get to play, after all these years!  And yikes.  I got a little nervous.  These people were intense, skilled, and young.  “Take a seat, Grandma,” I imagined them saying.  But I was a guest of a regular, so I had a little street cred.  And, everybody was very welcoming and friendly.

I stretched discreetly on the narrow sidelines, something we old people must do to prevent injury.  I reminded myself to take it easy, no need to go all out and pull something.  A few more full circle arm wheels and test jumps, and I was ready to go.  I felt my heart pounding a little as I stepped onto the court.  I was one of two women on my team, and my sitter-friend (the other woman) was very encouraging.  I served underhand, as I can no longer rocket it overhand like I could 30 years ago (working on this).  Two thirds of the way through the night my right knee started to get a bit wobbly, and I sometimes felt a strange zinging sensation up and down my lateral thigh.  Grandma, I thought.  It’s usually my left knee that aches.  This was a new pain, with no attributable trigger.

I had so much fun.  The general skill level ranged wider than I had initially observed, though it still skewed high.  I estimate that I ranked in the upper half, maybe upper 40%, rustiness not withstanding.  Everybody was mindful to make sure we all touched the ball, a very egalitarian league.  As such, I got to pass, set, dig, and even hit a few.  I held my own, and it felt good.  One young man gave me the compliment of my month when he said I seemed ‘not that old’ and ‘nimble.’  I could have hugged him.  I went home a little sore, and more than a little high.

***

I credit the last three years of fitness training for my utter lack of pain the next day.  After all, I’m doing things on the TRX that I could not have done at 16, and I’ve exercised 5 days a week, most weeks for the last 18 months.  I’ve relearned how to ride a bike, I can run 5K as a casual jog, and I’m as strong as I’ve ever been in my adult life.  I just need slightly more maintenance nowadays.

But the best part of the night was mental.  25 years ago my worry over what people thought of me loomed over my consciousness in a way that robbed my fun.  Back then every mistake I made on the court chipped away at my confidence, and more mistakes inevitably ensued.   Sometimes I’d have an “on” night, and I always had enough fun to keep me coming back, but too often I’d go home wondering if my teammates regretted my presence.

No more.  I no longer have anything to prove to anyone but myself.  I’m just here to have fun and maybe make myself better—and I can only do that if I’m with people who play better than I do.  I’ll own my mistakes and not beat myself over them—we all mess up sometimes.  I know what I can and cannot do.  I own all of me, and I’m okay.  Looking back, my self-defeating attitude was probably worse for team morale and performance than any dig I missed.  Not anymore!

Maybe some people already had this kind of self-efficacy in adolescence.  I can recall a few peers in my youth who had that calm, collected aura about them.  It wasn’t arrogance or superiority.  Rather, it was an unassuming and authentic self-assuredness, which often translated into a generosity that attracted others to their orbit.  That’s how I feel now, and I think this manner of self-confidence comes most organically with age.  It’s the same confidence I see even more in my older, wiser friends.  I might have run faster, jumped higher, and hit stronger in my teens and twenties, but I would never go back.  Life is too good now, with decades of accumulated experience and integrated learning.

My kids were there last week.  They watched me participate with enthusiasm, mistakes and all.  When I commented that I might not have helped my team much (we lost all our games), my daughter sounded surprised.  “But you’re good!” she said.  Like I said, I left more than a little high.

To Train Or Not To Train

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My sister and brother-in-law run marathons.  No, wait, they are elite marathon-running machines.  By next weekend, they will have run 150 marathons between them in just a few years, including Ironmans and ultramarathons, in 39 states and at least 7 countries.  They lead training groups for Team to End AIDS and enjoy a loyal following of running enthusiasts and friends.  So you can imagine my honor when they recently told me, “You could totally run a marathon, Cathy.  You’re already more fit than a lot people who start training.”

For a moment I actually considered it, because wouldn’t that be so cool, to enter that elite circle?  Then I quickly remembered: I. Hate. Running.  …For now.  But it got me thinking recently–talking politics may be like marathon training.  Some people really like it and do it well (by ‘well’ I mean they are informed, articulate, respectful, and engaging with people from all points of view—their discourse is elevated).  They resemble my sister and brother-in-law: athletes who consistently perform at the top of their training, with few or no injuries, leading others to follow in similar aspirations.

Other people, however, would sooner feed themselves through a wood chipper than strap on a pair of running shoes, or engage in political discussions.

Most of us are somewhere in the middle, I suspect.  I can run a few miles with my trainer if she makes me–the conversation and scenery distract me and the time goes by faster.  And I know I can slow down or take a rest if I have to–it’s safe.  But I have many other preferred exercise activities.  Could we consider talking politics as the elite marathoning of communication?  It is so hard to do well!

When I think of long distance running my mouth goes dry.  I get short of breath and my knees hurt already.  I feel the incredible slog, one heavy step after another–not at all like what I imagine my family feels, bounding weightlessly like antelopes toward their next PR.  I experience a version of the fight-or-flight response, a visceral sensation of threat: I’ll have blisters everywhere, I’ll never make it to the end, they’ll have to carry me, I’ll have a heart attack and die!

Maybe some people have a similar reaction to politics?  I don’t know enough, it’s too complicated.  It’s overwhelming, I’ll look ignorant, people will judge and shame me before I can even finish a thought.  It’s all so emotional, I can’t handle that, it will only escalate into conflict, my relationships will all be at risk, I’ll lose all my friends!

As you may have read, I have been trying to get some conservative friends to engage face to face.  I am genuinely curious about their points of view; I want to understand.  I want to practice my skills—curiosity, openness, empathy, identifying shared interests, withholding judgment.  Two invitations were initially met with a non-response.  After a follow up call or two, I am scheduled to meet one set of friends for dinner this week, and the other said he was too busy.  I feel like I’m dragging them out running when they would much rather play golf or go bowling.

I have realized: we don’t all have to keep up with every day’s new political freak shows.  We don’t all need to be the debate champions of our particular ideology.  Not everybody has to be a marathoner.

HOWEVER:

We all need exercise.  The body is built to move.  Regular physical activity, as we all know, reduces our risks of obesity, diabetes, and heart disease.  Did you also know it can decrease depression, dementia, and even cancer?  So pick your sport—just do some kind of movement every day!

Similarly, even if we don’t all talk politics, we all need effective communication skills, especially in the arenas of conflict resolution, negotiation, parenting (which encompasses them all), and the like.  We are social beings—we only survive by cooperating and living well within our tribes, and by tribes living well among one another.  That can only happen if we practice getting along.

So if you’re not a runner/marathoner, what do you do?  What is your thing, how often do you engage, and what keeps you coming back?  If you hate talking politics, how else are you already a great communicator?

Maybe you’re a natural at getting your toddler/tween/teen to see the wisdom of the rules and getting their buy-in to follow them.

Maybe you can always help your boss and coworker iron out their differences because you can understand both sides (are you in HR?).

Maybe you like to debate the merits of the Marvel Comic Universe vs. DC—and you could argue both sides because it’s just more interesting that way.

We all have areas where we shine, where we contribute to the tribe through words and actions.

I have picked up some tips along the way:

  1. Validate people’s feelings, even if you don’t agree with their position or behavior.
  2. Stay open to the 2% truth of an opposing philosophy or idea.
  3. Withhold judgment on the whole person even though they espouse an ideology you despise, at least until you know from multiple encounters that they have no shred of kindness or humanity in them.
  4. Look for what you have in common with people, and choose to focus there more than on how you differ.

So even if you’re not an elite running machine like my sister and brother-in-law, or you’re not your community’s foremost political pundit, know that your other training matters.

I may complete a marathon someday…  Never say never.  For now I’m happy to stick with my TRX, kettle bells, 7 minute and Betty Rocker workouts (once again, I have no financial interests in any of these businesses).  I appreciate my family’s invitation to run, and I respectfully decline at this time.  Similarly, I will try to be more mindful about inadvertently pressuring people to talk politics.  It’s never meant to be adversarial, only a bid for connection—I’m looking for training buddies!

I don’t need everybody to talk politics.  But I do need everybody to practice excellent communication, especially in political discourse.

We all need that.

On You, Team Captain and Tribal Leader

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NaBloPoMo 2016, Letters to Patients, Day 29

To Patients Who Think What You Do Doesn’t Matter:

Think again.

Yesterday I described You, the Elite Athlete.  All great athletes know they do not succeed alone.  They also appreciate the unique contribution they make to their teams.  What teams do you serve?  How do you lead?  It doesn’t matter whether you have a title or designation.  One of my favorite ideas is that no matter our instrument in the orchestra, according to Ben Zander, we can lead from any chair.

For now, think of yourself as Team Captain, or Tribal Leader.  You have invested in yourself by fueling and training, resting and recovering, managing your stress, and cultivating excellent relationships.  Now you can take the returns and reinvest in those around you:

Appraise:  Prioritize self-care

  • Like on an airplane: “Put your own mask on first.” Tribal leaders know that to effectively care for others long term, they first need to be healthy themselves.
  • Practice awareness and management of your emotions, and prevent emotional hijacking, so as to be emotionally available to our teammates and tribe members.

Empathize:  Speak the team’s language(s)

  • Think of your favorite teachers and coaches—they were able to relate to learners at all stages of development and team morale—and lovingly lift us all up.
  • “People don’t care how much you know until they know how much you care.” –T. Roosevelt

Inspire:  Lead by example

  • Effective leaders reject victim mentality, take responsibility for our actions, and model accountability for fellow tribe members.
  • When we captains can take our own mistakes in stride, as learning opportunities rather than shameful horrors, we make it safe for our teammates to do the same.
  • Everybody is then free to take more risks, voice more ideas, offer more of their authentic selves as a contribution to the whole,
  • Because they see us, their leaders, the ones who set the tone for the group, doing it, too.
  • Key here also is leading out loud—excellent captains articulate and coach the methods of self-awareness and self-management that help us all succeed.
  • By inspiring individuals to pursue personal excellence, leaders create a supportive milieu for collaboration and collective achievement.

Motivate:  Empower team members

  • Effective captains (coaches, leaders) recognize team members’ strengths and potential, as well as areas for improvement.
  • Rather than shaming teammates for mistakes or deficiencies, good tribal leaders provide feedback and encouragement, and more opportunities for practice and development.
  • They take into account each team member’s personal goals, and help to align them with those of the collective—excellent captains connect individuals to the whole.

If your actions cause others to

Dream more, learn more,

Do more and become more,

You are a leader.

–John Quincy Adams

What would happen if you treated yourself like a true leader?

On You, the Elite Athlete

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NaBloPoMo 2016, Letters to Patients, Day 28

To All Patients:

What would happen if you thought of yourself as an elite athlete?

I present tonight the first phase of the presentations I have given this fall to physicians, corporate executives, and tomorrow, a corporate design team.  See how it applies to you:

***

What makes you exactly the same as Pat Summit, Martina Navratilova, Michael Jordan, Dana Torres, Peyton Manning, Serena Williams, Wayne Gretzky, and Walter Payton?  You are an elite athlete.  You have a specific skill set which you spent years training and honing.  You continue, through practice and discipline, to refine it.  It’s an upward striving, just like an Olympian—Higher, Faster, Stronger!  And, you’re part of a team.

So how should you take care of yourself—your very valuable, elite athlete self?

Fuel & Train

  • “Regular people diet and exercise. Athletes fuel and train.” –Melissa Orth-Fray
  • Our bodies are our vehicles. Elite athletes’ vehicles require premium fuel and meticulous maintenance.
  • We all struggle with the same challenges—time, motivation, discipline.
  • Each day we have an opportunity to walk the talk, and practice what we preach. Every good lifestyle choice, no matter how small (apple instead of candy, stand rather than sit), is a step of intention toward health.

Rest & Recover

  • Chronic sleep debt increases risks for diabetes, obesity, impaired immune function: GET MORE SLEEP.
  • Rest and recovery are integral for sustaining long term performance and injury prevention—ie burnout. This applies for both physical and mental exertion.
  • Take your allotted vacations and really disconnect.  The world will still function (temporarily) without you.
  • Broaden your methods: 15 minute walk, 10 minute meditation, 5 minutes of journaling—unwind, unload.

Manage your stress

  • How do you know when you are ‘stressed?’ How/where does stress manifest in your body?
  • What are your existing resilience practices? How quickly do you abandon them when things get busy?
  • Exercise mindfulness: Live in the moment; breathe deeply; speak and act intentionally, not incidentally.
  • We are no different from toddlers—easily emotionally hijacked when tired, hungry, over-extended.
  • Elite athletes use the disciplines above to manage their emotions and stay focused.

Cultivate positive relationships

  • Coaches, teammates, trainers, psychologists, equipment managers—no athlete succeeds alone.
  • We thrive when we feel seen, heard, understood, accepted, loved, and safe.
  • It is only when our relationships are strong and we feel connected, that we can truly care for ourselves and our teams.
  • Who is your support network, and how do they hold you up?
  • Who do you support, and why/how does this fulfill you?

 

What is your sport?  Who is your team?  How does caring for yourself benefit those around you?  And finally, what can you do today, tomorrow, next week, next month, and in the next year, that will elevate your own health and well-being, and that of your team?  Please share your ideas in the comments!