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.

Mobility is Confidence

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It is Day 11 of NaBloPoMo 2017: Field Notes from a Life in Medicine, Day 10 of Bum Knee Cathy.

So far, so good!  This third time through NBPM is definitely easier and less stressful than before.  It’s not my best writing, but it’s not bad.  I’m spending less time thinking and writing, and having ‘way more fun.  Can’t say that much for BKC, though.  I’ve never had an injury like this and I’m not quite sure what to expect.  The good news is, swelling is decreasing and I limp a little less every day.

I had not gone 7 days without exercise in almost three years, and it was starting to feel a little too comfortable.  It also did not help that we had a bag of Kit Kats left over from Halloween—bad planning.  So on day 8 I decided to see what I could do in the gym.  Turns out, I still need to avoid activities that require me to plant my feet or fully extend the knees.  But there is still a lot I can do, and today I found a full suite of moves, some modified, that were enough to break a sweat, woo hooooo!!  Even though I wrote that I was good about losing my training discipline, I was still worried.

Today, however, I have my confidence back.  Earlier this week I reconciled with the possibility of not playing volleyball anymore, but I have not given up on my intention to get back on the court.  And if that’s not possible, then I can try the other things on my list: martial arts, kickboxing, tennis, and who knows what else?  Still so many possibilities!

The day before I hurt myself I passed a lady on the way to work.  She was older, obese, walking with a limp and a cane.  I came up behind her, slowed down, and passed her when space opened up on the sidewalk.  I suddenly appreciated my unencumbered gait.  How ironic.  My parents are almost 70 years old and they just returned from a month-long tour of China and Taiwan.  He golfs and she still precepts nursing students in the hospital.  Neither of them has ever had a prolonged period of immobility, even after major surgery.  They still move through life confident in what their bodies can do, looking forward to their next trip.  I know many orthopaedic surgeons.  With them I have shared patients who got their lives back after joint replacement surgery—able to walk, golf, and even ski again—without pain, and with confidence.

Tonight I appreciate that much more what my parents have achieved and what my colleagues do.  I appreciate my body that much more, and what is required to maintain it.  I appreciate the importance of conversations with my own patients, when we talk about establishing habits in middle age that will allow us all to be strong and healthy in old age.

How much do we take our mobility for granted?  For myself, not as much today as I did 12 days ago.

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.

 

 

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, 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!