Peritoneal Dialysis

Photo: our Ricky enjoys the overnight cycler. I was going to use this picture for the article in the newspaper, had it all cropped, formatted, and ready to go, then changed my mind because I spotted something in the picture that I didn't think we needed to put in the paper. See if you can spot what it is. Much more private posting the picture on the web, right?

Part three of a series on the treatment of renal failure. Why? Because a year ago my husband's kidneys blinked out like a couple of light bulbs, and renal failure has been the center of our lives since. Writers are always told to “write what you know,” so – renal failure. Part 3:
Peritoneal dialysis (PD) is a way of cleansing the renal patient's blood by putting dialysate, a fancy word for dextrose solution (sugar water), into the peritoneum of the renal patient, letting the solution sit there for a few hours (this is called the “dwell”) pulling toxins and extra fluid across the peritoneal membrane, and then draining the dialysate and putting in fresh dialysate and starting over. No bloodletting involved.
The peritoneum is the cavity in your torso where your vital organs and your intestines live. The cavity is lined by the peritoneal membrane, a sac that holds everything together and is rich in blood vessels.
The problem when PD was first used was that the abdomen had to be freshly punctured (this would be bloodletting) for each dialysis procedure, in effect putting the patient through surgery once or twice a week. Attempts to leave catheters in place were not successful because the site of the puncture or the peritoneum became infected.
PD was being used and improved during the same years as hemodialysis, starting before World War II, but was not used commonly until the 1980s. This was because Henry Tenckhoff designed a catheter that would not cause infection.
Dr. Henry Tenckhoff began working with Belding Scribner at the UW, that hotbed of dialysis research, in 1963. When Tenckhoff began working with PD patients, he had to go to their homes twice a week to perform the minor surgery of inserting a catheter into the patient's abdomen.
Dr. Tenckhoff observed that PD worked well and that PD patients did better in many ways than patients on hemodialysis. Eventually he developed what is now known as the Tenckhoff catheter, which could be placed into a patient's abdomen and left there, and with proper care would not become infected.
The Tenckhoff catheter is a piece of tubing which enters the patient's abdomen and has a coil inside the peritoneum. This inner bit has little holes in it, like drain field pipe on a much smaller scale. The holes facilitate the entry and exit of the dialysate. The outer bit of the catheter is a length of tubing with a connection on the end for attaching a tube to drain and fill the peritoneum.
Once patients have a Tenckhoff catheter placed in their abdomens and they have healed from the surgery, they are trained on how to do PD and then they do it at home, with frequent monitoring by a PD nurse. Testing is done frequently to monitor how the patient is doing and whether dialysis is working. Sterile dialysate is delivered to the patient's home about once a month.
There are two kinds of PD: manual, and machine assisted.
In the manual variety, the patient typically does four exchanges a day in which dialysate is drained from the peritoneum, and fresh dialysate is put in and left in – the “dwell” - for four hours or so, and then drained and replaced. An exchange takes 30 to 40 minutes.
In machine assisted PD, the patient hooks up to a cycler machine at night which does exchanges while the patient sleeps. Unfortunately the machines set off alarms if anything isn't quite right – not enough dialysate draining is the most frequent problem. So these patients might not get much sleep at night.
My husband started on manual PD, which turned out to be a full time job, but now he's on the overnight cycler machine. He feels and looks better than he has since he became ill over a year ago. We like PD, alarms and all.
Not everyone can do PD, but it's an excellent way to go if you can.
Next time: Kidney transplants

Hemodialysis Gets Serious

Photos, left to right: Dr. Belding Scribner, inventor of the shunt; Wayne Quinton, who built the first shunt; Dr. James Cimino, Dr.Kenneth Appell, and Dr. Michael Brescia, who pioneered the AV fistula which is used for hemodialysis today.

Dr. Willem Kolff built the first dialysis machines, but they were made practical for treating end stage renal failure by Dr. Belding Scribner at the UW.
Scribner grew up in Chicago, got his medical degree at Stanford and did his post-grad work at the Mayo Clinic. He joined the faculty of the School of Medicine at the UW in 1951. Like Dr. Kolff, he was deeply affected by the deaths of renal patients.
Dr. Kolff's dialysis machines could get acute renal failure patients through a crisis until their kidneys began to function again, but patients with end-stage renal disease could not be saved. Surgery to open up access to veins and arteries damaged blood vessels so that after a few treatments it became impossible for doctors to access a patient's blood.
Scribner said that one night in 1959 he woke up with the idea for a shunt in the patient's arm, using plastic tubes, one inserted into an artery and one into a vein, with the tubes connected by a piece of tubing in between dialysis sessions. He brought his idea for the shunt to Wayne Quinton.
Wayne Quinton was a medical engineer at the UW in charge of building, maintaining, and inventing medical instruments for the Medical School. Quinton figured out how to build the shunt Scribner had envisioned. Suddenly it was possible for people to have long-term dialysis, and end stage renal disease went from fatal to treatable.
Right: the Quinton-Scribner shunt

There were only six dialysis machines in Seattle, though, and there were more renal patients than could be treated. Scribner decided that he would not make the decision of who would get dialysis. A committee was formed to review cases and decide who would receive treatment. The formation of this committee is recognized as the beginning of bioethics. Such committees decide who will and will not receive organ transplants, for example.
Dr. Scribner worked with the King County Medical Society to found the Seattle Artificial Kidney Center, which became the Northwest Kidney Centers, in January, 1962. It was the first out-patient dialysis center, and was the model for how hemodialysis is done today. Currently any patient who needs dialysis gets dialysis.
Scribner and Quentin had revolutionized hemodialysis, but the shunt had problems – clots tended to form in the tubing, for example.
Comes now Dr. Kenneth Appell, who grew up in Queens, New York. After serving in the Navy in the South Pacific during World War II, he returned to New York to complete his medical and surgical training.
Dr. Appell installed many of the Scribner shunts, but was not happy with the problems they had, chiefly clotting in the tubing. He came to believe that it would be possible to create an arteriovenus (AV) fistula in a renal patient's arm. This means that an artery would be stitched together with a vein, with a hole (fistula) in between that would allow arterial blood to flow directly into the vein, thereby avoiding the problems of the shunts. Arterial pressure on the vein causes it to enlarge. It takes weeks to months for a fistula to “mature,” but then two needles can be inserted into the vein regularly to remove blood for dialysis and put the filtered blood back into the patient's body. This is the “gold standard” for hemodialysis today.
Two of Appel's interns, Drs. James Cimino and Michael Brescia, began doing Dr. Appell's AV fistula surgery in 1966.
Right: a drawing showing how an AV fistula is constructed within the arm


Since the 1960s, millions of lives have been saved by hemodialysis and the techniques developed by Drs. Scribner, Appell, Cimino, and Brescia and their teams.
As for Wayne Quinton – in 1959 he quit his job at the UW and started a business called Quinton Instruments to market his inventions which the UW declined to develop. Most famous of these were the Scribner shunt, and a treadmill he invented for cardiac stress tests. Every treadmill you see today can trace its history to the self-winding mind of Wayne Quinton.
Right: A drawing Rick made of his "wristula" in December, 2009, when he was healing from the surgery

Rick, Meet Dr. Kolff

Photo: Dr. Willem Kolff, center, with two colleagues and an early dialysis machine

Last October my husband, Rick, was diagnosed with “end stage renal disease.” That diagnosis is every bit as serious as it sounds.
There are levels of renal (kidney) failure. There is “acute renal failure,” in which your kidneys may recover enough function to carry on. Rick had that in 1997, which left him with partial kidney function for 13 years.
“End stage renal disease” means that your kidneys are done. Period. When Rick was diagnosed, what had been our normal life came to a halt, and we began living a “new normal.”
You learn a lot when the earth moves under your feet in a bad way. One of the first things you learn is how gracious and generous people can be when they see a need, and people have supported us in every way since last October. There has been so much kindness, there have been so many prayers, and people forwarded money that helped us pay the bills. It is a cliché to say that if I tried to thank everybody by name, I would no doubt leave someone out, which would be a pity. Like most cliches this is true, so I will simply say: Thank you. You saved us. Yes, you. Please take our gratitude to heart.
Last October 5, when Rick received this diagnosis, we had no idea what was going to happen to him, and where it was leading. Where it led was to home dialysis. I could do a lecture on dialysis. In fact, I think I will.
There are two kinds of dialysis: hemodialysis, and peritoneal dialysis. Hemodialysis is the cleansing and filtering of blood. The idea was around for centuries, but the process as we know it was pioneered by Dr. Wilhelm Kolff in Holland during World War II.
Kolff was born on February 14, 1911, in Leiden, Netherlands. He became an MD in 1938, and one of his early cases was a 22-year-old man who died of renal failure. Dr. Kolff thought there ought to be a way to save such patients, and he put his considerable mind to the task. In his research he found an article by John Abel, a pharmacologist from John Hopkins University, who wrote in 1913 about experiments with dialysis in animals.
After the Nazis invaded Holland in 1940, Kolff persisted in figuring out hemodialysis despite the Nazi occupation. He and his family, friends, and colleagues risked their lives to invent a dialysis machine using what materials they had at hand, including cellophane sausage casings, a cooling system from an old Ford, parts from a crashed German fighter plane, and washing machine tubs. Kolff's original idea was to give compromised kidneys a break so they could rest and resume functioning, then dialysis would be discontinued.
The first dialysis machine was completed early in the war, but the first successful treatment of a renal patient by hemodialysis was not until 1945. This patient was a woman in a renal coma. She had been a Nazi collaborator, hated by the people in the town where Kolff lived. He believed he was a doctor, not a judge, and treated her. She awoke from her coma, said, “I am going to divorce my husband,” and lived another six years.
After that it was a process of refining and improving hemodialysis machines. He sent five of his hemodialysis machines to countries around the world, including the United States. The machines evolved from helping people in acute renal failure through a crisis into also keeping people with end stage renal disease alive.
In 1950 Dr. Kolff immigrated to the United States, and in 1956 he became an American citizen. In 1957 he went to the University of Utah and started a Division of Artificial Organs and spent the rest of his life researching and developing artificial organs, including the artificial heart. Robert Jarvik, one of Kolff's graduate students, was the project manager for the development of an artificial heart, and the Jarvik 7 heart currently is used in terminal cardiac patients as a bridge to heart transplantation.
Dr. Willem Kolff died last year, February 11, 2009, four days before his 98th birthday. All hemodialysis patients alive today, including my husband Rick, and patients with many other terminal conditions owe their continued existence to Dr. Kolff and his insatiable drive to invent and improve machines that saved lives.
Dialysis machines gradually were refined and improved, but one of the main problems – how do you get a person's blood out, cleansed, and then back into the person's body? - remained a challenge. This brings us to University of Washington professor Dr. Belding Scribner.


Next time: Dr. Belding Scribner, the fistula, and modern hemodialysis

Boom! I say Boom!

Big excitement here last Tuesday - Obama came to town. That had all the news anchors twittering, but the real excitement was that some poor bozo who'd been away for a long weekend at Lake Chelan with his girl friend was flying back to Seattle and crossed temporarily restricted air space. Fighter jets scrambled out of Portland, Oregon, and about quarter to two it sounded like the whole world was exploding here: BOOM BOOM! The house shook, everything rattled - I couldn't imagine what it was - went to the kitchen door and again: BOOM BOOM! and again the house shook and everything rattled.
Very upsetting - we didn't know what was going on, and were looking for any sign of smoke, an explosion? Rick thought a neighbor was removing a stump. JD was in his room and thought a branch had fallen on the house. I didn't know what it was.
I drove up to town to pick up mail and looked for any sign of anything - nothing.
When Drew came home from work he solved the mystery for us: sonic booms, Obama in town, someone violated no fly space. Lordy. The guy in the float plane didn't know what was going on, landed at Lake Union and pulled in to Kenmore Air, the float plane base in Seattle, and he and his girl friend were in their car starting to drive away when someone stopped them and told him, Dude, you are in deep, deep kim chi.
The five o'clock news featured a video taken through a Kenmore office window of the guy (attired in a tank top, shorts, and sandals) having an extremely serious conversation with a Secret Service spook in dark suit & dark glasses. I'm told that Secret Service spooks have absolutely no sense of humor.
The girl friend was babbling to the TV interviewer: "We were clueless. We thought it was a quiet flight. We had no idea. I'm a hairdresser with a salon in Normandy Park!"
Just trying to distance herself from any ties to Al Qaeda, I imagine.
Meanwhile - the sonic booms scared the crap out of people all over Puget Sound, and crashed the 911 system in Tacoma. Among other things.
I guess Obama had a nice lunch at a bakery in Pioneer Square, and appeared at a fund raiser for Patty Murray, by the way. He was in town for four hours, and that was supposed to be the lead story on the five o'clock news, but the sonic booms came first.
I'll bet that pilot never makes that mistake again.

Letting My Freak Flag Fly

My goodness, it has been a long time since I've visited this space.
My friend, Susan, is recovering from her heart attack. She says she "died a little bit" that day. Scared the holy living crap out of everyone, too. But by the grace of God, rapid medical care, and a large dose of clot buster, she came back to the land of the living and I'm so grateful, as is her family, as are her friends. She is celebrating by doing more paintings (see above, "My First Self Portrait," which I really like)and by starting a new novel, which I wish she'd write more of so I could find out what happens to Martha, the protagonist.
So that's good news of a major kind.
The other major news, which you know if you read Rick's blog, is that Rick is now using the overnight cycler machine for dialysis. Yay! But - there's always a "but," isn't there? A qualified yay - the machine is finicky, persnickety, and a fussbudget. Rick has to watch it like a hawk to make sure it primes properly, and then if his first drain isn't large enough to suit the machine it starts giving alarms, and he ends up making phone calls to tech support, and to his PD nurse, Angela, who is a saint, really, at all hours of the night as the machine beeps and boops away. So he's still napping a lot during the day time to make up for the sleep he misses at night, and all is not bliss and happily-ever-after. Actually, when you have end stage renal disease, happily ever after is a pretty slim option, but damn it, you do the best you can, and the machine is both deliverance and pestilence at this point. More deliverance, so Rick is soldiering manfully onward as he and Angela and Baxter, the machine company, try to find the path where this method works best. It all takes time. It still beats going to Seattle three days a week for dialysis.
And it's kind of cool to see Rick walking around looking a little bemused because suddenly he doesn't have to go to Seattle, OR do manual exchanges during the day. Although he did do one today. Like I said, it's a time of tweaking the process.
People keep asking me how I am, how am I doing, what am I doing for ME. Um. Well. I'm somewhere between OK and ready to pop my cork. I could be either of those things, or both, at any given minute. Rick does not need physical care from me; he's fully functional. I hang around the house, do a little laundry, the dishes, sweep a floor occasionally, go out and pull a weed, and occasionally do paperwork like, oh, paying the bills. There are things I do not understand, like why his medical insurance through work paid for everything, and Medicare does not.
Also it seems that even though Swedish Hospital scans his medical insurance cards when he comes in for surgery, the information does not get passed along to the anesthetist or the radiologist, who send bills to his former insurance, which does not pay, and then we get these whopping bills in the mail and Mary starts to hyperventilate until I realize what's going on.
I still do not have medical insurance. I thought maybe I could get some once my Social Security started, but it started this month and I do not have enough money to get medical insurance. I am burning up brain cells, as usual, trying to think of ways to earn money. We'd like to do a Log of the Oatus book, and a Collected Spiritual Smart Aleck book, but these things never get much beyond the idea stage. Still thinking, still burning brain cells. We are going to declare bankruptcy, but, ironically, we haven't been able to afford it. Interesting.
One success: my hair is still growing. A pretty small thing, which requires very little effort on my part, but after two years it's getting long and it feels like an accomplishment. Ask anyone who has let their hair grow out - the accomplishment is getting through the middle stages. Originally I planned to let it get long enough to cut off and donate, but now that it is long, I'm not quite willing to let it go yet. Oh well. The longer I put off cutting it, the more there will be to donate, right?
And how pleasant it is to fuss about something as trivial as the length of my hair when there is so much to think about that is not trivial.
On that trivial note, I think I'll turn in. Blessings to you all. Thank you for all your prayers, good wishes, and material support. You have pulled us through so far, and we love you for it. Pleasant dreams.

My Friend Had a Heart Attack

My friend Susan Bardwell, the painter of the picture in the previous post, had a heart attack today.
I've never met her in person.  She lives down near Houston, Texas, and is a funny writer/journalist as well as a talented artist. David and Jane Shepherd introduced us, via email, and we've had a daily correspondence for the last two (three?) years. Like me, she's a smart aleck; has two adult sons roughly the same age as our sons who live with her and her husband; and has a grandson who lives with them because his father (her older son) has custody, so she ends up being mommy most of the time. Our grand daughter lived with us for almost three years, age almost 2 to almost 5, so I got to be mommy again for a while, also. We relate.
She and her husband produce what she calls a "paperless," The Angleton Journal,an electronic web newspaper they put out every Monday, and she writes a humor column for it. I haven't written a humor column since Rick got sick, but know what it's like and commiserate with her on the misery of deadlines.
My favorite quote on deadlines, and I can't remember who said it, is: "I love deadlines. I love the wooshing sound they make as they go by."
Susan is NOT like me in that she is a pretty good judge of character. I tend to think that everyone's great, unless I take an immediate dislike to someone, and I've often been wrong in my first takes, mostly about that thinking everyone's great. Susan worked for years as a crime reporter for the Houston Chronicle. She certainly got well acquainted with the less attractive side of human character there, and minces no words when she expresses her opinion of same.
She's a fierce mama lion for her family, and loves her whole overextended family in a prodigal fashion.
We came up with the acronym FASTOB, which stands for, "fat, average, sarcastic, tough old broad." Our sisterhood.
Oh, carp, she's just a real great buddy, and I hate it that she had a heart attack. I know she had one, at least, before, in her early 40s, and had some stents put in, so I guess it's not totally out of the blue, but it stinks. It sounds like the EMTs and the local hospital got the clot buster (or whatever) into her before she was airlifted so the obstruction was removed - washed away - I don't know – soon, and by the time the helicopter has taken her to the big hospital in Houston (Herrmann, I think) she was feeling better.
Her husband said she was scared, but by the time they left her at the hospital in Houston this evening she was joking with them. She'll be in the hospital a couple of days at least.
I'm still praying, for her health, and in thanks for EMTs, techs, doctors, nurses, and hospitals. We've spent so much time in the precincts of these people the last year and a half, and have acquired such respect and appreciation for them.
I am hoping she continues recovering well, and after she's home I'm going to try giving her a call. We've never actually spoken to each other. I think it's time.

My Friend Paints; and Watch Out for That Tree

Greetings, Dear Hearts and Gentle People ~
Above you see a painting of a scene down at Tramp Harbor here on Vashon Island. You can see the mainland and a few pale peaks of the Cascades in the distance, off to the east. What's extraordinary about this painting to me is that it was painted by Susan Bardwell, my writer friend down in Texas, who has never been to Vashon Island, as far as I know. A couple of weeks ago when my friend Sonya was here to take care of me (us) when I had surgery, we went down to Tramp Harbor one day to commune with the water and the shore, and Sonya said, "Take some pictures to send to Susan to paint." So I did. I didn't know she'd paint something right away, but she did, and sent me the digital file, which you see here.
I really like it. A lot. Susan has started painting in the last few months, kind of to her own surprise. To hear her tell it she woke up one morning and decided it was time to do something different that was for her and for fun, and painting was it. She's been sharing some of her efforts since then.
In the foreground, the bottom left corner as you look at the painting, you can see the gabion cages, which are hefty wire netting that hold large rocks together to protect the beach and the road from erosion. That's one of the details of this painting that blows my mind. And one of the things you might look at and say, "What IS that?"
It's exciting to me. I am not a visual artist, but I love visual arts. When I try to draw, I can do okay, sorta - my best subjects have been sleeping dogs and cats, and chickens - but I've never been able to bring color into the mix. It is foreign territory. I'm a pencil and ink sketcher, and only every third or fourth year or so.
So watching Susan learn to use space and color and perspective the way she does - Rick says, "I wish I could paint like her. She's fearless!" - is an honor and a great pleasure.
And I'm hoping if I praise this painting highly enough she might send it to me for Christmas.

Watch out for that tree: It's a windy afternoon here on the island. I went out into the yard to whack a few weeds, and then sat in one of the old plastic Adirondack chairs that ornament our yard, and watched the tall trees that surround our house tossing in the gusts as they came and went. I like to sit out in the yard; it's peaceful, and because we are surrounded by trees and there is a circle of sky overhead, I can lay my head back and look at the clouds whizzing by and think about not much of anything.
That's what I was doing until I heard a crack. It was the crack of something in a tree breaking, some part of a large limb or trunk. When a tree goes down, or a big part of a tree, it starts with such a crack and then proceeds to make a lot of cracks which gather and multiply and crescendo until it sounds, I am told, like a barrage of small arms fire, and the noise goes on until the piece that is struggling lets go and falls free, plowing through the undergrowth with a sigh and a whoosh, taking a lot of smaller trees and bushes down with it.
In that undergrowth is exactly where you don't want to be when a tree lets go. Now, I am as foolish as the next person. I sometimes plan what I would do if I heard a tree begin to fall in my vicinity. My plan is to get to my feet and head for the house as fast as possible, on the assumption, perhaps mistaken, that the house would shelter me from the force of the blow. Unfortunately I have lived long enough to know that what I'd probably do is sit there frozen and hope that tree didn't fall on me. A tree went down about twenty feet from our bedroom during a night storm some years ago, and as I heard it go I did not move, just froze there in bed and waited for it to be over. It fell the other way, into the ravine. Lucky.
That is why when I heard that crack I decided to come inside. So I did. And that brings us up to date.