Black and White Sunday: Maternal

Taken just this week, this seems appropriate for Paula’s Mother’s Day theme.

Every "Mom" is Beautiful in the Eyes of Her Children

Every “Mom” is Beautiful in the Eyes of Her Children

To learn more about the Opossum, or “possum,” go to “Mama ‘Possum at Last!”

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A Mama ‘Possum at Last

From my earliest memories as a child, I had a several nice big books with pictures and stories about common animals. The images were drawn, pen and ink in subdued colors. There were deer, raccoon, a wolverine and a drawing of a mama opossum (or “possum”) with a litter of babies riding on her back. So, I have known about this behavior for many years.

But, this morning was the first time I have seen it for myself, live, in nature. Looking out the kitchen window toward the pasture, I saw two possums walking along the fence. They then came around in front of Grover’s smokehouse, and it was then that I realized the larger, apparently mama possum had four little ones riding on her back. The second adult, smaller, presumably the male, skulked along behind them.

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Mama Possum kept a sharp eye on me as I approached for photos.

Of course, I grabbed my camera. Possums are not speedy creatures. I was able to get within a few feet to get some good photos.

Natural History

The possum is the only Marsupial native to North America. The female gives birth to up to several dozen babies that are less than an inch long. These babies make their way to the mother’s pouch on her belly. Inside the pouch are 13 teats .  Therefore, only the first 13 babies will survive, initially. Of these, eight or nine will survive to two-and-a-half months, when they will leave the pouch.

They then the climb up on the mother’s back and ride around there for four or five months. Life is harsh for babies, and if they fall off, they will be abandoned. Eventually three or four will survive to the point where they leave their mother. Even then, they may fall victim to predators or starvation. The female possum may have two or three litters per year.

Possums are omnivorous, eating a wide range of plants and animals, including fruits, grains, insects, snails, small mammals and reptiles.

Possums do play “possum” when attacked or threatened. This is an effective survival strategy, provided the attacker is not a hungry carnivore.

Also, possums have a prehensile tail, which means they can use the tail to assist as they climb through trees. They can hang by their tails, but only briefly.

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Angina – From Diagnosis to Treatment Part 3 – Treatment

Part 3 – EECP: “Snake Oil” or Treatment

Photography – Peggy Richmond

My next—and most recent—visit with Dr. B was following the catherization. I was still unsure about the likely course of treatment. After he mentioned EECP (Enhanced External Counterpulsation), I did a quick search to find out about it. My first impression was…, well not real positive. The term “snake oil” came to mind.” So, in my appointment, I was hoping to hear about some treatment options—drug therapy or some other options. He pointed out that, in my case, the only drug therapy would be expensive, and probably be for the rest of my life, and not really produce any improvement—just control symptoms. The EECP, however, would actually improve the arterial blood flow to the heart, around the partially clogged artery, without drugs.

Okay, maybe I should pay more attention, and I did more research.

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This image shows the increase in blood flow to heart muscles after EECP.

The counterpulsation sends blood under higher than normal pressure through smaller arteries of the heart, causing them to gradually expand and carry more blood, making up for the blood not getting through the partially clogged artery.

Dr. B. introduced me to Amy, the nurse who is in charge of the EECP treatments done right there in their offices. She explained how, when lying on the machine, cuffs around my calves, thighs, and abdomen inflate rapidly (essentially instantaneously) immediately after each heartbeat, increasing the pressure in the heart’s smaller arteries. When the cuffs inflate, they squeeze firmly and quickly, first on the calf muscle (gastrocnemius), then (milliseconds later) on the thigh muscle, and finally on the abdomen; then they immediately relax.This sequence is repeated at the pace of the patient’s pulse.

Each treatment lasts an hour, and the full course of treatment is 35 sessions over seven weeks, five days a week. If a patient must miss a treatment, they just add a day on at the end to make up the full 35 days.

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The EECP Bed showing the cuffs that will be wrapped around the calves, thighs, and abdomen.

Incidentally, after more research I learned that EECP became a medically approved form of treatment in 1995, and became approved for Medicare payments in 1998. That boosted my confidence a bit.

We set up a schedule, and I arrived for my first, introductory treatment. Alexis was to be the regular nurse for my treatments. She explained that the first session would be 20 minutes and that we would add 10 minutes each day until reaching 60 minutes. She also suggested that I wear pants without heavy seams (like my jeans) and suggested something like sweat suit pants—which I bought that afternoon after the first treatment.

The basic guidelines for daily treatments are simple: no food or drink within one-and-a-half hours before each treatment. They also suggest urinating just before beginning the session. I am halfway through my treatment program and I can attest that after an hour of being squeezed in the legs and abdomen, repeatedly at the rate of 55 to 65 times per minute, you do not want a full bladder!

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Nurse Amy is about to start the EECP. Note the cuffs around the ankles, thighs, and lower abdomen. Barely visible are wires attached to my chest that sense heart beats and control the rhythm of the machine.

I also learned that the sweat pants I got were not suitable. First, they were a synthetic material, and they were not tight, forming wrinkles under the pressure cuffs. These wrinkles created blisters. Amy found a pair of what looked like tights—supplied with the EECP machine—that fit snugly. I put large patch bandages over the blisters and wore the tights. Soon, the blisters healed and no new blisters have occurred. The key is to wear something that fits snugly to the leg and that will not slide around as the cuffs inflate/deflate. Do not wear shorts.

The daily routine is this: Each day, I arrive fifteen minutes before the scheduled appointment. My first stop is the bathroom, then down to the EECP room. Alexis or Amy is there to greet me. I wear my tights under my street pants, so there is no delay getting started. Shoes and pants off, socks stay on. Alexis takes my blood pressure, and I lie down on the bed. She straps the cuffs around my calves, thighs, and abdomen, snugly but not tight.  She also attaches three electrical leads to my chest. These leads, similar to those used on an EKG, send the signals to the machine to control the timing of the inflation of the cuffs. She also clips a pulse sensor on one finger. Once I am strapped in, she turns on the machine, and the cuffs begin to inflate, lightly at first, gradually building up to a firm, quick squeeze. At full pressure, the inflating cuffs produce a quick, firm, but not uncomfortable, jolt.

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The complete setup showing the control console.

The speed of the inflations is directly controlled by the heart, and the rate of inflations is the same as the patient’s pulse, typically a rate of 50 to 65 times per minute. Alexis has a computer control panel to monitor and adjust the pressures as necessary. The only thing more boring than lying on the bed being jolted by the machine must be sitting at the control monitor for 60 minutes!

It is difficult to move around much at all during treatment. Too much movement may cause the machine to skip a beat or two, which is a little annoying. I am told some people can read during the treatment. I prefer to take my MP3 player loaded with lots of music. Conversation, if there is something to talk about, is also possible, and I think they would allow someone to accompany me if that is what I wanted.

I just completed my 18th day of treatment. I have been out working in the yard, using a powered push mower. Before I started the treatments, I would get the pain in my chest (angina attack) after about 10-15 minutes of pushing the mower around. Now I can mow whole sections (30-40 minutes) with no discomfort. It appears that there is real improvement.

Once completed, the effects of the treatments are supposed to last three to five years. The treatment program can be repeated. For those eligible, the treatment program is covered by Medicare or most comprehensive medical insurance plans.

Angina – From Diagnosis to Treatment Part 1 – Diagnosis

Angina – From Diagnosis to to Treatment Part 2 – Treatment

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Angina – From Diagnosis to Treatment Part 2 – Testing

Part 2 – Testing to Confirm Angina and Select Appropriate Treatment

Test 1 – The Stress Test – Not Much of an Adventure

A week later, I was on a treadmill at the doctor’s offices for my stress test. I frequently used a treadmill—until the angina symptoms began to continue after the New Orleans trip. The test ran for twenty minutes. I was wired to an EKG device. During the test, the medical technician increased the speed and raised the incline on the treadmill. The speed was more than two miles per hour and the incline was at least ten degrees—I suspect more. I maintained this maximum speed and incline for three full minutes. Still, while I did experience some tightness in my chest, I did not get the more intense discomfort that I had experienced in New Orleans.

Following the stress test, the office made an appointment  for a heart imaging test. I was in the waiting room at the appointed time.

Test 2 – The Imaging C-Cam – The Adventure Continues

A young man in green scrubs called me back into an examining room. He explained that he was going to give me an injection. The injection was a liquid that would enable the imaging machine to see the details of my heart’s vessels. As I recall, he called injected fluid “magic juice” when I asked exactly what it was. I would have to wait a couple of hours for the “magic juice” to get into my circulatory system, then he would call me back for the actual scan. He suggested I get lunch and be back in two hours.

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Figure 1. The C-Cam is mounted in the box above the recliner. It hovers above the patient’s chest, moving every few seconds to take a series of images of the heart.

Shortly after I returned from lunch, I was ushered into the “imaging” room. The main feature in the room is the “C-Cam” (See Figure 1). It is a recliner with a large, square suitcase-sized camera mounted on an articulated arm above the recliner. He positioned me on the recliner, told me to hold still—for 14 minutes—while the images were captured. Once in position, the camera head hovered only millimeters above my chest and moved, ever so slowly, in incremental steps for the 14 minutes, taking images from a series of different angles.

After the test, I did a little research, and determined that the fluid contained a radioactive isotope, and probably one called technetium-99m (Tech-99). The key fact about this “radioactive” isotope is that it produces no more radiation than an X-ray, and that the isotope (since it was floating around in my system), has a half-life of about six hours, meaning that within 24 hours, radiation from the isotope is negligible.

Test 3 – Catherization – The Adventure Becomes More Intense

It was not unexpected. By now, I had spent some hours searching for everything to do with the causes and treatment of angina. Therefore, I was not surprised when Dr. B explained that he wanted to do a catherization. Basically, he would insert a thin tube in my femoral artery in my groin and push it in until it reached the aorta directly above the heart. There, he would inject a contrast agent into the blood that would show the details of the arteries around the heart using an X-ray imaging sysem.

If, as he suspected, it would confirm that an artery on my left ventricle was partially clogged. Depending on the results of the catherization, treatment would be drugs, a stent, or open heart surgery (bypass surgery). He also suggested that, if the stent was indicated, it could be inserted at the same time.  He would do the procedure on Wednesday when there would be a specialist on hand to do the stent implant, if indicated.  The office set up the appointment time—6:00 am—for the “same day surgery” section, adjacent to the Emergency room, at the local hospital, .

Preparation for the catherization begins in the receiving area of “same day surgery.” I was placed in a small hospital room, and given a hospital gown to put on, with instructions to take off everything but my socks. This included watches, rings, etc.  There really was very little waiting. Every step was scheduled and seemed to move along a very deliberate, but efficient pace.

From there I was placed on a highly mobile hospital bed and wheeled to the “Catherization Lab.” It said so on the door. (A momentary image from the Rocky Horror Show flashed through my mind:  “…come up to the lab and see what’s on the slab!”)

The lab had a prep area and the imaging area. Catherization (Figure 2) is done in a hospital “clean” room rather than a sterile operating room. Preparation was simple. I was hooked intravenously to a bag of saline, and given an injection to relax me. It was not intended for me to go to sleep, but just avoid being tense. The next step was to shave the insertion site for the catheter. Where is that? Sit upright in a chair. Place you fingers at the point where your thigh folds up against your abdomen.  Right there. The area had to be shaved and sterilized, and the nurse explained that she would shave both sides just in case the doctor had difficulty with the first side. But first, she discretely draped a towel from my navel down between my legs to “preserve my modesty,” like at that moment that was my main concern!

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Figure 2. Catherization: A long flexible catheter is inserted in the femoral artery in the groin and pushed all the way up to the heart, where a dye is released that provides contrast for the imaging camera.

Shaved and sterilized, they wheeled me over to the actual catherization area. There a nurse gave me shot of local anesthesia where the doctor would make the incision. There was a curtain obstructing any view of the doctor’s activities, nor could I see any of the imaging equipment being used. I could hear quiet voices, but not much else.

Catherization involves an operating table under a smaller imaging head, while a contrast dye, visible in X-rays, is injected through the catheter. X-ray images show the dye as it flows through the heart arteries. This shows where arteries are blocked. The contrast agent is delivered by the tube inserted in an artery in the groin area—in the same manner that a stint might be implanted.

I was awake for the entire procedure—and felt no discomfort. After about 10 minutes, my doctor, who had inserted the catheter came to the head of the “bed” and said. “The blockage in your heart is too long for a stint. See me next week about ‘EECP’.”  That also let me know that he had ruled out any kind of open-heart surgery.

Tomorrow: Part 3 – An Unfamiliar Treatment 

Angina – From Diagnosis to Treatment Part 1 – Diagnosis

Angina – From Diagnosis to Treatment Part 3 – Treatment

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Angina – From Diagnosis to Treatment Part 1 – Diagnosis

Part 1 of a 3-Part Series

Introduction

Earlier this year, I was diagnosed with Angina pectoris, pain in the chest caused by restricted blood flow to the heart during periods of exertion. The following is a three-part essay of my journey from first experiencing angina, through testing and diagnosis, and finally, what I consider a really clever (and medically accepted) treatment plan.

The purpose of this blog is to relate my personal experience in a way that others may learn from it, especially if they experience the same symptoms, or know someone who has. There is much technical information associated with the diagnostic tests, and I have provided links to Internet sources for those of you who want more on the technical details. They are not essential for understanding the basic story.

Part 1 – Diagnosis Angina

Over the past year—mid-2016-early 2017—I have had very occasional low-grade pain in my chest. It did not last long, and typically, I dismissed it as either indigestion or esophagitis. Yes, I did notice some additional discomfort radiating across my left shoulder and down my left arm. That was the clue that I overlooked. Until this past February, I would have classified the “pain” as simply an annoying discomfort of no real consequence.

Then, this February, my friend and I traveled to New Orleans to visit the World War II museum. We spent two 8-hour days on our feet looking at all of the exhibits. I had no pain or discomfort of any kind. The evening of the second day, however, as we were walking—briskly—to dinner it began. We had to travel two long blocks. At the end of each block we had to wait for traffic lights to change to cross the street. By the end of the first block, I experienced more than “annoying” pain in my chest, directly under my sternum, and also had the dull aching pain in my left arm. While we waited for the light to change, the pain subsided and went away. This was repeated during the second long block. From that point, we turned and followed a series of much shorter blocks. I also elected to walk at a slower pace. The discomfort did not occur again, and on the walk back I suggested a slower pace, you know, to just be able to take in the sights of New Orleans. Otherwise, I said nothing.

Routine Doctor’s Visit

Several weeks after returning home, I had a routine physical appointment with my doctor, Dr. S. Prior to seeing the doctor, a nurse always takes my blood pressure and asks a few routine questions, including asking about how I have been feeling. That prompted me to describe the above events. She made a couple of notes, left the room briefly, then returned with a portable EKG and took a quick scan of my heart.

Several minutes later, Dr. S. came in. She asked about the chest pain and I repeated the events as she studied the EKG. She said she saw a slight difference from my previous EKGs and she also said that I described the classic symptoms of angina. She had her office make an appointment for me with a cardiologist.

Angina Pain Map

The shaded areas show where angina pain may be felt.

At this point, you need to know something about me. For the most part, I have viewed life as an adventure, and while it has not always been pleasant, everything was an experience and a learning opportunity. Thus, it was with as much curiosity as concern that began my “journey through angina” that would last the next ten weeks (and hopefully, many more years).

The Not-So-Routine (for me) Cardiologist Visit

The Cardiologist, “Dr. B.,” is a tall, academic looking gentleman, clearly focused on the task at hand. I should note that his office appears to be “paper free” of records. He had my medical records from Dr. S on his laptop in the examination room. He asked me to describe what happened, and I repeated the New Orleans events to him. I closed by mentioning that Dr. S suggested I had angina. “Oh, you definitely have angina,” he said matter-of-factly. We talked very briefly, and he concluded, “I want you to have a stress test. We do that here. They will set up an appointment for you next week, or maybe the following week.”

At this point—and since, no medical person ever hinted at any sense of urgency. My interpretation of this was that I was not in any immediate danger of a heart attack, and I sort of let the schedule of events flow at relaxed pace.

In Part 2 – Testing to determine the type of angina and determine a manner of treatment.

Angina – From Diagnosis to Treatment Part 2 – Testing

Angina – From Diagnosis to Treatment Part 3 – Treatment

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Luna Moth and the Cat

My work space is in the loft, next to a window–convenient for gazing and daydreaming.

Earlier this week, when I sat down to go to work, I realized that there was a luna moth clinging to the screen outside the window. Not often is there an opportunity to get a photo of the underside of anything, much less a moth, hence the photo below.

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Luna Moth clinging to the screen outside my office window.

The luna moth is a member of the family Saturniidae. Moths of this family do not eat nor do they have mouth parts. The live for approximately a week–just time enough to find a mate. Judging from the relatively large feathery antennae, this is probably a male. The female antennae tend to be visibly smaller.

The window is also a favorite hangout for our cat, Mitzi. It is also the most direct route to my desk for her. On her way, she discovered the moth and became totally focused on learning more.

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Mitzi the Cat also likes the window–but this day she was particularly curious about the moth.

Her curiosity drew her ever closer, and she got as close as the window and screen would allow. The moth remained still throughout the encounter, and Mitzi finally lost interest. Later, I opened the window, and discovered that one of the moth’s legs was caught on the screen. I released it and it flew off in search of a mate.

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It is time to get a closer look!

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Cee’s Which Way Photo Challenge – March 24, 2017

My responses to Cee’s “Which Way” Challenge for the week.

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Guess where this is?!

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New Orleans Streetcar along the Waterfront

NOLA’s streetcar system is absolutely the best way to get around for a tourist.

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