#and last year my bp was so low and my heart rate so high that I had to be pushed in a wheelchair between the couch and the bathroom

[tj-crochets]

Crafting/vaccine side effects update: I am still not up for crafting but oh my gosh I feel so much better than I expected to! I did have a POTS flareup but my blood pressure never got below 100/60, so like it barely counts. I mean, the tachycardia was worse, but even that was nowhere near what it's been previous times I got the booster shots, and it's mostly resolved itself within like 24 hours of getting the shot instead of like three days. I'm still operating at a deficit of water and salt but I'm working on it bit by bit, and I was skeptical when my doc said I wouldn't need an extra dose of my salt-go-up pills* but he was right! Anyway point is no crafting updates today but there might actually be crafting updates tomorrow, which I did not expect to be saying *fludrocortisone! It helps me retain salt in a way almost approaching the normal human way of processing salt

[salt-baby]

#please tell me anything you may know about propranalol bc i've been on it for a year for tachycardia #that they can't find the reason for - and recently it's either getting worse or the dosage isn't strong enough anymore #they want to put me on metoprolol but the side effects listed are ... not appealing #and the fact you can't just stop taking it scares me but also i'd like to lay down to sleep #and not feel like my heart is gonna vibrate out of my chest #it's even more disconcernting when i check my bpm and it's in 70s but i still feel like i just got off a rollercoaster inside #they checked my heart and it looks and is functioning fine and don't seem to know what else to do # my bp is very slightly high so they latched onto that and like ok but they haven't even looked at #like adrenal gland issues even though my thyroid is also acting up #it's currently fine while i'm walking and moving around but trying to lay down i 'feel' my blood pounding in my ears #it's terrible trying to concentrate but i also can't sleep i am so tired also my legs keep cramping #idt it's pots though bc up til now the increased heartrate was if i was standing up and moving #thenit was under control for months #then suddenly the thyroid stuff kicked up and the tachycardia too just in the last month or so #they keep saying the propranolol was also 'off-label' for anxiety which they seem to be trying to say i have #but like yeah having a heartrate that untreated shoots up to over a hundred when sitting down doing nothing #does cause some level of anxiety you know?

I’m glad you asked! your tags prompted a bunch of research (which i had an absolute blast doing)

I feel very strongly about the usage of propranolol in pots because I think its extremely frequent prescription is reflective of a misunderstanding of how POTS works. to walk you through this:

I recently attended a talk given by a neurologist on forms of dysautonomia in children - POTS was a central focus. The presenter showed head-up table tilt data like this (which is from Cheshire et al.):

[image ID: a line graph from a scientific paper. the graph is of head up tilt testing data, specifically SBP, DBP, and HR. the graph is labeled “Postural Tachycardia Syndrome”, and the axis of the graph each have a short line labelled “50 mm Hg or beats/min) for the vertical axis, and “1 min” for the horizontal axis, to indicate scale. Below the lines of the line graph, testing periods are labelled “Supine”, “Head-up tilt to 70 degrees” and “Supine”, from left to right. All lines are variable, fluctuating up and down a few mmHg or BPM. the SBP line remains mostly level, the DBP line increases around 10 mmHg during the “Head-up tilt to 70 degrees” portion of the graph, and the HR line increases over 50 BPM during the “Head-up tilt to 70 degrees” portion of the graph. DBP quickly returns to normal in the second “Supine” section of the graph, with HR slowly returning to normal over the course of around 2 minutes. End ID ./. ]

The presenter went on to say that this proved that people with POTS don’t have any drop in blood pressure when they stand up, just a sudden increase in heart rate. which, isn’t how pots is understood to work.

in general, when you stand up, gravity is suddenly acting on your body (and the blood inside it) in a different way - suddenly, its a lot harder to get your blood up to your head (and to your arm or fingers, where blood pressure is measured). in healthy people, the blood vessels in the lower half of your body constrict automatically, and push blood back up to the heart. In people with pots, this is impaired, and blood starts to pool in the legs. 

As a result, sensors near the heart called baroreceptors (among others) realize that the blood pressure coming from the heart is low, and speed up the heart rate to compensate. This compensation happens almost instantaneously, hence why there’s no sign of it on the tilt table data, but regardless the blood pressure did still drop out. All the tilt table data tells us is that the rest of the body, those baroreceptors and other blood pressure mechanisms, that’s all working fine. In some people with POTS, there’s even a little dip in blood pressure before the HR shoots up. 

Eventually, though, if the drop in blood pressure is severe enough, the heart just can’t keep up, and the lack of blood to the brain makes you faint (syncope). People with POTS don’t have symptoms of just high heart rate, they have symptoms of low blood pressure as well. But some doctors think that because they can’t measure the drop in blood pressure, it doesn’t exist, and heart rate shoots up for no clear reason.

propranolol is a type of medication called a beta-blocker, which means it acts on certain kinds of receptors called beta receptors (and on certain types of those receptors, but I’m not getting into that here). in effect, it lowers heart rate, and can lower blood pressure as a result. It’s a very familiar medication to any cardiologist, and generally regarded as safe and mild.

But in people with POTS, that heart rate rise didn’t pop up out of nowhere - it’s really important to keeping you conscious! so decreasing the heart rate without thinking about the blood pressure isn’t really a great idea.

That said, there’s evidence its effective in people with POTS, from a variety of different studies, and its one of the first meds usually prescribed for POTS. However, in recent years, I’ve started to see some others arguing against it as well. 

for more on your specific symptoms:

What you described rang a bit of a bell for me. supine (laying down) and resting tachycardia aren’t really associated with the kind of POTS I know, although not completely unheard of. that said, you said you weren’t sure if your heart rate really was increased while lying down, but you were pretty sure you felt it (and I trust you - something is going on, even if you can’t catch it with a sensor). and you described yourself as slightly hypertensive - if its under 130/90 ish at most of your appointments, I wouldn’t worry. nurses don’t always have the best technique in taking blood pressure, and can often measure falsely high readings. over 140/100, and they’re probably on to something with the hypertension thing.

Anyway, those symptoms (hypertension and supine tachycardia) remind me of a subtype of POTS (a less common one) called hyperadrenergic pots. It’s proven pretty difficult to find stuff on this subtype, but I was able to find a couple papers. From Conner et al.:

“This form is characterized by a gradual onset with slowly progressive symptoms. Patients report experiencing tremor, anxiety, and cold clammy extremities with upright posture. Many patients note increased urine output when upright. True migraine headaches may be seen in over half of patients. Gastrointestinal symptoms in the form of recurrent diarrhea were seen in 30% of the patients.”

One paper mentioned those with a hyperadrenergic form of POTS had supine tachycardia that gets worse when upright (Ross et al., second paragraph of the introduction).

You’re on the right track with the adrenal gland stuff - to confirm this, there should be about a 10 mmHg increase in systolic blood pressure upon standing, and there should be elevated catecholamine levels (which has to do with adrenal hormones). Your doctors will have to rule out something called a pheochromocytoma, which is a benign (NOT CANCER) tumor on the kidney that can cause similar symptoms. (and if it is a pheochromocytoma, which they’d figure out using a scan like an MRI or CT, then they’d want to remove it surgically).

Your doctors likely didn’t test your catecholamine levels because its a pretty finicky test, and can be time intensive for both patient and administer. additionally, as a wild guess, this doesn’t seem like the kind of test insurance likes to cover.

So lets suppose you do have the hyperadrenergic form of POTS - what medication options are available to you? According to Conner et al., a couple! They list bupropion (wellbutrin), escitalopram (lexapro), clonidine, and labetalol (a different kind of beta blocker). Clonidine was recommended by other papers as well. Worth mentioning is that I did come across a study that suggested midodrine WON’T work for the hyperadrenergic subtype (Ross et al.), which Conner et al. agrees with.

And if you have the more common form of POTS (neuropathic), then it may be helpful to try fludrocortisone (or florinef). Some studies also suggest increasing blood volume (ie, drinking a lot of water and eating a lot of salt), which is what florinef does, can be helpful in the hyperadrenergic form, so florinef might be worth trying either way.

anyway, i hope all of this was helpful. you’re welcome to reply back with questions or comments, or send them to my ask box. i’m glad you liked my post, and hopefully my response wasn’t too overwhelming! I wish you the best of luck with your symptoms.

POTS Medication Vocabulary

after about the third time a doctor prescribed a medication that made my POTS drastically worse, and about three doctors visits past giving up on being an easy patient, i started asking my doctors the following questions whenever they prescribed a new long term medication:

is this medication a hypotensive? (will this medication lower my blood pressure?)

does this medication have a risk of tachycardia? (can this medication raise my heart rate?)

is this medication a diuretic? (will this medication dehydrate me?)

can this medication cause hyponatremia? (will this medication cause my body to lose salt?)

your doctor likely doesn’t know all of this off the top of their head for every medication, but they should know the most common adverse reactions. some may simply tell you they have no clue. i still think it’s worth asking to force them to consider these mechanisms.

for additional consideration:

Keep reading

[lindsayjabinal]

The Tangled Rosary ⏐ Memoir

By: Lindsay Rayne S. Jabinal

“I am diagnosed with C.” my mother said.

I was too stunned to speak. The wind shivered down to my bones as I heard those words. I felt like heaven and earth fell upon me. 

“Is this real?” I said to myself while thinking about what to say to my mom. 

As we sat down on a bench in the hospital, our tears instantly fell like raindrops. I hugged her like a bear, and we stayed quiet for minutes. I broke the silence and asked her.

“Do you want to eat somewhere, or do you want to go home?” 

“We can eat at home,” she replied. 

I can only hear the people talking in low voices as we exit the hospital, and my mind is floating in the void. She held my hand, and I felt her rugged hands like she was burning the candles at both ends for a long time but I didn’t dare to look into her eyes because I don’t want her to see the misery and weakness in me. Losing a mother is a painful and life-changing experience that can have long-lasting effects like loss of identity and purpose. I was drowning in a sea of sorrow, without escape, without relief, and I felt it slowly seeping into me.

I woke up to the voices of the nurse and doctors doing their daily rounds for my mom. The sun poured through the window of our cold white room. Another day had dawned, and it was the first day of my online class as a grade 11 student. I was in relief when I saw my mom sleeping peacefully after my uncle, and I put on the rosary on her.

“Good morning, everyone! Welcome to Maximo Estrella Senior High School." Ma'am Remigio said.

Although I can’t exactly recall my first subject that day. Many hours passed, and my third class is finished, and it was my break time, and I decided to join my classmates in their video call, hoping to get along with them. Suddenly, I notice the nurses that go back and forth in our room.

“Ano pong nangyayari?” I asked them.

“Taas baba po yung BP niya.” They said.

I tried waking up my mom but she did not respond. At first, I thought she was just in a deep sleep because she doesn't sleep well for days.

“Ma gising ka na po, kakain ka na po,”while trying to wake her up.

I panicked when she was not responding, even though I tried to wake her many times. 

“Tito ayaw gumising ni mama!” I said to my uncle with a shaky voice.

“Ate gising ka po muna kakain ka na,” my uncle said while she’s trying to wake her up.

I rushed to the nurse station and told them that my mom was not responding, and they immediately followed me. They showed us her pulse rate, and it was low. Hours passed, and she was still in a deep sleep. I was calling all the saints in my prayer, and telling them to save my mom. Before I opened my eyes I heard a long beep. A beep that I don’t want to hear again. I ran to the nurse's station as fast as I could. I was screaming, trembling, crying my eyes out, and begging them to save my mom.

“I am sorry hija, we did the best that we could," the doctor said.

My heart dropped, and my emotions exploded.

The day that I dreaded the most has arrived. I never thought it would happen this very soon, the day I never wanted to come. My sweet 16 became bitter. I still have an unfinished grieving for my grandmother for ten years.

“Why me, God?” I asked myself.

So many unsolved puzzles and questions were left in me. I was just a child on a sinking ship with no lifeboat, waiting for someone to give me a life vest. It was June, and it was already on stage 3 when we knew it, and I knew deep inside myself that it was too late. I was too late. The C was like a flash because it took her just four months. My mom was not ready, and neither did I. I still remember the sound of her last heartbeat, but it sucks that I can't even remember her voice. I can still remember the exact time when she left me but I do not know the feeling of her warm hug anymore. Until then, I was bawling my eyes out every night. The pain still eats me inside and out, and for two and a half years, the tidal wave of grief still washes me, smashes down upon me with unimaginable force, and sweeps me up into its darkness, where I still stumble and crash.

My life changed in a way that I didn't expect. My mom left a hole in my heart that no one could fill. She was my world, and now that she was gone, my world fell apart. I don’t even believe in the rosary anymore because that was the last thing my grandma held before she was gone, and that is also the last thing my mom wore. I have to be mature and independent in no time because I have no one to lean on. I am their only ‘unica hija.' Also, my father abandoned me for his other family. I don't have a home or family. All I have now is myself and the memories I hold.

[kk095]

Girl’s Night Out

Katie and Lauren were best friends since high school, and kept their friendship alive and well into adulthood. Katie was a 26 year old natural redhead who stood at 5’7 with brown eyes, fair skin, a skinny build, and A cup breasts. Her friend Lauren was also 26, had medium length blonde hair with bangs, blue eyes, and a tan complexion. She was short, only standing at 5 feet tall, had an average build, and perky c cup breasts.

The chilly winter night didn’t keep the two girls inside. The two were supposed to have a fun night out last night meeting up with some mutual friends at a bar, but unfortunately fate had different plans for Katie and Lauren. Katie decided to pick up Lauren so they could ride together, and be the designated driver for the group just in case that was needed. But after picking up Lauren, Katie took a sharp turn a little too fast on icy roads. The car flipped over, throwing the 2 girls around violently inside the vehicle as it tumbled down the empty, icy streets.  Their fun night came to an abrupt end before it even started, but it was only beginning for us at the ER.

As usual, nurse Nancy answered the call from dispatch. She nodded and wrote things down on a post-it note while I could hear a voice on the other end of the phone, but couldn’t make out what was being said. After the phone call, Nancy gave us the rundown. “ok everyone, we have 2 incoming patients involved in a single car MVC- rollover accident to be exact. Patient #1 has potential chest trauma and a seatbelt sign, possible tension pneumo on the left side. She’s awake and alert, but her vitals aren’t where we want them. Patient #2 is in rough shape. Blunt head trauma, possible c-spine fracture, and weak vitals. Blood pressure and heart rate are low, and was never conscious post accident. They intubated her at the scene. ETA is 5 minutes for both.” Nancy told us.

Two incoming trauma patients is a lot for our small community ER, but this wasn’t our first time handling cases like this, and I’m sure it won’t be the last. The nurses quickly scrambled around to prep the two trauma rooms and make sure we have sufficient supplies for both patients. Since our blood bank is small, we didn’t have enough o-negative for both patients given that we need to transfuse both of them, so we grabbed whatever we had, and got rhogam from the pharmacy. Dr Sarah was also summoned to our emergency department, given that she’s dual certified in trauma surgery and vascular surgery. With these two incoming patients, our resources and personnel would be spread thin, but we were up for the task.

Before we knew it, both ambulances arrived, along with our patients. I waited in trauma room 1 with nurse Nancy and nurse Heather, while Dr Lindsay, Dr sarah, and nurse Ashley waited in trauma room 2.

The medics brought Katie into trauma 1 where I was. She was crying hysterically on the gurney, squirming around a bit. “is Lauren dead?! Did I kill her?!” she cried out, wiggling around on the stretcher, while in a c-collar and head stabilizer. “I need you to stay still for us sweetie, ok?” nurse Nancy said calmly to Katie, trying to console the visibly upset young lady. Katie’s heart rate was high, but her blood pressure was low. I could see a clear and evident seatbelt sign on her sternum and left collar bone. Once we transferred her onto the table and under the large overhead light, I attempted to lower my stethoscope onto her chest, but she was a moving target. “where’s Lauren?! Is she ok?!” she said, sobbing. “hey, keep her still for a moment. Let’s get her started on transfusions in a moment. And let’s get something in her IV to calm her down a bit once her BP goes up.” I told nurse Nancy and nurse Heather.

Meanwhile in trauma room 2, Lauren was brought in. She was also in a c-collar and head stabilizer, but things were much more quiet in there. Lauren was unconscious and intubated, with her beautiful blue eyes remaining half open, staring blankly at the 3 women trying their best to save her. She had a nasty head laceration on her forehead above her right eyebrow, and there was blood coming out of her right ear. Her blood pressure and heart rate were low, so transfusions were immediately commenced. Dr Sarah checked Lauren’s eyes with a pen light. One pupil was blown, and the other was constricted, which is quite common in head trauma. Dr Lindsay ordered trauma labs to be run, while Dr Sarah wanted a quick x-ray of the head and neck.

In order to get the x ray plates under Lauren, the team had to carefully ambulate her since a c-spine fracture was suspected by paramedics. Dr Sarah and nurse Ashley rolled the patient on her side while the x ray plate was placed underneath the patient by Dr Lindsay. In a moment’s notice, the x ray was performed. “oh no… what a shame…” Dr Sarah said immediately after the x ray developed. There was a teardrop fracture at the c-5 level with a sagittal fracture throughout the vertebral body. Long story short, Lauren would be paralyzed from the neck down if she survived this, and there’s nothing anyone can do in regards to undoing the paralysis. The head portion of the x ray showed a temporal fracture on the right side, with a possible hematoma in that region of the brain based on an opaque area near the external auditory meatus of the skull, also explaining why blood was oozing out of her right ear.

Back in trauma room 1, I was finally able to lower my stethoscope onto Katie’s bare chest. “diminished breath sounds left side,  let’s get a chest x ray and an echo.” I ordered. Nurse Nancy went over to the opposite trauma room to get the portable x ray machine, while heather set up the ultrasound machine. Since that was ready first, I performed the echo. “no pericardial effusion or tamponade, but there’s blood near the heart and I don’t know where it’s coming from.” I said, thinking out loud. “what’s that by the aortic arch?” nurse Heather asked, looking at the monitor with me. “what do you see?” I asked her, curious to know. “go by the brachiocephalic trunk. Idk, something doesn’t look right.” She replied to me. I took a second look and agreed. “yeah, you’re right. I can’t put my finger on it, but something doesn’t look right. Normally people bleed out at the scene when the brachiocephalic trunk gets detached from the aorta, but we may have something going on there. I wanna get Sarah in here to get another pair of eyes on that. Let’s place a chest tube on the left side and get Sarah.” I told Heather.

While me and Nancy prepped the chest tube tray, Heather decided to pop into the neighboring trauma room to see if Sarah can take a look at the ultrasound. “hey Sarah… would you be able to take a look at something in here?...” Heather asked. “im kinda busy…” Dr Sarah says, picking up a galt skull trephine and a periosteal elevator. “yeah heather, just give us a minute. She’s gotta drill a burr hole.” Ashley added.

Dr Sarah already had the incision made in Lauren’s skull. It was a 4cm incision that was down to the periosteum. This is achieved by pushing down really hard on the scalpel during the cutting. The cut was made 2cm superior, and 2cm anterior to the tragus of her right ear- the most common location for a burr hole in the emergency department. The galt trephine was applied to the skull with gentle, steady pressure until the skull was eventually penetrated. The bone fragment got stuck in the device, so the periosteal elevator was placed down. There was a coagulated area if blood just beneath skull that did not drain, so suction had to be applied to the area so adequate draining of the subdural hematoma could take place. Sarah took a look inside the hole she made in Lauren’s skull and saw a pulsating bleed from a vessel in the temporal area. “suction! She asks urgently, while picking up a clamp off the tray that waited on the tray nearby. After the area was suctioned, Sarah placed a clamp on the middle meningeal artery , which was the source of Lauren’s bleeding. “ok, she’s under control for now. Keep up the transfusions and keep her BP up. I’m gonna see what they want next door.” Dr sarah told Lindsay and ashley.

Dr Sarah followed heather back into our trauma room. While heather was gone, we placed a left sided chest tube to alleviate the tension pneumo Katie was experiencing. The procedure was painful and Katie was still crying about it, but she was oxygenating better and her vitals improved ever so slightly. But we repeated the echo, and Dr Sarah took a look. “yeah, something is definitely off with the aortic arch. I think the brachiocephalic trunk is partially detached. That’s where the blood is coming from in her tension pneumo. I can fix that, but she needs to go up to the OR.” Dr Sarah told us. “Ok, page the OR and tell them to have something ready for me. I’ll be up in a few. I’ll take her up with Heather. The rest of you go over and focus on Lauren. Try to keep her stable, but she may need either the ICU or OR depending on how this goes.” Sarah ordered us.  

With that said, nurse Heather and Sarah wheeled katie out of the ER in anticipation of surgery. “please… make sure Lauren is ok… tell me how she is after my surgery…” she tells Heather as she’s being wheeled off. “of course! You and Lauren are both in good hands, ok?” heather replies, trying to be reassuring.

While Katie is brought upstairs to the operating room, me and Lindsay are holding things down in trauma 2 with Lauren. However, Lauren started to seize up- well, the best a quadriplegic could. Her eyes were rolling up and down repeatedly, and she was grunting and groaning, even though she wasn’t conscious. “her brain is probably swelling up. Let’s get a dose of ativan in her, and expand the burr hole to let her brain get some extra space. We need to do this quickly so the brain doesn’t herniate and make her brain dead.” I replied urgently. Nurse Ashley pushed the ativan into Lauren’s IV line, stopping the seizure in its tracks in a matter of seconds. I then picked up the galt trephine that Sarah used earlier, removing the bone fragment that got stuck in it. Meanwhile Dr Lindsay picked up a scalpel and extended the incision another few centimeters, and pressed nice and hard so the periosteum of the skull could be once again exposed for me. Once I got the piece of Lauren’s skull out of the trephine, I began making the second burr hole. Additional blood came out of the 2nd burr hole, but that was easily ameliorated by suction. Since the clamp was on the middle meningeal artery for what I felt to be too long, it was decided that Dr Lindsay and I would ligate the artery here in the emergency department. “do we have ligature equipment here in the ER?” I asked Lindsay, ashley, and Nancy, to which I only received shrugs. “ok, we’re gonna mix things up. Do we have dental floss down here?” I asked. “dental floss? You’re going to ligate this girl’s brain with dental floss?” Dr Lindsay replied skeptically. “I read a case of someone ligating the carotid artery with dental floss, I’d say it’s worth a shot. It’s either this or she slowly but surely goes brain dead.” I responded, defending my position, as unconventional as it may have been.

Dental floss was procured for me, and I began the procedure. I swapped the vascular clamp with a hemostat, which I placed perpendicular to the axis of the middle meningeal artery. I tied off the vessel with dental floss (yes, you read that correctly), and then used the hemostat from earlier to divide the vessel and disperse the bloodflow in 2 different directions. The bleeding was much more controlled this way, and the patient’s vital signs began to immediately improve. “hoky crap. I can’t believe that worked. Good job Dr Kenny”, Lindsay said to me. With improvement of Lauren’s condition, we decided to take her over to radiology for a much needed head CT.

The head CT showed evidence of bleeding, but the bleed was definitely more manageable, and likely wouldn’t be fatal. However, there was evidence of swelling on her spinal cord, and damage to her cervical spine. The fracture was unstable and required orthopedic surgery to reduce the fracture at some point, but paralysis was still going to be present. We then decided to transfer Lauren to the ICU to have them monitor her for the time being. Lauren was actually improving, but of course wasn’t out of the woods.

“I haven’t heard from Sarah in awhile. Why don’t you guys hold things down in the ER while I go pop up to the OR to see what’s happening.” I told the remainder of the ER team, to which they agreed.

I made my way up to the OR observation area. I entered the observation room and was immediately hit by a wall of sound from chirping heart monitors. Katie laid on the table with her chest cracked open. Her body was pale and pasty, and blood covered her torso, the table, and the floor below. The OR team was actively coding her to my surprise. “damn it, no change. Suction the area out and recharge the internal paddles to 30!” A slurping sound was heard from suction being applied to katie’s exposed chest cavity, and the paddles were recharged, lowered around her quivering heart, and a shock was delivered. Katie’s toes curled at one end of the table, showing off soft, silky wrinkles throughout the soles of her size 8 feet. After the shock, katie still remained in v-fib. “that’s it, I’m calling it. She’s been down almost a half hour. Time of death, 21:17.” Sarah said frustrated, throwing her blood soaked gloves into a disposal bin near the table. The OR team removed equipment, shut off the monitors, and covered up Katie’s body. “sarah! What happened?! She was talking to us in the ER!” I asked into the intercom for the OR, a bit surprised at what I saw. “the brachiocephalic artery was partially detached from the aortic arch. I tried to place a dacron graft and reattach it, but the graft just wouldn’t take and detached the artery more. She bled out and we coded her for a half hour, but you see how that went.” She replied to me. All I could do was shake my head and head back to the ER.

“Hey Kenny, how’d the redhead patient do up in the OR?” Dr Lindsay asked me. “… she died…” I replied after a brief pause, shaking my head. I continued by telling them exactly what Sarah told me. Unfortunately, it’s like that sometimes.

Ultimately, Lauren ended up making a full recovery. She needed 3 different surgeries: 2 on her neck, 1 on her brain, and a month in the ICU. But she ultimately made a dull recovery and survived the ordeal, but ended up a quadriplegic. She regained some sensation in her arms after physical therapy, but it was weak and limited at best, and required a lot of long term care. This was a tragic night for all of us involved, and just goes to show that sometimes survival isn’t always a pretty thing.

[nalgenewhore]

A rogue storm had her presumed dead and stranded on the red planet. Left on her own, astronaut Aelin Galathynius has four years to make it to the next drop-site, some two thousand miles. Armed with her smarts and dwindling supplies, Aelin attempts to survive on an inhospitable planet, when the nearest help is only millions of miles away. 

masterlist - ao3 - next chapter

Fuck this entire planet, Aelin Galathynius thought to herself as yet another bead of sweat trickled down between her shoulder blades. She wished she could wipe her brow, the stupid cooling system in her space suit was nothing in comparison to the blazing sun. Stupid planet, stupid planet with no atmosphere. 

It wasn’t just the sun, the piece of machinery she held was worth more than her entire life and with Fenrys Marama cracking jokes over the comms, she was not paying as much attention as she should. “I really hope that penetration test goes well for you, Ace. Is the core still soft?”

Despite herself, she huffed a laugh, “I’ll have you know that the CPT is no joke and this is serious science.”

“Oh, please,” his cocky voice crackled through the headset, “you’re a dirt engineer.”

Lorcan Salvaterre, from where he was helping Aelin steady the drill for the core penetration test, rolled his eyes but stayed silent, wanting to know where the argument was leading. The blonde astronaut was quick to reply, “Geotechnical and it’s soil, Mr. Fancy Aerospace Engineer. Isn’t your job today confirming that the FAV is still upright?”

Dry laughter was heard from their other crew members and Fenrys bit back, “Actually, it’s visual inspection of mission vehicles.” He paused for a second, “I’m very happy to report that on base inspection, the FAV is in good shape and yes, it’s still upright, dipshit.”

Before Aelin could speak, their commander cut in, “If you guys stopped leaving your comms open, we could all be exempt from the truly witty commentary.”

She frowned down at Lorcan Salvaterre, the mission leader and mechanical engineer, sticking her tongue out at her friend who smirked in response. A gentle, cool voice spoke up, “Happy to shut them off from here, Salvaterre.”

The golden-haired man child squawked in protest, “Hey! Radios are our only way of communication on this inhospitable planet-“

“Shut them off, Faliq.” The next thing Aelin heard was a slight static and then complete silence. “Oh, this is nice,” Lorcan said, the only person who could speak now. “We need fifty samples, G, one hundred grams each.”

Since her radio had been cut, she could only give him a thumbs up and focused on the task at hand. After a few minutes, the radio crackled back to life, Nesryn’s voice tight with worry, “Commander… you’re gonna want to see this.”

Lorcan’s head lifted up and he turned to look at the surface habitat, like their mission’s system operator could see him, “What is it, Faliq?”

A shiver of nervous energy straightened Aelin’s spine and she stopped the drill, her brow furrowing and her hands becoming clammy.

“Mission update. Storm warning.”

“I saw that on this morning’s briefing, we’ll be inside before it hits.”

“Storm’s gonna be a lot worse, estimate says to prepare for emergency departure.” Aelin breathed sharply as Lorcan exhaled, turning to look over her head at the horizon, his dark eyes calculating. “Commander?”

When his eyes slid to Aelin’s, she felt her heart drop. They were fucked. “Everyone inside the hab. Now.”

 +*+*+*+*+*+*

All crowded around Nesryn’s computer, staring at the screen where the words, ‘Abort mission’ flashed across it underneath the storm estimate, tension was high. Hardly anybody dared to breathe as the dark-haired computer engineer read the update, “…eleven-hundred kilometres in diameter…”

“That’s heading straight for us,” said Rowan Whitethorn, the mission doctor, tapping his finger on the screen and tracing the trajectory. “What’s the estimate force, Nes?”

The beginnings of the storm shook the structure and Aelin saw Elide Lochan’s - resident chemist - eyes narrow for a second before a mask of indifference settled over her features, even as she hooked her pinky around Lorcan’s, the black diamond ring on her left-hand glinting. They shared a small smile that made Aelin’s heart ache, but now wasn’t the time to be thinking of such things. They had a mission to worry about, she could fret over her aching soul later, Aelin chastised herself as her gaze flicked to the green-eyed man across the desk from her.

“Ninety-two thousand Newtons,” Nesryn all but whispered, her voice aghast.

Lorcan swore, tangling the remainder of his fingers with Elide’s and squeezing, “What’s the abort force?”

“Seventy-five thousand,” Fenrys read, his brows wrinkled with worry as he ran his hand over his short hair, brushing it forward into the wave pattern like he did when he was stressed, “any higher and the FAV will tip.”

“We’re scrubbed?” asked Aelin, worrying her bottom lip, the voice of her mother telling her not to do that sounding in her mind. All her life’s work, the whole crew’s life’s work just gone. The mission they’d worked themselves ragged for, over. Just like that. She wasn’t ashamed of the tears that pricked her eyes.

Red letters flashed across the screen, Prepare for emergency departure.

Elide’s calming voice brought the crew back, as she stepped away from Lorcan and leaned over the computer, analyzing what was on the screen, “Maybe it won’t be as bad as they say, they’re estimating a significant margin of error.”

Everyone turned to Lorcan, in the end – it was his call to make. Aelin nodded in agreement with Elide’s words, “Let’s wait it out.” His face was emotionless as his eyes shuttered, that mind of his running through each scenario he could think of. “Let’s wait it out,” she repeated.

They waited with bated breath until Lorcan shook his head once, “Prepare for emergency departure.”

“But-“

“That’s an order, G.” No one commented on the barely heard words, a look of mourning on Lorcan’s face. “We’re scrubbed.”

 +*+*+*+*+*+*

Debris struck the sides of the airlock tunnel as Nesryn pulled down the latch of the door, “Ready, Commander.”

Everyone turned to Lorcan, their suits and headlamps on. “Visibility is almost zero, stay together and if you get lost, follow my suit’s telemetry,” he indicated the bio-monitor on his arm with which they could home in on each other’s location and other various functions, “Wind picks up further from the hab, so be prepared.”

The airlock door opened and the six astronauts struggled further into the sandstorm, each step requiring full body effort. The three women tucked behind the men, keeping close, hands on oxygen regulators.

Through the screaming sound of the storm, they heard metal creaking – the Farnor Ascent Vehicle. Aelin stepped out from behind Lorcan, barely able to see her fellow crew members. “We need to shore up the FAV,” she yelled, hardly able to hear her own voice. If it somehow tipped, without them in it to launch, they would never get it up again.

“How,” Fenrys asked, his voice straining above the storm as he pushed along, Elide close behind him.

“We can-“ Aelin screamed as something ripped free from the habitat structure and crashed into her, lifting her off the ground and throwing her out of sight.

“Aelin!” Elide’s scream pierced the monotony of the whirling debris. Everyone froze, looking to where they had last seen her.

“What happened?”

“Something hit her and she was just gone, she flew west,” Elide cried, her voice shaking. That was her oldest friend, her sister-

“Galathynius, report.”

Nothing but static. Nesryn looked down at her bio-monitor, pressing on Aelin’s suit button. “Her suit’s offline, I don’t know-“

“Galathynius, report,” Lorcan’s voice broke and again, nobody answered him.

“Her decompression alarm went off,” Rowan said, “she has less than a minute.”

Lorcan’s stomach dropped, “Shit, ok, ok, Marama, get to the FAV and prepare for launch, everyone else, home in on Lochan.”

As Fenrys took off to the rocket, leaving Elide to face the storm herself, she stumbled, “I can’t see anything.” Slowly, too slowly, the remaining crew members struggled their way to her and huddled together.

“We’re gonna line up and walk west. Small steps, she’s probably prone and we don’t want to step on her,” said Lorcan, his voice raised. They nodded, confirming the plan and set out, eyes wide open, hands out as precaution in case… they tripped over her body. “Doc, report on Galathynius.”

Rowan read the information on his suit’s computer, “Faliq, her bio-monitor sent something, a ‘raw packet’-“

“Yeah, I got that,” Nesryn confirmed, reading what the others couldn’t. “BP 0, PR 0, TP 36.2.”

“Copy. Blood pressure, 0, pulse rate, 0, temperature, 32.6.”

“Temp’s normal,” Elide commented, confusion clouding her mind, “why is her temp normal.” It wasn’t a question.

As realization set in, Rowan paled, “It takes a while for, it takes a while for the body to… cool. Blood’s still hot.” At that, everyone stopped, whirling to Rowan where he flanked Nesryn and Elide.

“Commander,” Fenrys’ voice crackled over the radio, “we’re tilting to nine degrees, with wind pushing to eleven. It’ll tip at twelve.”

“If it tips, can you launch before it hits the ground?”

The pilot hesitated, “Uh… yes, sir, I can take manual control.”

“Copy that, everyone, get to Marama. Prepare for launch.”

Nesryn started, “What about you, Commander?”

“I’m going to keep looking, get to the FAV.” Nobody moved, Elide’s eyes wider than ever before and filled with tears. “Now.”

“You really think I’m leaving you behind,” Fenrys asked, his voice breaking. “Lor-“

“I just ordered you to, now get moving,” Lorcan said, in a tone that brook no arguments. When they still didn’t move, he cursed, “Fucking hell, I said go.”

With that, Nesryn and Elide tucked behind Rowan as they made their way to the FAV.

Once they were in the airlock and had pressurized the vehicle, Elide swore, low and in Blackbeak, “Dilo, what is he doing.” She was the first up into the cabin next to Fenrys, eyes on her fiancé’s telemetry, “He’s going too slow, he won’t be able to find her in time.” Nesryn and Rowan climbed up into the cabin and the silver-haired man was nearly shaking, eyes wide.

“Commander, we’re at 11.5 degrees, you need to get back here-“

“Faliq, can you use the proximity radar to find her?”

“It only works for metal, there’s not a single piece of metal on any of our suits.” Defeat bled through her voice.

“Copy. Give it a try,” Lorcan told her, still determined to leave no being behind.

“Lorcan, I know you don’t want to hear this,” said Elide, “but Galathy… Aelin’s dead.”

“Try the fucking radar.”

Fenrys shot Elide a look, “The fuck is wrong with you, Lochan?”

Her dark eyes were unreadable and she strapped herself into her acceleration seat, “My sister is dead, I don’t want my fiancé dead too.”

Their pilot went silent at that and turned his eyes back to the controls, “Negative on the radar, Commander.”

“Fuck, fuck, fuck,” Lorcan muttered, groaning in frustration and desperation. He was grasping at straws; they all knew it. “Nothing?”

Rowan had gone silent in his seat next to Elide and he offered her a bleak look, tight-lipped, when she reached over and squeezed his hand, no words to say. Everyone knew what had been between Aelin and Rowan, except for maybe themselves. Nesryn shook her head, “It can barely see the hab, there’s not enough-“

The FAV let out a screeching sound as it tipped more and Fenrys barked out, “Commander, you need to get back to the ship now. I got one more trick and then we’re fucked.”

Silence on the comms. Fenrys tried again, “Commander-“

“Copy that,” Lorcan bit out. “How far?”

“11.9”

Elide spoke, “Salvaterre, Galathynius is gone. We need to get out of here.”

Lorcan said not a word. Finally, Nesryn pleaded, “Lorcan, she’s gone, ok? We need you here.”

“Roger that,” his voice was defeated, “on my way.”

Despite themselves, they all let out a relieved sigh, breath they didn’t know they were holding. Maybe a minute later, the airlock whooshed and Lorcan appeared, staying dead silent and not meeting anyone’s eyes as he strapped himself in next to Fenrys. “Prepared for launch.”

“Roger that, Commander.”

The ship began to shake as Fenrys blasted the jets, pulling them up and out of the storm. The only words spoken were from the control system, marking every one-hundred metre mark they reached.

Half an hour later, they were docking on their rocket station, named The Lani, after the goddess of dreams – their expedition The Matron , phase two of a three-part mission. Once they had completed the post-boarding instructions, Lorcan spoke, rubbing his eyes as his shoulders slumped, “We’re done for the day, don’t worry about logs or the mission. I’ll, um, I’ll send a report.”

Everyone nodded and dispersed, grim looks on their faces. Lorcan stayed behind, leaning against the wall of the airlock. Elide waited by him, cupping the side of his neck and stroking her thumb over his jaw as it feathered and he dragged his eyes to hers. “I’m sorry.”

She just shook her head, indicating she wouldn’t speak of it now, “Not now, love.” Her lip trembled, her face crumpling before Lorcan tugged her against him and cradled the back of her head. She cried silently into his chest, her tears soaking through his shirt. All he could do was bury his face in her hair and whisper his apology, his heart splintering in his chest.

 +*+*+*+*+*+*

It was late. The other crew members were in their sleep-cabins, mourning the loss of their friend, no. Not friend, family. Their family was broken now. Lorcan was still up, sitting in the central area, staring at the blinking cursor on the computer.

With a heavy sigh, he began to type the report to the flight and crew director, Manon Blackbeak.

Blackbeak,

Mission Specialist Aelin Galathynius is presumed dead after being struck by debris during the storm late this afternoon on Farnor, day 18 of our 31-day stay. The remaining crewmembers were forced to abort the mission. Awaiting mission directions.

Commander Salvaterre

After sending it, anger sparked in his chest, indignation of the fucking unfairness of it. With a snarl, he slammed the laptop shut and stalked to the window, looking down at the planet until his eyes blurred and stung but still he watched, eyes roving over the red dirt as if he would be able to spot her body.

@mythicaitt​ @kandasboi​ @schmlip-scribble​ @the-regal-warrior​ @westofmoon​ @empire-of-wildfire​ @rhysands-highlady​ @city-of-fae​ @shyvioletcat​ @alifletcher2012​ @tangledraysofsunshine​ @ttakeitbacknoww​ @tswaney17​ @ourbooksuniverse​ @flora-and-fae​ @that-other-pineapple​ @sleeping-and-books​ 

comment to be tagged! 

[enniewritesathing]

Stuff where I talk about things

or the spoiler post, or some clarifications because there’s no dialogue/text with this with a dash of behind the scenes

under a cut because... well, I like to talk

Were!John leaping into the air like that?? funniest thing I’ve done, hands down. I was struggling thinking ‘okay, so how is this guy gonna die’ and the gremlin was like ‘well... maybe off the top rope shit?’

that’s what i named that whole sequence

I didn’t show that guy’s head being caved in or even the aftermath of it. I did pose it but it looked... weird. Granted, his head got smashed in but stll.

There was a good second of silence after the guy handling the anesthesia asked a series of questions.

“Hey, if a werewolf dies, it’s said they turn back human. So, why hasn’t [John] turned back yet?” [Famous last words]

You may ask how come no one figured that out? Would have the monitor picked up on any heartbeat? Or the screen at the head of the surgical table for any motion? The lead was too far away from the screen and also the bracelets that were on John’s wrists were taken off. 

that and were!John did play dead. Like his cover should have been blown when his eyes were closed.

I had to go find and get screens from various ECG readings and I gotta tell ya, I have learned a lot! I wanted to find some that had more readings (BP/Respiratory Rate/etc) but nothing I could use, low quality... and I couldn’t make them myself. Oh well. That would’ve been neat, I think.

That was the first ‘meeting’ between John and were!John. 

Also, I have to say, I didn’t think the difference between them would be that stark? John looks really young when he doesn’t have any body hair on him??

The shot of were!John daring the cop to shoot him is another good shot that I love. You know he called this man a “p*ssy”.

Were!John knew that the gun wasn’t going to shoot on the basis that he counted the bullets that were fired. It sounded different when lead researcher shot and killed the cop.

I really did feel bad when some parts called for John to be crying. No less than, what 4 times? I’m terrible! My boy D:

Posing 5 rigs and then setting them up? What a fucking nightmare. 0/10 what was I THINKING

The sequence that ended with were!John holding the heart of a seriously dead man... the beginning of it, he tried shifting the blame to the lead researcher, but were!John smelled the medicine used on him. That he was told to. Sure, but the counterpoint is that he could have refused to. The fact that he did it twice and then have the audacity to get all high and mighty about it when it was thought that were!John died. Just as complicit as everyone else in the room.

I’m glad this heart cc was made because the other one would have looked goofy looking. 

I had the idea of him taking a bite of it and looking very deranged and, y’know be Like That... but then I thought, he wouldn’t waste food much less a heart as they are extremely tasty when fresh. 

The pic of him in the dark? Probably the scariest shot of anything.

Would have he tried and killed the remaining person? Nah. For one, they weren’t a threat (despite the fact that Actual Security was with them, pointing shotguns in his face no less). Two, were!John was asked if he was done. And he was. He was exhausted. All of his anger was gone. And three, he sensed that he didn’t want to bring any more harm to were!John, treating him with actual kindness.

“You’ve made quite the mess. You must be tired, Johnathan. Let’s get you cleaned up.”

okay, back to the first ‘meeting’. were!John is mostly “hey, what the fuck is going on, why are we dying here??” and John... explains the situation and were!John is upset because he knows what’s up. 

They argue in how to stop the situation, or rather John is arguing with were!John to not kill whoever’s behind them dying. 

“If I don’t put a stop to this, then you will die. We will die.” The point is driven by the fact that John dies about twice during their meeting, and the last part of it he’s really weakened. This is when he cries because of the sheer pain that he’s going through. He doesn’t want to kill, but if it makes the pain stop, then...

This is the part that were!John tells John: “It won’t be you doing it.” It’s a very important distinction. “This isn’t your burden to carry.”

I would also say that this story tells it from were!John’s perspective and give his side of it. He is far more complex than what was said about him in the first place. He is... what’s the word I’m looking for, gentle? towards his human side. 

The plan was essentially, “the next time you die, let me jump in and handle business, but whatever you do, just stay put, don’t listen to any voices, don’t follow no one, etc.”

When were!John took over, the room turned black. When he gave John back control, the half he stood on was black, and John’s side was white. When were!John left, the room was back to white. I thought it would be a cool idea for ~subtle symbolism~.

Meanwhile, back at the surgery, it’s obvious that when John wasn’t turning back (forcibly), there were some arguments.

Basically, “eh, if he dies, we can bring him back and try again nbd, we’ve got ALL night and he’s been shown to be alright after. We’re going to reverse this.”

Funny how that worked out.

for real though, posing 5 rigs? setting them up? keeping track of who’s who?? 0/10.

And on another note, this story would not have been possible without all of the CC involved. It is a grocery list of things that I’ve been waiting on for a while, no matter how niche it was, but I’m glad someone made it and decided to share it. 

The time for were!John to do his business? ‘bout 10 minutes.

Oh!! I forgot about!! Using TOOL!! It’s a pain in the ass! I don’t know my angles! And I didn’t know what axis was what! That probably took me longer than I needed to! But stuff got flipped like I wanted it to or else the environment would’ve looked real goofy.

I think that’s it... for now... 

My favorite shots?! 

the mentioned were!John jumping off the top rope

The smile

The look of pure terror when the guy with the undercut realized that John wasn’t dead after all

Actually just all the looks of terror. I put extra thought into that.

that single shot of were!John crying before vindication. 

John on the floor looking shocked at seeing were!John.

were!John holding John as he (essentially) died and the taking over!!

how exhausted and done were!John looked as he stood up

what’s ya’lls favorite shot/sequence? :>

I’m not gonna lie, when I made the pose of John arching his back and popped in-game, I thought... okay that’s a little extra, but we’ll keep it.

when I was making poses for that part, I had an outfit that had tears (apartment!John is the other John and... what I’m saying is, it’s hard to keep track of two in one spot) and I left it in as a goof but then I was like “YO THIS CHANGES EVERYTHING”

i mentioned in a earlier post that John is an angry crier. and guess what??

he cries because he is angry. he is wrathful. 

And also the person who survived here was Brian’s contact in the story. Brian threatened to kill him/finish what were!John started if he came near John in any capacity. I mean... look at him. Dude’s a shrimp.

TIL there’s a photo upload limit and I busted it twice so, I guess if I have something as big as this, I better update as I go along.

This story and making it is probably the most ambitious thing I’ve done so far on this blog and I am glad I am done.

I may be missing something here but that’s what I’ve got on my mind.

EDIT: Okay, few more things.

Were!John knowing that John will most not likely remember any of this because of some amnesia side effects from the medicines and all of that.

But not really. John gets nightmares/night terrors from all of this. He tells what he remembers to Brian in the main story. It’s incomplete but he still knows. Hearing this prompts Brian to tell John to talk to his were self. They gloss over it in the story, but I would say that were!John tells him what exactly at some point.

And another thing, in the majority of this story, were!John’s sclera is black. What does this mean?

I didn’t know this CC existed but had I known about it, it would’ve been in the main story where were!John charges towards the bear that was gonna kill/eat Brian.

On that note, his sclera was white when he chased and cornered Brian before he figured out whoops, that’s his mate.

And I probably made that part a plot hole because given how were!John behaves in this story and then go buck wild when he first gets out in this story... I mean, it had been two years. maybe he was that excited and temporarily lost his goddamn mind?? Would he have done something to Brian if he wasn’t his mate? I don’t think so. If Brian wasn’t so scared, he’d do something as drastic and slap him hard enough to knock him out of it.

I guess?? well, plot hole I guess! ¯\_(ツ)_/¯

[nice-bright-colors]

Diagnosis Part Deux

The same exact fucking diagnosis that was given last Thursday night. Acute Bronchitis and Acute Sinusitis.

Chest X-rays confirmed no pneumonia present in either lung. So I was right, and did the right thing.

However, tonight I had the pleasure of meeting the lovely Physician Assistant that tried to stop short, then just flat out called me a walking stroke waiting to happen.

When I first got there: BP was once again in critical zone - meaning very fucking high. HR was also elevated. Gee, wonder why that was.

After 2 rounds of breathing treatments and some water (while waiting for the radiologist to read the X-rays), BP was down considerably into abnormal zone - meaning you should consider some pre-hypertension stuff. Resting heart rate also dropped 20 bpm

So the moral of the story are lessons that I’ve already known:

Stop stressing over what The Wife is always going on about. Maybe she is really slowly killing you, when in her mind she is trying to save you.

Keep calm with Doctor’s, PA’s, Nurses, etc. they will be utterly confused at how calm and jovial you are when your BP tells them I should close to Coding.

Low dosage of drugs do absolutely nothing for you. Kinda hard to tell them their business. Also I get it they don’t really want a patient telling them, ‘that’s not strong enough’. Or ‘ I have holes in my liver big enough for that pill to pass through and do nothing’. I’m a heavyweight when it come to these things. Found out the hard way during a vasectomy procedure years ago. But that’s another story.

So now I have stronger steriods and something to help with the coughing. They have suggested I don’t fly this week, but, well, I guess we’ll just have to wait and see. Meaning, no. I’m getting away for 1.5 days.

[heyybabyjude]

"momming" when life is painful - the ugly side of motherhood

I share a lot of posts about how fun things are, how sweet Jude is, and all of the good moments that go along with being a mother. I don't speak often on how damn hard it is to cope with life and it's constant changes, how painful being a mom to an infant can be, and how all of that can really bring down your mental health.

Before I get started, let me saying there is nobody in the universe I adore more than my son. I never get tired of him or being his mother. What does get exhausting is acting like it's easy, like nothing is wrong, and like we don't struggle. I've seen a lot of honest posts from other moms, so I'm going to share mine today.

It started when I was in labor with Jude. I tried to sound as optimistic as I could for my peers, even though I spent twelve hours in labor with the sinking feeling that my little dancing man wasn't going to make it. My blood pressure was high, his heart rate was low. One of our nurses was so emotional about everything, she left the room. I had to force myself to relax because every single time my BP went up, Jude's heart rate would crash. It was the most terrifying 12 hours of my life.

It was the ugly side of a beautiful birth experience.

Nursing Jude after birth came easy for awhile. However, after two days it became a constant battle to try and make things work for my baby and I. It was a wonderful experience overall, but there were times I would cry through an entire feed. There were a lot of times I was begging the universe ton Jude fall asleep so the pain could subside for four or five hours.

Nursing was an amazing experience, but it hurt like hell and it was very stressful.

At 7 weeks, Jude's dad and I had a fight, he packed up his things and left. My friends came over for awhile but after the left, Jude woke up and had a meltdown for hours. We spent a lot of time cuddling and bonding and I spent a lot of time summoning all of my strength for him.

I survived those awful weeks, but it was emotional and I was a trainwreck.

Over the last year/year and a half, I've had some great people by my side, but I've also lost most of my friends because I'm not willing to sacrifice time with my son for people who don't even try to get to know him. I've done a lot for Jude with next to no familial support and not much more from my friends, who promised they would be by our side.

The ugliest side of motherhood can be the loneliness.

Another huge blow to my mental health has been the nostalgia of a time when I had support and felt important to the people around me. I'm constantly reminding myself of what people were like before.

The nostalgia and the loneliness combined with already existing mental illness are killer.

I've never resented being Jude's mother. However, I've started to resent a lot of other people in my life. The broken promises, lack of support, and shitty behavior are exhausting. Everybody wants me to get help with Jude, yet few people are standing by us.

The ugly side of motherhood is crying because you desperately need interaction with other adults but people keep canceling, bailing, or don't even try to make time for you.

The ugly side of motherhood is watching your relationship with the person you thought you would marry one day dissolve because you're not the same person you were before you were pregnant.

The ugly side of motherhood is hoping your baby will take a nap so you can have five minutes to yourself to cry or eat or breathe.

The ugly side of motherhood is often times not having time to feed yourself because your baby needs all or your attention - so your first and last meals are after your baby goes to bed.

The ugly side of motherhood is struggling with anxiety, depression, PTSD, etc and trying to force yourself out of bed but you can't. It's also hating yourself because before the baby, a mental health day in bed was okay. Now, it looks irresponsible.

The ugly side of motherhood is seeing all the physical changes that have happened to your body and wanting to crawl out of your skin, wanting to shed the fat, and wanting to erase your stretch marks.

The ugly side of motherhood is battling an eating disorder while you have to force yourself to eat and keep your calories so you can keep feeding your baby breast milk.

The ugly side of motherhood is starting to starve yourself again because you hate the way you look and then finding out that your baby isn't gaining enough weight from drinking your milk because you're not giving him enough calories.

The ugly side of motherhood is crying AGAIN because you let your baby down because YOU can't conquer your own demons/battle with food.

The ugly side of motherhood is your friends and family blowing up on you because you were told you can call on them for help but now they're always "too busy".

The ugly side of motherhood is seeing your own flesh and blood support and spend time with people who have treated you terribly, but they can't make thirty minutes in a month to see your son.

The ugly side of motherhood is feeling like you're failing because you promised your baby a village and all he's got is his parents.

If you're upset about this post or you feel attacked, than it's time for you to do better. I'm making no apologies for calling people out anymore.

[rain0205-blog]

Terminal State

Summary:  She tried leaving, submerging herself in work to escape the horrors she had seen. The horrors she kept seeing. She never wanted to go back to that life. But when the Empire takes her home, she’s forced to face her past. Can she move on? Can she cope? Or will she require a bit of help? still bad at summaries, still working on it. ever so slightly more than slight AU gadioxoc

Hypoxemia

...

Dr. Virum was running around the emergency department like her head was cut off. There was a crash this morning, multi-car accident. It seemed to happen frequently in the city and things were a little hectic now the Glaives returned. Triage was a pain in the ass, however, they managed to get through the morning just fine; only one casualty and three in ICU. Ever since the Kingsglaives returned there was more activity in the civilians. Everyone was a nervous wreck, most people suffering symptoms created by anxiety. Virum hated psychology, there were too many variables. Cut and dry medicine, it was the reason she went to the emergency department.

The doctor also didn't like lingering patients, she got too emotional. Like this pregnant woman who was showing no improvement with their treatment. Virum pulled out her tablet, taking a breath and trying to focus before walking into the patient's room, heart heavy as the monitors beeped at her. The girl wasn't responding to anything, the infection was slowly killing her and if they didn't do anything it might finally reach the fetus. Dr. Virum sighed as she walked up to the patient, taking note of the vitals. Heart rate was low, BP was low, even the temperature was a little low. The woman had coded again during her shift and Virum was lucky to have restarted her heart again but she was sure that was the last time she could. The heart just couldn't take anymore and they had her in a medically induced coma in order to minimize the pain and discomfort. The patient was too anxious anyway, doing better not up and worrying about her baby. Unfortunately, the fetus was far too undeveloped to be taken out. If they lost the mother they lost the baby and Dr. Virum was not going let that happen. Analyzing the file, she wore a thoughtful frown as she again observed the patient and then the monitors began to scream in protest.

"Need help in here!" she shouted at the open door.

Two nurses rushed inside the room, awaiting her instruction.

"Respiratory arrest, the infection is making her hypoxic. We have to intubate, get me the laryngoscope," Virum instructed sternly.

One nurse carried out her orders while the other one got the ventilator ready. The doctor's face was focused as she carefully used the scope to help guide the tube into the patient's esophagus. Her hands were steady as the monitors screamed at her, trying to warn her of the devastation going on inside this woman's body. Virum took a breath, exhaling slowly as she worked her way through the cords and into the trachea. Satisfied, she pulled out the scope and hooked up the ventilator. The monitors calmed down and Dr. Virum breathed a heavy sigh of relief. Another thoughtful frown found her face as she observed her patient.

Meredith Noregn, 30 year-old. She had frizzy black hair, long eyelashes and olive toned skin. The patient wasn't very tall but she was gorgeous and glowed with her pregnancy. Until she came here into the emergency department trying to figure out why she was so short of breath, why she was so exhausted - and all they could find was an infection that was somewhere within her body. It made Virum sick that she was so helpless. And then an idea struck her, one last one, and hopefully, it would do the trick. The doctor ordered the medication on her tablet, hoping to see results before her shift was over. She had promised Gladiolus that she wouldn't do anything about work when she was done and she couldn't go back on that. She felt guilty for bailing on him yet again. He was very patient with her regarding her job, but she knew that until this woman was settled that the job would constantly be on the brain. Virum walked toward the nurse's station, smiling sadly at Gin while her tablet was in her face before scanning through patient files, content that there was nothing terribly pressing.

"Weren't you supposed to have the morning off?" asked Gin.

"Weren't you?" replied Dr. Virum, raising a brow.

The pregnant nurse just looked at her helplessly, "This city is going insane."

"War's a trying time," she shrugged.

"What do you think is going to happen now?"

"Just worry about your baby. Speculating the war only makes you miserable."

Gin sighed, "I guess you would know."

Virum nodded, watching as a nurse approached her patient's room with the medication she had ordered. She then walked into another room, trying to get as many patients out of the hospital as possible.

...

"Call a code!" Dr. Virum shouted.

Meredith was crashing again, this time her heart was acting up. Two nurses rushed into the room and Virum disengaged the machine, while one of the nurses started CPR. The other nurse got the crash cart and Dr. Virum pushed in the last amount of epinephrine that the patient could take. Once the paddles were ready she began her work. After four shock treatments, Meredith finally had a mostly normal sinus rhythm and the doctor once again let out a sigh of relief as she hooked up the ventilator once more. Pulling out her tablet, she punched in all the updates, heart still heavy about the medication not taking its toll at all. This woman was going to die and so was her baby. There was no way they could remove the child and keep it alive, it was too early. They just didn't have that kind of technology. If only she was a little further along. Virum felt tears well in her eyes, knowing that this was the last time she would be able to stop her patient from dying. The next time... well, that was it. The doctor put her hand on top of the patient's as the monitors hummed their stale tune. It just wasn't fair.

Gladiolus was standing at the nurse's station, talking with Gin, the pregnant charge nurse. Athenacia was supposed to be done her shift about fifteen minutes ago but a quick look into the room and he knew that she wasn't going to pull away just yet. It didn't look good in there and he assumed that this was the patient she was talking about earlier this morning. Gin was also looking in that direction, a sad look on her face. The Shield grew thoughtful as he watched her close the glass sliding door to the room and then draw the curtains so they could no longer see.

"She's not going to make it," said Gin softly.

"No?" asked Gladiolus absently, looking back at the nurse.

"She's saying goodbye. I hope whatever you have planned it involves a lot of drinking."

Gladiolus grunted, not really knowing how to respond, "Must be hard," was all he could manage, his eyes distant.

Dr. Virum drew in a staggering breath, hating that there was nothing more she could do for this patient. All this caused by an infection that they not only could hardly see, but couldn't even treat because of this woman's complicated pregnancy. Nothing was working, and now two lives were going to die because of it. This was unacceptable. There was no way she could just sit back and lose this battle, there had to be something more she could do. Virum studied the patient file, everything that had been done since the woman was admitted, desperate to see something to connect the dots.

Finally, an idea struck her. There was one last thing that she could do and she was hoping that it would work. Wiping her tears and sniffling a little, she walked to the doorway and closed the glass sliding door. Virum then pulled the curtains so that no one could see her, catching the eye of Gladiolus briefly. Walking back to the patient, she removed her latex gloves and holding her hands above Meredith. Drawing in a large breath, she focused intently on what she was doing, letting the breath out slowly as golden lights began to emanate from her hands and down toward Meredith. Dr. Virum watched as the pregnant woman was glowing gold before she could no longer keep up her work. Arms dropped to her sides as she felt a wave of dizziness spread through her body. It was only for a moment, her attention snapped back to Meredith once the woman opened her eyes. Virum smiled, as tears of joy welled within her tired hazel eyes. Meredith was choking and the doctor disengaged the ventilator, pulling the tube slowly out of the esophagus. The patient coughed and she encouraged more coughing to help get the tube out. Finally, the woman took a breath of her own, choking slightly. Dr. Virum took her tablet out of her lab coat pocket, keeping her eyes on the machines. They were all looking normal and it made her feel so much better.

"How are you feeling?" she asked her patient, who finally caught her breath.

Dr. Virum put on her stethoscope, having a listen.

"Fine," replied Meredith hoarsely.

"No discomfort?" she asked, hearing no struggle breathing and a strong heartbeat.

She moved to the swollen womb.

"My throat," the patient croaked.

"That's the tube and the medication. You gave us all quite a scare," Dr. Virum told her seriously, removing the scope from her ears and placing it back around her neck.

"Sorry."

"Don't be sorry. I'm just happy that you made it," said Virum, smiling brightly at the woman, "Because of your condition I'll need to keep you here for observation and order some more tests, but if you continue to improve, you'll be out of here in no time."

"Thank you."

Dr. Virum nodded, turning to leave the room. A smile was plastered on her face as she opened the curtains and left the examination room, catching the eye of Gladiolus and Gin, who were not expecting her to come back in such high spirits. The nurse looked like she was about to cry, those damn pregnancy hormones getting to her. Gladio, on the other hand, seemed to look relieved that she wasn't a mess like he thought she would be. Obviously, Gin's big mouth was at it again. As she approached the nurse's station, she ordered one nurse to bring in some water for the patient. Virum then had her tablet on the counter and began to update everything before signing herself out for the day. Her shift was done, she could finally leave. Gin was still smiling at her.

"You, are something else," said the ginger-haired woman.

Dr. Virum shrugged, "The medication finally started to work."

"I don't think anyone else can pull that stuff off besides you."

"We'll never know. She's stable, breathing on her own and her heart rate is strong, BP rising. I want a head CT, CBC, an echo and an x-ray. She needs to be monitored, I don't want this creeping back up on us again," instructed Dr. Virum.

"I love when you talk doctor," said Gladiolus smirking, "Maybe we can play later."

"Gladio!" she huffed, her face turning red instantly as her eyes widened.

Gin only laughed as she punched in all the orders given to her into her own tablet, "I don't even want to know."

Gladiolus only waggled his eyebrows at her, which caused the pregnant woman to laugh harder and the doctor to flush even more.

"I don't even care right now," Dr. Virum recovered herself as best she could, kissing Gladiolus quickly, "I'll be five minutes," she told him, practically skipping on her way towards the locker room out of sight.

The Shield only watched her with that crooked grin on his face, his amber eyes alight with her mood, "Is she always like that?"

"Only when she wins," answered Gin.

"She get attached to patients a lot?"

"Some. Mostly infants."

He grunted, "So she likes children?"

Gin gave him a look, "Slow down there big guy."

"I didn't mean it like that."

"Mhm. Nothing to do with playing 'doctor'," replied Gin dryly.

"Wouldn't you like to know?"

"You are trouble! You are a troublemaker."

He only smiled wider at her and the woman rolled her eyes.

"Cia doesn't usually get attached to any patient, but she always has a soft spot for young children and infants."

"Wonder why..." his face grew into a thoughtful frown.

"Couldn't tell you," she shrugged.

Gladio remembered a while back when they were in code grey and she was dealing with that young girl from the crash, Valentina. Athenacia was good with the child and the little girl seemed to trust her. He remembered the baby that needed the heart transplant, how devoted she was to make sure it happened. And now there was this pregnant mother who was going to die if she didn't do something. How many had she saved? How many had she lost? Gladiolus had another revelation about this woman he was with. Every day he seemed to learn something new about her that drew him closer to her. His thoughts were interrupted by the sight of her, still wearing her light green scrubs underneath her jacket, finding that there was no need to change. That same smile was still plastered on her face and that light in her eyes was shining brightly for the first time in days. Gladio regarded her in almost a loving manner. These were probably the types of days that made her feel good about her profession and he suddenly felt very foolish at having protested her coming in at all. Her job was who she was and the biggest reason he had come after her in the first place, he wasn't going to be selfish and take that away from her.

Athenacia waved goodbye to Gin as she walked out of the emergency department with Gladiolus. The girl was exhausted, the high she felt from saving her patient wearing off and the toll of her actions settling in, however, it was worth it and her smile returned to her face. The ride back to her apartment building was a short one. At least, that's how it felt. Athenacia wanted to get ready for the day, wondering what they were going to do now that she actually had some time off. As they got out of the car and walked toward the elevator, Gladiolus's phone chimed at him.

"I gotta stop at Noct's," said Gladio as they got inside.

"I have to shower or something anyway," replied Athenacia, hoping she could maybe get in one of her naps.

The Shield nodded at her, taking out a card and swiping it before pushing the top floor. Athenacia pushed the button for the seventh floor and they rode the short distance together. When the elevator stopped she smiled at him before beginning to step out.

"I shouldn't be long," he told her.

"Take your time," she replied, her smile growing tired.

Athenacia walked out of the elevator and down the hallway to her floor. The physician had a much easier time opening her apartment since she wasn't nearly as tired as last time she tried it. Closing the door, she heaved a sigh before kicking her shoes off and dropping her jacket and purse on the floor near the couch, walking straight into the kitchen. The first thing she grabbed out of the fridge was a beer, taking a look around. It was messy in here, she was best cleaning up a little but she was way too tired. Gulping down a long drink, she made her way to the bathroom.

The doctor began to run the water, deciding that she was finally going to have that bath she promised herself ages ago. As the sound of water filled her ears in the echoing room she began to remove her clothes, the steam starting to build as she observed herself in the mirror. There was some colour to her cheeks, the black circles under her eyes lessened than the last time she looked. That was a good sign, it meant that despite waking up twice last night she actually had a bit of a decent sleep. Her hazel eyes then found that ugly scar on her neck that ran down her collarbone and ended right where her armpit began. Athenacia sighed, hating the sight of that thing. It was ugly and it made her feel insecure about it. Pulling the tie from her hair, she tossed it on the counter before turning her back on her own image, the water finally ready for her. The girl submerged herself, relief washing over her aching body - though it didn't hurt in a physical nature it still soothed her soul and that's what she really needed right now. She needed to replenish her energy in order to get through the rest of the day. Her skin was red, as she was practically boiling inside but she didn't mind in the slightest.

Once she was finished cleaning herself she didn't put on anything fancy, only a pair of black yoga capris and an orange tank top. Athenacia had no idea what she was doing today and wanted to catch a quick nap anyway. Finishing her beer, she placed the bottle with the others on her night table and only pulled the light knitted blanket on top of her as she lied in her bed. She was dozing instantly, sleep claiming her much quicker than she anticipated.

...

Gladiolus walked into Prince Noctis's apartment without knocking, removing his shoes quickly at the door and walking down the hallway into the main room where three men were surprised he had made it so fast. Well, that was inaccurate, the Prince was lazily sitting on his couch with his eyes distant, Prompto was happily popping pieces of sweets into his mouth but stopped midway through one of them and Ignis only looking mildly curious as he finished cleaning up the kitchen. Gladio looked at Prompto, raising a brow and wondering why the young man was staring at him in that manner, mouth wide open, hand holding a piece of food about to be thrown in.

"What?" asked Gladiolus.

"Dude, how'd you get here so fast?" asked Prompto, the food still in his hands.

"The journey between floors is nearly instantaneous," quipped Ignis lightly.

"What?"

"He was at his girlfriend's," supplied Noctis, annoyed.

Prompto made a perfect O with his mouth, nodding in understanding and putting the food in his mouth. Ignis internally sighed at the Prince's tone, his face frowning in thought. The blond seemed to be the only one who didn't have a care in the world, the tension not getting to him - and make no mistake, there was a high tension here. Gladiolus was obviously missing something.

"What's eating you?" he asked the sullen Royal.

Noctis only glared at his Shield darkly, before turning his gaze out towards the window. Gladio looked at Ignis, knowing that was the only way he was going to get any answers here.

"Have you spoke to your father recently?" asked the Adviser.

Gladiolus shook his head, "Haven't seen him in a few days, he's been staying at the Citadel."

"Not surprising in the slightest. But you did learn of the emissary of the Empire approaching the Crown City and taking an audience with the King?"

"Yeah, something about a peace treaty."

"Precisely."

"What about it?"

"The terms are quite clear. We are, that is, King Regis is to surrender all of Lucis sans Insomnia to Niflheim."

"What?!" his eyes narrowed dangerously, his arms crossing in defence.

"That's not all of it," grumbled Noctis.

"Indeed. Another clause requires the Crown Prince to be wed to the current Oracle and former Princess of Tenebrae, Lady Lunafreya Nox Fleuret," explained Ignis.

"No one knows about it yet, I'm not even supposed to know," said Prompto.

"The King has yet to respond, though I daresay he'll accept..."

Gladiolus grunted in response, that part not really shocking him, "So what's the problem then?"

"They're forcing me to marry Luna," replied Noctis, nearly outraged.

"So what?"

Noctis looked back at Gladiolus, but actually had nothing to say. He returned his stare back out the window, trying to actually find a problem with the proposed peace treaty. In truth, there was no real issue with that part of the treaty, but he couldn't let his guard down and admit that he was actually happy about seeing Luna again.

"I don't know, dude. I think you got it pretty good. You get to marry a super cute girl, and one you actually like," said Prompto, popping more sweets into his mouth. Ignis took the plate away before he could devour anymore, "Hey!"

"You'll put on weight with more consumption," said Ignis sternly.

"You really think I'm lucky?" asked Noctis, looking over at Prompto with mild interest.

Prompto shrugged, "Sure. Not everyone gets to marry their dream girl."

"She's not-"

"If anything she's the one getting the shit end of the stick," teased Gladiolus, seeing the opening Prompto provided.

"Hey!" shouted Noctis, all previous discontent evaporating.

"Oh definitely," agreed Prompto.

Gladio grinned his defensive stance dropping. His phone buzzed and he pulled it out, checking on the message. Frowning, he quickly typed his response before looking up at the rest of them.

"I gotta go," he declared.

"Back to your girlfriends?" mocked Prompto in a sing-song voice.

Noctis only laughed, happy the attention was off of him.

"With Noct getting married that only leaves you left to die alone Prompto."

"Dude, what about Iggy?"

"He'll be fine, he knows how to actually talk to women."

"Noct!" Prompto whined.

"Don't look at me, where were you earlier?" replied the Prince with mock indignance.

Gladiolus only grinned as he slowly backed away, Ignis giving the man a glare at the trouble he was leaving him with. The Shield put his shoes on and crept out the door, closing it without a sound. The elevator ride didn't take long, walking down the hall to unit 708 and opening the door - again without knocking and politely took his shoes off. A brow was raised at the lack of shoes on the other side of the door, not expecting any of it to be cleaned. The Shield walked further in, stopping as soon as he reached the living area and smirking, leaning against the wall with his arms crossed.

Athenacia had music playing, her hair up in a lower ponytail as she danced around collecting garbage while she did so. The girl was singing even, taking a drink of a beer in between breaths. Her voice was absolutely terrible but Gladiolus suspected she was doing most of that on purpose. There was no way to tell how much she had drunk since she had come home but obviously she was having a good time without him. The Shield was almost starting to get jealous as he watched her, narrowing his eyes slightly when he noted she was favouring her right shoulder while she moved. And then she caught sight of him and stopped dead in her tracks. Her face turned beet red as she dropped her garbage bag and hastily turned off the music.

"Gladio," she was out breath from her own movements.

"Hey Doc," his grin was from ear to ear as he regarded her, "Don't stop on my account."

She flushed further, taking a long drink of her beer, finishing it and placing it purposefully on the counter, "I'm pretty much done here anyway," she tried to wave off, wincing as she did so.

"You hurt?"

"I just slept on it funny," she replied, wincing again as she moved her right shoulder

Gladiolus walked toward her, stepping behind her and placing his massive hands on her shoulders. Carefully, he began to prod around with his thumbs until he found the tender spot and then knead his fingers. The sounds of her discomfort reached him, though she didn't move at all. It was knotted, the entirety of her neck and shoulders completely tense, almost as if she had never had a massage before. Obviously she needed more time to relax.

"This is what happens when you sleep without me," he whispered in her ear.

He smirked when small goosebumps appeared on her skin where he was working.

"You're the one who had to go," she replied with mock indignance, still wincing once in a while.

Gladio didn't respond but finished working the tension in her shoulders. Athenacia turned to face him then, a small smile on her face and he realized he rarely saw her so exposed. In this light, he could see the scar on her neck to its entirety, his amber eyes rolling over it. The tissue started from her neck and travelled down just below her shoulder. It was much wider in the middle, the blemished skin almost looking fresh. The Shield took his hand and lightly traced his finger over it, from start to finish. That made her very self-conscious. It wasn't like he hadn't seen it before, usually, he just ignored it. This was the first time he had openly stared at it, gave it any sort of attention and she bit her lip in a nervous manner, flinching ever so slightly as he touched it. Athenacia hated that thing, it was so ugly. Her brows knitting into worry and she pushed his hand away, desperate to hide it from view. She took in a sharp, small breath as he took her cheek in his hand, forcing her to look up at his frown. Gladio used his other hand to push hers away and her anxiety rose as she watched his amber eyes travel back to her scar. Without warning, he bent down and kissed her damaged skin and she was almost frigid. His lips were tentative and light and she let out a breath she didn't even know she was holding, her fears melting away at his touch. The Shield brought his gaze back to her, placing his forehead against hers.

"You still owe me an exam," he spoke, his breath hot on her face.

She smiled slightly, biting her lip again nervously and he kissed her, her arms wrapping around his neck.

"What seems to be the problem?" she asked lightly, almost out of breath.

"Chest pain," he grunted.

Athenacia removed her arms from his neck, slowly slithering them down his upper body and underneath his shirt. The large man breathed in as her cold fingers worked their way up toward his heart and stopped.

"Your heart rate is slightly elevated," she said softly, "And your breathing is somewhat shallow. Perhaps..." she began to lift his shirt, "Relieving the pressure..." she pulled it up over his head, having to stand on her tiptoes in order to reach, "Should help..."

His shirt hit the floor and he grabbed one of her wrists, bringing her palm to his lips and placing a soft kiss there. The physician was losing her own breath, trapped within his gaze while her other hand ran through his hair, her fingers tangling in the brown locks as they kissed once more.

But as fate would have it, they were interrupted by the phone buzzing.

Gladiolus detached from her, looking almost annoyed.

"Don't look at me like that, my phone is turned off in another room," she held her hands up in surrender.

He groaned, taking out his phone, shaking his head at the message.

"I forgot I was supposed to meet with my dad."

"I thought you had the night off?" she frowned.

"Yeah, he called me home while I was up at Noct's. I was coming down to tell you I just..." he left it hanging, placing a hand on the back of his head sheepishly.

The girl nodded, "Go, don't keep your dad waiting anymore."

He grinned, giving her a quick kiss, "Thanks, Doc, see you tomorrow."

Athenacia smiled as he took off out the door without a second thought. She then let out a small laugh as she picked up his shirt off the ground. The door opened and she smirked as she held out his shirt toward the hallway. Gladio beamed at her, kissing her deeply once more before grabbing it from her and then turning to leave again.

[lithium-lossr]

It’s been a while since I’ve posted but mostly because after the appointments I was exhausted for days on end and all energy accumulated was spent on my toddler. Finally though, after a long nap, I have mustered enough energy weeks later to update my little tag for myself before I forget anything.

So here’s an update for myself.

Last I posted was how anxious and frustrated I was with the American healthcare System since, without insurance, 15 years of my life was depending on 30 minutes.

When I went in for that appointment I ended up only having an EKG, not the orthostatic blood pressure I expected. Which is fine, just really shitty when travel time is north of three hours, but my doctor knew their EKG prices are FAR cheaper than my areas so no worries. This appointment was 12/31/19

The nurse on the other hand was rather condescending, I thought. Maybe it’s the autism not catching tones right but i dunno. Felt off. I expressed I knew the EKG procedure since I’ve had several in the past so she didn’t need to walk me through it. She broke terms down for me and I also explained she had no need since I have a strong history in human anatomy but also have had several friends & my own sister being nurses. TYPICALLY I have nurses feel relieved or kinda happy after explaining I don’t need them to baby step me. Normally allowing that knowledge be known opens to some great convos that don’t involved every single step they’re taking. I felt some of her finishing comments about me being a “good little ekg taker since I’ve had so many” basically felt invalidating. I’m sorry I didn’t have you explain the whole process out to me like I’m a newbie. That you didn’t have to remind me 100 times to stop moving or talking. Maybe THATS why you fucked up the wire order and put my calves on my arms & messed up the chest one with another. Because you didn’t talk yourself through it. But hey, who knows. I don’t.

Anyways,

My EKG came back and it showed enough for us to set up and orthostatic bp appointment.

I was unable to find the EKG Results on the portal but I’ve requested them and will be adding them to my tag to keep track of all this.

For my orthostatic bp appointment I thankfully had a much nicer nurse. She had me lay down and did me up with a cuff and finger pulse oximeter. My oxygen was 99% (not to brag or anything *debbie Ryan hair pushback meme* but it’s Rona SZN bb)

I just focused straight up & ahead. Throughout the whole lay, sit, stand transition she asked me questions on how I felt. Just like any day my symptoms were strong and immediately on sitting up my chest felt sharp and tight. Slightly light on my top half. More I had to support myself the worse I felt. Started to realize how much I support myself with walls, chairs, bars, anything to keep me from having to hold my own weight because this sucked. When I stood my heart kept hurting and my body felt light. My legs felt like they were literally draining. Like I honestly feel like I’m in some sort of Stephen King movie with how it felt the blood fall. Feet felt heavy.

The poor nurse sounded so concerned. Several times she asked if I was going to pass out and if I needed to sit then sit but I won’t lie. If it took me passing out I was prepared to because I’m SO TIRED of this debilitating BULLSHIT.

To give better context on results I’m about to drop (to anyone who actually might be reading this and care) on my orthostatic bp I am:

-24 years

-114 lbs (51.7kg)

- 5’7” (170cm)

My results (copy and pasted from the portal)

Orthostatic BP -

123 / 78 supine R arm adult cmchale1 01-12-2021

127 / 95 sitting R arm adult Abnormal cmchale1 01-12-2021

134 / 91 standing R arm adult Abnormal cmchale1 01-12-2021

Conclusion came to yes, it is POTS-

“Dr. R______ has reviewed your nurse visit and states: Her symptoms and vital signs are highly suggestive of POTS, or postural tachycardia syndrome. There are a variety of reasons this can happen, but the most common demographic is young, thin females. Often, nonpharmacologic treatments can be very effective. Specifically, high salt diet, aggressive fluids, and a daily exercise program with cardiovascular training (e.g. interval jogging - let me know if she needs more specifics). Also, doing things to increase venous return (squeezing the leg muscles a couple times) before standing up can be helpful. Sometimes, a beta-blocker like propranolol can be used as needed to help with high heart rates, but should only be used in the context of the behavioral strategies. I'm happy to send some in, if she doesn't get enough relief with the behavioral approaches! Let us know if you have further questions.”

Since dealing with this so long most of these things have already been in place. I’m a r/hydrohomie and even recently updated my bottle to a half gallon hydroJug since my quart was just useless. Always ALWAYS empty. I have a relatively salty diet but will be getting supplements to boost, I just don’t really know what to look at for SALT/sodium tablets. Like, the thought of them existing never crossed my mind until I read about sodium intake. As for working out I won’t lie, I chase a toddler (16m) around all day so I definitely TRY to get a nice workout in but I’m exhausted after them. In Maine we are below freezing temperatures and inside just don’t have much room so I try to hoop or do some palates or something to get my muscles working. I used to be such an avid walker when I lived in town. Even in the winter I’d just walk to the store. But now the closest store is 5 miles away on a busy road in tourist/farm land so needless today it’s isolating for someone who doesn’t drive. Even when the weather is nice I never NEVER HAD TO DEAL WITH T I C K S. Northern Maine doesn’t deal with that. I saw my first tick at 19 years old 50 miles from my hometown. So not even something I had to worry about hiking in the woods up north. But HERE. PEOPLE KEEP A COLLECTION TO SEE HOW MANY THE CATCH EXCUSE ME.

Ugh that’s a tangent and a half but 🤢🤮 ticks

Little fucking paracites.

As for the medication, I’m glad that wasn’t the first thing she pushed on me. I LOVE having a D.O. over an M.D. Idc. If I have a choice I will pick a D.O. EVEYTIME. My goal is to eventually be off all pharms, even if right now it’s only Zoloft. After I stop breastfeeding I’m to add lithium back at a low dose and that’s just so much maintenance. Labs, med management, MORE refills. Adjustments. Sigh.

Adding also for anyone who does actuall read. I KNOW a cardiologist is who can properly diagnose me and help me more effectively than a D.O PCP. My pcp is literally just worried about my heart and that it was ignored so long. She also knows I have no private insurance and her office doesn’t take state. She’s worked with me in the most amazing ways to get me the best care for the CHEAPEST.

Her original plan was to have a holter monitor for 24hrs & ekg and go from there. I wasn’t able to get a holter to rent so unfortunately we had to relay on my Fitbit but I also got an finger pulse oximeter to track my symptoms especially when I felt them. I was suggest to also get a BP cuff but baby steps. I plan on ordering an electric arm bp when I can.

I had my EKG which clearly showed a need for a Ortho BP.

My overall plan was at LEAST get it addressed and in my records for when I eventually DO have to change PCPs for what ever insurance I can scramble up. That way my new pcp can see and maybe I can get in with a real cardiologist.

I’m just so damn grateful that my doctor listen to me. I love receptive doctors. Thank you Dr. R for being a Queen and not ignoring how I have to live and feel based on the words “I pass out randomly.” You gave your thoughts, I CHALLENGED them and you listened. Thank you. Thank you for not having a fragile ego and working on this together.

[nelliievance]

New Blood Pressure Adventure

This is my latest challenge. I found out I have pretty significant hypertension (elevated blood pressure), . This occurred at my new doctors office (general practitioner). I have had “white coat disease” in the past, where BP reading is elevated in the doctors office, but when I go home it’s fine. So when I got a reading around 170/90 on my Dr. visit, I told my new Doctor (more on her below) that and she took my word for it, and told me to go home and do a BP log for a week to show her on the next visit. Imagine my surprise when I got home and got in the range 170/90 multiple times!

Now some background. I was first diagnosed with hypertension more then 10 years ago, but is was not too bad, about 140/80, so my doc put me on low dose atenelol (beta blocker, 20 mg) I later switched to a different primary Doc near my work (at the time) whose a sports medicine specialist, who prescribed low dose lisinopril. Beta blockers are not the best idea for athletes, even amateurs like me, because they alter your heart rate response. ACE inhibitors like lisinopril work by blood vessel dilation so don’t have this problem. Then when I had incidents of AFIB due to aortic stenosis, my cardiologist put me on Metaprolol 50 mg to also control possible arrhythmias. Metaprolol is also a beta-blocker so acts to lower BP. I was on that till recently.

Around last October, I figured, you know what, it’s been more than 3 years since my surgery and I had no incidents of AFIB or other arrhythmia, so why do I still need Metaprolol?

So I phased myself off by the end of October, and continued on merrily to the present. Two mistakes: I did not consult with my doctor first, and I didn’t bother to check my BP. I forgot Metaprolol doubles as a BP med. Note to self: no self medicating, always check with your Doc!

I’ve also learned that there is a phenomenon called rebound hypertension which occurs when you go off some BP meds, especially beta-blockers. I’m not sure that’s relevant because I got off it a few months ago,

Fortunately I have a follow up with my new Doc. Presumably if I don’t have it down enough by then, she’ll put me on something for the short term, and in the long term work more on lifestyle interventions.

My New Doctor- Preventive Medicine!

My previous general practitioner retired a few months ago. I decided to look for a preventive medicine specialist as my new physician. I found Dr. Sepideh Moayed up in Campbell. I was very impressed by her website, she has great ratings, and gave me a free phone consultation. which clinched it for me when she explained her philosophy: spend more time with patients, do more in-depth investigation (preventive screening) than is normally done in physicals. And lifestyle interventions first (exercise, diet, stress relief, etc.), backed up by supplements or drugs as needed. But she is a fully-qualified practitioner of allopathic (“modern”) medicine when needed, Right up my alley! My first homework assignment is to do a detailed food log (she is also well-trained in nutrition), as well as the BP log, and she’s sending me off for the most detailed bloodwork I’ve ever had. The adventure begins!

Until next Friday, I’ll deal with the BP issue with all the lifestyle interventions I know. First, and foremost, I’m someone who errs on the side of too much exercise, not too little. So I’m cutting back on both intensity and volume for a few days: Elevated BP can be a side effect of overtraining. I did read up on exercise and hypertension and found an excellent paper on exercise prescriptions [1]. The major new wrinkle is recent findings about the intensity of exercise for BP lowering:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589552/

Recommendations in the past said low to moderate intensity, but now it seems the higher the better (although that should be discussed with your doctor, as it says in this article, you “may consider progressing to more vigorous intensities, however, the risk-to-benefit ratio has not yet been established”). So I’m going to stay with low and moderate till I follow-up with my new Doc.

I’ve also quickly implemented “low hanging fruit” measures I found on the web. I was already pretty much complying with the DASH diet, except for lowering sodium, so I’ve cut back on that. Relaxation is important so I’ve paid more attention to higher quality yoga and meditation sessions. It’s working so far, I’m down to 144/76 today.

I also found a great book Thirty Days to Natural Blood Pressure Control, by David DeRose MD MPH, Greg Steinke MD MPH, and Trudie Li MSN FNP. These authors have experience with Loma Linda University (of Seventh Day Adventist Study fame) and the highly successful Community Health Improvement program, and they have had dramatic results on BP lowering in practice. So I’ll go after what I glean from this book in addition to my Doctor’s recommendations.

I’m not at all bummed out about this, it’s just a new challenge. I’m just glad I got away with no permanent harm with my foolishness in going off a med without checking with my doc first. In fact, as Dr. DeRose points out, high BP can actually be the gift of a wake up call. Back in early 2017, I was doing very well on clean eating. At that time my wake up call was my ongoing aortic stenosis issue leading up to my surgery, as well as a bad triglyceride result from a blood test. But over time I got a bit more lackadaisical about it. It’s time to get more serious with the BP wake up call.

I will keep you posted on this continuing new saga.

References

Pescatello, R, et al, Exercise for Hypertension: A Prescription Update Integrating Existing Recommendations with Emerging Research, Curr Hypertens Rep., 2015.

New Blood Pressure Adventure published first on https://steroidsca.tumblr.com/

[kk095]

Sideswiped

*here's my latest story! There may be some typos and additional editing I need to do, but I hope everyone enjoys!*

Rachel was a 34 year old white woman with dirty blonde hair, blue eyes, and was of average height and had a slim build. Life seemed to be going pretty well for Rachel; she was recently engaged to her boyfriend of 3 years, and the two were planning both a wedding, and buying a house together. Unfortunately, fate had other plans for Rachel this morning.

She worked at a mortgage company downtown, and the commute was about 30 minutes each way. This morning, she had an important meeting to attend. While making the drive to the office, an SUV merged onto the highway without signaling or looking, sideswiping Rachel’s passenger side. Rachel wasn’t immediately injured, but she lost control of her car and slammed head-on into a guardrail. Her neck whipped forward, causing a whiplash injury. Her chest struck the steering column before being blown back by both the impact and the airbag. A loud crunch was heard from the car striking the guardrail. One of the windows broke, which sent a handful of glass shards flying around, which struck Rachel in her right cheek, and above her right eyebrow.

After the crash took place, traffic came to a screeching halt on the highway and EMS was alerted. The vehicle that struck Rachel fled the scene, but an eyewitness took a picture of the vehicle on their cell phone, which had a clear view of the license plate.

In the coming minutes, emergency services arrived on scene. Police helped direct traffic, while also talking to the witness who took the cell phone picture. The medics went up to Rachel’s mangled vehicle and began their initial assessment. Rachel complained of chest pain, pain during inhalation, neck pain, and feeling cold. EMS placed a c-collar on the woman and placed her on a backboard, then took her into a nearby ambulance. Once in the ambulance, Rachel’s top was snipped off, only sparing her black bra. There was apparent redness and swelling on her chest from the steering wheel injury. IV access was able to he obtained on scene, and a 5 lead ECG with portable heart monitor was set up. On scene, Rachel’s vital signs were BP 79/42, heart rate 126bpm, and oxygen saturation was down to 93%. The medics hung a bag of ringer’s lactate to combat her low blood pressure and to begin fluid resuscitation, and they started her on an o2 mask with high flow oxygen. During auscultation, distant heart sounds could be heard, along with diminished breath sounds on the right side. The ECG showed an alternating tall-short QRS complex.

During transport, Rachel was drifting in and out of consciousness, and began groaning in pain. The steering wheel injury caused fractures to a few ribs and her sternum, but based on her vital signs and other observations, she was likely experiencing a major thoracic injury. Rachel remained semi conscious during transport, and asked the medics to call her fiancée, to which they told her the ER will call him as soon as they get there.

A short while later, Rachel arrived at the emergency department. She was taken out of the ambulance and wheeled into the trauma bay while one of the medics updated a few members of the trauma team. Once in the trauma room, Rachel was transferred onto the table. A few nurses snipped off Rachel’s pants, and removed her shoes, leaving her barefoot and almost completely nude. The trauma team started Rachel on blood transfusions and ordered trauma labs. The next step was to order a chest x-ray and a FAST scan.

The chest x ray showed multiple rib fractures on the right side, along with a sternal fracture. There was also evidence of a ride sided hemothorax, and possible cardiac herniation into the right side of the thoracic cavity. The echocardiogram showed no evidence of cardiac tamponade, but that’s typically common in cardiac herniation cases since the pericardium is usually completely ruptured. However, the exact location of the ruptured pericardium couldn’t be found, so it was possible the tear was on the side, or back of the heart. In the meantime, the trauma team decided to order a chest tube placement on the right side, page radiology for a portable CT scan, and page cardiothoracic surgery for a consultation.

The right sided chest tube placement began promptly. The area of Rachel’s 6th rib on the right side was sterilized with betadine and an injection of local anesthetic was injected to numb the skin. A 3cm incision was made in the skin anterolaterally, which is just anterior of the mid axillary line. The underlying tissue was incised further so the pleural space could be sufficiently exposed. With the proximal end of the chest tube clamped off by a Kelly clamp, it was advanced into the small cut and a tunnel was made so the tube could be inserted deep enough to properly drain the blood that was squeezing Rachel’s right lung. Rachel yelped loudly, feeling the tube being forced into her chest while she was wide awake. Once the tube was correctly placed, a large amount of blood and air shot out of the tube, splattering all over one of the resident’s trauma gowns.

After the chest tube was placed, the trauma team had to hang another bag of blood products to compensate for the blood loss that was being experienced. Following the additional blood products being hung from the rapid infuser, radiology showed up with the portable CT scanner. The scan took several minutes, but her head, chest, abdomen, and pelvis were all scanned. The head, abdomen, and pelvis came back clear, but the chest portion of the CT scan confirmed cardiac herniation with a 12cm blowout of the posterior pericardium. The heart was sitting outside of its fibrous casing, and the pulmonary veins were stretched out, and possibly damaged or partially detached from either the left atrium or the right lung, but the scan’s findings were inconclusive when it came to that aspect of Rachel’s injuries. But shortly after the CT scan, Rachel’s vital signs began to deteriorate rapidly.

Rachel’s breathing was slowing down, and her eyes were wide open, with a scared look present on her face. Due to blood loss, both her BP and heart rate were dropping rapidly. Since her breathing was slowing down, the trauma team elected to intubate her for airway management purposes. Before intubation began, Rachel gasped dramatically a few times. Her eyes opened wide before letting out a calm exhale and going limp on the table. No pulse was felt, and PEA ran across the heart monitors, so rapid sequence intubation and resuscitation efforts commenced at the same time.

Up by Rachel’s head stood one of the residents, trying their best to navigate a 7.0 ET tube into the attractive blonde’s airway. Just a few feet away stood a nurse who was pumping the 34 year old’s chest repeatedly. A cracking noise could be heard during CPR because of the rib and sternum fractures that Rachel sustained in the accident. With life saving efforts ongoing, a nurse injected epinephrine and atropine into Rachel’s IV. Shortly after the drugs were administered, the ET tube was placed successfully and held in place with a blue tube holder.

Over the following few minutes, Rachel received deep, strong chest compressions. Her chest caved in rhythmically while her b cup breasts jiggled around. Her belly rippled and bounced outwards from the residual force of the compressions she received. At the 3 minute mark of the code, the trauma team pushed the next rounds of epinephrine and atropine into Rachel’s IV in an attempt to obtain a shockable rhythm. About 45 seconds after the meds were pushed, coarse v-fib appeared on the monitors. The defibrillator paddles whined as they were gelled and charged to 200 joules. After a cycle of CPR, the paddles were pressed up against Rachel’s chest and a shock was delivered once everyone stood clear. Her body trembled on the table in response to shock #1, but the monitors still displayed v-fib. A nurse immediately resumed strong, forceful compressions on the attractive blonde while the paddles were recharged to 300j. The paddles were pressed up against Rachel’s chest a moment later, and shock #2 was delivered. Rachel’s lifeless body squirmed on the table in response to the jolt of electricity while her beautiful blue eyes stared lifelessly above. V-fib still persisted after shock #2, so a cycle of CPR was performed while the defib paddles were recharged to 360. Once the paddles were ready, they were placed onto Rachel’s chest again, and the 3rd shock was delivered. Rachel’s body shuddered and flopped in response to the increased intensity of the 3rd shock. But like before, this shock failed to shock the woman out of v-fib. The paddles were recharged to 360 and placed back onto Rachel’s chest, and the next shock was delivered seconds later. Rachel’s feet leapt up just above the table before crashing back down half a second later, wrinkling the soles of her size 7 feet.

This 4th shock converted Rachel to sinus bradycardia, so ROSC was able to be achieved after a downtime of 5 minutes and 8 seconds. Rachel regained semi consciousness seconds after her heart was restarted. “hey there, welcome back! You gave us a scare!” one of the nurses said. Rachel’s eyes wandered around the room, and then stared at the breathing tube and EKG electrodes on her chest. Her torso was then covered up with a blanket before she was wheeled out of the trauma room and up to the OR. Rachel stared at the one nurse who talked to her as soon as she regained consciousness. Rachel had a confused look on her face, wondering what had happened in the last handful of minutes.

In the following minutes, she was transported to the OR and prepped for surgery. She continued drifting in and out of consciousness, and her vitals were still a bit unstable. Her BP was 60 over palp and her heart rate was down to 41bpm.

Once in the OR, Rachel was moved onto the OR table. With her unstable vital signs, the anesthesiologist had some concerns about her low heart rate and blood pressure, so a round of vasopressors were pushed in order to increase her bp and heart rate in order to start the surgery in the next few minutes.

After those few minutes came and went, Rachel was anesthetized and the emergency surgery began. Her chest was covered in betadine in order to sterilize the area and limit Post-OP infection. A cut was made in her 5th intercostal space, extending across the entirety of her anterior chest. Next, the underlying tissue and fat was separated, creating a space in between the ribs on both sides of her chest, while also exposing the sternum. The next step was dividing the sternum horizontally with a sternal saw. The saw made a high pitched grinding sound as it sawed through Rachel’s breastbone with relative ease. After the sternum was divided, a finochietto rib spreader was placed into the middle of her chest with the bar facing downwards towards her belly. The knobs on the spreader were turned, forcing her chest to open. Upon entry to the chest via a clamshell thoracotomy, there was a rush of blood. Suction was applied in order to restore a line of sight for the surgical team. Blood kept leaking from her chest and accumulating on her torso and on the table. It was decided at that point to place a 2nd chest tube for additional drainage. The 2nd chest tube was placed over the following minute or so, and the surgical attending was sprayed with blood upon placement of the chest tube. The 2nd chest tube was able to create better visualization of the thoracic cavity, but blood loss was becoming a problem. 2 units of O+ PRBC's were hung from the rapid infuser and a dose of rhogam was injected intravenously since Rachel’s vital signs were once again on the brink of becoming dangerous. The surgeon worked on locating the source of the bleed over the coming minutes while the rest of the OR team did everything in their power to maintain Rachel’s vitals; but as time went on, that became more and more of an uphill battle. The bleeding continued over the next 45 minutes or so, and at that point, Rachel went into pulseless bradycardia. The surgeon paused the surgery to begin internal massage on the 34 year old. A wet, rhythmic, squishing sound was heard while internal compressions were being performed. 0.5mg atropine and 2 micrograms/kg dopamine were pushed intravenously as part of the pulseless bradycardia ACLS algorithm. The aorta was cross clamped near the diaphragm, and a clamp was placed on the right pulmonary hilum since a bleed in the right lung was within the realm of possibilities.

4 minutes came and went until a shockable rhythm was obtained by the OR team. The internal paddles were called for and inserted into Rachel’s chest and a 10 joule shock was delivered. Her torso flopped on the table in response to the shock, but she still remained in v-fib. A 20 joule shock was then delivered. A dull, wet thunk was heard after the shock was delivered but once again, there was no change whatsoever. The internal paddles were called for once again and charged to 30j for the 3rd shock. The large, spoon shaped paddles were placed back into Rachel’s chest, and shock #3 was delivered. Rachel’s toes curled at the other end of the table, showing off the soft, prominent wrinkles in the soles of her feet. However, this shock sent her into PEA. Epinephrine and atropine were pushed into her IV and internal massage continued on Rachel.

At the 10 minute mark of the code, the surgical team was able to obtain a shockable rhythm once again, so the internal paddles were readied for the next shock. The blonde’s arms and head twitched for a moment before returning to their previous position, but the shock was unsuccessful. Her heart twitched in the doctor’s hands as a cycle of internal massage was performed before the next shock. Next, a 30j shock was delivered, making a dull, wet thunk in the OR. No change was present on the monitors, so another 30j shock was delivered shortly after. This shock unfortunately sent Rachel back into PEA. The surgical attending injected a dose of adrenaline directly into Rachel’s heart, hoping to stimulate the cardiac muscle.

The code droned on and on, eventually reaching the 20 minute mark of the code with Rachel deteriorating to asystole. Her heart sat still in the surgeon’s hands as they manually pumped her heart, desperately trying to bring the woman back to life.

The surgical team worked diligently on Rachel over the following few minutes, maxing her out on drugs, and performing internal massage. At the 25 minute mark of the code, Rachel’s pupils were checked and were fixed and dilated, while her heart sat completely motionless inside her chest cavity. Despite everyone’s best efforts, the code was stopped and time of death was called at 9:17AM.

The monitors were switched off and the ambu bag was detached. Next, the rib spreader and EKG electrodes were removed, along with the rest of the equipment. Her body laid limp and cold to the touch while her chest was closed up by the surgical residents. Lastly, a toe tag was placed and her body was covered up before being sent to the hospital morgue.

A short while later, Rachel’s fiancée was given the terrible news about what happened. Later on in that day, the person that sideswiped Rachel was apprehended for fleeing the scene of an accident. The suspect faced criminal charges, but was also sued civilly by Rachel’s fiancée and parents, and settled for an undisclosed amount.

Rachel’s autopsy revealed that she died from cardiac herniation, which disconnected the pulmonary veins from the right lung, explaining the massive hemothorax and blood loss she experienced.

[kristinsimmons]

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag

By ANISH KOKA MD 

The message comes in over the office slack line at 1:05 pm. There are four patients in rooms, one new, 3 patients in the waiting room. Really, not an ideal time to deal with this particular message.

“Kathy the home care nurse for Mrs. C called and said her weight yesterday was 185, today it is 194, she has +4 pitting edema, heart rate 120, BP 140/70 standing, 120/64 sitting”

I know Mrs. C well. She has severe COPD from smoking for 45 of the last 55 years. Every breath looks like an effort because it is. The worst part of it all is that Mrs. C just returned home from the hospital just days ago.

The youngest of six children, Mrs. C was born with many embedded disadvantages. Being born black in a poor West Philadelphia neighborhood in the 1960s is a story that too often writes itself with a bad ending.  But Mrs. C avoided the usual pitfalls that derail young women in the neighborhood early. No drugs. No alcohol. No teenage pregnancies. Finished high school. Mrs. C. worked for the hospital as a unit clerk, had her own place, health benefits, and even a retirement plan.

Certain life habits, however, carry a heavy price. George Burns, the comedian never pictured without a cigar who died past his hundredth birthday, may have been immune to the effects of tobacco.  Mrs. C was not. She started smoking when she was 16. She doesn’t recall why. Her dad smoking didn’t help perhaps. Nausea racked her body after that first drag. It eased up after. Too bad.

That measly cigarette became the great addiction of her life. Day by day, the exquisitely thin membranes of the lungs that mediate gas exchange were destroyed. By the time the disease manifests with shortness of breath and bluish tinged lips, it’s too late. Short of the very few who qualify for a lung transplant, the efforts of doctors at this point are for mitigation rather than cure.

Complicating things further, in Mrs. C’s case, the normally low pressure vascular circuit of her lungs became a high pressure circuit that places ever increasing demands on the normally thin-muscled right ventricle of the heart.  This jeopardizes the ability of her heart to handle changes in blood volume.

A little extra fluid and the right side of the heart ends up causing unbearable swelling in her legs.  A little dehydration and severe disabling dizziness on standing ensues. Adding to that that her tenuous lung function decompensates with the slightest respiratory infection, that chronic steroid treatment to decrease her wheezing suppresses her immune system, and that the young man down the street helpfully drops off Newports at her home for a few extra dollars, and it’s easy to see why the hospital is her second home.

The most recent admission to the hospital was for kidney failure related to taking too much fluid off with diuretics. What was to be a short stay for gentle hydration turned into a longer stay when a pneumonia complicated the matters (though a trip to the intensive care unit and a ventilator was barely but fortunately avoided).  She was treated by the pulmonology team and sent home on a lower dose of diuretics.

The situation I am now confronting puts me in a quandary.  Her edema and weight are up markedly just a few days after returning home.  Could her fluid overload be because her kidneys are shutting down? Or does she just need more aggressive diuresis?

Should I guess? Knowing her present renal function would be helpful. But even if the Theranos lab I could appeal to for help wasn’t fictional, I would have to get her to my office everyday or every other day while adjusting her diuretic dose.

And so it comes to be that, days removed from a hospital admission, I’m sending her back to the hospital to be readmitted.  According to some, this is not supposed to happen.

A policy on readmission

In 2008, the commission that advises Medicare – the Medicare Payment Advisory Commission (MEDPAC), issued a report that focused on hospital readmissions.

The focus on hospital readmissions had been of great interest to the health policy community for some time. At the core of this interest lies the belief that hospitals and physicians are incentivized to treat patients rather than prevent admissions.

The MEDPAC report wanted to discourage readmissions like Mrs. C’s.  And so it wasn’t a terrible surprise that, rolled into the 2010 Affordable Care Act, was a section called the Hospital Readmission Reduction Program (HRRP) which created a system for Medicare to penalize hospitals with ‘high’ readmission rates.  The program was rolled out in 2013.

At first, the program seemed to work like a charm.  Hospitals significantly ramped up their efforts at care coordination.  Teams of nurses and aids were assembled to make sure patients would get their medications as prescribed upon discharge and to check on patients once they got home.

Hospital readmission rates suddenly dropped and Medicare started saving money.  A staggering 81% of all hospitals suffered penalties in 2018, which translates to ~$500 million or 0.3% of total Medicare payments to hospitals.

A complex analysis

But there’s more to this too good to be true story.

The HRRP penalty schemes are risk-adjusted based on administrative claims data. Risk-adjustment is a statistical procedure to take into account the diversity in complexity and severity of disease among patients so they can be compared.

Physicians know that risk-adjusted claims data are of dubious value because they themselves are often the reluctant data entry clerk in the byzantine scheme that starts with adding diagnostic items to the medical chart and ends with generating a coded billing claim for Medicare.  Needless to say, there’s a huge potential disconnect between what a claim attempts to convey and the actual condition of a given patient.

Yet another major problem is that the risk-adjustment employed by the HRRP does not take socioeconomic status into account, when that is arguably the single biggest driver of poor outcomes and of hospital readmissions.  The creators of the HRRP program seem to believe that a hospital located in poor area shouldn’t get a break for having high readmission rates, perhaps because they believe that hospital systems in general should be mindful of health inequities and address “care gaps” (differences in care provided to poor vs. affluent patients)  in their neighborhoods no matter what.

Finally, the initial out of the gate benchmark for readmission rates on which the HRRP would adjudicate the need for a penalty was a national average.  In such a scheme, a Johns Hopkins Hospital serving inner city Baltimore could be pitted against a regional hospital in rural Montana with an entirely different patient demographics.  This made the regional hospital in Montana very happy.

Gaming the metrics

Regardless of these technical considerations, it is an adage of social science that any metric will be gamed, and healthcare is unfortunately not immune to that law.

One tool increasingly used by hospitals to comply with Medicare payments rules is to admit patients to short stay units, under so-called “observation status.”  Another is to put pressure on emergency departments to avoid readmitting certain types of patients.

So, instead of primarily functioning as a triage operation where sick patients would be turned over to the care of the cardiologist in the hospital, the ER has been increasingly housing and managing heart failure patients to save the hospital money.

But the ER physician or the hospitalist supervising the short stay unit and who just meet a patient in the setting of an acute illness are poorly equipped to know which heart failure patient to discharge after a diuretic dose and which to keep for advanced heart failure therapies.

Source: MedPAC’s June 2018 Report (http://bit.ly/2CXD0fJ)

Nowadays, the cardiologist is increasingly insulated from those decisions.  I have personally experienced with alarming frequency instances where I learn only after the fact that a complex patient of mine has been treated for heart failure in the ED.

And my experience seems to be shared by many of my cardiology colleagues, especially among cardiologists who work in academic centers that are most affected by the policy.  Luckily, some of them are also clinician-scientists that can do more than just whine to colleagues about the new policy.  They can also study its outcomes.

What do the outcomes data show?

In a pivotal study, a group of cardiologists (Gupta et al.) saw that the drop in readmissions that followed the introduction of HRRP was unfortunately accompanied by a reversal in the decade long downward trend in heart failure mortality. This reversal suggested a serious potential harm from the policy.

But the possibility of harm was quickly challenged by another group of researchers led by one of the biggest names in health policy: Harlan Krumholz, a cardiologist who directs the influential Center for Outcomes Research and Evaluation at Yale University.

The Krumholz group analyzed millions of Medicare claims data from 2007 to 2016.  They also found that mortality for heart failure patients increased, but concluded that no causal link between decreasing readmission and increased mortality could be established.

Krumholz at al. noted that mortality rates for heart failure started climbing before the HRRP program was announced and they noted no inflection point in mortality rates with the policy announcement in 2010.  The evidence for their claim is highlighted in the table below:

As can be seen in the boxed row, Krumholz’ team concludes that the increasing mortality slope post-HRRP is no different from that pre-HRRP because the change did not reach statistical significance at the obligatory and arbitrary P<0.05 level.  The actual P-value was 0.11 and the confidence interval for the positive increase in mortality slope of 0.006 is (-.002 to .015).  Even poor students of epistemology would be loathe to conclude this result excludes a signal of harm.  It seems entirely plausible that, with all the limitations of the data set in question, mortality may in fact have accelerated after the institution of the HRRP.  Yet Krumholz insists that no signal of harm is to be considered.

But this did not stop another group of cardiologists (Wadhera et al.) from adding their contribution to the HRRP literature. Using the same data-set that the Krumholz group used — Medicare claims data — these researchers found once again that accelerating mortality coincided with the announcement of the HRRP.  More troubling, they also demonstrated that mortality rose primarily among patients not readmitted to the hospital.

A messy science

Admittedly this whole business of analysis is incredibly messy, with a number of moving parts.

My brief summary doesn’t do justice to a variety of maneuvers taken by the various groups to account for many of the limitations inherent in this type of study. Two of the competing analyses (Krumholz, Wadhera) used Medicare claims data while the other (Gupta) used a more limited voluntary registry.

During the time period in question, there were also other policy changes such as the introduction of new hospital billing codes (MS-DRG) that sought to adjust hospital payment rates to patient complexity. Better patient coding meant higher reimbursement from Medicare.  Armies of “documenters” were then employed by hospitals to capture more revenue.

This means that the claims data gathered by the researchers might look significantly different from one time period to the next even if the patients themselves were ostensibly the same. As the readmission rate is risk-adjusted, it is eminently plausible and likely that systematically upcoding patient risk could actually have been the primary driver of the drop in hospital readmission rate.

The other program playing a confounding role is the Recovery Audit Contractor (RAC) program begun in 2010 to reduce payments for inappropriate hospital admissions. Hospitals responded to denials for inpatient admissions by expanding ‘observation status’ stays. Which was the biggest driver for expanded observation stays? RAC or the HRRP? Once again an exact attribution is impossible.

Denying the obvious?

Despite the messiness of the data and the variety of analytic methods used, a consistent and uncontested observation remains: Heart failure mortality has increased in the last decade. The question being hotly contested is Why?

Oddly, Dr. Krumholz is steadfast in denying the possibility that the policy may have caused harm, even though the independent and contradictory conclusions from the other research groups at least raises a reasonable doubt.  And Dr. Krumholz has been quick to cast shade on research that does not conform to his conclusion.

By tweet he appears to ask for a level of detail his own papers lack, and he questions the legitimacy of another group’s data-set, all the while resisting any calls to put the program on hold despite the paucity of evidence showing benefit, the signal for harm, and perhaps most importantly, the concern of clinicians who see a mechanism for harm.

Greatly admire @rwyeh and his group…appreciate his focus on readmission &public policy. For such high-profile article, really need more info about statistical weighting. Methods should be sufficient so others can reproduce results. Can’t do that here. Look forward to more info.

— Harlan Krumholz (@hmkyale) December 21, 2018

Can you account for why the registry you used had, on average, such a small number of patients per site. Did you determine how many patients coded with heart failure by CMS were in the Registry? Just curious about the selection. It may not explain your results…but is a question. https://t.co/WSvJAN8Jjd

— Harlan Krumholz (@hmkyale) June 2, 2018

Dr. Krumholz also places much weight on an independent analysis carried out by MEDPAC which concluded there was no link between policy and the uptick in mortality. This particular conclusion rests heavily on the assertion that heart failure patients in 2016 were much sicker than patients in 2010. Recall that this coincides with a period of more intensive coding over the same time frame, so it is impossible to say this with any confidence.

The MEDPAC conclusion also relies on an analysis that finds no correlation between hospital level readmission and mortality rates.

While technically true, that conclusion overlooks that a large number of hospitals exhibited reduced readmission rates and increased mortality. Perhaps MEDPAC feels that patients dying at low readmit/high mortality hospitals should be mollified by the knowledge that somewhere there’s a low-readmit/low mortality hospital to balance things out?

That Krumholz and MEDPAC display such certainty about the direction of the signal they observe, and take pains to discount other possibilities seems strange and suggests that pre-existing biases may be at work. What might those biases be?

Conflicts of interest: You get what you pay for

In a world where heads roll for undisclosed personal financial conflicts of interest, it is remarkable that the current dispute, while full of scintillating exchanges about “propensity weighting” and other arcane points of statistics, does not reference any other potential conflicts at work that might affect the conclusions being reached.

Medicare’s decision to start the HRRP program didn’t come in a vacuum. It was inspired by years of research from Dr. Krumholz himself, who suggested that preventing admissions should be a goal for any policy that would aim to move the system from one paying for “volume” to one paying for “value.”

As far back as 2003, Krumholz held the view that:

“Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues.”

If Krumholz’s unfavorable and crudely simplistic view of the operations and motivations of hospitals (and of the still relatively independent physicians staffing those hospitals) informs his position on health policy, it stands to reason that serious blinders would prevent him from seeing any evidence of harm in a particular policy that promotes the same view.

But that’s not all.  Krumholz’s group at Yale received grants from CMS under the auspices of the Measure and Instrument Development and Support (MIDS) program to study and produce the metrics and instruments needed to devise the readmission measures.

The MIDS program supports the “development and use of clinical quality measures which remains a critical healthcare priority and the tool of choice for improving quality of care at the national, community and facility levels” and it allocates $1.6 billion dollars to this purpose.

Thanks to a bipartisan act of Congress, a helpful little website, usaspending.gov, provides contract level detail about payments made to the Krumholz’s group from the MIDS program.  Those payments can be seen in the table below:

The numbers are staggering. I know little about how to interpret these data about federal contracts, but it sure appears that the Yale-New Haven Health Service group led by Krumholz has received $144 million dollars since 2008.

Yet the only clue to these payments in Krumholz’ published analyses of the HRRP program comes in one disclosure sentence in a footnote, as seen here:

It seems to me that the disclosure is hardly proportional to the amount of funding that his group receives and understates the inherent pressures it must be under to demonstrate that the policy did not actually result in higher mortality.

And recall that MEDPAC’s “independent” analysis that also rejected a policy-mortality link came from the organization that recommended the policy to begin with.  The bottom line is this: There’s a tremendous amount of face to lose and a massive source of institutional funding at risk if the policy is found to be harmful.

It now becomes more clear why, in the following tweets, Dr. Krumholz feels that only he can say anything definitive about readmission rates and mortality:

Um, @JAMA_current, even the authors say they cannot say their findings are causal… "but whether this finding is a result of the policy requires further research.” Why do you promote the paper as proving harm? Need to treat twitter like you do any of your Editorial comments. pic.twitter.com/xugasHvPWY

— Harlan Krumholz (@hmkyale) December 26, 2018

6/Hospitals that have improved their readmission rates tended to improve their mortality rates. Published in @JAMA_current… https://t.co/R7FXLwTMPp

— Harlan Krumholz (@hmkyale) December 22, 2018

A diversity of biases

Biases are ubiquitous.  When I was a cardiologist-in-training, spending hours on the hospital consult service for a fixed salary, I vividly recall looking for ways to avoid doing any work I considered unimportant or banal: The minor cardiac enzyme leak in a patient with a widespread infection; The extra heartbeats on the ECG that the ER physician didn’t like the look of; etc.  “Are you sure you need an official consult?”  “The chances we’re going to recommend doing anything about a small enzyme leak in an 80-year-old with a severe lung infection are very low… “ I was even successful sometimes.

Contrast these comments to my demeanor in private practice where I am acutely aware that my income relies on such consults: “I just need the patients name or room number…” “I’ll take care of it!…” “I can put in the orders if you’d like!”

But there are other biases and incentives that motivate human beings, apart from personal financial incentives. Do they pale relative to the financial ones as is so often claimed? How does one begin to quantify them?

When it comes to the HRRP policy, no individual person’s bank account ballooned every time a patient didn’t get admitted. And yet this is a story of ideological bias that drove the design of policy and now claims ‘success’ for its own program.  The HRRP saga is illustrative of the importance of non-financial bias and of the dangers of blinding ourselves to that bias.

The story also highlights the downsides of tweaking healthcare systems that were built to deliver more care.

Clearly, I personally have a direct financial conflict of interest to provide more care. Since I haven’t talked anyone out of a consult in 8 years, I’m probably guilty of participating in a system that detractors appropriately criticize for promoting overuse of healthcare.

But the problem is that some of those consults I was trying to avoid as a fellow ended up really needing a cardiologist. There was the 55-year-old Cambodian woman admitted to the medical intensive care unit with pneumonia who went into atrial fibrillation. I recall rolling my eyes and thinking that the ICU could certainly handle this without a cardiologist. It turned out she didn’t have a pneumonia. It was pulmonary edema from heart failure related to undiagnosed rheumatic mitral valve disease. She had been in the wrong unit. She needed diuresis, heart rate control, and eventual surgery to replace her valve, not antibiotics. Less isn’t always more.

Attempt to reduce inappropriate hospital admissions? Get ready to pay a price.  To contradict Dr. Krumholz, it is entirely probable that we are underestimating the upside of our current system when we contemplate changing the status quo.

We are underestimating the downside of our current system when we contemplate change. We need to take some risks to do better. #abimf2013

— Harlan Krumholz (@hmkyale) August 5, 2013

Final Thoughts

Ironically, the HRRP quagmire offers a number of clarifying lessons.

Empiricism in social policy is a subjective enterprise. The often parroted conclusion is that cold, hard, unbiased evidence trumps the biased, unmeasurable judgment of clinicians. Yet, frequently, real world data-sets are complex, the choice of analytic paths can be highly variable, and the instruments to measure success are often imperfect. As it relates to HRRP, which analysis should we trust? The choice requires faith. And if the currency here is faith, perhaps the concern of clinicians at the bedside has more value than advertised.

Metrics won’t save us. The narrative of metrics is an appealing one that promises hard and objective accountability. The problem comes when the metric (readmission) becomes disconnected from outcomes that actually matter (death). False and blind prophets are good descriptors for those who claim to be unable to see without metrics. The fools in this enterprise are easy to identify as those who think the answers lie with ever better metrics.

Conflicts of interest: Going beyond the simple narrative.  Focusing on biases induced by personal financial interests is a mistake. Personal enrichment is just one bias in a sea of conflicts. In the healthcare context, financial disclosures—while clarifying in themselves—may simply give cover to other, more perverse biases, unless those other biases are equally disclosed.  It requires diligence to ascertain the impact, and direction of bias.  Rarely do we get the opportunity to observe the direction of bias in policy research.  In the case of the HRRP, the presence of bias was made evident because research groups with opposing biases (clinician-scientists versus policy wonks) have reached conclusions that would be expected on the basis of those pre-existing biases.  How often is the problem of such bias examined in the design, implementation, and analysis of health policy?

Beware of technocrats with all the answers.  I am reasonably sure that if practicing clinicians would have been asked to devise a rule to reduce heart failure readmissions for the whole population they would have refused. It seems too challenging a task to get right.  Even if clinicians can be induced to participate in the design of such a policy, most would readily acknowledge the likelihood that it could harm some patients. It requires a special type of hubris to design a policy and refuse to acknowledge its potential for harm. Unfortunately, hubris within a public health community that believes only they can give us a better health system is more feature than bug.

As for Mrs. C, she has been home for 16 days. All fingers on both hands are currently crossed.

Anish Koka is a cardiologist in private practice in Philadelphia.  He can be followed on Twitter @anish_koka. This post originally appeared here on The Accad & Koka Report. 

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag published first on https://wittooth.tumblr.com/

[isaacscrawford]

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag

By ANISH KOKA MD 

The message comes in over the office slack line at 1:05 pm. There are four patients in rooms, one new, 3 patients in the waiting room. Really, not an ideal time to deal with this particular message.

“Kathy the home care nurse for Mrs. C called and said her weight yesterday was 185, today it is 194, she has +4 pitting edema, heart rate 120, BP 140/70 standing, 120/64 sitting”

I know Mrs. C well. She has severe COPD from smoking for 45 of the last 55 years. Every breath looks like an effort because it is. The worst part of it all is that Mrs. C just returned home from the hospital just days ago.

The youngest of six children, Mrs. C was born with many embedded disadvantages. Being born black in a poor West Philadelphia neighborhood in the 1960s is a story that too often writes itself with a bad ending.  But Mrs. C avoided the usual pitfalls that derail young women in the neighborhood early. No drugs. No alcohol. No teenage pregnancies. Finished high school. Mrs. C. worked for the hospital as a unit clerk, had her own place, health benefits, and even a retirement plan.

Certain life habits, however, carry a heavy price. George Burns, the comedian never pictured without a cigar who died past his hundredth birthday, may have been immune to the effects of tobacco.  Mrs. C was not. She started smoking when she was 16. She doesn’t recall why. Her dad smoking didn’t help perhaps. Nausea racked her body after that first drag. It eased up after. Too bad.

That measly cigarette became the great addiction of her life. Day by day, the exquisitely thin membranes of the lungs that mediate gas exchange were destroyed. By the time the disease manifests with shortness of breath and bluish tinged lips, it’s too late. Short of the very few who qualify for a lung transplant, the efforts of doctors at this point are for mitigation rather than cure.

Complicating things further, in Mrs. C’s case, the normally low pressure vascular circuit of her lungs became a high pressure circuit that places ever increasing demands on the normally thin-muscled right ventricle of the heart.  This jeopardizes the ability of her heart to handle changes in blood volume.

A little extra fluid and the right side of the heart ends up causing unbearable swelling in her legs.  A little dehydration and severe disabling dizziness on standing ensues. Adding to that that her tenuous lung function decompensates with the slightest respiratory infection, that chronic steroid treatment to decrease her wheezing suppresses her immune system, and that the young man down the street helpfully drops off Newports at her home for a few extra dollars, and it’s easy to see why the hospital is her second home.

The most recent admission to the hospital was for kidney failure related to taking too much fluid off with diuretics. What was to be a short stay for gentle hydration turned into a longer stay when a pneumonia complicated the matters (though a trip to the intensive care unit and a ventilator was barely but fortunately avoided).  She was treated by the pulmonology team and sent home on a lower dose of diuretics.

The situation I am now confronting puts me in a quandary.  Her edema and weight are up markedly just a few days after returning home.  Could her fluid overload be because her kidneys are shutting down? Or does she just need more aggressive diuresis?

Should I guess? Knowing her present renal function would be helpful. But even if the Theranos lab I could appeal to for help wasn’t fictional, I would have to get her to my office everyday or every other day while adjusting her diuretic dose.

And so it comes to be that, days removed from a hospital admission, I’m sending her back to the hospital to be readmitted.  According to some, this is not supposed to happen.

A policy on readmission

In 2008, the commission that advises Medicare – the Medicare Payment Advisory Commission (MEDPAC), issued a report that focused on hospital readmissions.

The focus on hospital readmissions had been of great interest to the health policy community for some time. At the core of this interest lies the belief that hospitals and physicians are incentivized to treat patients rather than prevent admissions.

The MEDPAC report wanted to discourage readmissions like Mrs. C’s.  And so it wasn’t a terrible surprise that, rolled into the 2010 Affordable Care Act, was a section called the Hospital Readmission Reduction Program (HRRP) which created a system for Medicare to penalize hospitals with ‘high’ readmission rates.  The program was rolled out in 2013.

At first, the program seemed to work like a charm.  Hospitals significantly ramped up their efforts at care coordination.  Teams of nurses and aids were assembled to make sure patients would get their medications as prescribed upon discharge and to check on patients once they got home.

Hospital readmission rates suddenly dropped and Medicare started saving money.  A staggering 81% of all hospitals suffered penalties in 2018, which translates to ~$500 million or 0.3% of total Medicare payments to hospitals.

A complex analysis

But there’s more to this too good to be true story.

The HRRP penalty schemes are risk-adjusted based on administrative claims data. Risk-adjustment is a statistical procedure to take into account the diversity in complexity and severity of disease among patients so they can be compared.

Physicians know that risk-adjusted claims data are of dubious value because they themselves are often the reluctant data entry clerk in the byzantine scheme that starts with adding diagnostic items to the medical chart and ends with generating a coded billing claim for Medicare.  Needless to say, there’s a huge potential disconnect between what a claim attempts to convey and the actual condition of a given patient.

Yet another major problem is that the risk-adjustment employed by the HRRP does not take socioeconomic status into account, when that is arguably the single biggest driver of poor outcomes and of hospital readmissions.  The creators of the HRRP program seem to believe that a hospital located in poor area shouldn’t get a break for having high readmission rates, perhaps because they believe that hospital systems in general should be mindful of health inequities and address “care gaps” (differences in care provided to poor vs. affluent patients)  in their neighborhoods no matter what.

Finally, the initial out of the gate benchmark for readmission rates on which the HRRP would adjudicate the need for a penalty was a national average.  In such a scheme, a Johns Hopkins Hospital serving inner city Baltimore could be pitted against a regional hospital in rural Montana with an entirely different patient demographics.  This made the regional hospital in Montana very happy.

Gaming the metrics

Regardless of these technical considerations, it is an adage of social science that any metric will be gamed, and healthcare is unfortunately not immune to that law.

One tool increasingly used by hospitals to comply with Medicare payments rules is to admit patients to short stay units, under so-called “observation status.”  Another is to put pressure on emergency departments to avoid readmitting certain types of patients.

So, instead of primarily functioning as a triage operation where sick patients would be turned over to the care of the cardiologist in the hospital, the ER has been increasingly housing and managing heart failure patients to save the hospital money.

But the ER physician or the hospitalist supervising the short stay unit and who just meet a patient in the setting of an acute illness are poorly equipped to know which heart failure patient to discharge after a diuretic dose and which to keep for advanced heart failure therapies.

Source: MedPAC’s June 2018 Report (http://medpac.gov/docs/default-source/reports/jun18_ch1_medpacreport_sec.pdf?sfvrsn=0)

Nowadays, the cardiologist is increasingly insulated from those decisions.  I have personally experienced with alarming frequency instances where I learn only after the fact that a complex patient of mine has been treated for heart failure in the ED.

And my experience seems to be shared by many of my cardiology colleagues, especially among cardiologists who work in academic centers that are most affected by the policy.  Luckily, some of them are also clinician-scientists that can do more than just whine to colleagues about the new policy.  They can also study its outcomes.

What do the outcomes data show?

In a pivotal study, a group of cardiologists (Gupta et al.) saw that the drop in readmissions that followed the introduction of HRRP was unfortunately accompanied by a reversal in the decade long downward trend in heart failure mortality. This reversal suggested a serious potential harm from the policy.

But the possibility of harm was quickly challenged by another group of researchers led by one of the biggest names in health policy: Harlan Krumholz, a cardiologist who directs the influential Center for Outcomes Research and Evaluation at Yale University.

The Krumholz group analyzed millions of Medicare claims data from 2007 to 2016.  They also found that mortality for heart failure patients increased, but concluded that no causal link between decreasing readmission and increased mortality could be established.

Krumholz at al. noted that mortality rates for heart failure started climbing before the HRRP program was announced and they noted no inflection point in mortality rates with the policy announcement in 2010.  The evidence for their claim is highlighted in the table below:

As can be seen in the boxed row, Krumholz’ team concludes that the increasing mortality slope post-HRRP is no different from that pre-HRRP because the change did not reach statistical significance at the obligatory and arbitrary P<0.05 level.  The actual P-value was 0.11 and the confidence interval for the positive increase in mortality slope of 0.006 is (-.002 to .015).  Even poor students of epistemology would be loathe to conclude this result excludes a signal of harm.  It seems entirely plausible that, with all the limitations of the data set in question, mortality may in fact have accelerated after the institution of the HRRP.  Yet Krumholz insists that no signal of harm is to be considered.

But this did not stop another group of cardiologists (Wadhera et al.) from adding their contribution to the HRRP literature. Using the same data-set that the Krumholz group used — Medicare claims data — these researchers found once again that accelerating mortality coincided with the announcement of the HRRP.  More troubling, they also demonstrated that mortality rose primarily among patients not readmitted to the hospital.

A messy science

Admittedly this whole business of analysis is incredibly messy, with a number of moving parts.

My brief summary doesn’t do justice to a variety of maneuvers taken by the various groups to account for many of the limitations inherent in this type of study. Two of the competing analyses (Krumholz, Wadhera) used Medicare claims data while the other (Gupta) used a more limited voluntary registry.

During the time period in question, there were also other policy changes such as the introduction of new hospital billing codes (MS-DRG) that sought to adjust hospital payment rates to patient complexity. Better patient coding meant higher reimbursement from Medicare.  Armies of “documenters” were then employed by hospitals to capture more revenue.

This means that the claims data gathered by the researchers might look significantly different from one time period to the next even if the patients themselves were ostensibly the same. As the readmission rate is risk-adjusted, it is eminently plausible and likely that systematically upcoding patient risk could actually have been the primary driver of the drop in hospital readmission rate.

The other program playing a confounding role is the Recovery Audit Contractor (RAC) program begun in 2010 to reduce payments for inappropriate hospital admissions. Hospitals responded to denials for inpatient admissions by expanding ‘observation status’ stays. Which was the biggest driver for expanded observation stays? RAC or the HRRP? Once again an exact attribution is impossible.

Denying the obvious?

Despite the messiness of the data and the variety of analytic methods used, a consistent and uncontested observation remains: Heart failure mortality has increased in the last decade. The question being hotly contested is Why?

Oddly, Dr. Krumholz is steadfast in denying the possibility that the policy may have caused harm, even though the independent and contradictory conclusions from the other research groups at least raises a reasonable doubt.  And Dr. Krumholz has been quick to cast shade on research that does not conform to his conclusion.

By tweet he appears to ask for a level of detail his own papers lack, and he questions the legitimacy of another group’s data-set, all the while resisting any calls to put the program on hold despite the paucity of evidence showing benefit, the signal for harm, and perhaps most importantly, the concern of clinicians who see a mechanism for harm.

Greatly admire @rwyeh and his group…appreciate his focus on readmission &public policy. For such high-profile article, really need more info about statistical weighting. Methods should be sufficient so others can reproduce results. Can’t do that here. Look forward to more info.

— Harlan Krumholz (@hmkyale) December 21, 2018

Can you account for why the registry you used had, on average, such a small number of patients per site. Did you determine how many patients coded with heart failure by CMS were in the Registry? Just curious about the selection. It may not explain your results…but is a question. https://t.co/WSvJAN8Jjd

— Harlan Krumholz (@hmkyale) June 2, 2018

Dr. Krumholz also places much weight on an independent analysis carried out by MEDPAC which concluded there was no link between policy and the uptick in mortality. This particular conclusion rests heavily on the assertion that heart failure patients in 2016 were much sicker than patients in 2010. Recall that this coincides with a period of more intensive coding over the same time frame, so it is impossible to say this with any confidence.

The MEDPAC conclusion also relies on an analysis that finds no correlation between hospital level readmission and mortality rates.

While technically true, that conclusion overlooks that a large number of hospitals exhibited reduced readmission rates and increased mortality. Perhaps MEDPAC feels that patients dying at low readmit/high mortality hospitals should be mollified by the knowledge that somewhere there’s a low-readmit/low mortality hospital to balance things out?

That Krumholz and MEDPAC display such certainty about the direction of the signal they observe, and take pains to discount other possibilities seems strange and suggests that pre-existing biases may be at work. What might those biases be?

Conflicts of interest: You get what you pay for

In a world where heads roll for undisclosed personal financial conflicts of interest, it is remarkable that the current dispute, while full of scintillating exchanges about “propensity weighting” and other arcane points of statistics, does not reference any other potential conflicts at work that might affect the conclusions being reached.

Medicare’s decision to start the HRRP program didn’t come in a vacuum. It was inspired by years of research from Dr. Krumholz himself, who suggested that preventing admissions should be a goal for any policy that would aim to move the system from one paying for “volume” to one paying for “value.”

As far back as 2003, Krumholz held the view that:

“Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues.”

If Krumholz’s unfavorable and crudely simplistic view of the operations and motivations of hospitals (and of the still relatively independent physicians staffing those hospitals) informs his position on health policy, it stands to reason that serious blinders would prevent him from seeing any evidence of harm in a particular policy that promotes the same view.

But that’s not all.  Krumholz’s group at Yale received grants from CMS under the auspices of the Measure and Instrument Development and Support (MIDS) program to study and produce the metrics and instruments needed to devise the readmission measures.

The MIDS program supports the “development and use of clinical quality measures which remains a critical healthcare priority and the tool of choice for improving quality of care at the national, community and facility levels” and it allocates $1.6 billion dollars to this purpose.

Thanks to a bipartisan act of Congress, a helpful little website, usaspending.gov, provides contract level detail about payments made to the Krumholz’s group from the MIDS program.  Those payments can be seen in the table below:

The numbers are staggering. I know little about how to interpret these data about federal contracts, but it sure appears that the Yale-New Haven Health Service group led by Krumholz has received $144 million dollars since 2008.

Yet the only clue to these payments in Krumholz’ published analyses of the HRRP program comes in one disclosure sentence in a footnote, as seen here:

It seems to me that the disclosure is hardly proportional to the amount of funding that his group receives and understates the inherent pressures it must be under to demonstrate that the policy did not actually result in higher mortality.

And recall that MEDPAC’s “independent” analysis that also rejected a policy-mortality link came from the organization that recommended the policy to begin with.  The bottom line is this: There’s a tremendous amount of face to lose and a massive source of institutional funding at risk if the policy is found to be harmful.

It now becomes more clear why, in the following tweets, Dr. Krumholz feels that only he can say anything definitive about readmission rates and mortality:

Um, @JAMA_current, even the authors say they cannot say their findings are causal… "but whether this finding is a result of the policy requires further research.” Why do you promote the paper as proving harm? Need to treat twitter like you do any of your Editorial comments. pic.twitter.com/xugasHvPWY

— Harlan Krumholz (@hmkyale) December 26, 2018

6/Hospitals that have improved their readmission rates tended to improve their mortality rates. Published in @JAMA_current… https://t.co/R7FXLwTMPp

— Harlan Krumholz (@hmkyale) December 22, 2018

A diversity of biases

Biases are ubiquitous.  When I was a cardiologist-in-training, spending hours on the hospital consult service for a fixed salary, I vividly recall looking for ways to avoid doing any work I considered unimportant or banal: The minor cardiac enzyme leak in a patient with a widespread infection; The extra heartbeats on the ECG that the ER physician didn’t like the look of; etc.  “Are you sure you need an official consult?”  “The chances we’re going to recommend doing anything about a small enzyme leak in an 80-year-old with a severe lung infection are very low… “ I was even successful sometimes.

Contrast these comments to my demeanor in private practice where I am acutely aware that my income relies on such consults: “I just need the patients name or room number…” “I’ll take care of it!…” “I can put in the orders if you’d like!”

But there are other biases and incentives that motivate human beings, apart from personal financial incentives. Do they pale relative to the financial ones as is so often claimed? How does one begin to quantify them?

When it comes to the HRRP policy, no individual person’s bank account ballooned every time a patient didn’t get admitted. And yet this is a story of ideological bias that drove the design of policy and now claims ‘success’ for its own program.  The HRRP saga is illustrative of the importance of non-financial bias and of the dangers of blinding ourselves to that bias.

The story also highlights the downsides of tweaking healthcare systems that were built to deliver more care.

Clearly, I personally have a direct financial conflict of interest to provide more care. Since I haven’t talked anyone out of a consult in 8 years, I’m probably guilty of participating in a system that detractors appropriately criticize for promoting overuse of healthcare.

But the problem is that some of those consults I was trying to avoid as a fellow ended up really needing a cardiologist. There was the 55-year-old Cambodian woman admitted to the medical intensive care unit with pneumonia who went into atrial fibrillation. I recall rolling my eyes and thinking that the ICU could certainly handle this without a cardiologist. It turned out she didn’t have a pneumonia. It was pulmonary edema from heart failure related to undiagnosed rheumatic mitral valve disease. She had been in the wrong unit. She needed diuresis, heart rate control, and eventual surgery to replace her valve, not antibiotics. Less isn’t always more.

Attempt to reduce inappropriate hospital admissions? Get ready to pay a price.  To contradict Dr. Krumholz, it is entirely probable that we are underestimating the upside of our current system when we contemplate changing the status quo.

We are underestimating the downside of our current system when we contemplate change. We need to take some risks to do better. #abimf2013

— Harlan Krumholz (@hmkyale) August 5, 2013

Final Thoughts

Ironically, the HRRP quagmire offers a number of clarifying lessons.

Empiricism in social policy is a subjective enterprise. The often parroted conclusion is that cold, hard, unbiased evidence trumps the biased, unmeasurable judgment of clinicians. Yet, frequently, real world data-sets are complex, the choice of analytic paths can be highly variable, and the instruments to measure success are often imperfect. As it relates to HRRP, which analysis should we trust? The choice requires faith. And if the currency here is faith, perhaps the concern of clinicians at the bedside has more value than advertised.

Metrics won’t save us. The narrative of metrics is an appealing one that promises hard and objective accountability. The problem comes when the metric (readmission) becomes disconnected from outcomes that actually matter (death). False and blind prophets are good descriptors for those who claim to be unable to see without metrics. The fools in this enterprise are easy to identify as those who think the answers lie with ever better metrics.

Conflicts of interest: Going beyond the simple narrative.  Focusing on biases induced by personal financial interests is a mistake. Personal enrichment is just one bias in a sea of conflicts. In the healthcare context, financial disclosures—while clarifying in themselves—may simply give cover to other, more perverse biases, unless those other biases are equally disclosed.  It requires diligence to ascertain the impact, and direction of bias.  Rarely do we get the opportunity to observe the direction of bias in policy research.  In the case of the HRRP, the presence of bias was made evident because research groups with opposing biases (clinician-scientists versus policy wonks) have reached conclusions that would be expected on the basis of those pre-existing biases.  How often is the problem of such bias examined in the design, implementation, and analysis of health policy?

Beware of technocrats with all the answers.  I am reasonably sure that if practicing clinicians would have been asked to devise a rule to reduce heart failure readmissions for the whole population they would have refused. It seems too challenging a task to get right.  Even if clinicians can be induced to participate in the design of such a policy, most would readily acknowledge the likelihood that it could harm some patients. It requires a special type of hubris to design a policy and refuse to acknowledge its potential for harm. Unfortunately, hubris within a public health community that believes only they can give us a better health system is more feature than bug.

As for Mrs. C, she has been home for 16 days. All fingers on both hands are currently crossed.

Anish Koka is a cardiologist in private practice in Philadelphia.  He can be followed on Twitter @anish_koka. This post originally appeared here on The Accad & Koka Report. 

Article source:The Health Care Blog

[angrybelieverconnoisseur-blog]

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So, I'm buying a new car. And have been getting lots of insurance quotes. They all ask what is the main use for this vehicle? and the choices are pleasure commute business and a couple other choices. My question is, which one gets the cheaper insurance? I work 3 days a week, and have 4 days off a week, so no, my main use isn't work, because I have more days off then I do work. Anyone have any ideas?""

Im 17 and getting my liscense soon how much will car insurance be 4 me with a used car that will b in my name?

I will be getting my drives liscense soon and my parents are putting limits to where i can drive and when and i wont be able to drive it when ever i would like, how much is car insurence gonna be with me for a used car that will be in my name ?""

Whats a cheap insurance company for a 16 year old boy?

Whats a cheap insurance company for a 16 year old boy?

Why not lower heath care insurance than universal health care?

I pay $450 a month for my health insurance, why dont they just cut the cost in half? Then people could afford it. Its alot for me but worth it, i had spinal meningitis at 18 and without id be dead.""

Need custom car insurance information?

I have a custom car, and am looking for information on custom car insurance. Rates and also brokers that cover this.""

Car Insurance and Tornadoes?

Just curious since I live in the heart of tornado alley in Southern Kansas... Say if my car was at home or at a store or other place of business and a tornado destroyed or damaged my car, will my insurance cover the damage? Full coverage.""

Can I use medicaid as a secondary insurance?

Hello. I live in the state of florida. I just found out im still covered under my mother's health insurance because Im under 24 and I am a full time student. I also qualify for and have pregnancy medicaid, but I want to go to a doctor with my moms insurance because I used this specific doctor for my last pregnancy. My question is, could I still use my medicaid to cover my co-pays with this ob/gyn?I called the office and they said they could send the bills to medicaid for what my mom's insurance doesnt cover. I dont have a job and can't afford to pay the co-pays/lab fees/hopsital fees. thanks""

""What is the cheapest car insurance in Toronto, Canada for a female student w/out any prior auto insurance?

I am 22 years old and have never had auto insurance b4. I do have the driver's certificate and currently have a G2. The basic coverage is fine as I will not be getting a new car. I'll be getting a 1998-2001 car not sure of the modell yet.

What car insurance do you have?

Im trying to find one that's cheaper I recently have 21st Century. What's the name of your car insurance and do you like it?

""Pregnant With No Health Insurance In Houston, TX?""

Hello Yahoo Community, I am married, pregnant, with no health insurance. I have applied for Medicaid and CHIP and was denied assistance based on my income, I apparently make too much money to qualify. I slightly cross the threshold. If you subtract our bills minus our earnings we're left with peanuts. We only pay for necessities not for commodities. There is nothing I can cut back on because we're paying for the basic stuff. I've look for insurances but I am having a hard time finding one that covers maternity costs and if they do they're tremendously expensive and out of our reach. Also since it's a pre-existing condition, most insurances don't cover it. Does anyone know about any programs where I can partially pay for the services? Or affordable insurances that I could apply for? I've researched extensively and can't seem to find anything. I am 10 weeks already and have not had my first pre-natal appointment. It's becoming rather stressful. Any help or information will be appreciated. Thank You.""

How much would motorcycle insurance on a yamaha r6 in nj be?

Idk how old I'll be when I get one, can I get an answer for ages 18 and 21 please? thanks!""

Classic Car Insurance for a 17 year old?

im wanting to buy a classic mini (1989) its a 1l what is the best way to go about insuring it..? i've seen adrian flux do cover you if you ring up but its limited mileage, how does that work :) Thankyou very much!""

I am looking into getting tenant insurance.?

Would it be safer to get insurance from an Insurance Company as apposed to getting it through a bank?

Can you get rental car insurance without having regular auto insurance!?

I don't own a car, but I plan on renting one real soon. I was just wondering if its required to have some auto insurance already prior to getting CDW for the rental.""

What is the cheapest/best insurance for a 24yr old student/ stay at home mom?

My 3month old is covered under medicaid, but I need help finding an affordable insurance for myself. My fiance is covered by his work for free, but it would be $200 a check for him to add me and we cannot afford that at this time.""

Anybody know of low cost health care in AZ?

I have a sister in AZ who has diabetes, high BP, retinal detachment, and something going on with her woman parts. She is 48, menopausal, and has no health insurance. Her medications are making she and her hubby quite short on $. He doesn't have med. through work. Disability does'nt help. He makes too much for public assistance. Any ideas?""

Cheap car insurance companies?

What car insurance companies are cheap... and do they have a web site/phone number so I can get a quote

How much would insurance cost for a 16 year old male for a 2006 corvette that is used and cost 15000?

the person has never had any tickets or got into any trouble ever.

Which motorcycle insurance is an better choice Geico or Allstate?

Which motorcycle insurance is an better choice Geico or Allstate?

Would insurance consider a 6 cylinder Pontiac grand am/prix a sports car?

i want a grand am/prix as my first car but my parents cant afford sports car insurance for a brand new 16 year old driver, also what could my parents expect to pay up to on insurance. ...show more""

How much does car insurance cost for teenagers?

how much would it cost to get car insurance. and dont you dare go telling me to go get a quote, i'll kick you in the nuts.""

Mandatory insurance?!?

Here in Massachusetts EVERYONE has to have health insurance, and if you wanna drive you have to have car insurance. How can this be legal? How can the government force me into buying a product or service?! Whats next, are they going to make it mandatory for everyone to buy 7th generation ipods? This is ridiculous. What if i dont want insurance? What if i cant afford it? WTF?!! Is their any legal way around this? Or are they going arrest me if i dont get any insurance? Should i board up my windows and stock up on guns?""

Car insurance?..........?

Who gives the cheapest car insurance?!

What's the cheapest insurance for a used 50k miles 02 Mitsubishi Eclipse?

I live in California, great driving record, getting a used 02 Eclipse 50k miles Automatic. How much is the cheapest insurance and what company do you recommend? (I currently pay $60/month for my Mitsubishi Mirage 2000 De Coupe, I would like a similar / cheaper rate).. any ideas on this?""

What is the cheapest car insurance for teens to buy themselves?

I'm 19 years old and shortly will buy my own car. I'm trying to be independent and need to buy my own affordable car insurance for my car. The quotes from name brand insurance co. like geico and progressive are between $800-$1300/mo. That is so crazy and obviously cannot afford that. Does anybody know where I can find reasonable priced insurance (non name brands) that just covers the minimum? My budget is $100 and less. BTW, I live in SouthFlorida.""

First Time Insurance?

Does anyone have any suggestions of companys for Insurance for a first time driver, i dont expect it to be too cheap but most qoutes ive had are Horrendous. also, cars that would be low on insurance would be great, cheers!""

How much would insurance cost for an 18 year-old college student on a used 2000 honda CBR 600?

How much would insurance cost for an 18 year-old college student on a used 2000 honda CBR 600?

How do I enforce my rights according to Ca Auto Ins. Law without an attorney.?

Their insurance accepted fault immediately. I have rights according to CA Auto Ins. Law, but Geico acts like they do not have to adhere to my rights under California Insurance law. The CA Ins board is watching, but they will not answer this and other questions.""

Im trying to find cheap insurance for new driver in jersey. i am financing a car for the first time.?

im going to need full coverage since i am financing a 2009 scion tc. also im 19 years old.

California after fires?

How long will it take for life in South California to return to normal? I mean quality of air, infrastructure, rebuilding homes. How was it in 2003? For example, for how long the ash will still be in the air?""

Best medical insurance for gastric bypass?

I have struggled with being overweight my whole life and I have decided I want gastric bypass. I currently do not have insurance and I want to buy insurance to cover the surgery. I'm not really sure how to go about purchasing insurance and which ones deny weight loss surgeries. I am 22 and in perfect other then being overweight, so I figure getting health insurance shouldn't be too hard to get approved for. Like I said just wondering which insurance is best for the surgery and any suggestions you have for purchasing health insurance would be great. Thanks!""

Which motorcycle will cost me less on insurance? 2004-5 600/1000cc crotch rocket motorcylce or 2008 Ninja 250R

No motorcycle experience at all. No driving record. 21/M/Florida. Never held a driver's/motorcycle license in the US. Am about to take the MSF course though.

What car would you get between the 06-07 scion tc or the 06-07 mitsubishi eclipse ?

Ok i know this question has been asked a million times on this, so let me be the million and one person to ask and hopefully for the last time. Thing is , i need to buy another care and is between those 2 cars and i just dont know which one to get. I don't know much about cars and so on so i would like some decent answers on which one i should get and why, my third choice was taken out of the equation when i read up on it on the kbb website, thrid choice was an audi tt but alot of people complained about how often it needed to be fixed for something The factors that most concern me are -Realibilty -Insurance cost -How much would it cost for maintance and repairs -which one is built better -which one of the two do you think looks better -which one will last me longer in the long run for those who would ask , i live in florida , and would like an automatic just incase those things are taken into consideration tours making my decision. i know this has been asked a million times but i really need to just settle for one or the other so please help me out thank you in advance for those who answer.""

Car insurance commercial ideas?

i have to make a script for a commercial about car insurance and i need some ideas of what to do.

""For my first car, what engine size and car do you recommend I get?""

What engine size do you recommend I get? Is a 1.4 liter a lot for a first car? Also, I understand the fact the bigger the engine, the higher the insurance will cost, but since I know nothing about cars I do not really know about all this engine size stuff. Also, apart from insurance, I understand about road tax and MOT, can you tell me how often I need to have an MOT and how much it costs? Thanks.""

Average cost of insurance?

what would be the average cost of insurance for a 16 year old male in georgia with an 09 mustang? with a honda accord? with a dodge ram? i guess really with a safe new sports car (cause the new mustangs are 5 star in all but one thing where they hav a 4 star in safety), with a new sedan, and with a new truck? thanks. and also how much might taking extra classes help lower the insurance? i mean defensive driving classes. and would being an eagle scout help any? i really don't know so im just thinking of things that might help. thanks""

Insurance Cost for Bike?

Hello I'm deciding on either a CBR 125 or a Boulevard S40. The only thing is I want to know around how much insurance each will cost(I live in Canada) And any other reason you think one bike is better than the other would be great. This is my first bike.

Which company has the cheapest Car insurance for 16 year old drivers? I live in NC.?

How big will the difference be monetarily between owning a Honda s2000 or a $1000 old mazda?

Insurance on a Firebird?

looking for cars with the lowest insurance rates but idk anything about that... i know sports cars are more expensive. age, location, record and all that too.. but are firebirds generally expensive to insure?? and bc its older will it be less expensive?""

Will state farm increase my auto insurance if I get a speeding ticket??

I got a speeding ticket going 88 in a 70 in GA. Thats 2 points on my license. I was wondering if a rumor that I heard was true. Some people were telling me that they give you your ...show more

Which Insurance is better?

I am looking for new car insurance, so I narrowed it down to Geico and Progressive? Anybody have any experience with either of them?""

Whatt is the mileage and insurance on a ferrari 348 spider?

http://cgi.ebay.com/ebaymotors/Ferrari-348-Spider-/330770734365?pt=US_Cars_Trucks#ht_21892wt_1170 that is the car, i want to know how much it would cost for gas if im using it as daily driver(is it possible to use one of these as daily driver?). how much would the insurance be monthly? i live in bergen nj and im 17.""

What would it cost to add someone who has a drink drive conviction to my car insurance for a couple of weeks?

It would be third party fire & theft; the same as me.

""Would like to know what is involved in starting to sell health insurance, part-time for restaurant workers?""

i have no experience, but know the restaurant business very well and know that most have no health insurance, any advise would be helpful, a test is needed and i live in missouri is there an outline for the test and what ins. companies are known for sponsering restaurants for an affordable price""

Which motorcycle insurance is an better choice Geico or Allstate?

Which motorcycle insurance is an better choice Geico or Allstate?

How am I supposed to afford car insurance?

I'm driving uninsured right now because for me to get car insurance is $900 every six months. That would crush me financially right now. Between rent and gas, and what little Starbucks pretends to pay me, not to mention food (and sometimes that's one meal a day, and even then it may be stealing expired sandwiches and pastries from the garbage can at Starbucks). So, it's utterly naive of the government to think of driving as a luxury , when in reality- when you have to travel 20 miles a day to get to work at Starbucks- walking is unrealistic. The bus routes do not go by there, by the way. How the hell do they expect a 24-year old man to afford car insurance, when he has to work to earn the money to pay for it, and he has to drive to work, and in order to drive he has to drive illegally?! The @#*%ing system is completely screwed up if you ask me. Don't get me started on how the hell I'm supposed to afford gas these days, either.""

What would insurance be for me with this car?

2004 nissan sentra se-r, silver, 4 door, manual transmission. I'm 17 years old and would drive the car to work and school about 5 days a week. I have never gotten a ticket or been in an accident.""

Taking a car off your insurance?

My sister is taking my car off her insurance and she says I still have to pay the $88 that I owe her every month. She cannot cancel the insurance until she has the tags, I sent her the tags yesterday and she'll turn it in before the first (the date I usually give her the money). So now I have no car to drive, do I still have to give her the $88 if she turns in the tags before the first? Please help. She's the type of person who will take as much money as she can from you, I do not know anything about insurance and she uses that over my head.""

Insurance on a car that is my moms?

Hey, I'll be getting my license tomorrow but I don't have a car yet. I asked my mom if I would be able to drive her car around but she said that if I get into a wreck the insurance wouldn't cover the repairs since she wasn't driving. She said I had to be on the insurance for it to be covered. Is this true? And is there anyway around that?""

Is it absolutely necessary for my car insurance company to have my husband's drivers license info?

My husband and I recently got married. We both keep separate finances and have our own cars and insurance policies. He actually owns cars jointly with his elderly mother and they have insurance together. He does not drive my car, he can barely fit in it. I have State Farm insurance. When I got my insurance I was told that they would cover anyone I choose to let drive my cars. I have 3 cars insured with them. I've been with them for 10 years, I've never missed a payment or had any claim of any kind. My husband doesn't feel comfortable giving out his information to anyone who does not need it. I think he has this right. State Farm claims it won't affect my policy so why do they need it? They keep calling me. I'm thinking of emailing them and telling them my opinion and that there are plenty of other insurance companies out there if they have a problem with it.""

Need auto insurance help?

I need to get insurance really quickly, buying a car soon. But I can't afford a huge down payment, nothing like $800 dollars... I've always been on my parents insurance (GEICO) and now I can't be on theirs, since I'm living on my own. Male, 20. I understand that insurance is generally highest for my gender and age... I need to insure a 2004 Honda Accord LX, Coupe, 3.0L V6.""

What kind of motorcycle could I get?

I want a vehicle and I think a motorcycle would be kickass. If anybody has any experience, please help me out. Is there a good bike I could get used under $3000 that I could ride on the highway (75 mph). Does your car insurance go up when you get the license? What would insurance cost for a 17 y/o male with no collisions or infractions? Any help would be greatly appreciated.""

How much is it for car insurance for a 16 yrs old in long island ny?

i am gonna be driving a ford station wagon 1989 escort

Cheapest car insurance???

what is the best place to get the cheapest car insurance???

Should i get a policy on My Dad's car insurance?

Hi all My Dad has been with Churchill a long time and says they are brilliant. I have been looking at my own policys and they are around 2.5k-3k which is so out of my price range it is unreal.I have checked how much it would cost to have my Dad as the main driver on another Churchill Policy on my car and have me as a name driver,Protect his no claims and i am also able to build up my own for future use with Churchill. The cost of this kind of policy totals at around 750. Should i take this or could there be any problems in the future.""

Is there short term car insurance?

I am going on a trip, and i am going to borrow a car from someone, and they don't have insurance on it..I wanted to know if i could get temporary insurance on it..""

If your a 20 yr old female in florida how much do you pay for your car insurance?

I just moved here and want to buy a car but i was wondering how much someone my age pays for insurance. A little help please? actual numbers would help

Was it wise for me to cancel my car insurance?

I had gotten into an accident. ICBC says it's 100% my fault, and I did just file an injury claim for myself and my family members that were in the car with me. I don't think my car is drivable, but if it is, then it's not worth fixing because I don't have collision and it would cost more to fix than how much I had bought it for. What I did yesterday, was cancelled my car insurance. But I was just talking to someone who told me that it wasn't a good idea to do that. And now I'm doubting myself. Will this be held against me? The person in the other car claimed injury and her car is also damaged. Did I just dig a deeper hole for myself?""

Car accident with no insurance?

I was stopped at a red light behind two cars. Both cars started to go and so did I the next thing I knew I had hit the car in front of me. The car in front of me hit the car in front of him. We all pulled over my car isnt to bad but I drive a suburban, the car in front of me was a smaller car so his looked a little worse. Nobody was hurt, and all cars were drivable, so we decided to not call the police we just all exchanged information. After we had finished and they left I immediately called my insurance lady to let her know what happened. I am not super clear on this next part, we have been going back and forth with our insurance since that call and will continue to fight it. When I called the insurance lady she said I wasnt covered. She said that they had received the last payment much later than it was due (not sure how because it was mailed the same time as always) but because of that our insurance had been cancelled. A couple of weeks ago they had chased our check, she said we were reinstated as of yesterday (the day of the accident) but because it was the same day they werent liable to pay the damages. We are going to keep fighting them because I dont think its fair. Even if they decide that they wont pay we can afford to just pay for the damages to the rear end of the car in front of us, because know matter what happened I am at fault for following to close. We cant afford to pay out of our pocket also for his front end and the rear end of the first car. Shouldnt those damages be covered by the car I hit because he was obviously following to close to the car in front of him? Im a little freaked out with all this, this is the first accident I have ever been in and we have always had insurance, so we thought. The insurance company did say they mailed us a cancellation notice but if they did we have never received one.""

Why are my insurance quotes so high?

I live in New Jersey, Plan on buying a 2012 mazdaspeed3. I am 18, which of course will make my policy higher. Currently, my car insurance runs around 300/mo on my parents policy. I cannot join their policy with the new car as it will be registered to me. The following are the rates ive been quoted Progressive - 6 month policy, $5,000 + $1,200 due at start-up Cure - 6 month policy, 6,200 + 1100 due at start-up Liberty Mutural - 6 month - 5200 + 1500 start plymouth rock - 6 month - 2,2009 + 679 start Why are these all so expensive? and why do they only offer me 6 month policies? thanks in advance!""

Should I contact my auto insurance company (accident was not my fault)?

Okay, my wife's car got stuck in the snow last week close to the subdivision. So I went out to get the car because she's not really good at driving in the snow, but I have ...show more""

What kind of insurance do I need?

I know nothing about insurance and this past year I've had a few problems which I paid straight out of my pocket. Needless to say it sucked horribly, thankfully my parents were generous enough to help me :) I now need insurance and its almost March 31st. I have a bad habit of procrastinating haha. So I know NOTHING about how insurance works etc. What is Obama care? healthcare.gov? medicaid? covered california? (I live in LA) I dont need Health Care (healthcare.gov) to get insurance like Blue Cross or Anthem right? Why are people paying for healthcare PLUS whatever insurance agency they get like Blue Cross. I currently have NO income, and I havent worked for a year so no taxes lol. I know health care helps with something that involves taxes. I'd like to get insurance and I heard that Medicaid is good for people with no income, but I'm going to have a small income soon. Do I need to contact healthcare.gov or medicaid or coveredca to get insurance with Blue Cross? What do you folks recommend? HELP!!!!! What is the March 31st deadline for? Do I just need to apply by then? And is that deadline for just healthcare/medicaid/coveredca or is it for the actual insurance company like Blue Cross? I'm so confused... Btw, I'm male, 23, live in Cali, currently no income. Thanks folks! :D""

Health insurance bills?

I asked a question about if health insurance companys bill you but I want to make this clear....so if I meat my deductible the only thing I have to do is pay the copay and I don't get anything in the mail from the insurance company but I can get a bill from the Dr or hospital that my insurance Didnt pay for?

Can i get affordable baby health insurance?

ready to have a baby soon but husband insurance would go from 250 to 700 a month (can't afford 700) if we have a baby but if me or the baby gets our own insurance somewhere it would be 250 but i have some health issues so i can't get my own insurance (i get denied everywhere, my job doesn't offer health insurance) so when i do get pregnant and have a baby can i get affordable insurance by it's self?I live in Colorado, will not use government help PLEASE DO NOT WRITE BACK IF YOU DON'T KNOW WHAT YOU ARE TALKING ABOUT OR SAY SOMETHING DUMB OR USELESS THANKS!""

Auto Insurance Help....?

I need insurance on my car, and i don't fully own it, my name is on the title and i finaced it so i have a lien on it....i'm only 20 so full coverage is pretty expensive! would it be possible for my dad to be able to add me to his policy?""

How much will it cost me to get insured on a Mitsubishi lancer evo?

i am 18 years old i am starting my driving test soon how much will it cost me to get insured on a 5 or 7 years old Mitsubishi lancer evo?

Is motorcycle insurance available for six months?

I live in an area where I can only ride for half the year, yet all of the policies cover 12 months. Does anyone know of a company that offers six month packages? A second question, does taking a Riding course offer a sizable discount with insurance companies? Thanks""

Insurance on a S2000 for a 45 year old man?

How much would it cost for a 45 year old man with a good clean record to own a S2000? I'm only 22 and planning on buying a IS300 (with manual transmission). If I do find one the car will be under my dads name and the cost will be around $150 a month!!! But how much for the S2000 (and under my dads name)? I want the IS300 but there so hard to find in MN with manual transmission and with very low miles on!!! So if the S2000 doesn't cost too much or maybe as much as the IS300's insurance, I probably would consider getting the S2000 since it's a bit easier to find one! (plus they look better!) (and also both cars are around $15,000) Thanks in advance!""

I am growing my insurance agency. Any sugguestions on how to avoid the time consuming busywork ?

I am good at getting people to buy from me, but hate all busywork . I am licensed and live in California, and sell personal health, life, car, and home insurance. I recognize that by not doing all the work, from running the quote to entering the data, that I should not be entitle to the full sum of the commission the carriers pay. Is there any franchise out there that has people who do all the deskwork so I can sell more? Its worth it to me to trade off part of the commish if I can get more people to buy from me. And I feel confident that I can bring more and more people in. My problem is that I lose oodles of time working their dec pages, typing in all their data to the various carriers.. Note: please dont answer if you are a recruiter. I am really looking for a good honest perspective from someone who has been in my shoes......Thanks so much.""

Getting Car Insurance for an American?

I'm trying to get car insurance for my wife who only recently passed her UK test. She has held a US license for many years (about 6 I think) and drove during that time with insurance and made no claims. However, it seems that some UK insurance companies don't recognise an American license or insurance history which is making the quotes extremely expensive. Up to 1500 for full comp on a basic family car (2003 Vauxhall Omega). Is anyone aware of any UK companies that would recognise her US license and quote accordingly for her driving history rather than treating her like a 17yr old? Thanks in advance.""

Which motorcycle insurance is an better choice Geico or Allstate?

Which motorcycle insurance is an better choice Geico or Allstate?

Health Insurance for 24 year old male?

Son has Blue Cross but it is now $137 per month......anyone know of any comparable insurance that is cheaper and has similar benefits? It is just him....no wife or no kids. Thanks.

Auto insurance for a 17 year old dirver?

ive had my license since christams and im looking for car insurance and im 17 years old how much is the average auto insurance for a teen like me and whats the best thing i can do thank you

Best life insurance...?

Best life insurance What is the Best life insurance company

No insurance ticket in calfornia?

i have car insurance with triple a for my truck... but i was cited for no insurance while driving my scooter. if i can prove i just bought the scooter will that release my ticket.... dont insurance poolicies state u have 10 days to report a new vehicle ??? any way to get out of this ticket

What is the cheapest car insurer for a 23yr old guy?

Obviously in the UK, so please no irritating as hell Try Patriot Insurance based in Washington ... So far, Zurich appears to be the cheapest. But i'm guessing we can go lower. Im trying to insure a 1997 Fiesta, 1.2, 3 door with immobiliser. Only doing 1000 miles or less each year. I have been out of driving now for 5 years. Can anyone recommend a cheap-as-chips car insurer? - It's ridiculous how just third party costs more than the car itself. My best qoute is around 580 - for third party ONLY. - A p*ss take. Thanks for your help.""

If i change my car insurance will my lien holder be notified?

I want to change to a different insurance company and have a an auto loan through my bank so my question is if i change will my bank be notified? I know it is wrong but for a few months i only had liability and if they are notified they can take my car if they see i didnt have full coverage right? I want cheaper insurance but dont want to get in trouble!

Car Insurance Help..?

I just turned 16 and got my license about 2 months ago. My dad and I are now car shopping for me and I found a car that I really liked, but don't know if it would be expensive insurance or not. If you could help and give me an idea of about how much it will be a month? 2001 Acura TL $5200 (Private Owner) 6 cylinder 3.2 liter vetec 4 door sedan automatic has a salvaged title passed state inspection 77,000 miles I also live in Ohio and my dad has state farm.""

How much do you pay for car insurance?

How much would the bill be for a 20-year-old male with the least amount you can get?

Teen car insurance question?

Hello. We moved this past summer and I currently reside with my grandparents for the purpose of keeping my job and staying at school. So he got a car insurance statement today saying that he has to pay nearly double his total amount just for me, a 17 year old driver, driving two of his cars. I only have a level 1 license by the way. They drive 2 new 2012 cars and trucks, would this price be accurate? Thank you.""

""Can I purchase a car, and tow it home without insurance?""

I want to purchase a car from a small car place, the man puts 30 day tags on it and mails the title to the DMV, but my father cant get off work to come put insurance on the car for me. So can I buy the car there, have the title put in my name, but have the car towed home and stored off the street until I can add it to insurance and get my own tags? or is it illegal to tow a car without insurance on it?""

Where can i find the cheapest insurance??

im 19. i live in california. ive never been in an accident and ive never gotten a ticket. i drive a 2004 suzuki forenza and i pay almost 200 dollars a month for insurance!!! i have to have full coverage because im still paying off my car, but come on i think thats a little ridiculous.. its more than my car payment. Any idea where i can get it cheaper and if so, how do i go about changing it?? any help is greatly appreciated!""

Car insurance is very cheap or very expensive?

Car insurance is very cheap or very expensive?

What do you recommend for cheap car insurance for a young driver?

I am 18 and passed my test 3 weeks ago today when i was 17! I have a Ford Fiesta 1.1 N reg! I have done my pass plus too! The best quote i have found is 967 and that is without telling them i have done my pass plus! It was also for third party fire and theft! Can someone recommend a cheap insurance company please! Many thanks

I am 19 in Texas. is it cheaper on insurance to do the whole teenager coarse or is it the same going adult 6hr?

My dad is wondering if it would be cheaper on insurance if I did the the three week teenager coarse or if it doesn't matter anf do adult which is one 6 hour class. Again I'm in Texas and a guy and know about how its cheaper for girls on insurance

Does it matter if you tell the insurance company?

that you are keeping your vehicle at 'X' address instead of your real address which is 'Y' address. Reason being that X is a way cheaper premuim than my Y premium. And its only for TPO insurance. Thanks

Which car is cheaper on the insurance part and on the second hand car dealler?

i will be turning 17 soon i am i boy and living in somerset in the uk so im looking 4 a car but i want 2 no which car would be cheaper on the insurance and on the second hand dealership Citreon Saxo 1.1 desire 3dr/5dr Vauxhall Corsa 1.0/1.2 club 3dr/5dr Peogeot 106 1.1 zest 3dr any other car which would be cheap tell me thank you

Insurance cost for Corvette?

Hey I'm 16 and have quite a bit of money saved for a car so im gonna get a decent one nd i was thinking a corvette. I was wondering about (I know no one knows exactly) how much the insurance is going to be on like a 00 or 01 model. Also if you know insurance cost of a 350z too that would be great. Thanks for the help

Live in FL need to know were to get low car insurance rate for my daughters 2001 saturn sl1?

She is going to need comp and collision because she owes on the car she is 22 and has 1 speeding ticket cost per month now is approx 170.00 any help would be great she has progressive now

Cheap car insurance...?

If you buy a shitty car for like $500, can you get insurance that only covers the other person in a crash and not you?? I know they used to have this?""

Do you need to stay with a certain car insurance for a period of time?

I need to get new car insurance but i'm short on money. Can I have one car insurance for a month or two and then switch to a new one?

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I'm a US citizen on a temporary work permit in Ontario. I'm trying to figure out the best way to register my car. If I can find insurance that would cover me in Canada I could maintain registration in Calif. Does anyone know about this? Is there an insurance company that will cover my car while I'm registered in Calif/driving in Ontario? Thanks!

Am I getting ripped off for car insurance?

Got my car insurance bill. I'm on a family plan with my mom and my sister. We did it because we were told it would save money. I'm in my late 20's, drive an older car(a ...show more""

""Car insurance, does it look bad to pay monthly?""

Car insurance companies can check your credit, so your financial stability must be important to them. A guess. So, does it look better if you pay them monthly or every 6 months? Paying every 6 months (or yearly if they let you) would show you are financially better (you have some savings). Do you think it really matters at all? At all?""

Affordable car insurance?

Hi; I recently bought a 2002 Pontiac Grand Am from a used car dealership and need to find some insurance on the cheap side for it. What I'm really looking for is something that simply makes the car legal, as I can't really afford anything over $40. I'm 23 and living in Harrisburg Pennsylvania so any insurance you guys know of that fall into my parameters would be great; really need this car for work.""

How is 18yr old meant to get car insurance?

I live in London and passed my test in February. I own Renault Clio 1.2 And the cheapest quote i got so far is 305 pounds per month, which is way too much for me. What companies are cheap? What can i do to start driving legally, searching for insurance is frustrating Dont say price comparison websites they suck cheapest quote there was 8k per year""

Which motorcycle insurance is an better choice Geico or Allstate?

Which motorcycle insurance is an better choice Geico or Allstate?

https://www.linkedin.com/pulse/car-insurance-want-my-ssn-quote-marshall-winkle"

[bodyinbalanceblog]

HOW PROTEIN AFFECTS BODY COMPOSITION

There is a lot of confusing information in the health industry in regard to protein consumption. Is it good? Is it bad? How much should I consume? When should I consume it? If I eat too much protein is it bad for my kidneys? Allow me to clear things up for you. 

Large-scale studies conducted at the South Shore YMCA, Quincy, Mass. have shown that protein indeed repairs and builds muscle fibers. 68 middle-aged men and women were enrolled in a supervised, 23-week strength-training program with a frequency of two to three days per week. Researchers examined body composition changes over a six-month training period, in which half of the participants consumed an organic soy protein shake immediately after performing their strength exercise. The result? Subjects who ingested the post-exercise protein drink increased their lean weight by 5.5 pounds, and decreased their fat weight by 9 pounds - a 14.5-pound improvement in body composition. Those who did not receive supplemental protein increased their lean weight by 3.9 pounds, and decreased their fat weight by 4.9 pounds - an 8.8-pound improvement in body composition. 

Protein is necessary to repair muscle fibers. That said, it’s consumption has a direct relationship with how much physical activity one performs in which their muscles are stretched and contracted. Most people do not engage in enough physical activity or weight training to warrant their high protein consumption. As a result, the excess protein not absorbed in the muscles has to be processed by our kidneys, shortening their lifespan and limiting their function. 

Why was this study done? Lean body mass (muscle mass) is one of the largest modifiable components of metabolism. Lean body mass is of interest to scientists because increasing lean body mass is an effective tool in the fight against obesity. This study was designed to understand what role protein plays in building lean body mass following intense exercise.

What did the study find? The study found that participants who consumed a protein drink following strength-training and endurance (treadmill, cycling) exercise gained approximately 25 percent more lean weight and lost 50 percent more body fat that those who were not supplemented with protein.

LINK: https://www.acefitness.org/continuingeducation/courses/support_items/OLC-PSM-NPEEE/NutritionJuly2014.pdf

Protein and Body Composition. Authors: Westcott W, Martin WF, La Rosa Loud R, Stoddard S. Athletic Business, April 2008. 

Over the past few years, a considerable amount of research has been published related to protein supplementation and muscle/strength development.12,6,2,10 Recent work has documented significantly greater gains in muscle mass and strength when protein is ingested in close time proximity to a resistance-training session.7,4 In a 12-week study conducted with previously untrained men, researchers examined the effects of consuming supplemental protein immediately after versus two hours after a strength-training session. Those who consumed protein immediately after their workout gained significantly more muscle size and strength than those who consumed it two hours removed from their workout.

After age 35, adults may lose 3 to 8 percent of their muscle mass per decade, and higher rates are commonly observed after age 60.5,8 Therefore, the ability to preserve or regain muscle and strength is an important factor with respect to aging and health. In fact, there is ample evidence that an average muscle loss of 5 pounds per decade is associated with a 3 percent-per-decade reduction in resting metabolism,9 which can predispose individuals to a dramatic increase in body fat.13,15 Thus, many have speculated that a significant part of the obesity problem may be due to muscle loss and the resulting metabolic slowdown. If so, well-designed strength-training programs should play a larger role in weight management and the many degenerative diseases/problems associated with obesity (e.g., diabetes, heart disease, stroke, back pain, arthritis).

Large-scale studies conducted at the South Shore YMCA, Quincy, Mass., have shown that previously sedentary adults who perform two to four months of regular strength exercise can add 3 pounds of muscle tissue.16,14 Resistance training has also been shown to elevate resting metabolic rate by approximately 7 percent, which equates to the expending of roughly 100 additional calories per day in a 175 pound individual, or 1.75 calories per pound.3,11 This is good news for men and women who want to slow the loss of muscle that accompanies the aging process, and establish or maintain a healthy body composition.

Table 1. Changes After Exercise ProgramChanges in bodyweight and body composition after 23-week exercise program (46 participants).MeasureWeek 1Week 12Week 23Six-Month Change

Bodyweight (lbs.)184.2183.1*181.9*-2.3*

Body fat (%)32.330.7*28.9*-3.4*

Body fat (lbs.)60.256.9*53.2*-7.0*

Lean mass (lbs.)124.0126.2*128.7*+4.7*

Waist girth (in.)37.235.8*35.7*-1.5*

Hip girth (in.)43.442.7*42.2*-1.2*

Systolic BP (mmHg)127126121*-6*

Diastolic BP (mmHg)757371-4

*Statistically significant improvement from week 1 (p < 0.05).

Protein Composition Study

Middle-aged men and women seem to be particularly prone to muscle loss, forfeiting about one-half-pound to 1 pound of muscle every year of life. In addition, they tend to eat less protein and have more difficulty assimilating the amino acids in the protein they do ingest. Consequently, we, the study team at the South Shore YMCA, decided to examine the effects of a standard strength-training program - with and without supplemental protein - on body composition in a group of adults averaging 59 years in age.

Although we have previously conducted strength-training studies in adults, most have been eight to 12 weeks in length. For this study, we examined body composition changes over a six-month training period, in which half of the participants consumed an organic soy protein shake immediately after performing their strength exercise.

We enrolled 68 middle-aged men and women in a supervised, 23-week strength-training program with a frequency of two to three days per week. Below is a brief description of the exercise protocol, which was adapted from American College of Sports Medicine (ACSM) guidelines:1

11 weightstack machines: leg extension, leg curl, leg press, incline press, seated row, triceps press, biceps curl, low back extension, abdominal curl, torso rotation and neck extension

One set of each exercise was performed, with resistance that permitted eight to 12 good repetitions.

Exercise resistance was increased by about 5 percent when 12 good repetitions were completed.

A controlled movement speed (about 6 seconds per repetition) with full range of motion was used.

To ensure comprehensive physical conditioning, during each session, subjects also performed 20 minutes of endurance exercise (treadmill walking and stationary cycling at 70 to 80 percent of maximum heart rate), and completed a 20-second stretch for the target muscle group following each strength exercise. For example, immediately after completing the leg extension exercise, participants stretched the quadriceps muscles, and immediately after completing the leg curl exercise, they stretched their hamstrings muscles.

All of the participants performed the same exercise program in our research facility under close supervision of our instructional staff (two instructors for each six-person class). Forty-six subjects completed the 23-week program. Twenty-four participants consumed a protein drink following their training session, and 22 subjects did not receive supplemental protein. The protein drink (Cinch, manufactured by Shaklee Corp., Pleasanton, Calif.) was prepared by mixing 1.5 servings in water, and provided about 270 calories, 4.5 grams of fat, 35 grams of carbohydrate and 24 grams of protein, and was fortified with free l-leucine.

Research resultsAfter 23 weeks of training, all 46 exercisers experienced significant improvements in body composition, including a 4.7-pound gain in lean (muscle) weight and 7-pound loss in fat weight (see Table 1). These changes appeared to be consistent throughout the six-month training period. For example, subjects added 2.2 pounds of lean weight during the first three months, and 2.5 pounds of lean weight during the last three months. Furthermore, participants lost 3.3 pounds of fat weight during the first three months, and 3.7 pounds of fat weight during the last three months. Study subjects also experienced reductions in resting blood pressure over the six-month exercise period. On average, diastolic blood pressure decreased by 4 mmHg, and systolic blood pressure decreased by 6 mmHg.

Subjects who ingested the post-exercise protein drink increased their lean weight by 5.5 pounds, and decreased their fat weight by 9 pounds - a 14.5-pound improvement in body composition. Those who did not receive supplemental protein increased their lean weight by 3.9 pounds, and decreased their fat weight by 4.9 pounds - an 8.8-pound improvement in body composition. As shown in Figure 1, the participants who consumed post-exercise protein added 1.6 pounds more lean weight and lost 4.1 pounds more fat weight than the no-supplement subjects.

Figure 1. Shake vs. Non-Shake GroupsChanges in body composition in the Shake vs. Non-Shake groups.

Discussion and applicationThis study confirmed the favorable effects of a fitness program on body composition and anthropometric measurements. An interesting finding was that the beneficial effects of a basic exercise program were observed at a relatively even rate over a six-month training period. Our 12-week findings are in agreement with previous short-term studies that reported approximately 3 pounds of lean weight gain and 4 pounds of fat weight loss. However, some have questioned whether the rate of these adaptations would continue over longer training periods. Our subjects experienced comparable changes in body composition during both halves of the six-month exercise program. Over the first three months they added approximately 2.5 pounds of lean weight and lost approximately 3.5 pounds of fat weight. Likewise, over the second three months they added about 2.5 pounds of lean weight and lost about 3.5 pounds of lean weight. Therefore, it appears that previously sedentary adults can attain significant and consistent muscle gains and fat losses over the first six months of a standard exercise program.

Another finding with practical application for middle-aged men and women was the greater body composition improvement experienced by the participants who consumed supplemental protein immediately after their workout. Subjects who consumed the post-exercise protein drink gained about 25 percent more lean weight and lost 50 percent more body fat. This observation reconfirms the finding that supplying the body with extra protein and carbohydrate following a combined strength/endurance exercise session promotes the addition of lean tissue and the loss of body fat. At present, it is thought that provision of protein after exercise increases the rate muscle proteins are made, which increases the amount of muscle over time.

Based on the results of this study, we found that a standard strength/endurance exercise program consistent with ACSM training guidelines is effective at increasing lean weight, decreasing fat weight and reducing resting blood pressure. Furthermore, we believe that consuming supplemental protein shortly after each training session is beneficial in helping promote desirable body composition changes (increased lean weight and decreased fat weight) associated with a standard strength/endurance exercise program.

References

1. American College of Sports Medicine.

ACSM's Guidelines for Exercise Testing and Prescription

, 7th ed. Lipincott, Williams and Wilkins: Philadelphia, Pa., 2006.2. Arciero, P.J., et al. Increased dietary protein and combined high-intensity aerobic and resistance exercise improves body fat distribution and cardiovascular risk factors.

International Journal of Sport Nutrition and Exercise Metabolism

16(4): 373-392, 2006.3. Campbell, W.W., et al. Increased energy requirements and changes in body composition with resistance training in older adults.

American Journal of Clinical Nutrition

60(2): 167-175, 1994.4. Cribb, P.J., and A. Hayes. Effects of supplement timing and resistance exercise on skeletal muscle hypertrophy.

Medicine & Science in Sports & Exercise

38(11): 1918-1925, 2006.5. Dreyer, H.C., and E. Volpi. Role of protein and amino acids in the pathophysiology and treatment of sarcopenia.

Journal of the American College of Nutrition

24(2): 140S-145, 2005.6. Elliot, T.A., et al. Milk ingestion stimulates net muscle protein synthesis following resistance exercise.

Medicine & Science in Sports & Exercise

38(4): 667-674, 2006.7. Esmarck, B., et al. Timing of postexercise protein intake is important for muscle hypertrophy with resistance training in elderly humans.

The Journal of Physiology

535(Pt 1): 301-311, 2001.8. Forbes, G.B., and E. Halloran. The adult decline in lean body mass.

Human Biology

48(1): 161-173, 1976.9. Keys, A., H.L. Taylor and F. Grande. Basal metabolism and age of adult man.

Metabolism

22(4): 579-587, 1973.10. Phillips, S.M., et al. Mixed muscle protein synthesis and breakdown after resistance exercise in humans.

American Journal of Physiology

273(1 Pt 1): E99-107, 1997.11. Pratley, R., et al. Strength training increases resting metabolic rate and norepinephrine levels in healthy 50- to 65-year-old men.

Journal of Applied Physiology

76(1): 133-137, 1994.12. Tipton, K.D., and R.R. Wolfe. Exercise, protein metabolism and muscle growth.

International Journal of Sport Nutrition and Exercise Metabolism

11(1): 109-132, 2001.13. Westcott, W., and T. Baechle.

Strength Training Past 50

, 2nd ed. Human Kinetics: Champaign, Ill., 2007.14. Westcott, W., and J. Guy. A Physical Evolution.

IDEA Today

Vol. 14: 58-65, 1996.15. Westcott, W., and G. Reinl.

Get Stronger, Feel Younger

Rodale: New York, N.Y., 2007.16. Westcott, W., and R. Winett. Applying the ACSM guidelines.

FMY

Vol. 22.: 40-43, 2006.