BREATHING LESSONS

"Don't forget to breathe,"  I remind my patients almost everyday.  It sounds funny but its so true.. I mean deep diaphragm breathing...in through nose and out through mouth  breathing.    

I say: "Smell the flowers and blow out the candle."  and most people laugh immediately and realize that yes they do not know how to breathe.  

Pay attention to your breath:  "Is your breath high up in your chest?"    "Is your mouth open"   "Are you anxious because you have not taken a deep breath today?"  "When you exercise, do you hold your breath some of the time?" 
As a dance teacher once told me;    "Let your body follow your breath."

Respiratory ailments is the catch all phrase for those with severe breathing problems:  Pulmonary disease, emphysema,  asthma, acute respiratory distress and chronic obstruction of the airway passages.  Anyway you want to name it..   IT IS SHORTNESS OF BREATH!

Every  twitch, twang and tweek of your muscle fibers  goes into the job of getting air  in thru the nose down through the trachea, through the bronchi into the bronchioles which  connect into the tiny air sacs (alveoli) containing the capillaries which  distribute  oxygenated rich blood throughout every cell in your body.   

I have seen how this disease looks:  The chest muscles prominently expanded, the shoulders drawn up high,  sallow skin stretched taut,  eyes vapid,   voice waxing and waning in volume.  Even  to force the facial muscles to smile seems like an enormous effort.

 I can get out my tools: the oximeter, the blood pressure cuff, the thermometer and stethoscope and get lots of measurements and we both agree on the numbers and we go through the motions of some sitting exercises to increase the heart rate and improve endurance with activity but still... every breath you take can sometimes feel like it could be your last.   

When I first heard a patient tell me that she will not leave the house without her portable oxygen tank completely full,    I had never even thought about needing to take "air" with you.    You literally  do just enough activity governed by how much oxygen IS  in your  tank...talk about self regulating or you will literally "run out of breath."

So take a slow deep breathe again.. where the air travels to the lower portion of the lungs where the oxygen exchange is most effective.. heart rate slows, blood pressure decreases, muscles relax, tensions relax and the mind calms.. and remeber how it feels to come up for air once in awhile.

"LA DOCTORA"

 No, I am definitely not the doctor, but the Physical Therapy Assistant.  I have been called; "LA DOCTORA" by mostly my Hispanic patients.  Walking thru the door of my patients home,  I feel like I am part of the slowly dying off club of those that make The House Call.  I am dressed in  my starched white lab coat and am carrying my proverbial little black bag. (only this time I have to sling it around my shoulder because it is  loaded down with so many more paper forms as well as necessary tools of the trade) I like to imagine myself as the Country Doctor of years past, coming to pay my respects to the family and to the  patient; bringing all the cures tucked away in my little black bag.   

I have the names of many diseases shuffling around in  my mind as I try to keep them all straight.  Lets see Who was the Hip replacement?  the Congested heart failure? the nurse that worked for 30 years in emergency rooms and now has esophageal cancer?  the woman who owned the candy store I used to go to...has frequent falling?  early onset alzheimers? parkinsons like gait, tremors of unknown origin,  and on and on and on...

I reach into my black bag, pull out the stethoscope to take your vitals, listen to your breathing,  look at an incision from a knee surgery, put my hands on your forehead, ask you your pain level,  make you grip both my  hands as hard as you can... "Come on harder, you can do it more, more," I say, and then I stop and file away this data and let you, the person,  tell me your story.

 I sit next to you usually on the couch or else on your bed with you.  You begin from the usual drop down menu: (in no particular order)  the onset of illness, what hurts, what makes it better,  medications you do not understand, hospital stays where knowone answered your call light for hours so you just took yourself to the bathroom even though the doctor stated strictly that you must never get up alone,   the nurse that got mad at you because you did not eat enough,  the caregiver who brought you clean fresh sheets and smoothed them down so flat you felt you could sleep like a baby again, the family member that chose not to come to visit,  your job.. how long will they hold it..and the beat goes on (as the song goes)

As I sit and listen, I think of the expression  "a laying on of hands."   


In religious terms, it is called "the divine healing. the placing of the hands of the healer upon the person to be healed... or  more specifically; the consecration: setting someone apart for the service of god; next, the transmission of a divine gift and finally the anointing with a healing oil...
In some ways this expression conjures up the pentecostal healings that still continue today... where  the almighty leader sets his hands on shoulders or head of a parishioner and behold the person would be able to walk again...or talk or any such bigger than life magic!


    We have our modern day charlatans, Hood winkers, hucksters, fraudsters, swindlers of the traveling medicine shows, disguised as the big bankers and insurance companies,  who lay claims to being able to cure anything while emptying out your pocketbooks at the same time.."the too good to be true" idea that will never fail to dazzle your wounded and tired souls   BUT,   I am talking about the laying on of hands as a metaphor for the art of  re-assurance,  conferring faith on another that things are destined to be better and that if you feel I have heard you out, have listened well, that you the patient and me "la doctora" have entered into some sort of an unspoken pact...and we  both get to feeling much better  as I reach out to shake your hand and thank you for your time...

THE EXERCISE LADY

In the exercise class 5 days a week at the Cypress Alzheimers facility,  three ladies sit next to eachother on a very large sofa in the front row.  One  tilts so far to the right as she sits and another sits very straight but both can follow right along with the teacher.

 Another lady cannot seem to stay on the beat but is transfixed by the movement.  The only man in the whole class sits way apart from the others at the back of the room and  does not smile at all.

 The rest of the people  are in various states of sleeping and waking and mumbling to themselves or sitting staring straight ahead not at anything or anybody it seems.  At the front of the class is the exercise lady; Hannah


"UP, DOWN, OUT, IN..up, down, out, in," Hannah speaks clearly and strongly as she demonstrates the arm movements to the twelve residents sitting in wheelchairs, sofas and recliners.


"Okay try to keep going," she continues," I am not going to tell you what to do: one, two three, in very good Janice, one, two, out, four."

She wears an extra large cap to cover her long thick braids which she occasionally flips behind her as if to dramatize  starting and stopping  each exercise sequence.  She speaks with a Carribbean accent ending each sequence of exercises with the word PER....fect...lingering a split second longer on the first syllable.


"Okay Mrs, Mackenzie, thank you for joining us," says Hannah as she acknowledges a woman who has stood up and does not know where to go. "Dya have ta leave us now then?" she asks and then back to the other exercisers who are still working hard, "Keep those legs marchin now.

"I know it getting harder when it makes my legs burn a little ya know? We gonna work just a bit more then we can relax alright."  A caretaker has come to help the lady who is looking stranded and takes her hand and leads her out of the exercise area.

"I see some people who need just a little help,"  Hannah  stands up, walks over to a lady in black and white spotted sweater, buttons in the front, who must weigh only 95 pounds and is perched on the edge of a giant chair looking like she might fall off any minute but miraculously she does not.

Hannah kneels  down in front  and holds her face in her hands as if she is cradling a baby and helps her move her neck from side to side:  "Excellent, there you go Marion...one, two, three, four five six, seven eight and relax.." then gets up to return to the front of the class again.

"Now take a few minutes to rest.  Let your bodies relax so that we can do this again. Breathe in," she says as she lifts her arms above her head, "and breathe out.. PER....fect.

IF THE SHOE FITS, WEAR IT!

                                                

"Your pedal extremities are colossal" crooned Fats Waller in his 1940's humorous song about a woman he loved with big feet.  "Yes your feets too big," he wailed,  "from your ankles down you  just gots too much feet."   but what he did not say (natch)  is that your  feet can also be too TINY,  have gout, plantar fascitis, fallen arches, mallet toes or my favorite: MORTONS NEUROMA .

The foot, with 26 bones, 33 joints and more than one hundres muscles ligaments and tendons,  truly needs good protection.       Many of my patients do not want to give up the "slipper shuffling" and there comes a time where I have to put my foot down (sorry)  and say:    "Get out of those small shoes for them there humongous feet.    I know you love those slippers but its time to lose them and start truly walking.

We all have our favorite shoes.  Think of the choices you have when you get dressed in the morning.  Isn't it true that there is  a favorite pair that you tend to want to wear?  The ones that also describe how you are feeling that day  Maybe sporty in those tennis shoes, or playful in a mid heel open toe,  sexy in your red high heels..                                                          

When you get to be in your 80's and 90's though,   the slippers begin to look really good.  I mean think how simple.. No more tying the laces, no more bending down,  no more finding socks to match.....Yep,, I find myself being a shoe salesman to my patients.

 Remember them? those guys you can't find anymore; the ones that actually measured your foot, then went to the back of the store,  pulled  from the shelves various shoes sizes and styles, brought them back, stayed there while you tried them on while you said  how you felt and looked in each pair. You had an accomplice.  Thats me on my job.

   After having knee replacement, this field worker would not give up his cowboy boots. I insisted he put on the tennis shoes that his wife had bought for him probably the only time he ever put on a pair.  He would never want to walk very far and after a few sessions he told me that he felt horrible without his boots on and even though  he knew it was not good for his knee, he could never give up wearing his boots..

Another woman who also had knee replacement told me she had no shoes that were comfortable anymore.  She was used to going out a lot with her very successful business man husband to lots of local high society  events.  She always dressed up.   When we went to her closet, there were about 100 pairs of shoes!  She said: "I cry when I come here because with my knees hurting, I cannot wear any of these..."  They were all quite expensive, modern, chic.... I told her its time for comfort.  She looked at me as if I just told her her house was burning down and then said: "Who should I give all these shoes to?"

When I met John, an 89 year old, he had diabetes, blood pressure problems and just general weakness.  He loved the kinds of shoes he wore now and had bought three pairs.    He had begun to cut through the tops of the leather of the shoes tto relieve the pressure as his feet had widened and he had a pressure sore on one toe.  We went online together, found the shoes he liked and ordered a larger pair.  He was thrilled.
     
I loved when one of my patients gave me  a pair of brand new high- top- super- white- ultra- suede -super padded tennis shoes.  I was hoping they would fit this 79 year old hispanic man, suffering from hip problems whom I knew could never afford them.   When I presented them with these shoes,  I was praying to god they would fit..He put them on and kept saying: "Esos, si son buenos,, esos si son buenos (these are good, these are real good) He showed off how well he could walk and even showed me he did not need his cane anymore!
  

There is just something about putting on the right pair of shoes.  Of course,  it certainly  helps when it is prince charming and he has come to find you to return your long lost slipper so that you both can live happily-ever-after....                                  

MY ODE TO RHUBARB

ON  an  autumn night with the pink and white moon overhead, sitting outside listening to jazz piano and drinking Honduran coffee with a slice of freshly pulled-from-the-oven rhubarb crisp.

Rhubarb picked from the soil for the first crop of the season.  It is the first time I have tasted rhubarb that is only two hours old.. two hours from being snapped from its
tightly wound center..and so, when I add the sugar and the lemon and apple juice, then bake, it immediately tenderizes and becomes a texture I can only describe as gooey, thick, piquant, not at all stringy...kind of like the texture of baked eggplant.  The oats on top and the butter and the cinnamon have just enough richness to offset the tart/sweet of the rhubarb.. the perfect mix in a fruit.  Oh my, I better stop.

When will the next crop come around again?  Those dinosaur leaves and their long thick magenta stalks.. I must wait.   I will wait.. I will  wait.

DO I HAVE A WITNESS????

"I told Glenda that the day will come when she will walk into New Hope
Baptist chuch with just the cane and her nice walking shoes.. Ain't that right sis?," says Kathryn looking at her  sister and putting away the leftovers from  lunch.
"I have faith in you, yes I do." she says to me as I get ready to work with Glenda, " You will make her walk good again.. I can just feel it."

  I had been working with Glenda for 3 weeks  after her hip replacement.  She had suffered a stroke 10 years ago but was able to get around with a cane until this last surgery.  Accoding to Kathryn, Glenda was also very depressed since her job as full time caregiver for their mom had come to an end. She had moved to California from Texas to live with her sisterover 1 year ago and Kathryn kept reminding her... Mom was dead.  It was time she looked after herself and started eating what she was supposed to... No more fried foods and sugary sodas like she was used to back home.

 "I think if we could get Glenda to the church,, I know it would do her good.  I bought her some crossword puzzles,  she helps me with the laundry and I make her get dressed every day."   Kathrn has posted notes all over the house with such sayings as:  Yesterday is gone, tomorrow is not here yet and today is a present."  or    "Don't let your thoughts tell you who you are."   or  "take it one hour at a time."   Glenda does not seem to notice any of this.. She  repeats to me only that the medications for the depression made her worse.  It was the devils work, she said.

When Kathryn was not around, Glenda did very well. She did all of the exercises without tiring, insisted on walking outside, talked about getting dressed up again, even looked proud of herself when I complimented her on being able to do the ankle circles without the whole bottom part of the leg moving.

"I never knew my foots could do that," she answered without hesitation.  In fact, Glenda was out of her large smock dresses the past few visits and was wearing slacks and shirts in bright solids with scarves to match. I insisted it was time to step out of her house slippers and so She had tennis shoes now which she could not believe were "so comfortable."      "I made you something," she said, as she handed me a bright pink crocheted cap with a red flower sewed onto the side, "I know that our therapy  ends soon" she said.

        "We sure would like to do something more special for you," said Kathryn  whileGlenda was doing standing exercises counting them out to herself.   We stayed in the kitchen inside because the house was filled with stuff everywhere you turned: a large fish tank, vitamin and nutrition books, plastic flowers, macrame hanging baskets, family photos... Glenda had not confessed yet to her sister that one day she would like to live in her own place.  Kathryn might be offended, she thought.

On the last day of therapy, Glenda opened the door and was standing there with only her cane.  She looked tall and radiant.  When she invited me in, I saw three men sitting down on the mantle of the fireplace.  They smiled huge  grins at me when I realized these were the deacons from her church that she always talked about.
"Do I have a witness" shouted one,  "God you are great" said another. and "Praise the Lord." as Glenda paraded from room to room with bright blue tennis shoes on, concentrating on her stride, striking her heel first, gaze  forward (not down as she had done for so many years) mouthing the words, right foot , left foot, right foot, left foot. When she turned around she took a deep breath, checked to see that her scarf turned right side up and began again looking as if she had never taken a step before in all of her blessed 65 years.
                                                                              AMEN.

"You put your right foot in , your put your right foot out.."

       "Legs come with a high price...  The motors controlling a leg have to alternate between keeping the foot on the ground while it bears and propels the load and taking the load off to make the leg free to move..All the while they have to keep the center of gravity of the body within the polygon defined by the feet so the body doesn't topple over"

from HOW THE MIND WORKS by steven Pinker

      I love this quote. Its a miracle that we walk without toppling over.
     "I was just getting out of the shower when the next thing I knew I was on the floor." is what I hear from so many people I visit in the homes. I often see the words "FALL RISK" on many patient  history reports.   What is most humiliating is when it is tactlessly posted on the  wall of an inpatients room in an effort to communicate to all other medical personnel that this patient is not safe to walk alone. When I was very new in Physical Therapy,  I  thought the sign meant that  I  risk falling by entering into the room..like maybe the floor was slippery or something...
         One of the hardest things to tell a patient is that they have to continue to use a cane or walker eventhough they think they are ready to go solo. Didn't  we all love to utter: "Look Ma no hands"  when we were children and realized we could walk without holding onto anything!!!   Its still a mighty thrill when one can leave crutch, walker, cane in the dust and take long solid strides by oneself.
Maybe that is what the hokey pokey was all about... you know that dance that we learned in kindergarten.  We celebrated each part of our bodies.. Remember?
"You put your right foot in
You put your right foot out
You  put your right foot in and then you shake it all about
You  do the HOKEY POKEY and you turn yourself about
Thats what its all about!

The leader or teacher would then call out various other body parts like: finger, toe, nose, chin elbow.. of course we all loved the bottom the best... especially the shaking it all about...

Trust me... Its almost alway best to put one foot in front of the other,.look ahead to where you are going and  as Nat King Cole said: "  Straighten up and Fly right"