Dialysis Blood

My wife’s kidneys failed when she was a teenager, and therefore she was getting hemodialysis for a good part of her life. The kidneys filter the blood to remove excess fluid and a wide variety of toxins. Hemodialysis replicates some of the kidney’s function when a person’s kidneys fail. In hemodialysis, your blood is cycled through an artificial kidney, which means that you have blood taken out, cleaned, and returned back in. Therefore, at any given time during treatment you have about half a liter of blood in tubes, outside of the body.

Access to the blood usually comes in two ways: via a chest catheter, or via needles. The needles are inserted into a surgically prepared fistula, which is a vein looped back into an artery. The blood is taken from the arterial side, cleaned, and returned back via the veinous side. The blood is cycled through over a period of hours, and during a dialysis treatment, quite a lot of fluid is removed from the body, anywhere from one to four liters, sometimes more. A person on dialysis loses anywhere from two to ten pounds during treatment.

A person on dialysis (my wife liked the term “dialyser” instead of “dialysis patient”) has this done anywhere from three to six times per week, for as many as four to eight hours per treatment. Usually, things go well. But, when you do anything at least one hundred fifty times per year, things sometimes happen. And when things happen on dialysis, they usually involve blood.

People don’t like seeing blood. They especially don’t like seeing blood on themselves. Some people faint when they see it, some people get queasy. If they cut a finger, or get a bloody nose, the blood-soaked bandage or rag or towel can freak them out. Blood is not an everyday event for most people.

That’s not true with dialysis people. Dialysis in a way is like controlled bleeding – you bleed into a tube, and you get it back. So, every single treatment they are seeing their blood in a tube. And when they are done, there’s at least a little blood when they pull their needles. Because the needles have direct access to the bloodstream, they have to hold the bandages against their access points for a good five to ten minutes just to ensure they don’t bleed out. Then they tape up a bandage and it stays there for a few hours.

When anomalies happen, they can be quite dramatic. And by dramatic, I mean lots of blood. They are dramatic, but as dialysers and their support people find out pretty quickly, dramatic doesn’t usually mean dangerous. Not usually.

My wife started home hemodialysis in 2008, and I trained to be her caregiver. As a caregiver, my job was to support her, to help set up the machine, to monitor progress, to help her start and end treatment, and to aid in emergency situations. Jenny was a pro at this. By the time we started dialysis at home, she had already had about fifteen years of hemodialysis experience. I wasn’t such a pro.

Most of the time things went well, but there were a few times when things went hairy. One time I was downstairs when Jenny was running, and my son ran to me screaming “Mommy needs you, she’s bleeding!” When I got to the room, there was a lot of blood, and Jenny had a bloody towel jammed on her arm, and it was soaking through and dripping, and she couldn’t get to new towels to put on top. I was freaked. She was not – she was cussing pissed.

“Get those paper towels. Put them over this. Help me press down. Harder!” And then, she was fine. The bleeding stopped, we swapped out the bloody mess with clean bandages. And there was blood on the carpet, on the chair, on her clothes. I still have the chair, and there are still blood stains on it. Not big ones – but they are there. She lost about a pint of blood all told, which is doable, but when it is spread all over, it’s dramatic!

Jenny put her own needles in. The process is to push a needle into the access point – the fistula – and you know you have it right when blood pops into the attached tube. You then let the tube fill, attach a syringe with saline, get rid of the air, and then push the saline into the tube. Then, do all this again with the second needle. The dialysis lines are later attached to the tubes.

One time Jenny developed an aneurysm, a bubble-like swelling, on the blood vessel in her fistula. As a result, she’d have to push through the aneurysm to get into the actual fistula properly. The aneurysm made it difficult to find the real vein. The result was that the access would gush blood from the aneurysm as she was poking the needle in trying to find the right access. As usual, she was all business. My God she was brave! I admit to being flustered, but for her, she had no choice. It was dialyze or die, and in this case the hospital was not an option. So, blood was pouring out as she stuck herself. My job was to keep the blood from dripping and to quickly put bandages on it when she found the vein. And to swap out bandages during treatment, because the aneurysm didn’t quite fully stop bleeding until after the treatment was done – several hours. This is obviously unsustainable, and yes we did indeed take a trip to her vascular surgeon to get it fixed up.

You go onto dialysis when you lose your kidney function. But really, dialysis is not about kidneys, it is about blood. It is about what the kidneys do, which is to clean the blood. Everything you do in dialysis is about your blood; it’s never about your kidneys. As a result, blood is the key component of daily life in dialysis. People on hemodialysis get used to blood. If they see some blood oozing from an access, they don’t freak out, they just deal with it. If a needle pops out, it’s not good, but, you deal with it. You can’t stand there getting queazy when blood is dripping down because that is what is dangerous: freaking out.

This post was prompted because someone posted a picture of one of their bleeding incidents on Facebook, complete with spilled blood and soaked bandage, and when I saw it, I thought “what a dialysis picture!” On any other forum, there would have been cries for deletion, for violation of rules, etc., but for dialysis people, it was a picture of something that happens all the time.

And then a few days later, someone else posted that someone in their dialysis unit died during treatment because their access was covered with a blanket and no one noticed the venous needle dislodged and that the patient had bled out. That made me extremely sad, and angry, because dialysis is hard enough without having to worry about bleeding out. But that worry is the price of the life dialysis gives.

The functions the kidneys provide are not meant to be exposed. The kidneys are located deep in your body and are not easily accessed. You have two kidneys: in technology terms, it’s a redundant system. You can live on 10% to 15% of your total kidney function. When you lose your kidneys, you are replacing that nice and protected functioning with pulling the blood out of the body and into the room. You are going from a safe situation over to one which has serious risks. It’s no wonder that events will happen, and it’s no wonder that people will get inured to them. People on dialysis are in a similar situation to soldiers at war. Their lives are constantly on the line. For dialysis people, they are in that situation for years, many times for the rest of their lives. The term “dialysis warrior” is used a lot in the dialysis forums, and indeed they are warriors, except the enemy is not an external force, but the failure of their own body.

And as in war, blood plays a big part, to the point where a pint of blood soaking the carpet is not that big a deal in the overall scheme of things. She was alive! And no little blood spill was going to change that.

 

 

Denied!

Recently, the NPR show Planet Money had an episode about Edward Thorp, the man who invented blackjack card counting. Thorp is a mathematician, and he saw blackjack as an interesting problem to analyze as opposed to a way to get rich quick. At the time he discovered card counting, the established idea was that there could not possibly be a “system” that would beat blackjack. The odds are what they are, the payouts are what they are, and the casino has a baked-in winning edge of about 1/2%, meaning they take fifty cents out of every hundred dollars wagered, no matter what.

Blackjack is an easy game. You and the dealer get two cards. You see the dealer’s top card, but not the “hole,” or face-down, card. Cards are valued as their numeric value; face cards count as ten; and an Ace can either be one or eleven, your choice. A Queen and a Nine are nineteen, a Three and a Four are seven, an Ace and a Six can either be seven or seventeen. An Ace and a Ten or face card is special: It’s a blackjack, and it pays you 1 1/2 times your wager.

Your job is to take your cards and get as close as you dare to 21, without going over (called breaking or busting). The way you do that is to ask for cards from the dealer when it’s your turn (called hitting), as many as you want, until you feel satisfied with your hand, or until you break by going over 21. So, if you are dealt a six and a four, making ten, you want to hit to get get closer to 21. If you hit and are dealt an eight, say, you have eighteen, and the odds are at this point that you will break if you hit again, so you elect to stay or stand. All players are playing against the dealer, not each other, and when all the players have played their hands, the dealer plays his. Dealers have no choice in what they do. Different casinos have slightly different rules, but the dealer always follows whatever the rules are. In most casinos, dealers must play until they get to 17 or better, or bust.  If the dealer busts, every player who didn’t bust wins. If the dealer gets between seventeen and twenty-one, each player who has a higher value than the dealer wins. If there is a tie, (called a push) it’s a tie and you keep your bet.

The casino edge varies based on their rules, but it is usually around 1/2%. Edward Thorp realized that this winning percentage was based on discrete hands, considered only as a single hand dealt from a full deck. What really happens is that in real life, the odds of who wins the hand depend on which cards have already been played from the deck. In other words, how a hand plays out is not the same hand to hand, but changes as the dealer plays multiple hands from the same shuffled deck.

For example, if you are playing blackjack with three players and a dealer in a single-deck game, you may have three or four hands between shuffles. When you play the first hand, all the cards played are now out of the deck. Therefore, these cards are no longer available for the remaining hands, changing the absolute odds of the game. If in the first hand lots of “tens” (10, J, Q, and K) and aces are played, these cards are no longer available for the subsequent hands. This lowers the odds for the player, and increases them for the dealer, because the dealer does better if there are more low cards and less aces available to make blackjack for a player. Card counting is the art of tracking which cards have been dealt, thus telling you what cards are left. By doing that, you can recognize the times when the remaining cards are in your favor, and therefore are more likely to win. To take advantage of this, you place a higher bet: two, three, even ten times more than your base wager. Therefore, when you win, you win more. Casinos quickly realized that they were wrong, that card counting was real, and got to the point where they were banning card counters and mixing up the rules to make card counting virtually ineffective.

My father was a mathematician working in the aerospace industry back when Thorp made these discoveries. Back in the ’60s, the only computers available were in huge companies and the US government. There were no personal computers back then. But, he was working in a lab where he had access to a huge mainframe computer, and so he developed a program that calculated the actual odds of blackjack in different betting scenarios and use cases, and he ran the program during “slack” time on his company’s computer. Overall, he simulated over one billion hands. Using the result he was able to validate Thorp and come up with a “basic game” of blackjack: when to hit, when to stay, etc., and the data was used as a basis of his first blackjack card counting system.

Because, yes, my father was Jerry L. Patterson, notorious in the blackjack community back in the day. I introduced him here last month. He wrote a book called “Blackjack: A Winner’s Handbook” in 1979, soon after casino gambling became legal in New Jersey. He started giving blackjack seminars and started to develop and market other systems for blackjack and other casino games. He did well over the years. Some of his systems seemed to teeter on the mystical, upsetting the pure math blackjack crowd. He was even called the “Witchdoctor of Blackjack” by one prominent hard-core card counting guru. My father is in his eighties now, and retired from the gaming business.

I take after dad in a number of ways, one of which is that I have a good feel for numbers. When I was younger, I decided to try out card counting and some of the other techniques. I quickly found out that it would be difficult to make a serious living as a pro blackjack player, and even if I could, it is a lot of work to get really good at the techniques and stay on top of the casino counter-measures to these techniques. I also know the odds well enough to know that if you screw up even a little, you will lose fast. Casinos only seem friendly; their real job is to suck you dry if they can, and they are good at it.

I visited dad a while back and thought it might be a fun thing for him to review his books and training materials and come up with a retrospective of his best systems in a new book – but alas, the copyrights belong to the publishers. But recently I thought, well maybe I could do it, be a sort of “Patterson plays Patterson” and take two or three of his best systems, learn them, and then see how they do now, now that casino gambling has spread far and wide across this land. He has systems for blackjack, craps, and roulette, and really, the games haven’t changed that much, so theoretically, the techniques should still have value with maybe a few tweaks. It also gives me an excuse to go to Reno and Vegas – with the bonus of being able to write off the trips as research. Then, I could put together a book about the experience. Win or lose, there’s a story here.

Well, I decided to run this idea by dad. “No way!” he cried. “That’s a terrible idea! There’s no way you can make money at it, and the casinos are wise to it now, and anyway it’s hard to learn it, and there are much better things to do with your time!”

I must admit, I was taken aback. He was adamant about it! I reminded him that casinos are not that savvy – remember Phil Ivey cleaning the clock of the Borgata. Remember that there are many more casinos everywhere, with varying levels of maturity. And, I told him, it would be fun!

“No way!”

We discussed this for a full forty-five minutes. He never wavered. I told him “but dad! You already gave me the first chapter! ‘The Book They Didn’t Want Written!  Patterson denies his own son!” It was all falling on deaf ears.

I tried to peel off which were his favorite systems. His legacy is his craps system, but he said “no, they’ll toss you out! They know about it now!” I told him, well, if they toss me out, at least I can’t lose any money.

Oh well, I tried. But, you know, I’m going to do this over the next few months. It is just too juicy not to. I don’t really have to ask him, because, you know… I have his books.

I’ll keep you posted.

 

We See Dead People

When I was a teenager, we had a neighbor next door who lived in the same house since the mid-1930s. She had a sister who was a pack rat, and subscribed to magazines and news papers, and never threw them away. Rather, she put them in the garage. After fifty years of this, the garage was full. Since my neighbor’s sister passed away, my neighbor asked me if I would clean out the garage for her for a sum, and said I could keep whatever I found in the garage.

The house was a nice thirties-style California house, two stories, with stucco and a Spanish tile roof, and three huge avocado trees in the backyard. The garage was detached, and was just big enough for a decent sized DeSoto if it weren’t for the fact that it was fully stuffed with newspapers and magazines. Over the next week, I attacked the garage.

The garage was a time machine. When I opened the garage door, I was confronted with stacks and stacks of relatively recent newspapers. Most of what I found was, at least to me, just a bunch of papers, and so I recycled virtually all them. However, I hit pay dirt when I got to the 1930s and ’40s, which was about 80% into the garage. I found dozens of copies of magazines like GQ, Look, Liberty, Life, and others. I kept a lot of them, and sold a number to used book stores in Hollywood.

The magazines I really prized, and the ones I still have today, were from the ’30s: The first few years of “Look” magazine, and a pile of “Motion Picture” and “Photoplay” mags. These magazines were so beautiful! The colors of the covers were so rich, with pictures of the stars, like Deanna Durbin, Olivia De Havilland, Delores Del Rio, Sonia Henny, Gary Cooper, and Clark Gable. I fell in love with the glamor that was 1930s Hollywood. All the stars were dressed to the nines. They all drove huge Duesenbergs, Cords, and Lincolns, and smoked Lucky Strikes (with the green pack), or Camels, or Chesterfields. They all smiled, and when they were not smiling, they were fighting over some man. It was a walk into a world that was vivid and alive before me, but which no longer existed.

I have a box set of movies that won the Academy Award for Best Picture. The first few movies were from the years 1929 through 1937: “Broadway Melody,” “Grand Hotel,” “Mutiny on the Bounty,”and “The Life of Emile Zola.” “Broadway Melody” was the first sound picture to win Best Picture. It won the Oscar eighty-seven years ago.

These four movies are worth watching. It is interesting to see how movies changed during the “Golden Age,” but more importantly, at a time when Hollywood was cranking out movies by the trainload, these were the best of their time, and are really well made, and entertaining.

As I watched these movies, I realized that everyone in them or involved in making them is dead now. Every actor, every extra, all the sound men, all the camera men, the screen writers, the directors, the producers, the caterers, everyone. And yet, here they are, alive, on the screen. You see and hear the actors. You hear the words of the writers, you see the direction of the directors, and the cinematography of the cameramen. They live on, even though they are no longer here in the flesh.

A few years ago I realized that technology has given us a gift that I don’t think people really understand. And that is: we are the first people who can see and hear what generations past really looked like and sounded like. Photography first started in 1839, and sound recording started in 1877, so we have records of people going back to the nineteenth century – all of whom are now dead. But movies with sound came into being in 1927, less than one hundred years ago. While photographs and sound recordings are great, movies bring people to life. It fascinates me that we can see people on the screen, and they are alive! And yet they are no longer with us.

We as human beings naturally put our generation and our era as the pinnacle of times. We know so much. We are dealing with problems no one ever heard of before. The ’70s, the ’60s, the ’30s – oh, it was so much simpler then! So much more innocent! They never had to deal with the problems we have now. How did they ever live without ATM machines or mobile phones? But I don’t believe there ever were innocent times. Humans are brutal and we tend to focus on the good and gloss over the bad when we cast our memories back to those “simpler times.”

When you you look at motion pictures from decades ago – ideally the best ones, but even the worst ones, you are forced to recon with the fact that these people really were alive. They breathed and they lived and they married, and mourned, and lived in fear, and triumph – and you know that these people, these generations now dead, had the same fears and aspirations, and desires, and faults that we have now. We have the benefit of hindsight – we know what happened after these movies were made, and we know what happened to the actors and the players in them, thanks to IMDB and Wikipedia. At the time, we didn’t know how the depression would end. Considering that other countries resorted to fascism and communism to attempt to solve their economic challenges, and given where Franklin Delano Roosevelt’s head was at, we could have easily become a socialist state. No one knew at the time. We do know that they partied and enjoyed their good times when they had them. It seems every generation thinks the old folks were stodgy and that they are the first generation to have fun and stay out all night. But we know that’s not true. We know because we read, but we really know because of the movies. The song “Lullaby of Broadway” won the Oscar for Best Original Song in 1936 – and it was about people who stayed up all night partying on Broadway:

When a Broadway baby says “Good night,”
It’s early in the morning.
Manhattan babies don’t sleep tight until the dawn.

If you clicked on the link above and saw the Busby Berkeley clip of all those dancers tapping in the movie, you have know know that virtually all of them are no longer with us. But they were alive! And every single one of them had their dreams and aspirations of making it in Hollywood, and every single one of them was flesh and blood. Whatever life they ended up having after this clip, it is over now.

Then we look at something like this, Fred Astaire and Ginger Rogers dancing to “Let’s Face the Music and Dance,” and marvel at how beautiful and poetic it is, and how alive Fred and Ginger are, and how even then people were desperate, had money problems, were discouraged, were suicidal, and:

There may be teardrops to shed
So while there’s moonlight and music and love and romance
Let’s face the music and dance.

We are human beings and yet we are so quick to forget that there have been human beings for thousands of years before our generation, and that every generation in every country, and on every continent, in every era, in every station of life, lived and loved and bled and hurt and died. And we have documented it now. The previous generations are no longer figments of  history books or snippets of novels about rich people, or books of quotations. We can see them, alive, on the screen, even though they are long dead.

I find it reassuring. I don’t feel alone in my experiences. While whatever we are dealing with now is real and urgent to us, it is comforting to know that other people faced similar and even worse situations and lived – at least in the aggregate. It is reassuring and sometimes frustrating to know that history has echoes. You can look at the fight Humankind has had with ignorance, want, and evil, and be discouraged that we still have to fight ignorance, want, and evil. And yet, while we have had horrific experiences as a species, we are still here, and we have won the major battles, albeit with casualties. We have dodged nuclear war, so far, when the odds were against us. We have become more tolerant over our existence even though there are still deep pockets of intolerance. We are winning the fight to transcend primitive tribalism, even though there are those that are grasping onto it with both hands. We are incrementally better. But we were also pretty damn good back in the day, as well. And now we have the proof we didn’t have before.