Another Blood Blister

Sigh. I saw a tiny blister on the bottom of my foot yesterday. By tiny, it was less than 1.0 x 0.5 cm. I was thinking I should pop it to drain the tiny bit of fluid out before it gets worse. Well, I guess my habit of walking on the treadmill barefoot wasn’t good for it since it seemed to grow to about an inch round and popped spectacularly today. I didn’t notice anything until I saw bloody spots on the kitchen floor. I think what happened was that I managed to pop it when I stood in the dining room. The blister is on the outside bottom of my foot. There was a large puddle of blood on the wooden floor, and lots of blood spray on the wall about a couple of inches high. I was just glad that it didn’t pop on the carpet; that would have been a mess. I got some wet wipes and cleaned everything up. I wrapped the would area with gauze/stretch bandage/tubular net dressing but it bled through in about 30 minutes. I’m not sure why it’s bleeding so much; maybe because it’s on the bottom of my foot instead of on the side like the last blister.

Cost of Dialysis

I finally got my first dialysis bill with Medicare. The statements are all from my work insurance, which is basically Blue Shield of California. There is a huge discrepancy in pricing for different insurance carriers.

MonthFebruary 2020March 2020April 2020
List Price$33,895.24$34,716.73$34.277.23
Blue Shield Price$25,590.89$26,211.08
Medicare Price$4,163.32
Statements from Work Insurance

I’m only seeing what my insurance paid out. For February and March, they paid ~$26k since I’ve hit my out-of-pocket maximum for the year. For April, I guess Blue Shield know the Medicare reimbursement dollars and they paid out only $837.98, which is ~20% since Medicare pays 80% of medical bills. If the numbers are correct, then my work insurance negotiated cost is over 6x what is paid by Medicare. For April, with 13 days of dialysis, the comes out to ~$320/session for Medicare. This is close to what a coworker told me (he used to work at Davita). The “cost” to Davita for each hemodialysis session is ~$280 so they don’t make much money from Medicare patients, hence the price gouging for patients with commercial insurance. Do they charge $34k/month for patients without insurance?

Stretcher Girl, Part II

The girl that has recently been coming in to dialysis on a stretcher is no longer here. I just noticed that she hasn’t been showing up for two weeks now. Hopefully she got a transplant or transferred to another dialysis clinic.

I know the mortality rate is pretty high for dialysis patients. Hopefully she is ok.

Mortality rates vary depending on the kidney failure treatment. After one year of treatment, those on dialysis have a 20-25% mortality rate, with a 5-year survival rate of 35%.

https://pharm.ucsf.edu/kidney/need/statistics

As I was walking out of dialysis Thursday, I noticed another patient being wheeled on a stretcher. Ugh, is that becoming more common? I don’t remember seeing patients on stretchers before stretcher girl above.

Frozen Pizza Dinner

On one of my last shopping trips to Albertson’s, I purchased a frozen pizza to try. I’ve actually never tried a supermarket frozen pizza before. I ended up getting a DiGiorno Supreme. It took about 20 minutes to cook in the toaster oven. I was surprised that the pizza fit into the oven.

I ended up having two slices. The pizza was not pre-sliced and the crust was pretty hard (I may have overcooked it), so we actually cut the pizza with a pair of kitchen scissors. The taste was on par with large chain pizzas like Dominoes or Pizza Hut. I think the pizza was $7.50 so about comparable to the chain pizzas. A good pizza that size will probably cost $20. Here is the nutritional information:

Nutritional InformationDiGiorno Supreme Pizza% DV
Serving Size1/4 Pizza (151 g)
Calories360
Total Fat10 g21%
Saturated Fat5 g25%
Trans Fat0 g
Cholesterol30 mg10%
Sodium810 mg35%
Total Carbohydrates40 g15%
Dietary Fiber2 g7%
Total Sugars5 g2%
Protein15 g19%
Vitamin D0 mcg
Calcium190 mg15%
Iron3 mg15%
Potassium180 mg4%
Nutrition Label on Pizza Box

I guess if you don’t eat the entire pizza, it’s not too bad for you. I think I’ll try a few different brands to see if I find something I like better. Not going to eat this everyday but good to keep one or two in the freezer in case no one wants to cook or order take out.

COVID-19 @Work 7/23/2020

The update today from work has the number at 92 in our office. Hopefully California has hit it’s peak in number of new daily cases and people are getting the message to socially distance themselves. I’m referring to this chart from the Orange County COVID-19 Dashboard:

Updated 7/23/2020

There appears to be a definite drop off in the daily reported number of cases since July. Hopefully it’s not due to the new reporting system mandated by the White House.

Updated 7/23/2020

However, looking at this chart, it seems there is a huge fall off in the number of tests reported. Is it because less people are testing because less people have symptoms? Without knowing the criteria for testing and reporting, it’s hard to make sense of all the data. I wish there was a summary dashboard with a simple stoplight with red = stay home, yellow = exercise caution and social distancing, and green = mostly safe, plus an up/down arrow indicating if things are getting better or worse.

Fistula Update 7/23/2020

Another failed attempt today. The same tech that usually sticks me is out again so one of the tech with the most seniority tried today. He was sometimes successful when we first started using the fistula but has been in a different pod for the past 3 months. He tried the arterial needle twice, was able to get some blood, but no flow. He used a short 16-gauge needle each time, and it hurt pretty bad the second time. Anyway, he gave up after two tries and we went with the catheter again. I held the gauze for about 10 minutes, let go, then promptly bled all over the chair. He rushed back, put a new gauze on the opening, and I held it for 15 minutes which stopped the bleeding.

I’m barely tolerating the dialysis sessions. I’m at four hours on the machine at 350 mL/min flow rate. Now I have to deal with the erratic needle sticking each session as well. Sigh… and still now word from UCLA on accepting my sister as a kidney donor.

Peripherial Neuropathy 7/23/2020

I’m in the middle of a neuropathy attack now. It started near the end of the dialysis session. The pain site is in the sole of my left foot, near the center of the foot. Of course, I can’t seem to do anything to affect it. Neither of the massagers do anything, and even walking did not help. It started as a constant dull pain, but has progressed to an intense stabbing pain that lasts about 5 seconds per attack and varies between 20 seconds to a minute between each stab. I’ve taken four Tylenol pills for a total of 2000 mg of acetaminophen but it hasn’t helped a bit. I’ve also been trying to sleep it off since 11:00 am (it’s now 5:30 pm) but have been unable to fall asleep due to the pain. It doesn’t feel like it’s subsiding so I guess I have to wait it out. Usually these attacks last about 24 hours. This probably means no sleep tonight either. Ugh.

CA Driver’s License + Real ID + COVID-19

My California driver’s license expires next month so I need to renew it. While looking at the renewal papers, I thought it would be good to get a Real ID as well since I’ll need it eventually. I do have a US Passport so it’s not urgent since the passport can be used as a Real ID, and I’m probably not travelling or visiting a federal building soon. Anyway, this renewal has to be done in person, and I and signed up to go to the Santa Ana DMV office. In hindsight, I probably should have picked the Costa Mesa office instead. I haven’t gone in yet; by filling out all the paperwork and uploading my documentation, the DMV said I can bypass the huge line even though they are not handing out appointments. I hope I don’t have to stand in line for hours when I do visit.

On that topic, it does look like the # of positive tests and deaths in Orange County is decreasing from the peak in early July. Maybe it will be “safer” if I wait a few days/weeks before going to the DMV

Fistula Update 7/21/2020 (updated)

I think the tech that usually sticks me is out so they used my chest catheter today. No one else even tried to stick me. That’s fine with me since the fistula area was itchy all weekend. By using the catheter, I get a break from the constant dull pain in my arm. I understand there is greater risk of infection from using the chest catheter but I’d like to see the statistics from my dialysis center. They seem to be pretty diligent in infection control and I did use the previous catheter for 20 months without any issues. The vascular surgeon hasn’t called me back yet. Not sure what’s happening with that.

Nephrologist came by just now and dropped my dry weight to 87.5 kg. I’m still not exercising that much so it’s probably due to not eating too much. For example, last night I skipped most of dinner because I felt close to throwing up again due to the strong garlic flavor in both dishes my dad cooked.

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Update: 7/24/2020

Got through to the vascular surgeon’s office. Appointment is set fo August 5th. Maybe this will get the dialysis nurse off my back.

Homemade Crème Brûlée (updated)

I decided to make another batch of crème brûlée tonight. Each time I make a batch, I hesitate a bit since it’s terrible nutritionally. To make six little cups of crème brûlée, I had to use two cups of heavy whipping cream, six egg yolks, half cup of sugar, and some salt and vanilla extract. I even added some strawberry jam to the bottom of each ramekin to give it some variety but probably adds a bit of sugar and other stuff too. I’m going to try and calculate the nutritional information of my homemade crème brûlée.

Nutritional ItemHeavy CreamEgg YolkSugarSaltPer Serving
Serving Size2 cups6 yolks1/2 cup1/4 tspn5 oz
Calories1,6003233870385
Total Fat160 g27 g0 g0 g31 g
Saturated Fat112 g10 g0 g0 g20 g
Trans Fat0 g0 g0 g0 g0 g
Cholesterol640 mg1,260 mg0 mg0 mg317 mg
Sodium160 mg49 mg0 mg560 mg128 mg
Total Carbohydrates32 g4 g100 g0 g23 g
Dietary Fiber0 g0 g0 g0 g0 g
Total Sugars0 g1 g100 g0 g17 g
Protein0 g16 g0 g0 g3 g
Vitamin Do mcg109 mcg0 mcg0 mcg18 mcg
Calcium0 mg131 mg1 mg0 mg22 mg
Iron0 mg3 mg0 mg0 mg0.5 mg
Potassium480 mg111 mg0 mg0 mg99 mg
Total was divided by six since I made six servings. This ignores the 1 tbsp of vanilla extract and a think layer of strawberry jam in each ramekin.

Yikes. The fat (from heavy cream) and cholesterol (from egg yolk) numbers are crazy high. I can probably cut one or two egg yolks out and replace some of the heavy cream with regular milk. Definitely shouldn’t be eating this all the time. I wonder what restaurant served crème brûlée looks like nutritionally. Probably just as bad or worse.

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This doesn’t include the thin layer of sugar added later to make the caramelized crust on top of the crème brûlée either.

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Update: 7/24/2020

Here is what the results look like after being half eaten.

Marie Calendar Frozen Meals

Heh. I used to eat a lot of these when I was living alone. It was a quick and cheap meal but it’s been many years since I’ve eaten one. After my failed experiment with Freshly food delivery, I went to the local Alberston’s and bought a few frozen entrées. They were three for $10 so much cheaper than the food delivery services. I had this for lunch:

It was okay. Their website showed a rating of 3/5 stars, and it was appropriate. The taste was fine but they put the turkey and the mashed potato in the same divider. Instructions said to mix it after four minutes, then heat for 3 minutes more. Well, the gravy all melted with the mashed potatoes so it’s more runny that pictured. Since it was frozen, it took longer to cook in the microwave compared with Freshly, but the results were about the same. Here’s the nutritional information from the box:

Nutrition ItemBaked Turkey%DV
Serving Size369 g
Calories260
Total Fat6 g8%
Saturated Fat3.5 g18%
Trans Fat0 g
Cholesterol45 mg19%
Sodium1,040 mg45%
Total Carbohydrates31 g11%
Dietary Fiber5 g18%
Total Sugars6 g10%
Protein19 g24%
Vitamin D0 mcg
Calcium30 mg2%
Iron0.7 mg4%
Potassium750 mg15%

It didn’t taste that salty but taste can be deceptive. The sodium and potassium numbers are higher than I’d like but acceptable if I watch what I ate for dinner. Again, for $3.34, it was not too bad.

I took three Renvela 800 mg tablets before eating since I don’t have the phosphorus numbers, and I’m cheating by drinking a can of Coke along with the frozen meal.

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I’m old. When I was growing up, we used to call these TV dinners. This was before the microwave oven was invented so everything had to be cooked in a conventional oven. The dinners were in aluminum trays covered by foil. For stuff like baked desserts and tater tots, you had to remove the foil over those compartments so it would come out browned and crispy. My favorite brand were the Hungry Man dinners from Swanson, especially the beef pot pie. Yum!

Ha ha, tater tots and apple cobbler

And everyone’s favorite…

I remember the mashed potatoes wouldn’t cook evenly so some of it was cold in the middle, and the stuffing would be burnt since it was next to the cobbler, which had the foil removed for cooking.

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Another memory. Since my sister and I grew up as latchkey kids, we would come home after elementary school to an empty apartment (parents were working late), and often I would have to “cook” dinner for both of us. One of my favorite TV dinners was the pot pie from Swanson/Hungry Man. I believe there was both turkey and beef. I would have to go into the oven for about 45 minutes and invariably, the gravy would spill out so I always had to lay down a sheet of aluminum foil. I think we had to use a fork to jab the crust as well so some of the steam could escape. This was in the late 70’s and early 80’s so about 40 years ago.

I would get the crust much more brown that pictured

Weight Update 7/20/2020

I may as well put my weight history up today as well. The nephrologist lowered my dry weight by another 0.5 kg to 88.0 kg last week. I think it’s because my blood pressure is still high, and my ankles are a bit swollen, mainly because I had to work a lot and sat around too much. I haven’t been eating that much so I should see some weight decrease unless I’m retaining too much fluids.

The trend lines are at ~89 kg. I left the dialysis center at 87.4 kg this past Saturday, which is the lowest ever since I started dialysis. I haven’t cramped yet during the past 9 months so it’s likely they can drop the weight some more.

Sleep Update 7/20/2020

Last two months have been terrible for sleeping. Not sure if it was the a-fib or new medication but I was hardly getting any sleep at night while taking a lot of daytime naps. This morning, I finally got some sleep that was recordable by Fitbit. It was also the longest I’ve slept in weeks.

Fitbit gave this a sleep score of 64 (Fair)

If you add up all the sleep times, this was about 5 hours and 16 minutes of sleep. Here is a longer trend:

It definitely seems to be increasing over time. However, I had a-fib during most of May and the heart beat was too fast or shallow for Fitbit to pick up. I think I slept more than three hours/day if you add up all the naps.

Multac (dronedarone)

Back when my a-fib started, my regular cardiologist prescribed me to take 400 mg of Multac twice a day. It’s an anti-arrhythmia medication similar to amiodarone (I guess they all have the -darone ending) but with less side effects. Here’ some more info from their website.

What are possible serious side effects from taking MULTAQ?

MULTAQ may cause serious side effects including slowed heartbeat, inflammation of the lungs (including scarring and thickening), low potassium and magnesium levels in your blood, and changes in kidney function blood tests.

What are the most common side effects?

The most common side effects when taking MULTAQ include stomach problems such as diarrhea, nausea, vomiting, stomach area pain, and indigestion; feeling tired and weak; skin problems such as redness, rash, and itching. Tell your doctor about any side effect that bothers you or that does not go away.

I think I was experiencing some of the side effects while taking Multec. For sure I was vomiting more often. It was mailing at meal times but lots of fool smell or taste would trigger a reflex reaction. I think at one point I was throwing up 4x in one week. I also think my slower than normal heartbeat post-ablation is partially due to the Multac as well. Before a-fib, my heart rate was in the mid- to upper-50’s. With ablation + Multac, I was seeing high 40’s and low 50’s. Now that I’ve stopped taking Multec, heart rate seems to be a bit higher and I’m throwing up a lot less. However, if it’s like amiodarone, the half-life of the drug may be pretty long, which means some of the effects will linger for weeks.

You can see the trend line starting to rise when I stopped taking Multac a week ago.

Face Mask Policy

I just read that Walmart, Kroger, Target, and other large retail chains are going to require masks for customers at their stores nationwide. Until now, each store has followed the local county-level rules for mask usage. I think this is a no-brainer. It’s much easier to tell everyone to wear a mask than to track requirements across 6,000+ stores for Walmart. Seriously, there is no downside to wearing a mask. I really don’t get the mentality of those refusing to wear a mask. Are they the same people that don’t believe in vaccines and motorcycle helmets? Will they reject a COVID-19 vaccine when it becomes available?

I went to the local Albertson’s to pick up some medication from the pharmacy and some groceries. This is in the midst of a high infection area in Orange County, and everyone, with no exceptions, was wearing a mask. They also had employees sanitizing shopping carts and directing traffic at checkout to maintain social distancing. I believe they won’t let you in without a mask, though not sure if it’s a national policy or if they are following local guidelines.

Stir Crazy (updated)

stir-cra·zy /ˈstər ˌkrāzē/adjective
psychologically disturbed, especially as a result of being confined or imprisoned. “she’d be in danger of going stir-crazy if she had to look at the same four walls any longer”

It’s been about four months since the beginning of the COVID-19 lock-down. Add the three months of medical leave I had post-heart surgery, I’ve been stuck at home for about seven of the last eight months. I was already looking for dialysis-friendly travel options but now things are even worse since mass transportation seems to be out of the question for now. My sister and family are taking off today for a week trip to Bryce Canyon and Zion National Parks. I’m a bit envious but even with no pandemic, I couldn’t go that long without access to a dialysis clinic.

So what are my options now, if any? I guess the only option are short road trips to secluded areas to minimize social distancing risks. Since I drive an older Tesla Model S with only 240 miles of range, it takes even more planning to make sure a charger is always readily available. Like all the fantasy trips I was planning before, I’m limited to departing Saturday afternoon and returning by Monday night since that’s the longest gap between dialysis sessions. However, with the spike in cases in California, it’s probably still too risky to travel anywhere, especially if I take my elderly parents along too.

Unfortunately, we’re probably going to be stuck at home for the rest of 2020.

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Update: 7/19/2020

After looking at a few maps, I think the only areas within two days driving round-trip is Santa Barbara, Las Vegas, or San Diego. San Francisco and Monterey/Carmel is cool but a bit too far to drive. If I leave right after dialysis Saturday, I could get to the Bay Area by 10:00 pm. That would leave only Sunday to do stuff since I would have to leave from home by noon Monday.

For the closer destinations, I could get there by dinner time Saturday, then have one night, all day Sunday, and probably most of the day Monday before returning home. Cambria looks like a nice place to visit. I can also stop by Santa Barbara, Solvang, Santa Maria, and Pismo Beach on the say there. The problem is finding something to see or do that’s not crowded with other visitors looking to escape “confinement” as well.

COVID-19 Cases in Orange County

Found this map/infographic on r/orangecounty on Reddit. Apparently, the data is from here. So both my house and the dialysis center is in the City of Orange, which has one of the highest case count per 10,000 residents at 94.4.

Here is a map of median household income in Orange County.

There seems to be a rough correlation between case rate and median income. As expected, comments on the Reddit thread blames income inequality. Basically poorer people live in denser housing and can’t work from home. However, South County seems to be where all the anti-mask protests are taking place yet infection rates are lower then North County.

Questions:

  • What is the main driver of COVID-19 infections? Are people getting sick at work from co-workers? At home from family members? At extra-curricular gatherings from strangers?
  • Why would there be a spike in cases in early June? Is it restaurant openings? Church services? Gathering at beaches and parks?
  • Is the spike in cases uniform across all cities or also related to household income? Why or why not?
  • How is the case rate related to mask utilization rate?

Sure, if you live with more people, the infection risk goes up, especially if family members have to work or are not socially distancing when out. However, my company’s HR department claims that all COVID-19 cases at work are from non-work contacts. In the end, I’m trying to judge the risk of living in a dark red area. Should I go food shopping in Irvine instead? Without tracing the source of each case, it’s hard to manage risk.

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I just noticed the highest cumulative age group for number of cases is 25-34. Is that because that’s the group with the most population or is the case rate also the highest? Did that change over time, i.e., since the spike, or was that always the case? If it was a recent development, since we were told that COVID-19 initially affected older and immuno-compromised people, then being poor doesn’t explain the numbers. It’s likely that younger people are ignoring precautions and going out post Memorial Day. Maybe Santa Ana and Anaheim has a higher percentage of younger people.

Lab Results 7/16/2020

Sigh. Got some of this month’s lab results back. I was hoping that the Urea Reduction Ratio (URR) would be higher so I can get the clinic to cut my time back down but it came in at 64.0%. The minimum is actually 65%. I think I’m close enough that they won’t increase the time again but for sure it won’t decrease this month so I’m stuck at four hours.

The only other number worth noting is the Phosphorus results. Last month, it came in high at 5.9 mg/dL. I believe the upper limit is 5.5. This month, the result was 4.6 mg/dL, which is much lower. There seems to be a lot of variability in the test results. For some reason, I didn’t see a line for Potassium but that number has been pretty stable for a few months.

They also did an Hemoglobin A1C test this time. I’ve been off all diabetic medication to prevent another episode of hypoglycemia. Most of my readings in the morning has been ~80 mg/dL so the blood sugar seems to be under control. The A1C reading was 5.5%, which is normal.

From American Diabetic Association

Sleeping During Dialysis

The session went by quickly today. I usually read or watch a video on my iPad but today, it was all music and napping. I think I fell asleep for the first after returning to hemodialysis at the clinic. It was even caught by my Fitbit.

The nap was only about two hours but it’s the longest nap ever (at dialysis). I wish more days can go like this so I won’t feel the boredom of sitting for four hours. Some of the awake period is probably when the blood pressure readings were taken. I was on the chair from about 5:45 am to 9:45 am.