Tuesday, February 24, 2015


Supper Club Talk, Feb. 2015

Lynn A. Brant

The road to my brother-in-law's house in western North Carolina is very narrow and twisting.  On one side is a steep bank of rock and on the other side is a steep drop-off into a stream.  Merely getting off the pavement in places would send the car over the edge.  I attend closely to my driving on this road, which is unlike any in Iowa.  A texting teen would come to a bad end in short order.

If we were to stop the vehicle in a moment of time as it travels along this road we would see that the car is always headed either into the bank or over the cliff.  But I have traveled this road many times without disaster.  I am able to anticipate the curves and turn the steering wheel just the correct amount to be able to stay on the road.

I use this road as a metaphor for humanity's travel through history.  Looking ahead at any one moment, society might appear to be headed toward certain catastrophe such as in the spring of 1940 when the Nazis were in the process of destroying Europe, during the McCarthy era when free speech and democracy were in jeopardy, and during the Cold War when nuclear annihilation seemed almost certain.  We continue down this twisting road as we see a dysfunctional Congress in Washington and war-torn countries in the Mid-east doing their best to destroy civilization.  But even if we negotiate the curves presented by Iraq, Syria, and the Ukraine, we have even greater threats ahead that might well bring on a global catastrophe ending civilization.  The direction in which we are headed at any one moment is unsustainable, and whether we negotiate the tricky curves in the future depends upon the decisions and good luck of many people.

Josef Fox was a teacher of philosophy and humanities at the University of Northern Iowa.  He was also a member of this Supper Club.  After Fox died, Tommy Thompson put together a collection of his writings into a slim volume entitled A Faith in Reason.  Included in Fox's book is an essay entitled, "The Present Predicament of Mankind" written in 1973.  According to Dorothy Grant's history of The Supper Club, Fox also gave a talk here by the same title in 1975.  The predicament he describes is that faced by the world of increasing population, decreasing resources, and environmental degradation.

Of course, Joe Fox was not the first to speak of these dangers in the 1970's.  The Population Bomb by Ehrlich, The Closing Circle by Barry Commoner, and The Limits to Growth by The Club of Rome, among others, were in circulation at the time.  Many people thought these warnings were nonsense, but many others, including myself, thought these ideas were spot on.  My own writings in support of this general view of things appeared in one environmental impact statement I was helping to write at the time and in at least one of my journals. 

Over the intervening forty years, civilization has made it around the curves on that twisting road.  No great global catastrophe has yet destroyed our culture, we have not run out of resources, and we aren't choking on each other's waste.  In many ways we have partially cleaned up our pollution and have increased our immediate supply of natural resources, such as natural gas, but many of the dangers of the 1970's, sometimes in a new guise, are still with us.  We still have a predicament.

Recent articles in the scientific literature point out the predicament of unsustainable trends that are ignored by economists and national governments that pay more attention to GDP growth than to environmental issues.  The problems are well documented in scientific studies. *

In 1970 the world's population was about three and a half billion people.  Today there are over seven billion and approaching nine or ten billion by 2050 and 10 to 12 billion by the end of the century.  What level will it reach?  The trip down that road in North Carolina started in an agile sports car, then it shifted to an SUV, and now it is becoming a lumbering bus.  More and more people are along for the ride.  **

Many resources, such as minerals, energy sources, and agricultural commodities, have been extended and increased through new discoveries and new technologies.  Newly discovered deposits of minerals and new technologies to extract them have kept humans from running out of these materials.  Oil and gas are now produced from shale deposits once considered uneconomic.  Hydraulic fracturing is making the United States less dependent upon foreign sources.  Wind turbines spin to light our streets and power our electronic devices.  Increases in agricultural productivity have produced so much food that we are now using it to make fuel.

The world is much richer than it was in 1970.  People in many parts of the world are consuming more metals, more energy, eating more meat, and living in larger houses.  The impact of the population growth is intensified by this growing demand of each of these persons who also want to drive cars and live the good life.  And who has the right to deny these people the things that many of us already have.  That trip along that metaphorical road in North Carolina not only now has more passengers, but the bus is going faster and faster.

In 1970 towns were still spraying DDT to control mosquitoes and farmers were still using it to control other pests.  Bald eagles were in decline because the pesticide was making their eggshells too thin, and DDT was showing up in human milk.  Spray cans were using chlorofluorocarbons (Freon) to make them work destroying the protective ozone in the stratosphere. 

Today we no longer manufacture either DDT or CFC's.  Eagles are back and the ozone layer is beginning its slow recovery.  We have partly resolved acid rain by controlling sulfur dioxide from our power plants, and many other pollutants we once dumped into the global commons are no longer released.  However, our environmental degradation continues as we pollute with new substances such as neonicotinoids which may be causing as much damage as DDT did.  We are also extracting resources in ways that do more environmental damage.  Many of these newly discovered resources are in places, such as the bottom of the sea, that involve impacts upon systems never before affected.  For instance, there is great need for the sand found in northeast Iowa and adjacent states to extract oil and gas using hydraulic fracturing (fracking).  And the need for greater amounts of fertilizers and pesticides to obtain maximum yields in our farm fields is creating new and greater impacts upon the oceans.  Meeting the demand for all these resources to keep billions of people alive and in relative wealth is increasing damage to the planetary ecosystem.

In an impact statement I helped write in 1974 for a power plant that would burn a railroad car of coal every five minutes, I mentioned the threat that all that carbon dioxide would have on the climate.  I was way ahead of the times.  Only a few technical books and the occasional article in Science ever mentioned global warming at that time.  The hot summer of 1988 and the first mention of this topic in the press was a long way in the future. 

Now the glaciers are melting at an accelerating rate, sea levels are rising, and weather patterns are shifting.  I doubt Joe Fox mentioned global climate change as part of the "predicament" in his talk to the Supper Club back in 1975.  Although a warming planet is unlikely to kill us off, it does add stress to the systems that maintain human welfare.

Joe Fox probably didn't mention another problem I have heard or read little about.  In fact, the technological optimists of the world wouldn't recognize such as a problem at all.  I am referring to what I shall call "technological dependency".  Technological dependency started early in human history.  When our primitive ancestors started to move into colder climates and had to rely upon foods that needed cooking, they were dependent upon the technology of building and maintaining fire.  This technology helped the people spread across the globe and certainly helped them increase their numbers.  And of course, fire also enabled these early people to accomplish other tasks as well. 

The evolution of technology, for the most part, whether it is building fire or employing medicine to fight off the latest communicable disease, adds to our comfort, pleasure, safety, and general well-being.  Agriculture is an example.  Growing crops and domesticated animals increased the carrying capacity of the landscape.  Many more people could live within a given area by growing crops than they could by just hunting and gathering.  Growing paddy rice can support as many as 1,000 people per square mile.

But as any Iowa farmer knows, agriculture sometimes fails.  Too little or too much rain, early frosts, insects, and disease can all reduce, or in some cases, destroy the crop.  Crop failure has put a lid on population growth for millennia, and it often leads to starvation, poverty, war, and other nasty things.

The industrial revolution brought forth new machines to grow and harvest larger crops, to carry them to distant markets, and to successfully store the excess for use in leaner times.  Because of world trade, Iowa corn doesn't feed just Iowans, and the people in this state also eat from the tropics and all the rest of the world.  A failed crop in one place can be met by the crop in another.  In addition to supplying the world with greater amounts of food, modern technology and engineering have improved sanitation, medicine, and safer childbirth that have all allowed the world's population to soar, and it continues to grow at a high rate.  Africa is supposed to quadruple its population this century.

The seven billion people alive on the planet right now owe their life, wealth, and comfort (those having wealth and comfort) to an integrated set of high-tech systems that provide food, employment, and all the rest of the things needed for such a life.  For each billion more people added to the earth we need to solve many more problems through even greater advances in science and engineering.  In my analogy, this is steering the vehicle around those curves on that North Carolina road.  But therein lies another problem.  Each of these advances in technology increases our dependence upon those advances.  Ever increasingly complicated systems depending upon other configurations of technology to hold them together makes for a shaky foundation for the billions of people on the planet.

Once in Maine I was touring lighthouses and I asked, "Why do you still have them when nearly every boat is equipped with GPS?"  "What if the GPS system fails?" was the answer I got.  That made sense to me.  I know I don't want to be out in the dark along the coast of Maine without navigational aids.  At another time, I was listening to a speaker from Iowa State University about precision agriculture that depends upon GPS to steer tractors and administer the correct amount of seed and fertilizer so our land can "feed the world".  I asked what would happen to precision farming if the GPS system failed.  "Oh, that wouldn't happen", was the answer I got.   Hmmmmmm! 

We don't know how often they occur but there have been extreme outbursts of the sun throwing gigatons of material toward the earth.  In the 19th century there was an outburst that would today bring down the electrical grid, mess up a lot of electronic systems, and might fry the GPS satellites.  Without an electrical system, our way of life would, at least temporarily, come to an end.  Manufacturing and communications would cease and without GPS there would be a lot of lost motorists on the highway.  Precision farming would be temporarily set back, but lobstermen might continue to find their way home.  But it need not be an extreme solar outburst.  Last September one disgruntled contractor set a fire in an air traffic control center that disrupted air travel across the nation.  If the actions of just one person could do that, think what a global economic meltdown or a nuclear war would do.

But perhaps the greatest long-term threat of all is the loss of biodiversity.  We are in a period of mass extinction greater than at any time since the dinosaurs were wiped out some 65 million years ago.  Can the human species continue to live and prosper in an ever-diminishing global ecosystem?  As someone once made a comparison to a person flying in an airplane as it flew thousands of feet above the ground and watching rivets come out of the wing.  Surely the loss of one or a few rivets would not cause the wing to fail and lead to a crash, but how many can be lost before catastrophe occurs?  We have no idea what the answer is to that question.  We simply do not understand what vital role each species plays in global ecosystems.  Yes, many have a bit part in the play and are not missed when they disappear, but some or some number of certain groups are vital.  Our domination of the planet is driving many species to extinction.  First it's the big cuddly things, but as time goes by the ones that we don't notice - and might be most important - disappear to never return.  That increasingly crowded, lumbering bus in North Carolina is going faster and faster, but now the road is getting narrower.  How long can we keep it on the pavement?

In light of these dangers, I think humankind has a predicament - a predicament somewhat different from the one Joe Fox described in the 1970's but a predicament nevertheless.  And I think the dangers are real, and that our civilization, as we know it, is in great peril.

Of course, there have always been pessimists like myself, and their worst projections usually don't come true.  However, sometimes they do.  I'm sure there were pessimists in 1914 as The Great War broke out, and then in 1941 Admiral Yamamoto warned that if Japan went to war with the United States his country would be defeated and "reduced to absolute poverty".  Many Jews in Europe were not pessimistic enough to imagine what would happen to them as the Nazis came to power.  On the other hand, optimists make the world move forward, solve problems, and lead to greater welfare of humanity.  Some think the problem of too many people will cure itself - as it most certainly will do, the question is how will that happen.  Some want to engineer solutions to technical and environmental problems, and I expect many of these efforts will be successful.  However, can we negotiate the next curve, and what will we find around that next corner?

In 1977 and 78 I did fieldwork for my doctoral thesis in the mountains south of Helena, Montana.  The mountains were covered by a forest, dating back to the last big fire, and dotted by sedge meadows where glacial ponds once glistened in the sun.  About the only evidence of human activity, other than the narrow gravel road crossing the mountains, were the small diggings by prospectors in their search for gold, but even those were nearly obliterated by the intervening century.  Hardly anyone but a few hunters in the fall would wander this land.  In 2011 I revisited the site.  The narrow road was widened for logging trucks, some stream crossings had new bridges made of concrete, the trees had been mostly killed by the bark beetle infestation, and loggers were removing their dead trunks.  The landscape appeared dead, brown, and littered by no-trespassing signs placed around the old mining claims.  I was somewhat heart-broken. 

After a time to reflect, I began to look at the landscape in an entirely different way.  I started to think like a geologist.  What I saw in 2011 was just the present configuration of that landscape.  Some 12,000 years ago the land was barren and rocky.  Glacial ice covered part of the area, and no trees grew there.  After a while, the glaciers melted and dwarf birch trees grew around the ponds that were becoming filled with new life in the warming climate.  Eventually the pine forest moved up out of the valleys to blanket the hills.  Fires reduced the forest to ashes untold times.  A mountain in Oregon where Crater Lake now stands blew its top and covered my research area with volcanic ash.  What a mess that must have made.   What I saw in that beautiful landscape in 1978 was only one configuration of that mountain.  In 2011 I saw another configuration; one where the beetles and loggers had destroyed the forest.  But just as the configurations of earlier times when fires, volcanic eruptions, and prospectors brought about change in the landscape, time will erase the configuration of the beetle destruction too.  A thousand years from now - perhaps after human folly totally removes us - the road will have washed out, the concrete bridges will have crumbled, and the forest will grow, burn down, and re-grow a few times.  The configurations of form, processes, and materials come and go.  Nature is ever-present.  The Helena Mountains have seen a parade of configurations, and eventually even the configuration of the mountains themselves will pass.

It's not as though we are the first to alter the earth in a major way.  The landscapes of Europe and Southeast Asia were greatly changed many centuries ago by the people living there.  The earliest Native Americans, within a short time of their arrival on these two continents, annihilated the megafauna of the Americas that apparently rivaled that of Africa.  Iowa, with its corn and soybean fields, is nothing like it was a few centuries ago.  And early European settlers in eastern North America found a landscape very different from what it had been a few centuries earlier when the Native Americans were busy farming and altering the land.  The "untouched wilderness" these Europeans saw was what grew up after disease wiped out the natives a century or so before.  Our present population is not unique in changing the planet, but there are now seven billion of us wielding technology that is so much more powerful.  The configuration of the world today is unlike anything that has ever come before.

We need not worry about saving the earth.  The earth will go on with or without us.  Our worries should be about saving the habitability of the planet.  The present configuration of the earth includes seven billion human beings with many more billions on the way.  It also includes bits of wildness and species of plants and animals we care about.  Configurations of nature we see in our national parks and other places give us pleasure.  Our very existence depends upon a continuation of certain configurations that permit agriculture, forestry, and living spaces for these billions of people.

But global configurations are changing.  Crowding more and more people onto the planet is bringing forth great change as we convert our landscape into what amounts to a human feedlot.  The inadvertent change we are bringing to the climate will make it harder to maintain this feedlot.  The earth has seen much warmer temperatures in the past, but there weren't ten billion people trying to make a living back then.  The combination of climate change, over-crowding, pandemic disease, religious tribalism, and nuclear war will likely some day reduce the human population to a fraction of the present numbers. 

On the other hand, by dint of wise actions, we may solve our greatest problems facing us in the early part of the 21st century.  It need not turn out badly.  In any case, the human predicament in the future will be of a different character.  Whatever the case, the present direction we are headed down that twisting road is not sustainable.

Now, I ask the members of this Supper Club, how should we act in the light of this unsustainable course we are on?   I suggest that simplistic actions such as driving a Prius and recycling our tin cans is not enough.  Our individual impact upon the earth is far greater than actions such as these can mitigate.

Some of the biggest blunders made in history have been when human actions did not account for changing configurations.  For instance, the nineteenth century military tactics failed to work in 1914 when warfare introduced machine guns.  And the Maginot Line designed with WW I in mind failed horribly in WW II.  Getting rich by borrowing money to buy more stocks, that worked so well in 1928, did not work so well at the end of 1929.  I argued against the coal-fired power plant proposed for Waterloo because the old model of building more coal-fired plants to sell ever-increasing amounts of power was out of date.  Waterloo city leaders couldn't see that, but economic events overtook the situation, ending the planned facility.  Today coal-fired power plants are being shut down and wind farms are springing up.  We need to face up to the present dangers of the present configuration in new and creative ways.  Going on as if having 25 grandchildren and pretending this is to be celebrated, as Mitt Romney has done, is not facing the dangers of the present configuration.

I am suggesting, along with many others in the scientific community, that doing business as usual in light of a rapidly-growing human population, destruction of biologic diversity, increasing technological dependence, as well as pollution, warming climate, and resource depletion will lead to disaster for civilization.  We need to greatly alter our view of where we are going and how we intend to get there. 

How should we act?

*   Dasgupta et al., and McNutt, Science, 19 Sep 2014.
** Gerland et al., Science, 10 October 2014

POSTSCRIPT:  My pessimism was a topic of part of the good-natured discussion after this talk to which I would like to add this comment. 

We sat there in a Cedar Falls restaurant in the comfort of the warm room on a cold night outside with the knowledge that we can go home to a warm house, full refrigerator, and not have to worry about being awakened in the night be a creditor about to throw us out onto the street because we have no money or some military action that will threaten our lives.  Optimism regarding the future is easy in this setting.  Unfortunately, most of the world's population does not live in such wealth and comfort.  The misery created by extreme poverty, political power struggles, religious fanaticism, and such are not that of a pessimist, but rather are facts of the world we see only dimly from our sheltered lives.

Monday, January 19, 2015

Beth's Story: Looking for the New Normal

Beth’s Story
Max Kirk
January 20, 2015

I. The Call
May 21, 2013 was a Tuesday which started out like any other day for me in the office after a trial. On Monday I had finished a trial for the executor of the estate of a long time client who had loaned a local ne’er-do-well $50,000. We had found a promissory note but the deadbeat claimed that he had paid the money back two days before my client died. At that time he claimed they had a long conversation and that he had left $50,000 on the kitchen table in one pile. A major problem with his story–not the only one–was that the in-home hospice records confirmed that my client could be aroused only by painful stimulus at this time and was hardly very chatty on the day in question. The trial had gone well and I was preparing to spend my day digging through files on my desk. At 9:20 I received the call.

A paraeducator at Kittrell Elementary School called and asked if I could come over right away. Something was wrong with Beth. She had come in a little late and had parked her van across two parking spots in the parking lot. She said she was fine but was having problems finding her words and the staff was worried. I left right away and went directly to her school which is only about ten blocks away from my office.

When I arrived at Beth’s classroom Principal Green had Beth in a wheelchair and all of the children had been taken to another teacher’s classroom. Beth was arguing that she was just fine and objecting to all the fuss and bother about her. She did mention to me however that her right hand seemed tingly and soon she said her right leg felt heavy. The Waterloo Fire Department EMTs had been called and upon arrival they immediately assessed a possible stroke. They recommended that Beth be taken by ambulance to the Allen Memorial Hospital since the neurological services there were the best in town plus their emergency department was new and state of the art. Beth was placed on a gurney and while she was plenty scared she also knew she was in good hands and that I was right behind her. Before Beth was taken on the hospital gurney through the school the principal had announced to all teachers to keep all of the children in their classrooms until further notice. As Beth left the school there was not a sound in the hallways.

I followed the ambulance and arrived and at the hospital maybe ten minutes behind them. The Allen Hospital Emergency Department has rooms consisting of three walls with a curtain facing the hallway. As I tried to find Beth’s cubicle a nurse asked if I was there for Beth Kirk and then took me aside. I have dealt with a lot of healthcare providers in my 40 years as a lawyer and I immediately sensed that this nurse was in charge and in full stride. He advised that a CT had been given before Beth was even off of the ambulance gurney. The radiologist immediately diagnosed a massive bleed in the left hemisphere of Beth’s brain. No one knew if it was progressing or not. He said the condition was far beyond the “capability of this institution to handle” and for this reason an air ambulance had been called for transport to University of Iowa Hospitals and Clinics. They had already placed a call to UIHC and the on call neurosurgeon was then giving instructions to the Allen Hospitalist. The nurse advised I could see Beth in a minute as they were removing jewelry and giving her some sedation. He asked if I had any questions. Once in a great while there is nothing left to say and this was one of those times. I knew that the wheels had been set in motion and that I was simply along for the ride.
I called my step daughter Brenna and she met me at the Allen ED. I called my step son Justin who called the family and went to be with Beth’s mother and other family members.We  were with Beth for about fifteen minutes before the air ambulance crew arrived. Beth knew she was in trouble. Her speech was now very labored and her right side was almost completely paralyzed. Her eyes were wide open and she was scared. We could not take away that fear but tried to comfort her as best we could. She looked at me and said “what” and then repeated “what, what”. Her voice then trailed off. We told her that we suspected she was having a stroke and she was going to go to Iowa City for treatment. I can never forget the next words from her which were the last she was to speak for many weeks. . . “No! Fuck No! Fuck!” By this point the sedation was starting to take effect and the air ambulance crew arrived.  They tried to speak with Beth but at this point she could not respond. Beth’s speech was lost within thirty minutes. The ambulance crew intubated her for the flight stating “it’s easier to do it here than in the air.” Hard to argue with that logic.

The helicopter pad is across Dale Street from the Allen ED entrance. Beth was loaded as and we stood together and watched the helicopter take off for UIHC. Our trust was in the hands of those air ambulance personnel who would try to keep Beth alive for the next 25 minutes as well as the UIHC doctors who waited for her.

When I arrived at the neurosurgery floor the diagnosis had been made: intracerebral hemorrhage. Brenna had arrived before me and learned that the situation was very grave and that Beth would probably die within the next thirty minutes if an emergency surgery was not performed. Consent was given and the surgeons performed a left craniectomy with hematoma evacuation. We later learned that before the surgery the midline shift of Beth’s brain was 10 millimeters which was reduced to 4 millimeters after the surgery. The surgeons found no evidence of a bleeding site and no evidence of any clot formation. The mass removed was measured at 86x51 millimeters.

Following her surgery Beth went to the neurosurgical post op floor affectionately known as 6 JC West. She required a mechanical ventilator and was heavily sedated. Even with the sedation, there was almost constant thrashing and flailing of her left arm and leg. The right side of course remained silent. The tricky thing about post op care with a neurological patient like Beth is the need for frequent and ongoing neurological assessments by the nursing staff and physicians. For this reason, Beth was kept on the edge of sedation so the personnel could see what was going on. For the first three days the thrashing continued in a wild manner. She would try to pull the ventilator out and destroy the numerous IV lines running to her body. For a time a mitten and restraint was required on her left arm. Her left leg was also restrained. As you might imagine, such restraint only made her flail and thrash even more violently.

I learned a lot watching Beth and watching the neurosurgical care team. I learned that the staff neurosurgeons and a gaggle of residents made rounds at 5:30 a.m. If you wanted to speak with them that was the time. I learned that her ceaseless flailing was referred to by the staff as “the jitters–they all do it.” While there was a certain amount of relief in knowing that this was a somewhat expected result it did little to comfort us seeing her in such distress. I also learned that Propofol is a wonderful medication. Once administered it calms the muscles almost immediately but doesn’t affect respiration. When Propofol is discontinued the muscle function returns in a matter of minutes so that the neurological status can be assessed. Before this drug both the patients and staff would wear themselves out from the constant flailing and thrashing until the patient either improved or died.
I learned there is a certain comaraderie among family members whose loved ones are neurosurgical post op at 6 JC West. Across the hall from the patient area is a large common area where families may stay. The chairs are ingeniously designed to fold out into sort of a bed which when made up with sheet provided by the hospital becomes a very serviceable sleeping area. There are all manner of people in the waiting room. One young woman had a husband who had been in post op for several weeks. She appeared to be running on vapor fumes and I saw no one around to comfort her. The son of one family was in the bay next to Beth. If possible he was doing worse than her. His injuries were from a motorcycle accident (no helmet) and his recovery was apparently complicated by meth withdrawal. One night a family came in at about 3:00 a.m. talking very excitedly in what I’m sure they thought were hushed tones. Not so. Their family member was undergoing surgery and everyone present understood their anxiety. We  stayed there for four nights. The staff wanted someone to be present as often as possible for consultation if something occurred during the evening hours. Those were some long hours either at Beth’s bedside or sleeping on a makeshift chair. Nowhere was the family more needed however.

After a few days Beth was moved to the ICU ward and her outlook gradually improved. The thrashing calmed. She slept almost constantly and was moderately sedated. Her respirations were still supported by a ventilator. We knew she would not die from the stroke but the extent of her recovery was completely unknown.

One of the first problems in ICU was weaning Beth from her ventilator as she could not protect her airway. To remove the ventilator while she could not protect her airway is to invite aspiration of saliva into the lungs which can result in a possibly fatal condition. Not being able to protect her airway meant a tracheostomy to the neurosurgeons. For them this was a simple measure which would make the patient care much more predictable and easier. Another thing I learned is that in the ICU the neurosurgeons are certainly free to make their orders but the ICU staff physicians implement those orders as they see fit. The orders to install a tracheostomy were given on the Friday before Memorial Day 2013.  If at all possible I wanted to avoid a scar on Beth’s throat. I discussed my concern with ICU staff physician Dr. Debra Szeluga. Dr. Szeluga is a squat, strong and fearless physician who said she would prefer to do the trach with her “A” team on board. The problem as she saw it was that her “A” team would not be around until the Tuesday after Memorial Day. She stated that of course if an emergency arose they could react but if none occurred until Tuesday we’d be just fine. Over that long Memorial Day weekend physicians continued to examine Beth until one said “Hey I’ve got a gag reflex”.  That was quickly confirmed by a colleague and as slick as anything the ventilator tube was disconnected and the breathing tube removed with a single not too gentle pull. Beth was breathing on her own and protecting her own airway. I cried at such a simple and wonderful thing. I could never catch up with Dr. Szeluga to thank her as she was always engaged with and surrounded by numerous residents where ever she appeared. I am sure she is not always right but with Beth her artful delay prevented a permanent scar.

During the post operative and ICU phases of Beth’s recovery she was fed through a nasal gastric tube which at best is intended for short term use. It becomes uncomfortable for the patient and the volume and type of nutrients it can handle is limited. While Beth was able to protect her airway she did not yet have a robust swallowing reflex and there was always the fear of gagging on any type of food product. For this reason her physicians elected to proceed with a stomach feeding tube. While this seems straightforward enough it wasn’t for the reason that Beth had previously had a gastric bypass which greatly reduced the size of her stomach and also reduced the target for the tube insertion. Another complicating issue was the fact that Beth had undergone surgery to repair a ventral hernia a couple of years earlier resulting in a steel mesh covering the front of her stomach and small intestine. After much discussion and debate a clever group of surgeons decided they could do a somewhat lateral approach avoiding the wire mesh and go into the jejunum which is the second part of the small intestine. The drawback of the jejunum tube is that digestion is compromised and the volume that can be taken at any one time is limited. The benefit was that the nasal gastric tube could be eliminated much to Beth’s relief. The food product introduced through the J Tube was a delightful concoction sold under the trade name of Jevity. While it’s pretty funky looking stuff it sustained body and soul for Beth for the next several months.

The intensive care unit does not rehabilitate rather they stabilize and evaluate. I interviewed several rehabilitation options in the early days of June 2013. All were fine facilities but the family wanted to get Beth home to the Cedar Valley if at all possible. To be accepted at Covenant Medical Center Rehabilitation Unit a patient has to be able to demonstrate the ability to follow directions and swallow. To swallow means to protect the airway and Beth could do that. Following directions was another matter however. In those days Beth’s responses to a question or command were often random and seldom correct. The nurse evaluator from Covenant Rehabilitation was visiting with Beth and putting her through her paces to see if she would qualify for admission. One of the commands to illustrate following directions was to stick out her tongue. Beth opened her mouth a bit and it sure appeared that her tongue came out in response to the command. This from a woman who two weeks earlier was running a room full of behavior challenged K-2 graders in a special education classroom. Anyway, the Covenant nurse and I declared victory and noted that Beth could follow directions. In the week it took to get admission to Covenant Rehabilitation Beth improved but on that day it was a close question and one on which I was pleased to get the benefit of the doubt.

II. Covenant Medical Center Rehabilitation
The task of Covenant Rehabilitation was to work with a lady suffering near complete aphasia with dense paralysis of her entire right side with continuing cognitive problems. Beth was also very restless and would roll out of her bed if left unattended. Dr. Rozek and the staff at Covenant Rehab began occupational, speech and physical therapy on the very first day. They worked with Beth on her personal hygiene, reacquainting her with the hairbrush and toothbrush. Beth’s restlessness continued and despite her paralysis she would roll out of bed. She was moved to a bed positioned on the floor to minimize injury if she rolled out during the evening. For about three weeks either I or another family member would stay with her every evening. Bedtime was about 8:00 p.m. and the evening was punctuated by several nursing checks as well as periodic nightmare like outbursts from Beth. It was as if she were having night terrors. With hugs and reassurance the night terrors would pass and gradually she processed out of this phase of her recovery.

Initially, Beth’s speech improved dramatically much to the amazement of Dr. Rozek and the Covenant speech therapist. Beth worked with flash cards and picture identification and her speech was progressing in a splendid fashion until early August 2013. At that time for no known reason Beth’s speech began to become sluggish and less distinct. Within a matter of ten days her speech had gone from coherent, intelligible expression to virtually nothing. Everyone sought an answer and none was forthcoming. Dr. Rozek changed medications deleting some and adding others in an effort to see if there was a medication basis for this decline in Beth’s speech. Frankly nothing seemed to help and from September through November 2013 it appeared as if Beth’s early wondrous strides in speech recovery were going to be lost. Needless to say, this was a terribly disheartening setback for everyone.

After the first three weeks I no longer had to stay with Beth during the evening. She was comfortable and enjoyed her therapy. The staff became like an extended family and the routine seemed somewhat normal. But as with so much of Beth’s ordeal, whatever appeared to be normal would not last. In the case of Covenant Rehabilitation her health insurance carrier decided that she was no longer making progress but was rather in a maintenance mode of treatment. For this reason, they required that she be moved from the hospital rehabilitation to a different rehabilitation facility. We knew this day was coming and we spoke with Beth about it on many occasions. I don’t know whether she understood or just chose to ignore the inevitable. When the time came Beth was terrified by the prospect of moving to yet another rehabilitation facility. I’m sure she felt betrayed and was scared to death. It took several hours for Beth to accept the inevitable. On the day of the move however she was not a happy camper.

III. NewAldaya Lifescapes
During the summer months while Beth was undergoing her rehabilitation at Covenant I searched for rehabilitation alternatives in the Cedar Valley. We are fortunate to have many fine facilities and I settled upon NewAldaya Lifescapes formerly the Cedar Falls Lutheran Home, 7511 University Avenue, Cedar Falls, Iowa. Their rehabilitation facility was not new but the equipment was very serviceable and the staff seemed to be committed and very approachable. On the first day she was there one  of the therapists came to Beth and refit her in a different wheelchair and spent a lot of extra time, making Beth feel welcome. She had a private room in the rehabilitation wing at the facility and they worked with Beth daily in terms of speech and a continuation of her therapies. Soon Beth was walking with a brace and the assistance of a staff person. Considering where she had been a few short weeks earlier this was truly a milestone.

During Beth’s surgery the skull was removed from the left side of her head. As a result the left side of her head was concave and her brain not protected by anything but skin. This condition forced Beth to wear a helmet when she was up and about. The grandchildren decorated the helmet with all kinds of jewels and sequins and it was quite a sight to behold. While Beth did not appreciate being required to wear a helmet it was part of the new normal and she accepted it since there were really no alternatives for her own safety.

Speech continued to be a problem throughout the fall of 2013. The therapist introduced Beth to an interactive computer tablet. The screen would display subjects which she could select. Within each subject would then be certain detailed responses from which she could choose. As an example, one application displayed all of the grandchildren with prearranged questions for each of them. Beth would not be able to speak but would tap on the computer screen choosing the application she wanted and then the computer voice would ask the questions. Through a combination of symbols and pictures it gave her the means of some self expression.

Beth was seen by her neurosurgeons at UIHC on several occasions and everything was progressing nicely. Continued CTs of the brain showed that the healing process was complete and the basic neurological structures were intact. Beth had lost a lot of brain tissue however which was to be expected given the severity of her stroke. In late October Dr. Matthew Howard noticed a shift of the midline of her brain which he was not entirely satisfied with. Thinking that this was possibly part of the cause of Beth’s aphasia they elected to repair the craniotomy which would restore a normal dimension to Beth’s skull and eliminate the need for the helmet. She was delighted with this prospect and wanted to proceed with the restorative surgery. I’ll never forget the informed consent given by Dr. Howard. It was pretty brief and to the point and essentially said that this was a simple procedure and they very seldom had any complications. If there was a complication however he stated it could be catastrophic but he wasn’t worried about it. Beth and I looked at each other and decided that if he wasn’t worried about it why should we worry about it so we elected to proceed. Instead of using the bone flap which had been removed in May, the surgeons elected to fabricate a titanium flap using 3D dimensional models from the CT of Beth’s skull. The surgery went off without a hitch and Beth was extremely pleased as her appearance started returning to normal.

Unfortunately, the speech did not return to normal and we continued to muddle through with hand gestures and signs and grins and grimaces and a little artful guessing at what she was intending to express. We assumed that this would be our new normal and did as best we could.

On Sunday November 23, 2013  Brenna was with her mother when Beth suffered a grand mal seizure. It lasted for a few minutes and was a new development. Beth was taken to Covenant Medical Center. The seizures were soon stabilized but it was obvious that further evaluation was necessary since this was not normal. As things turned out, it was extremely fortunate that no neurologist at Covenant Medical Center was available for consultation and would not be so until after Thanksgiving. A prompt referral was made to UIHC where Beth went to 6 JC East for neurological evaluation. It was discovered that Beth was suffering from ongoing seizures and that the seizures were quite possibly a source of her aphasia. Medication was administered and Beth was discharged back to NewAldaya the day before Thanksgiving 2013.

Within a matter of days we noticed an improvement in Beth’s speech. To have some improvement after such a long period of aphasia was heartening for everybody. One day before Christmas I went into Beth’s room where she was working with Sara Oltrogge, the NewAldaya speech therapist. They had put aside the interactive computer and Sara was working with Beth on various flash cards and pictures to test her vocal ability. Beth was doing quite well. I wondered if this would be the new normal. I remember looking at Sara stating “she is doing really good isn’t she.” Sara turned to me and said “I very seldom get to see somebody who makes such a drastic improvement in so short a time. It’s amazing.” That was one of the best days we had on our search for the new normal.

This enthusiasm was tempered however by ongoing physical problems. Beth developed pain and discomfort in her lower extremities in late December 2013. She was having more trouble swallowing and in general was not feeling well at all. An ultrasound was ordered which revealed a large clot in her right leg, basically from the calf to the thigh. Appropriate anticoagulant therapy was introduced and Dr. Karmini placed a filter in the vena cava so that if a clot did break loose the damage would be minimized.

Janaury, February, and March were spent with minimal physical therapy since Beth had apparently reached the maximum physical improvement that could be expected. She was still relying upon tube feedings with the Jevity solution. Her swallowing was stronger and bit by bit her speech continued to improve as her swallowing improved.

I knew more could be done for the speech but was not sure where to go. I talked with Judy Harrington, a retired professor at the Department of Speech Pathology at the University of Northern Iowa. Judy put in a good word and gave me direction and Beth had an evaluation in April 2014 at the Roy Eblen Speech and Hearing Clinic at UNI. This was a rather intensive two hour evaluation where Beth was really put through her paces by staff and their eager graduate students. I was allowed to watch from behind a two way mirror as Beth struggled and struggled to do the very best she could. This was one evaluation she wanted to ace and she did an extremely fine job. The upshot, they could help Beth and she was admitted to therapy at the Eblen Speech and Hearing Clinic starting in the summer sessions of 2014.

The summer sessions were productive but the speech therapy really took off in the fall semester of 2014. The therapy would take various forms such as name as many farm animals as you can. When she started Beth was able to name two and then she would hit a roadblock. This was true for other topics as well. It was amazing what she would recall however. Once, she was asked to name as many colors as she could and Beth said “red and fuchsia.” She wasn’t able to come up with anymore colors without prompting and afterwards I asked her “fuchsia?” and she said “well it’s what came to my mind.”

After a few sessions Beth was able to name three items and then four and then five before she hit the roadblock. When her sessions concluded she was able to name twelve to fourteen items. There were many other types of testing she underwent. Her descriptions, vocabulary and attention to details continued to improve. From being unable to name more than two states, two animals or two foods without prompting she was now going to twelve to fourteen consistently with no prompting. The two step instructions were a struggle for Beth. As an example, she would be asked to touch her nose and then raise her hand. Sometimes nothing would happen and sometimes she would be able to do one but not the other. At the end of the session, she was able to consistently follow two and even three step commands. The new normal was quite pleasing.

The interactive computer has been left on the shelf. Beth’s voice has progressed in strength and clarity to the point where she now uses an Ipad with an application that lets her do voice activated texting. This has opened a whole new area of communication to Beth and she no longer feels as isolated and alone because she can reach out and text friends and family. Sometimes the Ipad doesn’t pick up exactly what she means but it’s close enough that we can all understand and more importantly she can receive communications. Beth’s right side field of vision was impaired by the stroke but she is able to turn her head and read quite well.

As we start 2015, Beth continues to improve on her core strength and is much easier to move from her comfortable armchair to her wheelchair. I can do it without assistance and with very little fear of injury. Beth has learned to stand on her left leg, plant her right leg and pivot so she is not dead weight when she moves. The danger of falling is ever present but with care and attention our new normal way of transfer has worked well.

The goal is for Beth to come home and live with visiting nurses’ assistance as well as my help. We have a ramp to our home. We have renovated the bathroom with a wheelchair accessible shower. We have a wonderful van and transport is a breeze. Blaine’s Farm and Fleet sells aluminum ramps which fold up like a jackknife allowing us to get over a two or three step barrier with ease. All in all, our normal means of transportation works quite well.

We work, we plan, we seek the new normal. We love each other and we have amazingly adjusted to our new circumstances. Our retirement plans have certainly changed but that’s okay. When Beth and I were first married she placed a quart mason jar on the dryer to hold loose change. The label on the jar was “Trip to Barbados.” We may not get that trip taken care of but we’re going to get in the van and drive to see the redwoods. Sooner or later. It will seem entirely normal when we do it.