Medicine for Magdalena – Checkup with Ron Rosedale

Magdalena had diabetes and congestive heart failure.  This is a true story, and this is a real transcript of a checkup that Magdalena and her family agreed for me to record, with Dr. Ron Rosedale in 2004.  We have changed some names to hide identities.  It’s a hard story to begin sharing because these are people I know and care about.  We share this interview in hopes that it will provide information useful to other people facing  challenging illnesses.

DR. ROSEDALE:  We are going to start with Magdalena . . .

MAGDALENA:  Mmhmm.

DR. ROSEDALE:  Right?

I’m Shelley Schlender.  We’re listening to Ron Rosedale in the summer of 2004, in his Denver office with 67-year old Magdalena.  She had diabetes and congestive heart failure.  That constant hiss is the sound of the oxygen that was sent from a small green tank into the tubes that sat in Magdalena’s nose, to feed her lungs with air.

DR. ROSEDALE:  And you’re how old?

Magdalena’s daughter, Carmen, translated this question into Spanish for her mother, and for a moment, Magdalena seemed to pause, confused, before she finally answered.

CARMEN:  67.

Seeing Magdalena’s hesitation, Dr. Rosedale grinned and asked his question another way.

DR. ROSEDALE:  How young?

A rapid exchange in Spanish followed between Carmen and her mother.  Magdalena’s weary face grew lively.  Her eyes twinkled, and her voice lilted with a teasing chuckle as she said something that made her daughter laugh.  Carmen translated for Dr. Rosedale.

CARMEN:  That’s why she didn’t understand the first time, and she’s 67.

In mid-July of 2004, Carmen was worried about her mom.  Magdalena had been in the hospital several times that year.  She had been in the Intensive Care Unit just two weeks before this visit to Ron Rosedale’s office.  At the ICU, hospital staff had taken Carmen aside and warned that, the way things were going, it was time to get her mom’s papers in order.  At that time, Carmen had been using Dr. Rosedale’s nutritional approach for over two months.  Dr. Rosedale had been leading the group for free, as part of a small community project that had invited him to help them, as they checked out his dietary ideas of low-carbohydrate, adequate protein, and high quality, high fat eating.  Carmen had seen a big improvement in the health of the entire group that was following Dr. Rosedale’s approach, including hers.  Because Ron Rosedale’s nutritional approach had been helping Carmen, she wondered if it would help her mother.  But Carmen’s mom had so many health problems going on, and was taking so many medications; Ron felt that she needed more attention than he could give if she simply attended the small community group.  And while the entire group had been urged to consult their doctors about their changes in diet, so they could have assistance in being monitored and adjusting medications, most of the community members had hesitated to actually talk with their doctors.  Of those who did, the responses from their regular physicians were not always helpful or encouraging.  Several people reported to the group that when the labs on their medical exams had shown big improvements in weight, cholesterol, blood pressure or other standard markers for health, their doctors had congratulated them on finally switching to a low-fat diet.  And most of the community participants, when told this by a doctor, didn’t explain that they were now doing a HIGH-fat diet.  In some cases, when one of the community members got up the courage to correct the doctor and explain what Dr. Rosedale’s diet is, their regular doctor said it was a bad idea.  Not always.  Sometimes the doctor had been enthusiastic, and those members of the little community group came back glowing from the praise and validation.  But that kind of response was the exception, rather than the norm.

So, Carmen had been uncertain that Magdalena’s doctors would be comfortable teaming up to help her change her diet to Dr. Rosedale’s approach.  And Dr. Rosedale was concerned that Magdalena would need some medical monitoring.  So that’s why she was here today.  Dr. Rosedale had agreed to see her in his office, as a special situation.

She had arrived there exhausted, using a walker, plus Carmen’s arm around her, so she could walk a few steps before resting again, her wheeled green oxygen tank trailing her, because of the problems in her lungs.  It had taken 15 minutes to go from the parking lot and up the elevator.  But now she was in Dr. Rosedale’s office for a checkup.

DR. ROSEDALE:  And the major reason you’re here, I understand, is because of congestive heart failure?

There was a moment of silence, as Magdalena looked with confusion at her daughter.

DR. ROSEDALE:  You don’t speak English very well?

MAGDALENA:  No

DR. ROSEDALE turned to Carmen:  You’re going to translate.

CARMEN:  Yes, I’ll translate.

DR. ROSEDALE:  Anyway, congestive heart failure is a major problem?

CARMEN:  Yes

Congestive heart failure happens when the heart loses the ability to pump blood properly.  This leads to many problems, including a very increased risk of heart attack, lack of oxygen, and fluid building up in the lungs.  That fluid can build up so much, a person basically drowns.  In the early 1970s, perhaps 2 million Americans suffered from congestive heart failure.  By 1994, that number had grown to nearly 5 million.

There are many possibilities as to why.  Diabetes is one of them.  Some medical researchers are concerned that the statin drugs that are given to reduce heart attacks might have a side effect of increasing the risk of congestive hearts.  But that’s a very controversial theory.  More commonly agreed is that diabetes increases the risk.  And, indeed, as diabetes increases in the United States, so does congestive heart failure.  Here we are in Ron Rosedale’s office, with, Magdalena, age of 67, one of these congestive heart failure statistics.

DR. ROSEDALE:  Blood pressure?  And has Magdalena had any heart attacks before?

CARMEN:  No.

DR. ROSEDALE:  No heart attacks.  Other than congestive heart failure, any other problems with her heart?  Do they know why it has congestive heart failure?  Sometimes there’s outside reasons.  Sometimes it can be lung disease that makes your heart have to work too hard.  Does Magdalena have lung disease?

CARMEN:  Yes

DR. ROSEDALE:  Emphysema?

CARMEN:  Yes.  She smoked.

DR. ROSEDALE:  You’ve heard the term in her medical records COPD, chronic obstructive pulmonary disease?

CARMEN:  Yes.

DR. ROSEDALE:  COPD.  So that’s probably what’s causing the congestive heart failure.  Now, there are two major divisions to the heart.  There’s kind of a left heart and a right heart.  Left ventricle and right ventricle.  Do you know which one is in failure?

Carmen and Magdalena didn’t know.  So Dr. Rosedale took a closer look at Magdalena.

DR. ROSEDALE:  Looks like fluid is building up in her belly.  Is that where the build up is?  In her belly or her lungs?

CARMEN:  They have never said anything about fluid in her tummy.  She has hernias in her tummy.  That’s one of the cause of her fluid.

DR. ROSEDALE:  It’s her left ventricle that would be failing if it’s her lungs that are filling up.  You’re not sure of that?  Do you have any of her old records?

CARMEN held up a thin beige manila folder:  No.  I have only a list of medications she’s been taking.

DR. ROSEDALE started writing on a doctor’s memo pad:  This is going to be a list of instructions.  One is going to be to have last hospital discharge summary and tests faxed to my office.  Okay?  That would be important.  The discharge summary in particular.  It will describe everything that went on in her last hospital admission.  What they did and all the medications she took and was left on and all that stuff.

CARMEN frowned slightly, as she thought about what the document that Dr. Rosedale was requesting:  That’s the summary that’s not usually given to the patient.  They gave us two sheets that is just the list of medications.

DR. ROSEDALE nodded:  So this is your followup stuff.  This is something you would get from the doctor or the hospital, and just have them fax it over here.  Okay?  And when did you get out of the hospital?

CARMEN translated, and MAGDALENA replied:  La semana pasada?

CARMEN:  Two weeks?

DR. ROSEDALE:  Almost two weeks ago.  So the discharge summary should be done.  It’s done by the doctor in charge, and it should be ready by now.  That would be a good thing to look at, so I don’t have to start from square one.  Having the discharge summary will mean that I can see what they’ve prescribed, what tests have been done.  Right now I’m guessing a little bit as to what’s been happening.

But with the thin sheet of papers that Carmen had obtained, there was at least a short history of Magdalena’s past conditions.  Ron Rosedale looked it over now.

DR. ROSEDALE:  Congestive heart failure diagnosed seven years ago.  Diabetes.  How long have you had diabetes?  Thirty years?  Twenty years?

MAGDALENA:  Bente cinco . . .

Magdalena had said “twenty-five?” with a guessing sound.

DR. ROSEDALE:  Approximately . .  .Thirty years?  On insulin for 23 years.  And you’ve got . . . um . . . feet.

He tapped his pencil crisply, thinking of how to ask a medical question in a simple way.  What he would be asking about next was a condition known medically as “Intermittent Claudication.”  It’s a sort of angina of the legs.  According to the National Institutes of Health, “Angina,” also known as chest pain, is discomfort that occurs when an area of the heart muscle doesn’t get enough oxygen-rich blood.  This can be caused by plaque buildup or constricted vessels, meaning vessels that have narrowed or grown stiffer because they’re puffed up and inflamed.  While angina is a condition that doctors commonly check and monitor, there’s another place where constricted vessels can cause muscle pain—that condition known as “intermittent claudication.”

DR. ROSEDALE:  Do you have pain in your legs when you walk?

Carmen translated and her mother blinked at this question that wasn’t asked very often in a medical checkup.   The look on her face made it seem as though it had not occurred to her that a constant pain she lived with in her legs was something a doctor would want to talk about.

MAGDALENA:  Yeah

DR. ROSEDALE:  Where?  In your calf?

CARMEN translated, and her mother replied in Spanish, and Carmen then explained:  Her lower back legs.

DR. ROSEDALE:  That’s what hurts when you walk?

MAGDALENA:  Esto y aqui . . .en la noche . .

CARMEN:  The back of her knees, and at night her veins are altered.  Enlarged.

DR. ROSEDALE:  When she walks.  Let’s just talk about the pain when she walks right now.

CARMEN:  Quando caminas . . .

MAGDALENA explained in Spanish, then CARMEN said:  It’s the pain when she walks.

DR. ROSEDALE:  When it hurts after she walks, and she stops walking, does the pain go away?

CARMEN:  It gets a little better when she stops, but then she says that it affects her.  Her chest starts hurting when she stops walking and then her neck also hurts, and her arms feel very tired.

DR. ROSEDALE:  Does it go away when she stops?

MAGD.  Si . . .

CARMEN:  It goes a little bit away when she stops, and if she sits down she feels much much better.

DR. ROSEDALE was asking these questions as a detective might ask questions, trying to solve a case, and now, he seemed to relax and be pleased, as a detective might when they have a clue that was helpful.  Indeed, in other conversations, Dr. Rosedale had shared that sometimes, he’s seen patients where they’ve seen neurologists due to the pain in their legs.  They’ve seen physical therapists and other specialists.  They’ve had back surgery recommended, or pain killers in high doses, and yet the pain doesn’t go away.  But if he puts them on his diet, the pain in their legs goes away in less than a week, and usually, so does any angina – chest pain around the heart.  He didn’t say all these things at this moment, in this medical checkup with Magdalena.  He was still gathering information.  But he did look at the list of medications, and as he did, his face grew hard and angry.  He spoke crisply though, and kept his voice neutral:  Okay.  So she’s on these and these?  Two pages of drugs?

CARMEN:  Yes

DR. ROSEDALE:  Okay.  And these were done before the hospital admission.

CARMEN:  Yes, There’s one I think that was done in the hospital. There’s some the doctor wrote down.

Dr. Rosedale turned his attention from the list of medications and started writing on the notepad again, full of concentration as he combined steps for action with explanations about medical conditions that are often overlooked, such as diabetes caused by insulin resistance.  Insulin resistance happens when the body’s cells resist the signal of the hormone, insulin.  Insulin Resistance means, in a way, that a person’s basically eating a diet too high in sugar and carbohydrates, and their doctor is prescribing TOO MUCH insulin and medication for what their body would need if the person simply changed their diet.  The combination of the wrong diet and the high doses of medication often create a vicious cycle, and the insulin resistance gets worse and worse.  Now, that’s a description that’s contested by many standard doctors and diabetes experts.  They would argue that there’s no harm in giving a person extra insulin, to keep blood sugars lower.  But, that kind of “what’s the harm in more medication” overlooks a number of side effects.  That’s all background about what Dr. Rosedale may have been looking for in this checkup, and what he said to Carmen and Magdalena next.

DR. ROSEDALE:  This set of data was done in May.  OK.  There’s one lab that has not been done that we’re going to need, and I’ll write that on here.  Needs C-Peptide.  Serum.  Okay?  That needs to get done.  It has to do with her diabetes.  It lets us know how much insulin her own pancreas is still able to produce, if anything.  Okay?  And that’s very important.  We need to find out if she’s still capable of producing insulin on her own.  And if so, then the need for insulin by shot is much less important.  In fact it would be desirable not to take it.  If a person has too much insulin, most of the time diabetes, and I definitely suspect that in Magdalena’s case, this was the case, that her diabetes arose not because of too little insulin but because her cells weren’t listening to insulin.  And her pancreas was actually producing too much insulin.  The excess insulin causes fat to be stored around the arteries and makes asthma worse and all these other bad things.  Now she didn’t need that.  It didn’t make her smoke.  Smoking caused a lot of damage, and that certainly contributed to her congestive heart failure, but so did the high insulin.  And if we can get her off some of that insulin, it will help her a great deal.  High amounts of insulin that she’s giving herself and that she might be producing on her own causes fluid retention.  It causes excess fluid.  That’s why she had high blood pressure.  High blood pressure was actually caused by the insulin she was taking.  And the extra fluid puts a greater burden on her heart.  Got too much fluid floating around.  It makes it harder for your heart to handle all that fluid.  That also contributed to the congestive heart failure.  A lot of that fluid ends up in her lungs.  Now, she’s taking a bunch of diuretics to try and get rid of that fluid.  We can’t change that right now.  But the diuretics cause then further insulin resistance, and greater insulin requirements, which causes then fluid retention.  So then she’s in this horrible vicious cycle where basically driving with the accelerator and the brakes on at the same time.  And that’s not very good for her health.  We need to break that cycle.  We’re going to start breaking the cycle with diet.  And then we’re going to start working on some of these medications.   Because they’re getting in the way, more than they’re helping, actually.  They treat the symptom, but they make the underlying disease worse.  So you take one step forward, two steps backward.  Or three or four or five.  And we don’t have very far to step backwards, as you’re aware at this point.  We don’t have time to step very far backwards, so we need to make these changes as fast as we can.

Dr. Rosedale now turned his attention back to the long, two-page list of medications of Magdalena.  And now, his voice carried a tone of anger.

DR. ROSEDALE:  Some of the writing I can’t quite read.  Is that Glucophage?  No, Glucovance.  Okay.  That’s dumb.  Get off of that.  Lasix we have to be on right now.  Propranolol is a Beta blocker.  Predinisone. is that for her asthma?  Insulin 70/30, we’re going to change that, provided that Magdalena will adhere to the dietary changes.  It’s going to be really important, because otherwise we can’t change her insulin.  So we’re going to be making changes based on the assumption that she will be changing her diet.  Okay?

With a look of determination, Carmen nodded.  And since she had been eating the way that Dr. Rosedale recommended for over two months, she knew what he was talking about, when it came to how he’d recommend that her mother would eat.  Magdalena didn’t know yet what this diet was.  But watching her daughter, Magdalena nodded, too.  Dr. Rosedale continued looking down, and reading from the list, his face a mask, and yet, still seeming angrier the more he read.

DR. ROSEDALE:  Advair is for asthma.  Verapamil is another thing for blood pressure.  Calcium Blocker also makes her diabetes worse.  Next one, Trazidone, she takes for sleep.  The next one, I can’t quite make this last one.  Says for her stomach.  Preva?  I can’t quite read that.  Maybe you can.  Do you know what this is?

CARMEN:  Prevacid.

DR. ROSEDALE:  OK, that’s an acid blocker. Of course, the universal statin drug, which right now, she should probably get off of.  I’m going to go out on a limb on that one.

CARMEN:  Which?

DR. ROSEDALE:  Lovastain.  It’s a statin drug.  It makes it harder for her heart to beat. It’s the last thing she needs right now.  Okay?  They’re worried about long term cholesterol, which has nothing to do with her heart disease, number one.  But the immediate effect of it is that it weakens her heart.  She’s got heart failure.  We need as strong a heart as we can.  She’s got to get off of it.  Hydrazaine is another thing for her blood pressure.  Aspirin.  And Prozac.  So I’d say she’s taking her fair amount of drugs, making money for a lot of people.

He said that last statement with bitter humor.  At this point, I spoke up, saying,  “There’s a chance that the doctor involved might be receptive to talking with you.”  I said this with hope, not knowing that, like most other doctors who our community group had interacted with, Magdalena’s doctor was NOT going to be in favor of this change in diet.  Ron Rosedale, with years more experience explaining his unconventional diet to other medical professionals, sounded cynical as he responded to me.

DR. ROSEDALE:  Great.  I’d be happy to.

I caught the cynicism and decided to defend Magdalena’s regular doctors, who I was certain were well-intentioned, and wanted to see Magdalena healthier.  “My guess is that they’re following protocol.”

DR. ROSEDALE:  I’m sure.  They definitely are.  There’s no question that everybody gets put on statin drugs, but there’s a down side.  And right now, I’m just more concerned about, um, trying to save your life, really than I am about politics in medicine.  One of the things that Lovastain, the cholesterol drug does, is it depletes the body of something called Co-Enzyme Q 10, which is necessary for muscle function. Your heart is a muscle.  Probably the most important muscle.  We’re going to do the opposite.  We want to put her on a lot of Q 10.  So we don’t want to put her on something that something else is trying to get rid of.  That’s not really a good thing to do.  So, we’re going to have a supplement list of things we’re going to go on.  But the most important thing at this point is going to be diet.  And diet will allow her to lose more fluid than any of these drugs will.  And then I would say in a short period of time, we’re going to try and reduce that Lasix.  Lasix also gets rid of magnesium.  Magnesium is necessary for her cells to listen to insulin.  So, having low magnesium makes her diabetes worse, which makes her need more insulin, which causes fluid retention.  Which is what the Lasix is trying to get rid of.  So again, it works into this horrible, vicious cycle.  So we’re going to need to get as much magnesium into her as we can.  But there’s only a certain amount that your intestines can handle at a time, otherwise it gives you diarrhea.  We’ll spread it out and try and see if we can reduce that Lasix as soon as we can.

Dr. Rosedale was writing rapidly as he spoke, and soon he focused simply on looking at the medications and writing, and tapping his pencil furiously.  Watching as he concentrated, it was like watching a bomb specialist trying to sort through a tangle of wires that are connected to a ticking bomb.  To stop the bomb from going off, some of the wires had to be disconnected.  But if the wrong wires were taken off too soon, the bomb would explode, right there in his hands.  That image reminded me that right now, Magdalena’s congestive heart failure was a ticking bomb.  Her doctors had told Carmen to get Magdalena’s papers in order.  She was a half a step away from death at every moment.  By trying to help her, by trying to turn this whole situation into a healthier result, Dr. Rosedale was fencing with Death.

DR. ROSEDALE:  We’re going to have so see Magdalena again pretty soon because of all these changes.  Because of all the drugs that you’re on.  Okay?  And we’ll talk about diet first, but don’t let me forget to listen to her heart and lungs before she leaves.

DR ROSEDALE (turning to Magdalena):  Do you weigh yourself every day?

MAGDALENA:  No?

DR. ROSEDALE:  You need to.

CARMEN told her mother in Spanish, “You Have to”:  Necesitas hacer.

MAGDALENA:  OK

DR. ROSEDALE:  It’s one of the ways to know whether you’re accumulating fluid.  Initially when the weight comes down, most will be water, not so much fat.  But that’s good.  We want you to lose some of this excess fluid.  Reducing the excess fluid makes it easier on your heart.  But we want to do it without the diuretics as much as we can.  The diuretics will cause most of that fluid to come out of your bloodstream.  So it’s making your heartbeat fast.  Even though you have all this fluid in your tissues, you don’t have it inside your arteries.  And that’s not such a good thing.  Okay?  So I want you to weigh yourself every day.  And write it down.

CARMEN translated, and MAGDALENA said:  OK.

DR. ROSEDALE:  That’ll be good for your other doctor too.  When are you supposed to have another chest x-ray.

CARMEN translated, and MAGDALENA said:  Con Paula.

CARMEN:  She’s going to try to go to the doctor every Friday, because the doctor also told her to go there often.  She wants to keep an eye on her.

DR. ROSEDALE:  Good.  Okay.  Well, it will be something that’s difficult to listen to her lungs because of her emphysema.  And to be able to see how clear her lungs are, about the only way to do it will be with a chest x-ray.  I imagine she had a chest x-ray when she was discharged from the hospital.  I suspect they’ll want another one very soon.  Has Magdalena been on oxygen for a long time?

CARMEN:  It’s been probably a year.

MAGDALENA:  Poco menos.

CARMEN:  Less than a year.  Probably eight months.

DR. ROSEDALE:  Okay.  The diabetes we can certainly help, and we can certainly help the blood pressure without using all these medications and can help the congestive heart failure up to a point, because a lot of that is from the damage that’s occurred to her lungs.  The damage to her lungs can be reversed maybe a little bit but not very much.  It’s kind of a structural thing.  The tissue has kind of died, and we can’t reverse that too much, but we can make it a little bit better.  So that’s kind of what we’re dealing with.  And the blood pressure, we can, I think, certainly improve upon.  So those are our endeavors.  We want to help the diabetes and in that way we can reduce the blood pressure.  And get rid of some fluid without having to use these drugs which has some long-term side effects.  And even some circular side effects.  How often is Magdalena’s blood pressure taken?

CARMEN translated, and MAGDALENA said:  Quando voya.

CARMEN:  Every time she goes to the doctor, every week or two weeks.

DR. ROSEDALE:  She doesn’t take it herself.  Do you have a way to do that?

CARMEN:  Yeah.  We can get one of those.

DR. ROSEDALE:  Good.  That would be important, because blood pressure can change very rapidly within the week.  And then we need to reduce the blood pressure medications, or she’ll get very faint.  Now, How much insulin is she taking?
CARMEN:  She takes 24, 25 units in the morning, sometimes nothing at night because her sugars get very low during the night and she’s afraid.  Sometimes she just uses 4 or 5 at night.

DR. ROSEDALE:  And she’s using 70/30 insulin.  About 24 units in the AM and 0 to 5 units PM.  And that’s it?  Okay.  How often does Magdalena check her blood sugars?

Here, there came another issue that wasn’t clear to Dr. Rosedale at that time, and which Carmen and Magdalena didn’t mention.  You see, Magdalena was retired, and lived on a very tight budget.  She had a small apartment in low income housing, and she relied on government health care plans to pay her medical bills.  But the state’s computer system for government payments was not working properly, and so it was not paying for her regular healthcare needs, such as for the daily supplies needed for taking blood sugars.  Taking insulin shots, which Magdalena did, can cost at least a dollar a day.  Taking blood sugar measurements at least four times a day, which is a wise idea for someone like Magdalena, can cost two dollars a day.  And right now, Magdalena’s insurance wasn’t paying for any of this.  So she was “guessing” on the right amount of insulin to be taking, and she was saving her money by not checking blood sugars at all.  Magdalena didn’t explain all this at the moment, and at this time, Carmen may not have realized the extent of Magdalena’s medical payment problems either.  So Magdalena simply said she hadn’t been checking her blood sugars, and her daughter translated.  And so, in this exchange, it just sounded like Magdalena had gotten casual about checking her blood sugars.  It didn’t occur do Dr. Rosedale that finances were actually what stood in the way.  He was doing his part.  He was seeing Magdalena for free in this office visit.  It wasn’t obvious to him that other financial issues could still stand in the way.

CARMEN:  She hasn’t checked her blood sugars recently, or lately, like probably the last two days.

DR. ROSEDALE:  Does she have a blood sugar monitor?

CARMEN:  Yeah, she does.

DR. ROSEDALE:  And she knows how to check it?

CARMEN:  Yes.  We just need to get the strips.

DR. ROSEDALE:   Okay, so we need to . . . uh.  Okay.  Check blood pressure daily.  We’re going to be making some changes, and some of the changes will be fast.  So monitoring by her regular physician once a week, which I’m sure is all they could do.  That’s actually pretty good, and they’re not to be faulted for that.  But it’s not going to be enough.  So we need to do some self-monitoring everyday.  So that will be weight, blood pressure, blood sugar.  Check blood sugars every day, before breakfast and before bedtime.  Okay?  (WRITING ALL THIS DOWN)  I want you to keep chart of blood sugar, blood pressure and weight daily.  FAX to office every two days for now.  Okay?  You have a FAX machine?

CARMEN:  Yes

DR. ROSEDALE:  Because we’re going to have to make adjustments in the medications.  In the insulin.  In the blood pressure medications.  So we’ll have to stay in contact.  But we’ll give you a few guidelines right now.   If blood pressure goes low, do you have an idea of what it usually runs?

CARMEN:  Sometimes it’s .  . . . 140 over 90, or 68.  I just remember some of the numbers I saw at the hospital, and it went too high, like 220 over 60.  I don’t even remember, but it was too high, like 240, 220, and I think she’s always probably around 135.

MAGDALENA:  Siesta no recuerrdo quanto.  En la hospital, es la ultima, lo creo.

CARMEN:  She’s not sure, but she remembers 140 and 150.

DR. ROSEDALE:  (TAPPING PENCIL)  We’ll reduce the Verapimil.  That’ll be the first one, if the blood pressure goes low.  That means less than 110 over 70 for her.  If the blood pressure goes less than that, reduce the Veratimil . . . right now it’s 360 Milligrams.  If it’s low, reduce to ½ tablet.  If it stays low, stop altogether.  Okay?  If blood pressure—I’ll call it BP for blood pressure.  If blood pressure continues low, you’ll reduce something else.  Some of the blood pressure medications have dual roles.  So I think we’ll reduce the hydralazine to ½ dose, or altogether if you can.  Okay?  (Flipping page.)   My next thing I’m going to want to lower over time is going to be the Lasix.  But it doesn’t just lower blood pressure, they’re using it to get rid of the excess fluid.  That’s why it’s going to be very important to take daily weights.  Because when we start reducing that fluid buildup, I want to make sure the weight is not coming up, indicating that she might be retaining fluid.  Okay?  The Glocovance is a combination drug.  It has Glucophage and probably glyburide. . . I’d rather she just took the glucophage without the other half.  That’s all we can do to reduce the insulin for now.  It would be better to . . change insulin to MPH from 70/30.  We’re going to have to change the insulin.  OK?
CARMEN: OK

DR. ROSEDALE:  If she changes her diet, she won’t be able to stay on that insulin.  Her sugars will crash.  We need to go on a different kind of insulin.  Part of which, you’re already taking.  But it’s combined . . . The insulin Magdalena is taking a combination of fast acting and a slow acting.  We only want the slow acting.  The fast acting is to bring down spikes of sugar from eating carbohydrates.  If we’re not going to be eating the carbohydrates, we won’t be spiking the sugars.  And then, if you took that fast-acting inuslin, it would cause her sugars to go low.  She cannot take that.  So, how can you get insulin?

CARMEN:  She gets it from pharmacy in Boulder, and they give her a discount.

DR. ROSEDALE:  Do you have to pay for it?

CARMEN:  Yeah.  We have to pay for it.

DR. ROSEDALE now relaxed, now that he had an action plan in place.  And perhaps the fact that Magdalena was paying out of pocket for her insulin touched him in a way that connected him back to Magdalena and Carmen.  So in a light-hearted, friendly way, he explained:  The type I’m switching to is not a particularly expensive one.  So hopefully you won’t have to waste too much of what she’s already bought. But, before you leave, we need to get you a prescription for it.  Okay?  Or I probably should do it now.  Or I’ll forget!

After Ron Rosedale left the room to get the prescription ordered, Magdalena explained her hopes, with her daughter translating.

CARMEN:  She really wants to feel better, to feel well.  She’s willing to make the changes.  She says that the only thing that could happen is, if she gets ill and she has to go to the hospital, they will make changes and how will that work?  That’s a question that she has.

RON (RETURNING WITH PRESCRIPTION)  Okay.  That’s for the new “old” insulin.    And you have to kind of monitor . . . you need to monitor your blood sugars.  Are you going to be involved in her care?

CARMEN:  I can be with her in the morning and also in the afternoon.  During the day my daughter is with her.  And I can talk with her.  She’ll be able to help.

DR. ROSEDALE:  That would be great.  She might need help with changing her insulin requirements.  I’m going to change the glucovance into glucophage.  That will lower her insulin production.  One of the components of the glucovance causes her own pancreas to produce more insulin.  But in so doing, it stresses out the cells that make the insulin and causes them to die over time.  We don’t want that.  Long-term it’s not good.  And that certainly would be one way to lower her insulin.  Although it won’t be apparent in the insulin she’s taking.  Her total insulin is determined by how much her own pancreas is producing and how much she’d taking by shot.  I don’t want her to take the kind that is trying her to whip her own pancreas into producing more insulin.  That is stressful to the pancreas.  She doesn’t need any more of that.  So we’re going to take off one of the components of the drug that she’s taking and use the other component.  Similar to what we’re doing with the 70 30 insulin.  We’re just going to use the 70 portion and not the 30.  And the glucovance, we’re going to use the glucophage portion and not the glyburide.  Okay, you’re going to use a whole bunch of Co-Q10.  You’ll stop the lovastatin for now. Okay?  I said for two months.  I’m being politically correct, then we’ll reevaluate it.  Right now, we want her heart to beat as powerfully as it can, and the lovastatin’s getting in the way of that.  OK.  We’re going to change glucovance to glucophage.  Oh, wait a second here.  Her creatine’s doing pretty good?  Let’s see.  I would need updated laboratory work.  I need the laboratory work that they did in the hospital.  The only laboratory data here from the hospital is her blood count, but not the chemistry.  Basically what I need here is the creatine.  For now.  Okay, the glucophage, one, 1 three times per day with meals.  So you have to stop the glucovance.  I’m going to circle it.  So you’ll know.  And we’re changing the insulin, too.  That’s what we’re changing right now.  And then you might change, I’ll put a square around verapamil, and I’ll put a square around hydralaine.  Those are the two blood pressures you might have to lower, depending on what happens with her blood pressure.

CARMEN:  So if her blood pressure goes low, then we are going to lower both at the same time.

DR. ROSEDALE:  You’re going to do first the Veratamil.  I wrote it down.  And then the Hydralazine.

CARMEN:  If we go to that pharmacy, she gets a discount, and I think she was referred by her regular clinic, so I think it will work with any prescription it brings and we will get the discount.

DR. ROSEDALE:  It’s really important that she does not take the glucovance and glucophage together.  Okay?  That would be a bad mistake.  Okay, now Magdalena’s going to have to change her diet.  You already know what to eat.

CARMEN knew this question was for her.  And she answered with confidence:  Yes.

DR. ROSEDALE now turned to Magdalena, as her doctor translated his next question:  OK.  What would be a typical breakfast?

MAGDALENA:  Una tortilla, triga.

CARMEN:  One egg, some cereal, and one wheat flour tortilla, and the milk with the cereal.

DR. ROSEDALE:  Okay.  Anything to drink?

MAGDALENA:  Agua.
CARMEN:  Just water.

DR. ROSEDALE:  Okay.  That’s good.  That’s the one good thing.  Egg not so bad.  How’s the egg cooked?

CARMEN:  Poached egg with very little grease, and she uses canola oil.

DR. ROSEDALE:  Okay.  The tortillas she uses, you’re going to switch tortillas.  To La Tortilla tortillas. You can get them at Vitamin Cottage. Those are the only ones that Magdalena can use.  Are you familiar with those kind.

CARMEN nodded, thinking of the low carb tortillas that didn’t taste as good as regular tortillas, but at least were shaped like them:  Ah, yes.

DR. ROSEDALE:  Do you use them?

CARMEN:  I don’t use them, because I don’t like them.

DR. ROSEDALE:  But you know what they are?

CARMEN:  Yes.

DR. ROSEDALE:  Those are the only ones that Magdalena can use.

CARMEN translated, then when Magdalena nodded, looking confused but trusting of her daughter, DR. ROSEDALE said this:  And only half a tortilla at a time.

As Carmen translated this dietary restriction, along with others to bring her carbohydrates much, much lower, Magdalena started laughing . . . as sound that transcended language barriers as “You have GOT to be kidding me!”

DR. ROSEDALE:  For Magdalena, We have to go to more extreme measures here.

CARMEN translated, and in disbelief, MAGDALENA SAID:  And no puedo comer la fruita . . .

CARMEN:  She’s asking about fruit and jello, because she knows I was not eating fruit.

DR. ROSEDALE nodded, adding:  She cannot eat cereals.   She can eat two eggs and half a tortilla.  That would be a breakfast.  Okay?

CARMEN:  That was one of her questions.  Since the beginning when I told her about the diet.  She says if her sugar level goes too low, what should she drink to bring it up.  Because she usually uses orange juice.

DR. ROSEDALE:  We will be trying to prevent high and low blood sugars.  It will be less likely by changing the type of insulin we’re using and changing the diet.  But if it does happen, two swallows of orange juice.

CARMEN:  She says just not getting to that level of . . . but she says, it’s fine.  If she’s not going to require a lot of the juice, and her sugars are not going to go that low, because she feels really bad when that happens.

DR. ROSEDALE:  OKAY.  Then after we change the diet, we’re already reducing her total insulin by changing from the glucovance to the glucophage.  She might still need to take less insulin.  Now the insulin we’re changing her to is a long-acting insulin.  I’m going to hope that she can get off of it totally over the next month or two.  We’re just going to have to wait and see.  So, if her sugars are running low all day long, then the next day she should take less.  There should be a gradual decline in her blood sugars, in which case, you can reduce her insulin requirement.   I’m going to say start with the same you’re using now, 24 units of NPH insulin.  Reduce, depending on how low her sugars might go, reduce insulin if sugars . . . now when Magdalena gets a sugar reaction, when it goes low. . . how low does it go?

CARMEN:  52, and I remember one, 74.  Sometimes, she’s 29.

DR. ROSEDALE:  Okay, 74 wouldn’t be so bad, unless she gets symptoms.  If you’re healthy your sugars will run 74 anyway.  I’m going to say, reduce insulin if the sugars go under 80.  And then reduce by 5 units at a time.  If it’s staying low, you might have to reduce.  You might have to go off of it.  Great!  How fast is hard to guess.  So you just have to check the blood sugars and see what happens.  Do we have her weight recorded today?

CARMEN:  175 and some ounces.

DR. ROSEDALE looked again at Magdalena, who is just barely five feet tall, and he calculated her likely lean body protein mass:  No more than 50 grams of protein per day, and not more, and remember, it’s not a high protein diet.  No more than 15 grams protein per meal.  That would be about the size of a deck of cards for a piece of meat.  So half of a half of a chicken breast.  Does she like nuts?

CARMEN:  Yes

DR. ROSEDALE wrote more instructions on the pad:  Good.  If hungry, she can snack on a few nuts.  Almonds, walnuts, pecans.  Not peanuts.  She can eat some cashews, but not many cashews.  Not peanuts, not cashews.  Other nuts are fine.  Nuts are not the same as seeds, so don’t eat seeds such as sunflower seeds.  I don’t care where she gets her protein.  I prefer she doesn’t eat a lot of red meat until I see her other laboratory level and we see how much iron she’s been storing.  If we know how much iron she’s storing, we’ll know whether she needs to reduce iron-containing foods.  If she hasn’t had a ferritin level checked, we need to check it.

CARMEN explained all this for Magdalena, and then explained that her last check showed normal ferritin levels.

DR. ROSEDALE:  Oh, good.  So her ferritin is probably not a problem.  So no . . . and I capitalized, DO NOT EAT TORTILLA OR STARCHES.  So do not eat sugar or starches, and I capitalized it.  Other than La Tortillas.  That is her only bread like product.  No rice.  No cereal.  No potatoes.

CARMEN:  But oatmeal.  She loves oatmeal.

DR. ROSEDALE:  No oatmeal.  It all turns to sugar.  Really quickly.  If she eliminates that stuff, we might get her off the insulin totally.  And getting her off the insulin totally, her fluids are going to come down.  And then we can get her off the Lasix.  And that’ll help her heart beat harder.  And then we can start reversing these vicious cycles that are taking place in her right now.  Take a medication for one thing then it ends up causing something else that she need to take a medication for.  It’s gone on now for a long time and therefore you have lots of medications.  We can start reversing that.  Ideally, when we’re all set and done, maybe a little for her lungs, and I don’t know if we’ll need anything for blood pressure or not.  If we do, maybe the Imdur and that might be it.  It helps to dilate the arteries of her heart a little bit. But other than that, I’d like to see her off of almost everything else.  Now we’ll see how close we can come to that accomplishment.  I don’t know.  Now, certainly, we can help the diabetes, and diabetes underlies a lot of everything else.  Her numb feet will get better over time.  But will take a long time.  Probably several months or a year even.  But that’ll get better too.  A lot of things are going to get better.  She can pick up her energy a little bit.  And then there’s some supplements she’s going to be taking.  You know the diet pretty well.  We’ll give you, see if they have that done yet, and we’ll copy these instructions to pin on your refrigerator or wherever you want.  And, make sure that you do that chart of blood sugars, blood pressure and weight and fax it over.  Make sure that you replace the glucovance.  if you don’t take the glucophage, I don’t care that much, but do not take the two of them together.  That would be a severe problem.

Carmen nodded as Dr. Rosedale told her all this.  Her look of determination said she was going to work to make this happen.

DR. ROSEDALE:  Change the insulin today.  Probably do that today.  She’s already had her shot this morning.  If she starts the diet today, she won’t need a shot tonight.  The changes take place rapidly if you don’t eat sugar.  Obviously if you don’t eat sugar, the sugars go down.  Also, we just got through breakfast.  What would be a typical lunch?

CARMEN:  Chicken, salad.  She’s eating a little because she doesn’t have good appetite since she left the hospital.  So she just eats a piece of chicken and a salad.

DR. ROSEDALE:  And how about dinner?

CARMEN:  Sometimes the same thing she ate for lunch.

DR. ROSEDALE: Those will be fine.  Chicken, chicken salad. Teach her what to eat, and we’ll give a list of food that she can and can’t eat.

CARMEN:  For a snack she eats a yogurt and crackers.

DR. ROSEDALE:  We’re going to change that.  That’s gone.  OK?  No yogurt, no crackers.

CARMEN:  For her tea she uses the sweetener, Nutrasweet.  Can she continue taking that.

DR. ROSEDALE:  I would not use sweeteners.  She’ll crave the sweets more and that’s when she’ll want the yogurt, that’s when she’ll want to fruit.  I would just stay away from sweets for now, and then it’s easier.  If you’re not constantly reminded of sweets, you won’t miss it.

MAGDALENA as this was translated, again gave that almost-panicked laugh of disbelief, her voice registering, “You’re kidding?!?”

DR. ROSEDALE:  It’s very important that she doesn’t cheat.  Especially not for the first three weeks.  After three weeks it becomes a lot easier to follow the diet if you’ve been strict from the very start.

CARMEN translated.

DR. ROSEDALE:  Keep some almonds around.  Either dry roasted or raw.

MAGDALENA:  Okay

DR. ROSEDALE:  Does she like guacamole?

CARMEN—Yes she does.

DR. ROSEDALE:  Some people cut the la tortilla into smaller segments and then bake it in the oven to make kind of crackers to dip into the guacamole.

Carmen and Magdalena talked about this, and Magdalena seemed to like the idea.

DR. ROSEDALE:  OK.  We do have a ferritin of 25.  Good.  Now we will write down a list of supplements.  One, I will be sorry to inform you will be expensive and long term.  We’ll see what we can do short term, but it is something she’ll need to stay on it indefinitely. That’ll be Co-Q10.  The raw price at the factory that makes it in Japan has gone way up. They are starting to charge a lot more because they can.  There are only two factories that make it.  Unfortunately.  But that doesn’t change the fact that she needs it.  Whereas you and I take one, she’s going to take 6 a day.  And if it weren’t so expensive, I’d have her do twice that.  It’s vital to her health right now.  Two at breakfast, two at lunch and two at dinner.  She’ll take Diabest.  Arginine.

CARMEN:  TRANSLATES

DR. ROSEDALE:  Okay.  This is what she will need, for right now, and that’s actually keeping it as simple as I can.  And on here, right here is what she should be taking, and this will say something else on the bottle, so I’ll write that here.  Thiacid, I think.  Take Co-Q10 2 at breakfast, 2 lunch, 2 dinner.  Diabest.  Arginine.  That means empty stomach.  Thiacide, Lipoic acid.  Acetl Carnitine.  Potassium.  Ascorbic Palmitate, a form of Vitamin C.  Vitamin E.  For 6 weeks.  Okay?

DR. ROSEDALE:  Now, the Lasix, is Magdalena also taking Potassium?

CARMEN:  Yes

DR. ROSEDALE:  Even so, I’m putting her on other potassium with magnesium also.  And that’s not a mistake.  In addition to the potassium she’s taking for the Lasix, she’ll take this other for 6 weeks, and I am hopeful that in a couple of weeks, we’re going to start getting her off that Lasix, or at least greatly lowering the dose.  Okay?  So, we need to, let’s find out if she’s going to have another chest x-ray and see how clear that looks.  If there’s no fluid in her lungs, we can start weaning her off the Lasix.  I don’t need to see the actual x-ray.  I’ll take the radiologist’s word for it.  Thanks.

DR. ROSEDALE:  Copy those  . . .

This ends Magdalena’s first appointment with Dr. Ron Rosedale, two weeks after she left the Intensive Care Unit congestive heart failure that was getting worse each time she ended up being hospitalized.

Carmen and Magdalena talked with Dr. Rosedale about how to connect up with her regular doctor.  Magdalena said that she would talk about all this at her next regular appointment, depending on if she could get a car ride to it, since she doesn’t have a car.  Checking blood pressure, we would later find out, was also somewhat complicated, since the nearest blood pressure checking place was at an Albertson’s supermarket several blocks from where she lived, and she didn’t have a  car, and she had hardly the energy to walk from her bedroom to the bathroom.   And, there was the new diet.  Many, many things to see about and do.  But at least, there was a new possibility.  Magdalena left, talking about how if she got better, she’d be able to teach other people about how to be healthy as well.  The key would be HER getting healthy first.

This concludes this special program about Magdalena—part 1.  There are other episodes to follow.  Always remember to consult with your physician before changing your medications, and also tell your doctor about dietary and supplement changes you make.