| A Schnitzel In Time... Saves Lives! |
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"We need a consult," said the voice on the other side of the phone. A quick look at the LED read-out on my "smart-phone," anchored the caller to the pediatric nephrology department. "She is 11 years old and refuses to comply with the dietary requirements of her ESRD." _option_option_option_option_option
Shaare Zedek is one of the only medical centers in Israel to have separate adults and children dialysis departments. They were a forerunner of separate dialysis units since the late 70s, over 30 years ago. One visit to the sixth floor dialysis rooms, when they are in full swing, is worth a thousand words. In one room, adults sit hooked up to dialysis machines. Some are weary, uncomfortable, nauseous, and clearly unhappy; many are sitting there alone. One connecting door away, the brightly decorated pediatric dialysis room is abuzz. Sure the kids and young adolescents who are having their blood "laundered" are less than comfortable for the most part. But their developmental needs are being met with the help of the constant team of teachers (Hebrew, Arabic and English speaking), art and music therapists, as well as an occasional medical clown (see the film "Patch Adams"). In addition, there are teens volunteering to cheer them up and bring them "normalcy" from "outside." Dialysis patients must be hooked up three times a week for about three to four hours each time to the machine that exchanges and purifies their blood, as their kidneys have stopped doing so. ESRD stands for End Stage Renal Disease. This is a condition of total or nearly total and permanent kidney failure. People with ESRD must undergo dialysis or kidney transplantation to stay alive. Hemodialysis and a proper diet help reduce the amount of wastes, which accumulate in the blood. A dietitian can help plan each patient's meals according to the doctors' orders. When choosing foods, one should remember to: · Eat balanced amounts of foods high in protein such as meat and chicken. · Watch the amount of potassium eaten. Potassium is a mineral found in salt substitutes, some fruits, vegetables, milk, chocolate and nuts. Too much or too little potassium can be harmful to the heart. · Fluid intake must be limited. Fluids build up quickly in the body when the kidneys aren't working. Too much fluid makes body tissues swell. It also can cause high blood pressure and heart trouble. · Avoid salt. Salty foods make one thirsty and cause the body to retain water. · Phosphorous intake needs to be limited. Foods such as milk, cheese, nuts, dried beans and soft drinks contain the mineral phosphorus. Too much phosphorus in the blood causes calcium to be pulled from bones. · Calcium helps keep bones strong and healthy. To prevent bone problems, your doctor may give you special medicines. You must take these medicines every day as directed. There are other options for treatment of ESRD: Peritoneal Dialysis is a type of dialysis that uses the lining of the abdomen to filter blood. This lining is called the peritoneal membrane. Types of Peritoneal Dialysis 1. Continuous Ambulatory Peritoneal Dialysis (CAPD) is the most common type of peritoneal dialysis. It needs no machine. It can be done in any clean, well-lit place. 2. Continuous Cyclic Peritoneal Dialysis (CCPD) is like CAPD, except that a machine, which connects to the catheter, automatically fills and drains the dialysate from the abdomen. The machine does this at night while the patient is asleep. 3. Intermittent Peritoneal Dialysis (IPD) uses the same type of machine as CCPD to add and drain the dialysate. IPD can be done at home, but it's usually done in the hospital. IPD treatments take longer than CCPD. Not everyone with ESRD has the option of choosing which form of dialysis that they may use. Diet for peritoneal dialysis is slightly different than diet for hemodialysis. One may be able to have more salt and fluids; eat more protein; have different potassium restrictions; may need to cut back on the number of calories eaten. The calorie limitation is because of the sugar in the dialysate that may cause the patient to dangerously gain weight. The final option for ESRD is Kidney Transplantation, which is a procedure that places a healthy kidney from another person (or cadaver) into the patient's body. This one new kidney does all the work that the two failed kidneys cannot do. A surgeon places the new kidney inside the body between the upper thigh and abdomen. The new kidney may start working right away or may take up to a few weeks to make urine. The "original" kidneys are left where they are, unless they are causing infection or high blood pressure. Here too, diet plays an important role. However, for transplant patients, it is less limiting than it is for dialysis patients. The diet probably will change as medicines, blood values, weight, and blood pressure change. Again, transplantation is not a possibility for all (or even most) ESRD patients. I went up to meet the young girl who "wasn't cooperative" with the life-saving dialysis stratagem. Alexandra (not her real name) is a twin. Her sister has normally functioning kidneys, which makes the three times weekly visits and serious discomfort especially difficult for Alexandra. She would never wish this disease on anyone, least of all her sister but it just doesn't seem fair! To add insult to injury, she cannot abide the special menu she has to eat. Especially no chips (as french-fried potatoes are known here) and other fried foods. "What," I ask her, "is the best thing about coming here to the hospital? I know that the dialysis and stuff is the worst." She looks at me a moment and grudgingly tells me: "The Chicken Schnitzel." I glance over her head in the direction of the nurse, and discover that Alexandra may eat this fried, breaded, fatty protein food only when on dialysis, as then her blood is "cleansed" as she eats it. The nurse goes on to say that Alexandra is "spoiled" because she only wants that food every time she comes and refuses to eat anything else - this too is also not "good" for the dialysis recipient. Ever a solutions person, I ask if she could bring the schnitzel from home and have it while on dialysis. "That's also a problem," I was told in almost unison by Alexandra and the nurse (would the rabbi okay the kashrut, which is another issue, but not one that I was going to attempt to tackle). "What's the primary difficulty," I asked. Alexandra has tried to get her mother to make the SZS (Shaare Zedek Schnitzel) and it never comes out the same as the one made in the hospital commissary, and worse than that, no one can figure out the "secret" recipe. "This is a very difficult problem," I say. "Will you give me a week to see if I can solve the problem? Alexandra, you have to promise you will eat properly, at least until I fail at my job. Give me a chance to succeed. Will you do that?" She looks at me solemnly, and pronounces: "Four days, not a whole week." "It's a deal; let's shake on it," I answer. We have a life-and-death issue here. I know my limitations as a Neuropsychologist. Who cares what her cognitive ability is, when her life will indeed be at risk if she won't eat a proper diet? I call the director of the kitchen. We have a life-and-death case on our hands. I have his attention. I tell him that there is an 11-year-old who is "dying for your schnitzel" (in Hebrew it is a double-entendre, "he maita al ha-schnitzel shelcha" means "she's crazy about it.") "What's the problem?" he asks, "I'll send some up." "No, that will not be good enough," I respond. "Can we have an appointment to discuss this with you?" "You mean bring the patient down to the kitchen?" he asks in amazement. "Yup, that's what I have in mind." He gives us an appointment a half an hour before she is scheduled to begin her dialysis two days hence. I phone her to say it is imperative that she must arrive early for dialysis. (This is akin to going to the dentist early to have your teeth pulled; early, so as not to miss out on any of the fun!) I remind her that she has given me one chance to "not fail" and she owes me, because "we shook on it." Reluctantly, she agrees. At the appointed time I meet her at the dialysis unit. We go down to the bowels-of-the-ship, as it were, the kitchen which is on the first floor of this ten-story building; the third floor and below are all underground. Waiting to greet us is the head of the kitchen, Mr. Rudel, and his chief chef. They have never had request such as this, nor had they ever been so complimented as to have a patient want to meet them and discuss their schnitzel. Wonderfully, they have prepared a demonstration and a tour of the kitchen. First, we take the chicken out of this massive fridge, then it goes to this spot where it is dredged in flour and specially spiced breading mix and then it is lightly fried. Not only do we get a "show" in keeping with a Julia Child demonstration, but also a sample of the breading mix, and the "secret" recipe! The pièce de la rèsistance was that they had prepared a few portions for Alexandra to eat then and there, and later while she was on dialysis. Glowing, she hunkered down to the feast. Then, with recipe and extra portions in hand, we went up to meet the thrice-weekly dialysis, head on. We arrived and the nurses see crumbs on her face as well as the dish laden with schnitzel. "What is all this?" they ask with a mixture of awe and a tinge of jealousy. When Alexandra tells them about our "appointment" they ask to see the recipe and just taste to spice mixture. "Sorry," says Alexandra, "I promised not to reveal the secret recipe." "I'm sure you might make an exception," I murmured, as I exited "stage left," the nurses glaring at me. Well, you can't win them all, I say to myself, as I return to the safety of my office.
Source via internet: Health Topics Index | Search | Health Sciences Home. Copyright 2003, University of Utah Health Sciences Center. Originally published in the Jewish Press on November 1, 2006. |
