Cymbalta off

So just to finish the thoughts, the off stage is really the worst.  After i weaned to 0mg, i had an ok first week, except for consistent vertigo.  Week 2 left me realizing why there is a claim that some titrate individual beads out of the capsules to wean the last few milligrams.  Apparently this end stage is the worst, but i wasn't ready to take a step back from the plan.  The worst i had was a day where i could barely move my head side to side without some crazy vertigo that made me stay home and just play video games with my brother.  That week also had me in emotional mood swings so bad that i could only ask people to forgive me the bits of crazy that would overwhelm me and make me sad and weepy one second, frustrated and angry the next, then hopeless and crying.  But this passed. 
Week three of being off, the vertigo is much milder, but now the chronic pain symptoms are seeming to rear themselves.  Add to this an odd exhaustion.  I've been sleeping a lot and it's not mitigated by caffeine.  So i believe these symptoms might be the last in the series, because the emotional lability has certainly evened out.  I'm still exercising but randomly with this exhaustion.  I'm eating, i'm motivated to do things, and am writing again, which is cool.  This week brings me the imposed assessment of my ability to play well with others, and will hopefully give me some new tactics to be a better human being.  I'm realizing that the labeling department of psychologists is overwhelming, but if i come out of all of this with some new tools to be a little slower, less impulsive to jump to conclusions or offer my opinions which may be crap, then i will have gained something.  If i get back to school doing this, that would be even cooler.

Cymbalta on and off from a nurse's POV

My reasons for deciding to seek professional help were a temporary state of depression that needed some therapy, and then ultimately, pharmaceutical help.  I do not have a clinical diagnosis of long standing depression.  As a health care provider in some of the most stressful environments, it was hard to even walk into a psychiatrist's office with my complaints.  But in the long run, i feel that all that has happened to me in the last two years has taught me about myself, and given me more insight into something i knew so little about and about which i had a long time been predjudice.
I'm putting this medication information out there as personal information about the medication i was prescribed.  I do not represent anyone or anything with this posting.  While i was looking for advice on how to safely navigate symptoms of withdraw, i found many useful and not so useful sources.  Some things to expect during weaning/cold turkey from my scanning:
 GI complaints (IBS Symptoms, diarrhea, nausea, constipation, cramping, etc)
Nerve firings that feel like "brain zaps" or twitches of muscles
Vertigo
Headaches (some almost like migraines)
Mania (even if you didn't have it before)
Worsening anxiety
Return of depression
Listlessness
Lack of Energy
Nothing
Flu-like symptoms
unlikely suicidal completion (this last one is *very* subjective and i can't find source data). 
For most the removal of the drug will have some minor complaints.  Most should subside after a month being drug free.  Please keep your doctor in the loop *especially* with neurological symptoms to avoid missing something and if you feel any desire to harm yourself or others.
 
The symptoms going on Cymbalta for me were in some ways similar to statistics.  While 30mg did nearly nothing for me, i found a sweet spot at 60mg.  Please allow me to explain that going on Cymbalta was a trade of one set of symptoms for another.  It is by no means a "miracle drug" or an easy way out, nor is it easy to accept some of these symptoms.  My doctor and i chatted and chose this because i was also having emotional chronic pain symptoms which i had evaluated and were unfounded by almost any physical and lab test you would do on a 30 something year old.
Not eating/Nausea:
Anorexia i had because of anxiety and stress worsened and also turned into a "central" (you'll see why i call it that in a minute) nausea: one that when i yawned caused me to want nothing to be in my mouth ever, ever, ever.  This is way different from usual nausea where you want to vomit.  That was never the problem.  It was more just a desire to push everything out of my oral cavity, including my tongue, tonsils, uvula and teeth. 
Dreams:
I also had some crazy dreams with dream sequences that were clearly the culmination of my anxiety for that day, week, month. 
Sexual side effects:
Some sexual side effects were there, but hardly the kind that some people face.  Just a dulling of any pleasure, or difficulty getting there.  But the affection and sexual feelings never fully went away as they do for some. 
Weight change:
I am second percentile for weight loss.  Cymbalta is the only drug that causes measurable weightloss in patients, and the average initial loss is 10lbs which evens out and returns to an average of 2lbs over the course of treatment.  By the time i had culminated the stress, the anxiety, (added bonus the lack of continuous large doses of estrogen and progestrone in favor of the Mirena¨tm), the anorexia and the medication, my total weighloss was 32lbs (150lbs --> 118lbs).  This was something i couldn't even do while marathon training.  The least i have weighed since middle school was 140lbs.  So when i suddenly went from a size 10 to a size 4/6, you can imagine my surprise.  I stopped getting on a scale at that point.  I could mostly look in the mirror and know i hadn't gained anything or had lost more.
Was it all worth it:
In effect: yes
For the year or so i've taken it, i stopped crying all the time.  I could motivate myself to do some work more than what was required to drag myself to work.  I didn't reach my goal of being able to exercise daily, but i did manage to consistently ride my bike to and from work.  My anxiety stuck around, but i wasn't having panicky moments where i couldn't get my chest to stop hurting or my heart to stop racing.  I've not ever had a situation i couldn't handle till the instigating event that snapped my whole emotional state into a panic.  The bigger picture does show a slow build to losing my usual coping skills, but because of the rapidity with which the symptoms presented, learning meditation and relaxation techniques while i was knee deep in anxiety wasn't going to work.  Those are things that need to build, like muscle groups while lifting.  So taking Cymbalta was a metaphorical set of crutches to get my foot healed so that i could go do my physical therapy (so to speak)
Now all the down sides of my weaning.
As i've gotten to the lowest doses of Cymbalta, my neurologic system has decided to mess with me.  Without a lick of alcohol, i get some pretty wicked vertigo.  I also wake up with a headache almost daily.  It's not a demon drug.  It's just got some trade-offs like almost every antidepressant the world over.  It turns out that it will muddle around with your basic nerve function because it muddles around with two of your neurotransmitters.  Norepinephrine, it turns out, is vital to a lot more than just your psychological well being. And serotonin, similarly, is vital to other processes (90% of its function and production is in the gut, which explains the GI complaints, and it also is something responsible for migraine headaches).
I'd just like to document how the last 6 weeks have been going.  Up until last week GREAT!
I started my weaning process from my start of 60mg in 10mg increments per week, as i had been warned of the side effects of too fast a taper.  These pills are worse than steroids (which also require a specific taper regime and also messed with my head-literally).  When i tried weaning directly to 30mg, things were *bad*.  I had headaches, muscle aches, flu like symptoms, and weird anxiety. 
So up until last Sunday things were wonderful (i am now at 10mg/day).  But when i felt like i had a stomach bug from eating crab cakes on a train (i know, it was one of the smartest decisions i have ever made about food), i also developed the vertigo: the kind that when you move to fast the world spins.  One time, while shifting my glance to the right, i felt like my vision was in filmstrip form, but going side to side instead of up and down. 
I also noticed my mania.  I have been cleaning and organizing and reorganizing.
And i have bouts of unexplainable anxiety that comes on when i don't expect it.

But here are some bright spots:
Week 2 of running after not doing so for at least 2 years
Genuine happiness making freeze pops out of freshly juiced produce
I'm eating almost normal sized meals again and actually crave desserts again!
Getting lots of support in learning how to do relaxation techniques, and practicing meditation thanks to roryk's insightful bit
I'm not weepy or depressed
I'm actually excited about things in my future and i don't feel like i'm stuck in that crazy tunnel in Switzerland anymore. 
If you have any questions, feel free to ping me.  Friday starts my first no Cymbalta week, and i will be managing some hefty stress over the coming weeks and months.  I believe i will be fine.  And that is a pretty cool place to be.

Another nother cheese cheese burger burger please

 Patient is diagnosed with a significant Abdominal aortic aneurysm.  So this usually entails a bulging off a major part of the aorta.  All sorts of things can cause it, and you can usually medically treat it with some medication, making sure that enough blood is flowing down to your legs and it doesn't rip open (which is the big risk and usually will require surgery.
Here you can see them exposing and opening the aorta at the site of the aneurysm.  In this very skinny man's case, his was the size of a soft ball. 

Yes, almost everything that you see in that picture that isn't hands, tools or drapes is the site of the aneurysm.

 Oh, the plot thickens.  So the inside of your vessels absolutely should not look like this.  All that browning cottage cheese stuff, it turns out....not so good.  That is the accumulation underneath a plaque that the patient developed caused either by a trauma to the inside of the vessel, fat or mineral deposits, or some other genetic issue.  What has happened is that a bunch of inflammatory mediators and platelets and all sorts of other junk gets stuck under a little area of the plaque causing it to expand and bulge.  Eventually, when the blood vessels is stretched to its max, it will tear and as it tears create a smaller and smaller likelihood of survival. 

This is the same sort of process involved in those "plaque" deposits in your heart.  Except that eventually they tear off and that mass of stuff goes and blocks off a narrower portion of your arterial system. 

Here you see the stuff they pulled out of the artery.  These are all the pieces of gunk that had accumulated there, from different types of blood cells, cholesterol, etc.
Did i mention how it smelled? 
Imagine an infectious wound that has been brewing for a few weeks under a bandage.  It's about like that.







To repair such a thing, it's not like you can give up another vessel in your body to replace your giant aorta like you can with one of your tiny coronary arteries.  That's where the miracle of plastic (i mean silicone) comes in.  Medicine is full of interesting stuff and i love looking through the surgical cabinets to see what all can be replaced in the body from joints to valves to *blooooooood vessels!*  So there are many different sizes of silicone replacement aorta you can get from the tiniest of tiny (like in a neonate that needs palliative care for a congenital problem) to enormous.  This is the biggest i've ever seen.  (Though i did once sit in an OR waiting for the right *length* of vessel because it wasn't standard stock and they come in different materials, diameters, coatings, etc).  This last photo is of that tube.  I would say it was at least 1/3 the length of his aorta when they were done. 
The patient is happily discharged.

Theater Exile does The Lieutenant of Inishmore

A really great theater group here called Theater Exile is willing to bring all the dark humor to Philadelphia that it thinks might be tolerable.  Along with 1812 Productions (of All Wear Bowlers fame) they are one of my favorites. I read the Lieutenant of Inishmore when i was in college studying Irish literature and it stuck with me as one of the funniest and darkest plays i'd ever seen or read.  Later i would find the Pillowman and All wear Bowlers, and David Sedaris and other plays that would invoke similar dark guffaws. 
Set on Inishmore, an island to which i've been in Ireland, that is rough and rocky atop cliffs that are ravaged by the seas, it is about an INLA (Irish National Liberation Army) officers' return home after finding out there is something wrong with his beloved cat.  It turns out "Wee Thomas" the cat is dead, and the young man, "Mad Padraic," is a raging lunatic with designs on creating a splinter group from the INLA splinter group from the IRA because it doesn't meet his needs for violence (but claiming it is because he needs to make Ireland free from all the evil of the world-your typical homicidal zealot).   Hilarity and violence ensue.

Theater Exile did a really find job adding some interesting mashups of traditional irish folk songs with Hip Hop, rock, metal, and pop between scenes that added to the shows edgy nature. The staging is also amazing.  The single set conveys all you need, and adds a gotchya humor, while keeping its most contentious actor under control until he's needed.  
In the lead role, Paul Felder does a really good job at just comedic crazy.  He's perfectly balanced as seemingly morally superior and vacuous at the same time, without an evil bone in him.  He is both sympathetic and pathetic, and this is how i've always seen his character.  Just batsh*t crazy. 
Elena Bossler has some pretty big shoes to fill.  Her role was actually vacant because of a terrible loss to the theater company.  While unsure if it was time or youth, her acting seemed more melodramatic than calculated.  However, she was supposed to be a crazy patriotic 16 year-old who wants more than anything to have a cause for which to fight and more importantly be noticed.  Hers was one of the least engaging performances of the night.  Perhaps this was because her flinging herself at Padraic seemed as though she needed to prepare for them, and often seemed impatient for her line or cue.

My favorite performances were delivered by William Zielinski (Christy) and especially Pearce Bunting who delivered a brilliantly believable drunken Donny midway through.  Donny's lines were frequently delivered with such comedic precision, that one couldn't help but laugh at the speed of his speech, his timing and pauses.  With the help of Robert DaPonte as Davey, their chemistry was really well received.  In the final standoff scene, their roles shine.  Even when all the actors are on the stage, they seem to steal the show with their interactions, eye contact, gestures, and slapstick.

Overall, i came out really happy i forced myself out into the rain to see the show, and look forward to these guys doing more of their Irish series.  Pump Girl was pretty wonderful and dark as well, albeit a more modern piece that tries to be slightly more serious. 
One can almost forget how serious this play was in its day.  The critique of blind Irish nationalism and violence that was sometimes not quite about a free Ireland anymore might be lost on contemporary American audiences.  However, it is important to remember in context to appreciate all its humor.


There are only a couple more days to see it, so get out there.  Ends this Sunday.

Flower show

So Philadelphia has this totally ridiculous flower show every year (by ridiculous i mean huge).  Before this year, i had never gone.  Ericka convinced me and thus educated me.  They have several exhibits like this one:  the "window box" competition.  This was my favorite, and next to it was a "city porch" style competition that included a Caribbean porch full of beautiful tropical plants and the porch dressed like a tikibar.  There were also competitions between various types of plants (succulents, orchids smaller than..., orchid any type, orchid hybrids, rooftop greenery, topiary, etc.).  Really, i wanted to hate it a lot.  It's pure excess in a time when we, as a global community, could use a much different boost than a show of opulence-especially in Philadelphia.  Seeing the good in the use in the convention center, and the huge draw of the suburban tourists, I still went.  I should do everything at least once.  And have you seen some of these plants?
These guys are so awesome.  Heather, a friend from school gave us one of these guys as a present one year on.  It managed to bloom a second time (which for our household is so far unheard of for orchids).  

She got it for us because it was affectionately called the "darth vader" orchid.  Um.   It looks nothing like Anakin Skywalker.  Then there were a bunch of other lovelies.  My very favorite orchid was the crazy lioness butterfly looking one.

Another, in the "tiny orchid" category (which is to say you could have bought your orchid the night before the competition, or didn't need to have grown it that long that it was enormous and full of flowers) used bark as the root base for the plant and then hung that bark from an upside-down flower pot. 
It was such an imaginative way to handle a plant that lives off trees and put it into a horticultural exhibit with a bunch of pretentious snoots, that i'm glad that it got at least an "honorable mention" (which i notice happens to rebels in competitions on the east coast).
This thing suits my aesthetic sense for sure.  I don't know why, but white sage style outcroppings, the contrast of the bark, the iddy biddy, mountain-top, edelweiss-like flower in the midst of all the roughage is just a beautiful sight.  Among the pretense of the other flamboyant orchids, its quiet statement seems more beautiful. 


There's also a bonzai exhibit which was surprisingly underrepresented, but i suppose with a minimum of 12 years needed to groom even a tiny tree to be the shape you want, that makes sense.  This is one of the younger of the bunch.  One was 60 years old.  Others 40 and younger.  It is hard for me to imagine the endurance and patience involved in grooming a bonzai.  There is no instant gratification, and being able to see the long view in concept and then prune accordingly when it comes to plants seems daunting.  The results, however, are something i really love to see.  The trees came from India, China and Japan.  Interesting mixes and breeds, some with pine tree like leaves, other like this, and others still with barely any leaves and fat chunky trunks and branches.



Lastly, there was the "shape your plant/s into something interesting."  There were quite a few interesting pieces like planes and one that used my very favorite lilies in a vase and had them cascade down like a lopsided chandelier.  It won top prize and it was probably justified for a successful modern interpretation of the classical flower layout without too much fluff and pomp.  But one should note the amazing dragon duo.  I believe they were made from seeds and bark instead of flowers and grass.  That alone makes them rebellious, but wooooo!

Root canal

It turns out root canal isn't so bad.
But i say that with the caveat:  it's not that bad if you had excruciating pain prior to the root canal.  The good thing is that i can sort of read xrays, and some symptoms led me to believe something was wrong but i thought it was something else because i'm neither a dentist nor an endodontist.  (oh, and i was repeatedly told it was just sensitivity that won't ever go away and i would need to use sensitive toothpaste).
If you look at my xrays (this is post rubbery post placement with the clamp still on my tooth), you'll notice that around the bottom of the root it looks weird.  This is fluid accumulation, usually a sign of infection.  This went with my weird, unable to locate exact source, random, flare up aches that i would feel in that area periodically.  So off to the endo i go.  Three drillings and fillings with some rubber tubes in my roots later with medication added to prevent infection and some pretty bad aches that got me on antibiotics, and then also an antifungal (which is allegedly the a-bomb of mouth/tooth issues) i realized some things: i'm a wuss about my teeth (the doc had to give me some tough love to get me to stop calling about the pain), teeth are scary, i don't want the pain that usually brings one to a root canal, and that Dr. Vettraino is not only a lovely woman with a beautiful Italian accent, but she is patient and explanatory and wonderful.

What i thought was neat in all this was the process at the end.  So the xray shows the rubber tips they place down into the four roots of the molar.  They are specially treated and the tooth is rinsed out with chlorhexidine (the napalm of antibacterials).  The stuff above it is the temporary filling material that will later be removed by my dentist for a permanent one, and a crown is slapped on top of the whole thing.

The other photo is me braving a photo of myself with a giant hole in my tooth.  If you know me at all, you know i can't handle two things in medicine: bones and teeth.

aminos

I'm excited to show off my necklace.  Special thanks to Raven Hanna who owns Made with Molecules.  Her work is pretty spectacular.  You can find her on etsy at molecularmuse and she likes to make things that involve science!
If you know the letters that represent each of the amino acids, and can speak German, then you might be able to figure out what it says. ;)