High Desert Pulse by Western Communications, Inc.

Pot in a pill Itâ&#x20AC;&#x2122;s here. Itâ&#x20AC;&#x2122;s legal. So why does Oregon still have medical marijuana?

End-of-life treatment When more is too much

The package deal Truth in food labeling

Back-to-school health Are they up on their shots?

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PULSE H I G H

D E S E R T

Healthy Living in Central Oregon

SUMMER/FALL 2009 VOLUME 1, NO. 3

How to reach us

Denise Costa | Editor 541-383-0356 or dcosta@bendbulletin.com • Reporting Betsy Q. Cliff 541-383-0375 or bcliff@bendbulletin.com Markian Hawryluk 541-617-7814 or mhawryluk@bendbulletin.com Lily Raff 541-617-7836 or lraff@bendbulletin.com • Design / Production Anders Ramberg Sheila Timony David Wray • Letters Send letters on health topics to: E-mail: pulse@bendbulletin.com Mail: P.O. Box 6020, Bend, OR 97708 Limit 250 words. • Corrections High Desert Pulse’s primary concern is that all stories are accurate. If you know of an error in a story, call us at 541-383-0356 or e-mail: pulse@ bendbulletin.com • Advertising Jay Brandt, Advertising director 541-383-0370 or jbrandt@bendbulletin.com Sean Tate, Advertising manager 541-383-0386 or state@bendbulletin.com Kristin Morris, Advertising representative 541-617-7855 or kmorris@bendbulletin.com On the web: www.bendbulletin.com/pulse

The Bulletin

All Bulletin payments are accepted at the drop box at City Hall. Check payments may be converted to an electronic funds transfer. The Bulletin, USPS #552-520, is published daily by Western Communications Inc., 1777 S.W. Chandler Ave., Bend, OR 97702. Periodicals postage paid at Bend, OR. Postmaster: Send address changes to The Bulletin circulation department, P.O. Box 6020, Bend, OR 97708. The Bulletin retains ownership and copyright protection of all staff-prepared news copy, advertising copy and news or ad illustrations. They may not be reproduced without explicit prior approval. Published: 8/3/2009

WRITE TO US We encourage response from our readers. Send your letters of 250 words or less to pulse@bendbulletin.com. Please include a phone number for verification.

Page 4

HIGH DESERT PULSE

Contents |

18 21 26

HIGH DESERT PULSE

COVER STORY

MARIJUANA AS MEDICINE Medical marijuana soothes chronic symptoms for users, but leaves others feeling very uncomfortable. Is there an effective alternative?

FEATURES

WHEN MORE TREATMENT IS TOO MUCH Planning for the end of life. TIME TO CALL THE DOCTOR? Assessing your kids’ symptoms. THE PACKAGE DEAL What’s true about food labeling?

DEPARTMENTS

12 15 23

GET READY: MOUNTAIN BIKING Prepare this summer and be trail-ready by fall.

BODY OF KNOWLEDGE Work opposing muscles for a looking-good shape. Take the quiz to see which pair with which!

30 38

HEALTHY DAY, OUR WAY A family-friendly outing that beats the heat.

STAYING FIT: HOW DOES HE DO IT? At 79, Ironman Lew Hollander shares his tips. SORTING IT OUT: BACK-TO-SCHOOL IMMUNIZATIONS A clip-out guide to low-cost shots.

LAUGHTER: THE BEST MEDICINE Tall tales of scardom.

COVER PHOTOS BY ROB KERR, PHOTO ILLUSTRATION BY ANDERS RAMBERG PHOTOS FROM TOP: ROB KERR, DEAN GUERNSEY, ANDY TULLIS, ROB KERR, WITH PHOTO ILLUSTRATION BY ANDERS RAMBERG

HIGH DESERT PULSE • SUMMER / FALL 2009

26 Page 5

Cover story | MEDICAL MARIJUANA

ROB KERR

Martin Halsey is one of more than 20,000 Oregonians allowed to use marijuana as medicine. Halsey, who is quadriplegic, says it eases painful muscle spasms.

Marijuana as medicine

Could pharmaceuticals make Oregon’s program obsolete? BY LILY RAFF

et’s do a little experiment with marijuana: We’ll start with the plant, with its iconic, five-fingered leaves and its fuzzy flowers filled with potent psychoactive compounds. Now forget that it’s rolled into joints, smoked out of bongs and baked into brownies. Ignore that it’s the most widely used illegal drug in the U.S., and the cause of more than 872,000 arrests each year. Strip away its multitude of slang names, its prominent place in rap music and Cheech and Chong movies and its reputation as a gateway drug. Instead, focus on the plant’s reported medicinal properties. The herb has been found to quell nausea, control pain, relax spastic muscles, relieve eye pressure, stimulate a poor appetite and calm anxiety.

Page 6

So let’s extract those helpful properties from the herb and put them in a controversy-free pill, available in precise doses by a doctor’s prescription. Voila. Medical marijuana, objection-free. OK, fun experiment. But why not try it in real life? The short answer is, scientists already have. A synthetic version of one integral part of marijuana is available by prescription, under the brand name Marinol. But the long answer is, of course, more complicated. Marinol doesn’t work for everyone. And it replicates just one of the hundreds of chemical components in marijuana, at least 70 of which are unique to the plant. Here’s where politics barge into our experiment. Other forms of marijuana-based prescription drugs are scientifically possible, experts say, but legal and social hurdles prevent widespread medical research on the plant. HIGH DESERT PULSE • SUMMER / FALL 2009

FEDERAL REGULATION OF DRUGS Controlled drugs are divided into five categories, called schedules. Schedule I drugs are the most tightly controlled and Schedule V the least. Here are some examples: Schedule I: Heroin, marijuana, LSD, “the clear” (used by athletes; effects similar to steroids but harder to detect) Schedule II: Cocaine, morphine, amphetamines, Ritalin (anti-Attention Deficit Disorder) Schedule III: Marinol, anabolic steroids, ketamine (general anesthetic used recreationally as “Special K”) Schedule IV: Xanax (anti-anxiety, antidepression), Valium, Ambien (sleeping pill) Schedule V: Lomotil (anti-diarrheal), Robitussin A-C (cough syrup with codeine), pyrovalerone (stimulant used for chronic fatigue syndrome) Source: Code of Federal Regulations, Section 1308

STATES WITH MEDICAL MARIJUANA PROGRAMS Since 1996, 13 states have passed laws permitting medical use of marijuana.

WA OR

MT ID

N.D.

WY UT

N.D.

NE CO

KS OK

NM TX

MI IN

MO AR LA

NY OH

PA WV

NC SC

TN MS AL

ME MA RI CT NJ DE MD DC

GA FL

AK HI Source: The National Organization for the Reform of Marijuana Laws

ANDERS RAMBERG

And so patients in Oregon, and the other 12 states that permit marijuana use for some medical reasons, continue to rely on the natural herb, with all the health risks, connotations, contradictory laws and controversial politics still attached.

Tangled laws All drugs regulated by the federal government — from prescription medications to illegal substances — are sorted into one of five classes, called schedules, according to criteria such as medical value, potential for harm and risk of abuse. Schedule I drugs are the most tightly controlled, and Schedule V the least. Marijuana is a Schedule I drug, which means the federal government recognizes no medical use for the drug, and its possession, sale and consumption are illegal in every case. Indeed, some medical marijuana opponents argue that with so many prescription drugs legally available, there is no real need for marijuana. Oregon is one of 13 states, however, that have passed laws permitting marijuana use to treat certain medical conditions. These laws prevent state or local authorities from arresting medical marijuana users who are in compliance with the state program. In 1998, Oregon voters approved an initiative that allows patients with certain medical conditions and confirmation from a doctor to pay about $100, fill out some forms and obtain a medical marijuana card. The card is good for one year, then it must be renewed. State law allows the cardholder to consume marijuana, grow up to six mature plants and keep up to 24 ounces of dried, ready-to-use marijuana on hand. But Oregon’s laws do not necessarily prohibit the federal government from making drug arrests. After all, marijuana is uniformly illegal in the eyes of the federal government. This puts medical marijuana users — as well as the doctors who HIGH DESERT PULSE • SUMMER / FALL 2009

sign their medical marijuana forms and their designated growers who prepare the drug — in a precarious position. Several doctors and medical marijuana users declined to be interviewed for this article. “I think some doctors just don’t want to get caught up in it,” says Dr. Stephen Kornfeld, an oncologist at Cancer Care of the Cascades, which is affiliated with St. Charles in Bend and Redmond. “There’s some fear that (the state) could change the law and decide to go after the doctors who have been allowing their patients to use it.” Oregon’s medical marijuana program started small. Just 600 Oregonians signed up for the program in 2000. Now there are 988 patients enrolled in Deschutes County alone. Statewide, 20,307 patients held medical marijuana cards as of July 1. One participant is Martin Halsey, who is quadriplegic and lives in Bend.

Profile of a user Halsey had completed a tour of duty in the Air Force and was working as a ski lift operator at Mt. Bachelor in 1985 when he went skiing during a blizzard on his day off. He launched himself off what he thought was a ski jump near the main ski lodge, but it turned out to be a rocky outcropping covered in a thin layer of snow. He landed head-first. As his body hit the snow with a thud, he heard his neck crack. “Luckily, I ended up on my back,” he recalled recently from his tidy mobile home in northeast Bend. “I could breath.” Halsey remembers his goggles were askew. He couldn’t move his arms or his legs. Snow was coming down so hard that he couldn’t see the sky. He was terrified. A co-worker skied down the run after Halsey and found him lying in the snow. Page 7

Cover story | MEDICAL MARIJUANA

ROB KERR

Marijuana is grown indoors, under special lights. Support groups offer horticulture advice for patients.

“I told him, ‘Don’t move me, I broke my neck,’” he said. The co-worker threw a jacket over Halsey to help him keep warm, then rushed down to find help. Halsey’s neck was broken between the fifth and sixth cervical vertebrae, just a few inches below the base of his skull. He is completely paralyzed from the chest down. He has some movement in his arms, but little strength. He struggles to hold even light objects in his hands. He uses a motorized wheelchair that he

can steer and control with one hand. Muscle spasms cause Halsey, who is now 53, near-constant pain and make it hard to fall asleep. “I have a lot of anxiety,” he adds. “Anxiety just goes with the territory of being injured.” In the years since his injury, Halsey has tried a long list of prescription drugs to treat his symptoms, including muscle relaxers to ease painful muscle spasms and pain medications to temper inflamed nerves. He has also tried a number of antianxiety pills.

But many of those drugs made Halsey feel loopy and drowsy. And some of the drugs had no effect whatsoever. Instead, Halsey now smokes one joint, or marijuana-filled cigarette, each day. That’s a little less than half a gram of dried marijuana flowers. He waits until about 5 p.m. when he’s home for the night, back from the library, the doctor’s office, a friend’s house or the aquarium store where he buys supplies for his saltwater fish tank. Within minutes of his first inhalation, Halsey feels the seizing muscles in his hands relax. He worries less. The constant pain dulls to a more bearable level. But he’s not too drowsy to watch a baseball game or manage his online fantasy baseball team until bedtime. Halsey’s medical marijuana card does not limit how much marijuana he can consume. But Halsey says that even though he could smoke marijuana all day long, he wouldn’t. “I don’t need that much of it,” he says. “And I have a life. I have things that I want to go do during the day.” That’s the irony of Halsey’s decision to smoke marijuana instead of popping pills. Despite marijuana’s popularity as a recreational drug, Halsey says it actually makes him feel less foggy and drowsy — more like himself — than the prescriptions. His physician, Dr. David Stewart, a rehabilitation specialist at The Center: Orthopedic & Neurosurgical Care & Research, says he believes Halsey.

MARIJUANA: PLANT VS. PILL

Comparing marijuana with its synthetic prescription form, which goes by the brand name Marinol.

Marijuana

Marinol or generic equivalent

Form

Dried flowers or leaves

Pill

Method

Smoking • Reaches bloodstream in minutes • Potency varies by plant • Risk of lung damage

Swallowing • Reaches bloodstream in 1-2 hours; individuals absorb sesame oil (in which medicine is dissovled) at varying rates • Consistent potency at levels of 2.5, 5 or 10 milligrams per color-coded pill

Swallowing (usually in baked goods) • Reaches bloodstream in 1-2 hours • Potency varies depending on temperature, how well batter was mixed, etc. Federal status

Illegal; Schedule I drug (no approved medical use, high risk of abuse)

Legal by prescription; Schedule III drug (accepted medical use, moderate risk of abuse)

Oregon status

Legal use and possession permitted for patients who apply for and obtain a medical marijuana card

Legal by prescription

Cost

• Illegal to buy marijuana in Oregon; cardholder or named designee must grow it; requires equipment, space, sunlight, water and knowledge of horticulture • Street price $8-10 per gram or about $300 per month

$12 (generic) to $24 (name brand) per pill from local pharmacies; at typical dosage of two per day, $720 to $1,380 per month

Ingredients

• Delta-9-THC and approximately 70 chemicals unique to marijuana • 400 other chemicals that may temper the psychoactive effects of delta-9-THC and may have their own medicinal properties

• Synthetic delta-9-THC • Sesame oil

Effects

• Can make users feel high, drowsy or weird • Reduces anxiety, nausea, pain and eye pressure • Stimulates appetite • Can cause paranoia • Exact effect varies by individual

• Can make patients feel high, drowsy or weird • Reduces anxiety, nausea and pain • Stimulates appetite • Exact effect varies by individual

History

• Used for thousands of years for medicinal and recreational purposes • Regulated by the U.S. government since 1937

• Developed and tested in 1980s; FDA-approved for chemotherapy and AIDS patients in 1985 • Generic version (dronabinol), approved in June 2008

Sources: Dr. Donald Abrams, Oregon Department of Human Services Medical Marijuana Program, NORML, Marijuana Policy Project, Bend area pharmacies, Solvay Pharmaceuticals Inc., Central Oregon Drug Enforcement

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Page 10

Number of patients with medical marijuana cards from 2000 to 2008: 25,000 20,000 15,000 10,000 5,000 0

23,114

Oregon voters approved a measure in November 1998 that allows patients to legally use marijuana to alleviate severe medical symptoms.

10,254 13,055 15,726 17,989

According to Stewart, doctors accept the fact that any drug — prescription or otherwise — will have different effects on different individuals. In fact, the doctor says he has had patients who tried marijuana but, unlike Halsey, found that it made their pain worse. “That’s the whole appeal of marijuana as a recreational drug: It enhances your sensory experience, whether it’s music or whatever activity. And so I’ve had patients who came to me and said, ‘I thought I’d try it and all it did was really enhance my … pain,’” Stewart recalls. Stewart says he had no qualms signing Halsey’s medical marijuana form. Stewart knows and trusts Halsey, who has been his patient for years. “This is not minor back pain,” Stewart adds. “He is in a lot of pain and he deserves access to whatever medication gives him the best quality of life.” Under Oregon law, no physician may prescribe marijuana. Marijuana is not sold at pharmacies like a prescription drug. Instead, a patient fills out an application for a medical marijuana card. As part of the application, a state-licensed physician must sign a statement that: • The applicant is a patient. • The applicant has at least one of nine approved conditions or symptoms listed on the form. • Marijuana may mitigate the patient’s symptoms. “Actually, the form makes my job very easy,” says cancer specialist Kornfeld. “Because I’m not prescribing anything. I’m just checking a box that describes my patient’s condition.” The system allows doctors to refuse to sign a form. All of the doctors interviewed for this article said they are comfortable denying a patient’s medical marijuana request. They said they would not sign an application for someone who is not a regular patient, or for a patient with mild symptoms. “The last thing I want is to get labeled as the local ‘pot doctor,’” Stewart says. “I don’t want to be flooded by patients who all they’re after is a marijuana card.”

6,075

A doctor’s opinion

GROWTH OF OREGON'S MEDICAL MARIJUANA PROGRAM

600 1,700 2,492

Cover story | MEDICAL MARIJUANA

‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08

Source: Oregon Department of Human Services Medical Marijuana Program ANDERS RAMBERG

“The last thing I want is to get labeled as the local ‘pot doctor.’ I don’t want to be flooded by patients who all they’re after is a marijuana card.” Dr. David Stewart, rehabilitation specialist at The Center Stewart, who is one of seven busy doctors in The Center’s department of physical medicine and rehabilitation, says his patients have a three-month wait for an appointment. “If I got 10 more patients a month who were looking for a (marijuana) card, that would push things out even further for the patients who really need to see me,” he says.

Potential for abuse Some doctors interviewed for this article said they would refuse to sign even for patients with certain approved conditions. Stewart says he would not approve marijuana use for an Alzheimer’s patient, HIGH DESERT PULSE • SUMMER / FALL 2009

ROB KERR

Martin Halsey’s medical marijuana card, good for one year, is issued by the state.

“Actually, the form (for medical marijuana) makes my job very easy, because I’m not prescribing anything. I’m just checking a box that describes my patient’s condition.” Dr. Stephen Kornfeld, oncologist at Cancer Care of the Cascades

because consuming marijuana is more complicated than, say, swallowing pills. Alzheimer’s disease, an illness that involves debilitating loss of mental function, is on Oregon’s list of conditions approved for medical marijuana use. “Giving (marijuana to) somebody who is already losing their orientation and their basic ability to make good judgments … is not a good idea,” Stewart said. Some nonprofits, including one called Mothers Against Misuse and Abuse, or MAMA, hold traveling clinics specifically to help patients qualify for Oregon’s medical marijuana program. A patient who has an underlying medical condition that is listed on the medical marijuana application may bring his or her records to a MAMA clinic, pay a $250 fee and a physician will, in many cases, sign the application. MAMA organizers say they are providing a service to sick Oregonians. Deschutes County District Attorney Mike HIGH DESERT PULSE • SUMMER / FALL 2009

Dugan says the clinics are one example of how the medical marijuana act is being abused. He suspects that recreational marijuana users are obtaining cards to avoid the threat of arrest. A medical marijuana card, Dugan says, has become “a virtual get-out-of-jail-orprosecution-free card.” After citing the number of medical marijuana cardholders in Oregon — more than 20,000 — he adds, “if you believe that there are that many sick people who cannot be treated without marijuana, I’ve got a bridge for sale.” Stewart admits that he feels some uneasiness over signing any medical marijuana application. He says he is always careful to tell patients that he does not condone their use of marijuana. And he notes that in patients’ charts. “There’s this extra anxiety with marijuana, because there’s a very strong prescription against it at the federal level,” Stewart says. “And … you could be perceived as suggesting it.” Unlike the drugs Stewart usually prescribes, marijuana plants grown by a patient or the friend of a patient haven’t been tested by the Food and Drug Administration. “It’s not entirely benign,” he says. “It’s probably easier on your system than a lot of drugs you can take. … But you really don’t know how it’s affecting your underlying health.” That’s because despite marijuana’s prominence as a criminal substance, and Continued on Page 32 Page 11

Get Ready |

MOUNTAIN BIKING

Get ready to roll Start now and spend autumn wheeling the Central Oregon trails BY LILY RAFF

n its surface, mountain biking is intimidating. Its name conjures images of spandex-clad athletes racing down steep hills and flying over logs. But it doesn’t have to be that way. Mountain biking can be as simple as pedaling along a flat, easy dirt path. “If you can ride a bike, you can go mountain biking,” says Lev Stryker. Stryker, along with Melanie Fisher, owns Cog Wild Mountain Bike Tours in Bend. Every summer, they lead first-time mountain bikers on trails through Central Oregon. And Brad Boyd, the owner of Eurosports in Sisters, teaches a mountain biking class at Central Oregon Community College each spring. The trick, they all say, is to build skills and confidence gradually. Here’s a plan to get in the saddle and off-road before the leaves change color.

August: Get in shape You don’t have to be a serious athlete before you hit the trail. But you should be in good overall condition. Get a doctor’s permission if you’re over 60, have serious health problems or have been sedentary for years. Quads, hamstrings and glutes are the main muscles engaged during cycling. Get those parts in shape by — you guessed it — riding a bike. Spend some time on smooth, easy roads or use a stationary bike at the gym. Include some hills in your road route, or increase the resistance on the stationary bike, to give your muscles more of a workout. It takes some real strength to get up bumpy hills on a mountain bike. “The first time you go up a hill on your mountain bike, it’s very hard,” Stryker says. “But … there’s a downhill.” While you’re riding at a comfortable speed, practice the “at ready” position: Your weight should be out of the saddle and evenly distributed on both pedals. The pedals should be equally high off the ground, to maximize your ground clearance. “If your weight is off the saddle and you’re relaxed and looking down the trail, you’re ready for whatever’s next,” Boyd explains. Assume this position when you move to the trail, and your bike will easily move over any roots or rocks, without knocking you off balance. Page 12

ROB KERR

Cyclists pedal past High Desert scenery on a flat, easygoing bike trail.

Make sure you can comfortably pedal a bike for at least 30 minutes before going off-road. Central Oregon has lots of easy mountain biking routes, and there’s never any harm in turning back early to avoid fatigue. But trails offer their own challenges, and you don’t want to be huffing and puffing during your first few dirt rides.

September: Get in gear Not all bikes are created equal. Mountain bikes have sturdier frames and wider, knobbier tires than road bikes or cruisers. Don’t hit the trail on a bike that is equipped only for pavement. “Get a bike-shop-quality bike,” adds Boyd. “… You’re setting yourself up for failure if you have the wrong equipment.” A decent mountain bike runs about $500. But you don’t have to spend that much to get started. Most bike shops in the area offer a full-day rental for $30. Rentals are a great way to try out the sport and test different bikes; many HIGH DESERT PULSE • SUMMER / FALL 2009

shops will apply the cost of three rentals toward the purchase of a new bike. Mountain bikes are divided into three general categories. Hard-tail bikes have solidlooking frames. Front-suspension bikes have springy-looking devices beneath the handlebars, to cushion the ride slightly. Full-suspension bikes have springs at the rear of the bike, too, for even more cushioning. Stryker recommends starting with a hardtail bike. “It’s simpler, it’s less maintenance and it … helps you learn to ride the trails better,” he says. But Boyd and Fisher both recommend a front-suspension model. “It cushions you a little, but it’s all you need,” Fisher explains. Any bike rental includes the use of a helmet for no additional fee. Always wear a bike helmet — it could prevent severe head injuries or even death in the case of a fall, and it provides protection from low-hanging branches. Know your route and have a map on hand in case you get lost. Buy a map of local mountain biking trails at the same shop where you rent a bike, or at any sporting goods store in the area. The Central Oregon Mountain Bik-

ing & Cross-Country Skiing Trail Map (by Adventure Maps, about $10) is a waterproof topographic map with trails that are colorcoded according to difficulty. If you don’t own a bike rack, employees at the rental shop will help you remove the front wheel so it fits into your car. Local experts recommend starting at Shevlin Park. The trails there are relatively rock-

free and the hills are gradual. Other beginner-friendly trails include the Suttle Tie and Peterson Ridge trails near Sisters, and certain portions of the Deschutes River Trail and the Phil’s Trail network west of Bend. Take some time to cycle around the parking lot and learn the components of the bike. A mountain bike has a front and rear brake,

TRAIL ETIQUETTE • Share the trail: Mountain bikers are usually the fastest trail users, so they should yield to all other non-motorized users, including hikers, runners and horseback riders. “Yielding means stopping and putting your foot down on the ground,” Stryker says. • Stay on course: Single-track, or a trail that is so narrow that hikers must walk single-file, is the holy grail of mountain biking. To keep tracks from widening over time, it’s important that cyclists stay on trail even while passing others. To pass, keep your tires on the trail and lean your bike and body to the side, away from the person you’re passing. • Yield properly: When approaching another cyclist head-on, the person going uphill has rightof-way. The person pointed downhill should pull to the side of the trail, stop and wait for the uphill cyclist to pass. • Leave no trace: Don’t ride on muddy trails; ruts will form and soil will erode, damaging the trail for months or even years. Pack out all trash and belongings. • Give back: Help take care of your favorite trails by joining the Central Oregon Trail Alliance or the Sisters Trail Alliance. For information, visit www.cotamtb.com or www.sisterstrails.com.

Get Ready | MOUNTAIN BIKING Essentials for trail biking: 1. The right bike: Find a good fit for your body and your budget at a local bike shop.

2. Helmet: Make a habit of strapping one on every time you mount your bike.

3. Tire-changing tool: Essential, as flats are common on rugged trails.

4. Tire tube: Carry a spare on every ride. 5. Tire pump: It fits folded up and at-

tached to the bike frame until it’s needed.

6. Water: A hydration pack lets you ride for

several hours without risking dehydration. Be sure to carry snacks as well.

7. Patch kit: Save a punctured tire tube from having to be replaced entirely.

8. Padded shorts: They make a long,

bumpy ride much more comfortable.

9. Gloves: Improve your grip and protect

your hands from scrapes, sunburn and blisters.

10. Map: Handy even when you’re not lost; use one to find new routes as your confidence builds.

10 PHOTOS BY PETE ERICKSON

each controlled by a lever attached to the handlebars. A mountain bike also has a front and rear gear shifter. Practice shifting gears and applying the brakes. Know which hand controls the front brake and which hand controls the rear brake. Know which direction to shift gears to make it easier or harder to pedal. “That shouldn’t be your focus when you’re out on the trail,” Stryker says. Next, start pedaling that bike along a trail. Go at a comfortable speed and watch carefully for roots, rocks and other obstacles. Congratulations, you’re mountain biking! If you hit a rough patch of trail or run out of steam riding up a hill, don’t feel bad about dismounting the bike and walking. “Walking,” Stryker says, “is part of mountain biking.”

October: Get better Practice will make you a more confident cyclist, able to cover more varied terrain. Page 14

Focus on finding a comfortable “home” gear and then shifting as needed. “The main thing is to select a gear that lets you pedal easily but doesn’t have you spinning wildly,” Stryker says. If you have friends who bike, and are supportive of a beginner, go on rides with them. They can show you new routes and give you some tips. In certain cases, however, it’s a good idea to build skills before pairing up for rides. “You don’t want to go with friends who are aggressive cyclists and push you too hard or you’ll end up in a scary situation. And you usually don’t want to learn from your significant other,” warns Boyd. “It doesn’t matter if you’re male or female, it’s hard to learn from your significant other and not get in a fight.” Get involved in a local volunteer group to help take care of bike trails and to find other riders at your skill level. The Central Oregon Trail Alliance and the Sisters Trail Alliance arrange rides and work parties. Women may join the Bend Bella Cyclists, a group of fe-

male road and mountain bikers who take organized rides and hold clinics throughout the year. Branch out by riding in different places. Learn basic maintenance, including how to change a tire; flats are common in mountain biking. Ask an employee at a bike shop to show you how, or read about it in any basic mountain biking book. As your cycling improves, you may find that additional equipment adds to your comfort and improves your riding. A pair of cycling gloves ($5 to $30 at local sporting goods stores), for example, will reduce blisters, scrapes and sweaty palms. And a water-toting backpack ($15 to $70 at local sporting goods stores) will allow you to ride farther without risking dehydration. According to some avid cyclists, fall is the nicest time of year to spend on trails. Just remember to stop and admire the scenery every once in a while. “Go have fun outside,” Fisher adds. “That’s the whole point.” • HIGH DESERT PULSE • SUMMER / FALL 2009

How does he do it? |

LEW HOLLANDER

Fit at any age Local phenom proves there is no age limit for athletes BY LILY RAFF

ew Hollander approaches human health just as he approaches his work as a physicist: He develops a theory — whether it relates to vitamins, stretching or weight training — and then conducts experiments. For proof that this scientific method of fitness works, look no further than Hollander himself. In May, Hollander qualified for his 20th Hawaii Ironman World Championship — a 2.4-mile swim, 112-mile bike ride and 26.2-mile run — just three weeks before his 79th birthday. It’s no wonder, then, that Hollander is an Oregon legend. This spring, Hollander entered the multi-sport Pole Pedal Paddle for the 18th year as a pair with 73-year-old Roger Daniels. Some Portland men in the 35-44 age group named their team “Gunnin’ for Ironman Lew.” Their goal? To finally beat the septuagenarian pair after years of trailing them. “It was the ultimate compliment,” Hollander says. The youngsters pulled out a win this year, but only by a few minutes. For all his age-defying athleticism, Hollander insists he’s a regular guy. He employs a daily routine of calisthenics and stretching. He makes sure he eats plenty of fruits and vegetables, but still allows himself daily doses of chocolate. “If it has chocolate in it, I’ll eat it,” he says. He also drinks beer and wine. And he insists that he doesn’t spend all of his time working out. He reads, writes and plays pingpong, among other things. As a major race approaches, Hollander ramps up his training. But during the lulls between competitions, he simply makes sure he gets some exercise each day. “Today I feel like going for a bike ride,” he says, “so I’m going to do that.” Once he decides what kind of workout he wants to do, he calls his buddies to see if anyone wants to join him. “I prefer to work out with someone else,” he says. Hollander makes sure he always has some sort of athletic competition on the horizon. “I wouldn’t get out of bed in the morning if I didn’t have an entry sent in,” Hollander says. Hollander hasn’t suffered any chronic joint pain, and he credits it to the glucosamine and other joint-friendly supplements he started

HIGH DESERT PULSE • SUMMER / FALL 2009

ANDY TULLIS

Lew Hollander strides through the 2007 Oregon Duel in the Desert Duathlon. Now 79, the Bend physicist remains competitive in endurance sports.

LEW HOLLANDER Family status/occupation: Married, with six grown children; physicist Activities: Swimming, cycling, running, tennis and horseback riding Splurges: Anything with chocolate in it; occasional beer and wine Setbacks: Hollander has no chronic injuries, but he has been hurt. During an Ironman triathlon in New Zealand 10 years ago, he broke his pelvis and a couple of ribs when he tumbled off his bike in the second leg of the race. Hollander limped through the 26.2-mile run — “in 7 (hours and) 58 (seconds), my longest marathon ever,” he says — to finish.

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How does he do it? | LEW HOLLANDER taking nearly 40 years ago. One time, while walking back from the barn after giving his horses vitamins and supplements for their joints, Hollander, who is a longtime horseback rider, stopped in his tracks. “I had just given them all this stuff and I thought, ‘Why aren’t I taking it?’” he recalled. Every morning, Hollander drinks a tall glass of greenish-gray sludge that contains probiotics, vitamins, protein and minerals. “It tastes better than it looks,” he says. He does about 100 pushups and 200 abdominal crunches every day. This routine, along with basic stretching, usually takes about half an hour, he estimates. Hollander doesn’t do any weight training. For the rest of the morning, Hollander works at his desk. He owns a physics research company and has a patent pending on a new method of making nanodevices. The scientific term “nano” refers to objects that are just a few atoms wide and a few atoms tall. “I put off the long rides and exercise as long as possible,” he chuckles. Whether he runs, bikes or swims, Hollander exercises for at least an hour each day, and he gives his maximum effort for at least a couple of minutes of each workout. During sustained aerobic activity, such as jogging or cycling, for example, the body uses oxygen to break down glucose and create energy. During more intense spurts — sprinting up a steep hill, for instance — the body’s demand for oxygen exceeds its supply, so the body relies on energy stored in the muscles. This is called anaerobic activity. Most people can only perform this intense exercise for up to two minutes at a time. Anaerobic activity burns fewer calories than aerobic activity. But some athletic trainers say it is a key to improving athletic performance. Hollander subscribes to this theory. “Go anaerobic every day,” he advises. “Most people haven’t been anaerobic since they were 15.” Hollander insists that he doesn’t push himself as hard as he did before he turned 70. His long-term goal is simply to stay fit and active as long as he can, and so far he sees no reason to stop.

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ROB KERR

The walls of Lew Hollander’s home are layered in medals, trophies, ribbons and pictures from a long life in outdoor activities and athletics.

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Beyond medicine |

END-OF-LIFE PLANNING

The decision of a lifetime We talk about quality of life. Shouldn’t we also talk about quality of death? BY BETSY Q. CLIFF

he end of Dale Stewart’s life began when he was 83, five years before his death. He was diagnosed with prostate cancer in 2003, and the doctors gave him a choice between radiation or what’s often called watchful waiting, monitoring the cancer but not treating it. The otherwise healthy man chose radiation, said his wife, June. That was the beginning of an odyssey through the medical system, with stops for cancer treatment, heart surgery and a major procedure to alleviate diabetes symptoms. There were multiple treatments for bleeding, several therapies for cancer, treatments for the side effects of treatment. Each week brought multiple doctor appointments and, during bad weeks, a hospital visit, said June. “Dale’s social life was going to the doctor.” Dale’s bladder failed a few years after it was damaged by radiation therapy, June said, and he had a permanent catheter placed in his abdomen. He developed multiple infections, each of which needed treatment with antibiotics. Medicine controlled each episode, but each new procedure left Dale a little weaker. He lost the ability to drive, to play golf and, as things got worse, to take care of himself. “As you lose those abilities,” June said, “it’s devastating to your person.” In May 2008, he developed another infection. If he went to the hospital, they both knew the routine: He’d be hooked up to an IV, given medications to clear it up and sent home, likely a week later. He had done it many times before. “Do you want to go to the hospital?” June said she asked him at their home in Touchmark at Mt. Bachelor Village in Bend. “No,” June recalled him saying. “I don’t want to do that anymore.” About a week later, he died, the infection having taken over his already frail body. Dale Stewart was 88. Dale likely could have been treated for that bladder infection and might

Page 18

ANDY TULLIS

June Stewart looks at pictures (above) of her late husband, Dale, at her home in Bend. Dale eventually decided to stop medical interventions. At left is a family photo of the couple taken in 2001.

have lived some time longer, maybe days, maybe weeks, maybe months. But, his wife said, the couple made the decision to stop the endless treatments and to end their painful journey through the medical system. Doctors and hospice volunteers supported them, she said, but it was the Stewarts’ decision and theirs alone. “It’s a decision that you have to come to after trying so many things. It’s HIGH DESERT PULSE • SUMMER / FALL 2009

a hard decision to do,” she said. “Nothing was healing. In fact, he was going downhill,” she said. “You just have to know that there comes a time.” For the Stewarts, stopping treatment was a rational decision, a natural step after trying to help Dale for years. In some ways, however, their actions represent a radical shift of perspective, not only in their own lives but for the culture of the medical system. The modern medical system, particularly in the United States and other Western countries, is designed to treat illness, to try to heal patients. Most of the time, those goals are aligned with a patient’s goals. After all, who doesn’t want a hospital visit to make him feel better? Near the end of life, however, a person’s goals may change. Sometimes, treatment becomes futile and patients resign themselves to the illness, accepting the inevitability of death. Yet the medical system can make it difficult to shift those goals. Not all doctors feel as comfortable talking to patients about the end of life as they do discussing treatments. In the emergency room, protocols often dictate that patients receive any potentially helpful drug or procedure. It runs against the grain to forgo treatment. That can mean patients end up with unwanted therapies that have little chance of making them better. “People really need to be reminded,” said the Rev. Heather Starr, a Unitarian Universalist minister and part-time chaplain at St. Charles Bend, “that in 2009 the hospital can do a lot of stuff that you might not necessarily want done.” When patients or families do not want to embrace every available treatment, it’s often up to them to stop the inertia of the medical system. They must become advocates for the kind of care they want, particularly if that is no care. “It’s up to the individual to say, ‘Hey, I’m not having this anymore. This is it,’” said June Stewart. But all too often, doctors and end-of-life experts say, people do not express their wishes for care at the end of life or, if they do, those wishes are not honored. When those wishes are not known, the medical system defaults to the most aggressive type of care. In many cases, the result is costly, invasive care that may not help patients. “Sometimes modern medicine takes patients down the road where we’ve taken people too far,” said Dr. Stephen Kornfeld, a Bend oncologist and former medical director at a local hospice. “We’ve caused a lot of suffering and we haven’t really benefited them at all.” HIGH DESERT PULSE • SUMMER / FALL 2009

PETE ERICKSON

“People really need to be reminded that in 2009 the hospital can do a lot of stuff that you might not necessarily want done,” says the Rev. Heather Starr, a part-time chaplain at St. Charles Bend and Unitarian Universalist minister, pictured visiting with a patient at the hospital.

Too much treatment End-of-life care advocates are particularly concerned that, of the people who die each year in the United States, 30 percent die in hospitals, according to Medicare data. Better, they say, to die at home or in a palliative care setting designed for comfort instead of treatment. In hospitals, patients are more likely to receive aggressive interventions at the end of life, including feeding tubes, breathing machines and multiple resuscitations. “It’s pretty much a default that if you’re in the hospital and an event happens, they’re going to call a code (give an emergency resuscitation),” said Dr. Jeffrey Absalon, a Bend physician who specializes in internal medicine. “We may be able to continue to do more, but it may no longer be in the patient’s best interest.” Resuscitation, restarting a stopped heart, is particularly vexing to many physicians and end-of-life care advocates. There’s a perception among patients, they say, that resuscitation will help heal someone, even if the un-

derlying problem has nothing to do with the heart. Instead, it does not help patients with terminal conditions, but merely stalls the inevitable and causes more pain. “I’ve been to many codes at the hospital, and the question is, why are we coding this person?” said Dr. Robert Boone, a Bend oncologist and former medical director at a local hospice. “I mean, she’s dead. They say, ‘Code Blue Room 8.’ You go there and there’s a 95-yearold lady. She’s lying there and blue. She hasn’t had a heart attack; she’s dying of pneumonia. She stops breathing and the idea is all we have to do is invite George Clooney in, put her on a breathing machine and all of a sudden she’s 25 and healthy again. It doesn’t work.” The number of terminally ill patients who leave the hospital after a resuscitation, Boone said, is close to zero. “They end up on a ventilator in the intensive care unit and their family has to pull the plug,” said Boone. “They’re never going to get better. They’re never going to wake up. They’re really dead except you’ve got this machine that can

“Sometimes modern medicine takes patients down the road where we’ve taken people too far. We’ve caused a lot of suffering and we haven’t really benefited them at all.” Dr. Stephen Kornfeld, Bend oncologist Page 19

Beyond medicine | END-OF-LIFE PLANNING

PETE ERICKSON

A POLST form hangs on the refrigerator of Mary DeBates, 90, at her apartment in Aspen Ridge in Bend. POLST, which stands for physician orders for life-sustaining treatment, is one method for helping ensure a person’s end-of-life wishes are known. keep their heart and their lungs beating, and that’s such a tragedy for people.” Oregon is better off than many places. The state has led the nation in a movement about quality of care at the end of life. Compared with the national average, fewer people die in hospitals here; just 19 percent of patients in

Central Oregon, according to Medicare data. Dr. Susan Tolle, an internist at Oregon Health & Science University and director of the Center for Ethics in Health Care, was one of the leading developers of a form known as POLST, which stands for physician orders for life-sustaining treatment. POLST is cited

as a model for end-of-life directives. Because it is a physician order, it directs nurses, other physicians and EMTs about how to care for patients. The POLST form, for example, dictates whether to resuscitate a patient, when to give the patient antibiotics and how much medical intervention the patient wants. In Oregon, the forms are used in nursing homes, hospice programs, doctors’ offices and hospitals. About 87,000 forms are distributed each year in the state, according to the national POLST Web site. Central Oregon, Tolle said, is particularly good in end-of-life care. “You have remarkably high rates of hospice referral,” she said. There exists here “a culture where death at home is more common than in most parts of the state and far more common than in most parts of the nation.” That makes it easier for doctors to initiate conversations about death with patients, she said, and more likely that patients will already be thinking about less invasive care at the end of life. Continued on Page 35

Kids’ health |

WHEN TO CALL THE DOCTOR

Where does it hurt? When reading the symptoms adds up to calling your family doctor BY BETSY Q. CLIFF

t starts with a whine. “I don’t feel good.” That, as any parent knows, can be enough to derail a day. Going to work? That’s out the window. School? Not happening. Dinner plans? Forget ’em. A child being sick is often a minor disappointment, one of the bumps in the road of life that everyone gets over. Yet it can still leave parents with many questions: Can the child go to school? Does she need to see a doctor? Should I treat his illness or just let him rest? As children get ready to head back to school — and often into sick season — High Desert Pulse called a number of pediatricians for their advice on when to seek medical attention. Charts at right and on the next page list the symptoms that are considered to signal more serious issues. In general, parents should trust their gut, physicians say. “Parents are experts on their kids,” said Dr. Peter Boehm, a pediatrician at Mosaic Medical Clinic in Bend. “Even though they may not be able to list in detail why their (kids) are sick, they usually know.” The primary thing parents should remember, said Dr. Megan Neuman, a pediatrician at Legacy Health System in Portland, is that no matter what other advice you get, if “you still feel that something isn’t right, that instinct trumps everything.” Younger children and babies, pediatricians said, are more likely to need to be seen by a doctor more often. In particular, babies who develop a fever should go to a doctor’s office, said Dr. Neil Ernst, a pediatri-

HIGH DESERT PULSE • SUMMER / FALL 2009

cian at Cascade Medical Clinic in Redmond. “A fever is not harmful, but what it can tell us is that there may be something underlying that needs to be investigated.” Ernst said younger children who are not fully immunized can be susceptible to infections such as meningitis. The Hib vaccine, generally given in several doses in the first year of life, protects against a common type of meningitis. Once kids have their vaccines, he said, a fever is less likely to signal a serious disease. Kids of all ages should see a doctor immediately if they have a fever with a rash, said Dr. Brenda Hedges, a pediatrician at Central Oregon Pediatric Associates in Bend. A rash that is not elevated and has a purplish tint is also very worrisome, Hedges said, as it can be a symptom of a severe blood infection. Trouble breathing and lethargy bad enough that parents have trouble getting their children to do anything are bad signs, doctors said. And they said to watch for blood in vomit or stool. “Pay attention to the kid,” said Neuman. “If they are eating and drinking and playful, then they may be OK. If they are not, then they may not be OK.”

The school question The question of whether a child can go to school or day care gets into not only how the kid feels, but also how contagious he is. “That’s a complicated issue because there’s an ethical piece to it,” said Boehm. Kids, he said, should not go to school if there is a chance they will infect other kids, particularly if they have come back from a

WITH A COUGH, CALL THE DOCTOR IF... • Cough is barky, voice is hoarse and inhaling produces noise, which may mean moderate or severe croup • Child is less than 1 month old • Child is less than 3 months with cough for more than 3 days • Cough has led you to keep the child home for more than 3 days • Coughing is continuous • Earache, sinus pain, chest pain or nasal allergy are also present

WITH A FEVER, CALL THE DOCTOR IF...

• Child’s age is: – Birth to 6 months with rectal temp over 100.4˚ – 6-24 months old and fever (rectal temp over 100.4˚) is present for more than 24 hours – Older than 24 months with temp of 105˚ or fever (oral temp of 99.5˚ or rectal temp of 100.4˚) for more than 3 days • Fever is accompanied by stiff neck or rash with purple spots SOURCE: LEGACY HEALTH SYSTEM ILLUSTRATIONS BY GREG CROSS

Continued on next page Page 21

Kids’ health | WHEN TO CALL THE DOCTOR trip with an illness. On the other hand, Boehm said, he’s more liberal when kids have caught a cold that half the class already has. In that situation, he said, the chances of your child transmitting an illness are reduced. Kids who have a fever are generally still contagious, said Hedges, and should not go to school or day care. Another reason to keep kids home is if they are vomiting or have diarrhea, something Neuman gracefully refers to as “uncontrolled secretions.” As in, if your kids have uncontrolled secretions, you should not make someone else take care of them. Physicians said kids are usually OK to go back to school if they have a mild cold and are not acting sick. “If they have a little bit of a runny nose and if they have enough energy,” said Ernst, “then I say send them to school.”

WITH AN EARACHE, CALL THE DOCTOR IF... • Child also has a stiff neck • You see pink or red swelling behind ear • Earache is severe and not improved within two hours of taking ibuprofen • Child is younger than 2 years

WITH VOMITING OR DIARRHEA, CALL THE DOCTOR IF... • You see signs of dehydration, such as a very dry mouth or no urine within 8 hours • Child is confused, has a stiff neck, a bulging soft spot on neck or a fever above 105˚ • Child also has a headache • You suspect poisoning • There is blood in the vomit and it’s not from a nosebleed • Child has abdominal pain that doesn’t improve after vomiting • Child also has fever temperature above 105˚ • Child is younger than 3 months and vomits more than twice • You are giving your child Pedialyte or other hydrating drink and the child vomits everything for more than 8 hours

Err toward caution Regardless of what symptoms your child has, parents who are worried should call the doctor. Many offices have a nurse advice line to help parents decide whether they need to bring the child in. There are also several Web sites that can help — check out www.legacyhealth .org/kidcare or kidshealth.org. But, doctors say, when in doubt, it’s always better to call. “I tend to err on the side of calling,” said Hedges. “We would rather have them call us and come in than be worried.” •

WITH A RASH, CALL THE DOCTOR IF...

• Rash is purplish or has blood-colored spots • Rash is all over the body • Child also has a fever • Child has large blisters on skin, or bright red skin that peels in sheets • Girl is menstruating and using tampons • Localized rash has a bull’s-eye pattern and child has possibly been exposed to ticks • Localized rash has lasted longer than 7 days or includes pimples or peeling fingers • Teenager has localized rash in genital area

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Sorting it out

BACK-TO-SCHOOL SHOTS

Up on their shots? Low-cost vaccinations for kids can reduce the sting for parents

ROB KERR

Deschutes County Health Department registered nurse Kate Moore gives immunization shots to La Pine Middle School student Dion Roccasalva.

BY LILY RAFF

Give your child a great start to the school year by taking advantage of free and reduced-cost clinics in Central Oregon.

IMMUNIZATIONS

• Jefferson County Health Department immunization clinic

Students in Oregon are required to be vaccinated against diphtheria, tetanus, pertussis, polio, chickenpox, measles, mumps, rubella, hepatitis B and hepatitis A before beginning kindergarten or first grade. This is the second year that hepatitis A has been required. Some school districts were lenient last year but will enforce the requirement more strictly from now on.

Where: 715 S.W. Fourth St., Suite C, in Madras When: 2 to 3:45 p.m. Mondays and 9 to 11:45 a.m. Fridays Cost: $15 per shot for patients without insurance; patients with insurance pay actual costs up front and then submit receipt for reimbursement Other info: Walk-ins only, no appointment needed Contact: 541-475-4456

• Deschutes County Health Department immunization clinic

• Crook County Health Department immunization clinic

Where: Deschutes County Health Department, 2577 N.E. Courtney Drive, in Bend When: 3 to 7 p.m. Aug. 26 Cost: $15.19 per shot for patients without insurance; private insurance and Oregon Health Plan accepted and billed, so patients do not have to pay up front Contact: 541-322-7400

HIGH DESERT PULSE • SUMMER / FALL 2009

Where: 375 N.W. Beaver St., Suite 100, in Prineville When: 8:30 to 11:30 a.m. and 1 to 4 p.m. Mondays Cost: Varies according to vaccines and patient’s ability to pay; patients with insurance pay up front and then submit receipt for reimbursement; $12 administrative fee added Other info: Walk-ins only, no appointment needed Contact: 541-447-5165

• Shots for Tots: Immunization clinics for

children in day care, preschool or school Where and when: • Prineville: Aug. 29 at Crooked River Elementary School, 641 N.E. First St. (541-447-6488) • Sisters: Sept. 19 at Sisters Elementary School, 611 E. Cascade Ave. (541-549-8981) • Redmond: Sept. 26 at Hugh Hartman Campus, 2105 W. Antler Ave. (541-923-4840) • Bend: Oct. 3 at Pilot Butte Middle School, 1501 N.E. Neff Road (541-383-6260) • La Pine: Oct. 10 at La Pine Middle School, 16360 First St. (541-536-5967) All clinics held from 10 a.m. to 2 p.m. Cost: Free for patients without insurance; private insurance and Oregon Health Plan accepted and billed Contact: Heather Kaisner, 541-322-7400

Continued on next page Page 23

Sorting it out | BACK-TO-SCHOOL SHOTS

HEALTHY BEGINNINGS Healthy Beginnings provides a series of tests for children from birth to age 5. Some parents sign up their children because of concerns about their speech, vision, hearing or behavior. Others simply want their children screened prior to entering kindergarten. Healthy Beginnings offers 12-point screenings to check the physical, mental and behavioral development of preschool children. Where and when: Throughout Central Oregon; call for exact locations and times • In Bend on Aug. 18, Sept. 4 and Nov. 20 • In Redmond on Aug. 7, Sept. 25 and Dec. 11 • In La Pine on Oct. 16 • In Sisters on Oct. 30 Cost: Free Other info: By appointment only Contact: 541-383-6357 or www.healthybeginning.org to sign up

SPORTS PHYSICALS A pre-sports physical is required by Oregon law at least once every two years for children between seventh and 12th grades who wish to participate in sports. • Where: The Center: Orthopedic & Neurosurgical Care & Research, 2200 N.E. Neff Road, Suite 200, in Bend When: 5:30 p.m. Aug. 11 for boys and Aug. 13 for girls Cost: Free Other info: Exams performed on a first-come, firstserve basis; all students must bring a copy of the presports physical form signed by a parent; form may

be downloaded at www.centerfoundation.org. Contact: Laura Schwendiman, 541-382-3344 • Where: Pioneer Health Care Center, 1103 N.E. Elm St., in Prineville When: 5:30 to 7:30 p.m. Aug. 11 Cost: $10 per student Other info: No appointment required; if parent or guardian not present during the exam, the child should bring written permission; all students must bring copy of the pre-sports physical form filled out and signed by a parent. Contact: 541-447-6263

HEART SCREENINGS Free heart screenings can identify hidden heart defects in student athletes, from sixth to 12th grades. They include an echocardiogram, an electrocardiogram and heart rate, blood pressure, body mass index and cholesterol tests. Where: The Heart Institute of the Cascades, 2500 N.E. Neff Road, in Bend When: Twice a year; dates to be determined upon registration; half-hour appointments scheduled according to a waiting list Cost: Free Other info: To register, call 541-706-4960 with the student’s name and a parent’s phone number and e-mail address; parents will receive an e-mail with the student’s appointment time and date.

GENERAL CARE School-based health clinics provide regular checkups, sick visits and immunizations for babies, children and teens. Appointments and walk-ins welcome. Run by nurse practitioners, these clinics are more like a doctor’s office than a school infirmary. Nobody is turned away for inability to pay. Summer schedule is listed below; call for fall schedule. Where and when: Call clinics for exact hours • Redmond: Wednesdays at Lynch Elementary School, 1314 S.W. Kalama Ave. (541-504-3589) • Bend: Tuesdays and Thursdays at Ensworth Elementary School, 2150 N.E. Daggett Lane (541-693-2222) • La Pine: Mondays, Wednesdays and Fridays at La Pine Community Campus, 51605 Coach Road (541-536-0400) • Madras: Mondays, Tuesdays and Thursdays at Madras High School, 390 S.E. 10th St. (541-325-0490) Cost: Sliding scale depending on income; private insurance and Oregon Health Plan accepted Other info: Parents asked to call for appointment or to check estimated wait time before bringing children to a clinic. •

Body of knowledge | POP QUIZ

Bicep curl

Pair them up

Back row

Back extension bend

Leg extension

Assisted chin-up

Hip abduction

A balanced workout leaves you in good shape, but which muscles are complementary? BY BETSY Q. CLIFF

Chest press

Leg curl

Hip adduction

Abdominal bench

HIGH DESERT PULSE • SUMMER / FALL 2009

ome trainers call it working the “mirror muscles,” those muscles you can see in the mirror. “If you watch people in the gym, guys in particular, they spend a ton of time working pecs and biceps and they forget their backs,” said Kyle Will, a personal trainer and owner of WillRace Performance Studios. That, said Will, is a mistake. Training the complementing muscle groups, those on the front and the back of the body, is essential for safety, performance and appearance. “It’s definitely important,” said Will. “Oftentimes injuries are the result of an imbalance in strength in muscle groups.” Working the complementing muscle groups can also help with performance, said Will. When you throw a frisbee, kick a ball or make a ski turn, you’ll be incorporating all muscles, so it pays to train them all. And, there are aesthetic reasons. Fail to work out both sides of the body and you might end up tromping around like the Incredible Hulk. “If you’re really tight in the chest and biceps,” said Monica McClain-Smith, fitness director at Juniper Swim & Fitness, “then that will give you a hunched-over appearance in the shoulders.” Each major muscle group has a complement; the most well known are biceps and triceps. Can you match the exercise on the left with the exercise that strengthens the complementing muscle group on the right? • Answers: 1 - D (tricep/bicep muscles). 2 - A (pectoral/latissimus dorsi muscles). 3 - C (hamstring/quadricep muscles). 4 - E (inner thigh/gluteus maximus muscles). 5 - B (abdominal/lower back muscles).

Page 25

Truth in labeling |

THE PACKAGE DEAL

Is what’s on the box what’s in the box?

PHOTOS BY ROB KERR PHOTO ILLUSTRATION BY ANDERS RAMBERG

e l o h w

Sorting the wheat from the chaff BY MARKIAN HAWRYLUK

f you’re looking to eat a healthier diet, food manufacturers are more than willing to help. Just be careful whom you trust. The nation’s food manufacturers have figured out that healthy eating sells, and they’ll do just about anything to convince you their product is healthy even if it’s not. It’s hard to get your cart halfway down a supermarket aisle without seeing a product touting it’s high in this or low in that. Nutritional experts warn that more often than not, such claims are marketing sleight of hand designed to magically transform a nutritionally deficient product into something you’re likely to put in your cart. “The sad truth is when you take food manufacturer claims at face value, you frequently end up being tricked into buying brands that fail to truly qualify as healthy,” said author and nutrition expert Kerry McLeod. A former junk food junkie, McLeod says she fell hook, line and sinker for the marketing claims on packages when she tried to improve her family’s diet. “One day the light bulb went off and I started looking at the ingredients,” she recalls. “I literally went and looked through my entire pan-

Page 26

try. I’m not exaggerating: 90 percent of what I was buying that I thought was super healthy had all kinds of junk ingredients.” It’s so easy to fool consumers because there are few rules governing what a manufacturer can claim on the packaging. The label can’t outright lie, and products can’t say they cure diseases without proof. But that leaves plenty of room for misleading claims and half-truths that can leave well-intentioned consumers scratching their heads. “Families are busy. Both spouses are working. They have less time to prepare homecooked meals, but they still want to serve their families something nutritious,” says Eris Craven, a registered dietitian with Bend Memorial Clinic in Bend. “So it makes it really easy for food companies to take advantage of that and try to display their food products as healthy when, in fact, they’re not.” In 1990, Congress mandated a standard Nutrition Facts label on every package to help consumers sort through the numbers. But the rules governing the labels need to be updated and strengthened, said Ilene Ringel Heller, staff attorney with the nutritional watchdog group the Center for Science in the Public Interest.

“The Nutrition Facts label wasn’t designed for obesity,” she explained. “It was designed to remedy heart disease and cancer. So there was a big emphasis on fat.” There isn’t enough emphasis on calories, she said, which experts say is the real culprit in weight gain. Meanwhile, food manufacturers have figured out how to formulate products so they look good on the Nutrition Facts labels, manipulating ingredients and servings sizes to get the desired effect. For example, Heller pointed to Healthy Choice soups that come in microwaveable bowls. “One person is going to eat that,” she says. “But under the regulations the company is allowed to say ‘about 2 servings.’ While the calories are still OK, when you multiply the sodium, it goes from being a product that’s under the 480-milligram cutoff for being considered healthy to being 800 milligrams.” Most nutrition experts agree that the first step in finding truly healthy products is to ignore the front packaging. “Our first rule of thumb is speed-read

HIGH DESERT PULSE • SUMMER / FALL 2009

through the front label,” McLeod says. “No good can come from it. You have to ensure you’re really getting what you think you are.” That means reading both the Nutrition Facts label and the list of ingredients. “If you don’t understand the ingredients on the list, you don’t know what you’re putting in your body,” Craven said. “Maybe you shouldn’t be eating it.” Labeling rules require ingredients to be listed in order by weight, so that can help consumers judge the nutritional value. “If you’re buying juice and the first three ingredients are water, high-fructose corn syrup and then maybe even an artificial sweetener, and then the fourth ingredient is juice, that tells you all you need to know,” McLeod said. While that sounds like a lot of work, nutrition experts say consumers can quickly learn which products pass the test and which they should simply pass by. Purchase the same products and you won’t have to spend hours reading the labels. Or you can avoid the packaging mess altogether and stick to more whole foods. “If you stick to buying whole foods and minimize the processed foods, it’s really going to cut down on food products that have all these health claims that are false and have no scientific backing,” Craven says. After all, when was the last time you saw a reduced-fat, extra-fiber, made-withwhole-grains apple?

DON’T FALL FOR THE HYPE • Ignore the claims and symbols on the front of the box. • Check the Nutrition Facts label, remembering to notice the serving size. • Read the ingredients list; products are listed in order by weight. • Avoid foods with long lists of ingredients or ingredients you don’t recognize. • Zero trans fat may not really mean zero. Look for partially hydrogenated oil in the ingredients list. • Consider what may have been added to products when something was removed. • Watch the sodium content. What percentage of your daily allotment is in this product? • Not all Omega 3s are created equal. • Look for whole wheat breads, preferably 100 percent whole wheat. • Buy more whole foods and fewer packaged products.

Tricks of the trade Claims on packaged food products can often be misleading, making it difficult to choose truly nutritious products. Here are some common tricks manufacturers will use.

GRAIN OF TRUTH Federal dietary recommendations have hammered home the notion that half of your grains should come from whole grains. That’s made the words “whole,” “grain” and “wheat” valuable marketing terms. Consumers see “wheat bread” and assume it means whole wheat. (In fact, most bread is wheat bread). Multi-grain only means it has many grains. It doesn’t tell you how many of those are whole grains. And make sure you bring your glasses with you. Some breads trumpet whole wheat in large letters, making it easy to miss the “Made with” in tiny letters just above it. And made with whole wheat gives you no indication of the percentage of whole grains in the product. Sarah Lee recently bowed to pressure and changed the packaging for its Soft & Smooth Made With Whole Grain White Bread to stipulate that it contains only 30 percent whole grain.

ZERO MAY MEAN MORE THAN ZERO The FDA allows products to claim no trans fats if the product has less than 0.5 grams of trans fats per serving. Quaker Granola Bars’ box claims 0 grams trans fat, but partially hydrogenated soybean oil is listed twice in the ingredients. Some manufacturers will make serving sizes unrealistically small to get below the per-serving limit for listing no trans fat.

HIGH DESERT PULSE • SUMMER / FALL 2009

REDUCED MEANS REPLACED Light or reduced means the manufacturer took something out, but it probably means they put something else in. Take juice, for example. For its Light Grape Juice cocktail, Welch’s takes out some of the juice along with its calories and nutrition, and replaces it with water and artificial sweeteners. The product has half the calories of regular grape juice, but 60 percent less fruit juice. Chips Ahoy Reduced Fat Chocolate Chip Cookies contain 20 fewer calories per serving and 3 fewer grams of fat, but contain two additional sweeteners and a filler (soy lecithin) as well as 40 milligrams more sodium.

Page 27

Truth in labeling | THE PACKAGE DEAL STACKING THE DECK

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Consumers are swayed when manufacturers can present scientific studies proving a health benefit. But when a company pays for a study, it usually gets the result it wants. Kellogg’s Frosted Mini-Wheats, for example, now tells parents it will keep kids full and “focused.” The Federal Trade Commission nixed the company’s previous campaign claiming Mini-Wheats were clinically shown to improve kids’ attentiveness by 23 percent. The actual study is described on the cereal’s Web site. The research found kids who ate a breakfast of Mini-Wheats had 23 percent better memory than kids who only drank water for breakfast.

PHOTOS BY ROB KERR

MISDIRECTION The FDA will not allow companies to use the term “saturated fat-free” if the product contains more than 0.5 grams of trans fat, but doesn’t have the same requirement for term “trans fat-free” if the product contains a lot of saturated fat. As a result, many products are “trans fat-free” despite having plenty of artery-clogging saturated fat. Hot Pockets Ultimate Pepperoni Pizza displays 0 grams of trans fat on the front of its packaging, but still carries 50 percent of a day’s saturated fat. And products that are fat-free still aren’t calorie-free or even reduced-calorie. Manufacturers will add sugar and other fillers to account for the changes in taste and volume.

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Omega 3 fatty acids found in fish and certain algae have been shown to benefit heart health. Diamond Walnuts packaging shows it contains 2.5 grams of omega 3 per handful, but doesn’t tell consumers it’s not the same omega 3 shown to prevent heart disease. Omega 3 fats from fish sources have been linked to heart health, while omega 3 fats from plant sources have not. Meanwhile, eggs contain too much saturated fat and cholesterol to be able to claim a heart-health benefit. But that hasn’t stopped egg producers from jumping on the omega 3 train. They simply list the omega 3 content and let consumers infer a benefit.

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WHAT’S IN A NAME Using fruit in the product names can lead consumers to conclude there’s fruit in the product, especially if they can put a picture of the produce on the package. Tropicana Peach and Papaya drink contained neither peach nor papaya juice. The company was eventually forced to change the name. Gerber Graduates Fruit Juice Treats for Preschoolers has lots of fruits pictured on the box, but contains little actual fruit juice in the package.

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HIGH DESERT PULSE • SUMMER / FALL 2009

PLAYING THE SYMBOLS Knowing that consumers are increasingly confused reading labels, manufacturers, grocery store chains and industry groups are creating their own nutritional symbols to help identify healthy choices. Don’t believe them. Consider that Kraft awarded its Sensible Solutions logo to the Maxed-out Deep Dish Pizza Lunchables product for kids. The meal contains more than 100 ingredients, including such kid favorites as the preservatives potassium sorbate and sodium ascorbate. It contains 14 grams of fat and 720 milligrams of sodium. While other Lunchables now come with 100 percent real juice, this package includes a bottle of water and Kool-Aid drink mix.

USING THEIR GOOD NAME With only 60 calories per cup and 14 grams of fiber from whole wheat and bran sources, the Original Fiber One cereal was a big hit. But additional products in the Fiber One line got progressively worse. Fiber One Honey Clusters doubled the calories, sodium and sugar. Fiber One Chewy Bars replace whole grain fiber with functional fibers such as chickory root extract and maltodextrin. Functional fibers don’t add calories, but don’t contain the same beneficial nutrients as whole grain or bran fiber. And Yoplait Fiber One Creamy Yogurt had no whole wheat or bran but plenty of sweeteners, preservatives and carmine, a red coloring made from ground-up bugs. •

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NEED MORE HELP IDENTIFYING HEALTHY PRODUCTS? Consider these resources: • eBrandAid.com Sign up for free and receive regular e-mail updates with new product evaluations by Kerry McLeod. You can also download a healthy eating guide with hundreds of pre-approved products. • Nutrition Action Healthletter Published by the Center for Science in the Public Interest, this monthly newsletter examines the nutritional content of storebought products and restaurant foods. Subscriptions cost $10 a year. Subscribe at www.cspinet.org/nah.

HIGH DESERT PULSE • SUMMER / FALL 2009

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August can be a tough month for kids. The novelty of summer vacation can give way to a heat-induced ennui that leaves them with the body posture of a wet noodle, capable only of lying motionless before the TV. Perhaps it’s time for a day of active, family fun that will beat back the temperatures and the boredom.

1. Start with a family breakfast at McKay Cottage, a casual neighborhood restaurant inside a beautifully restored historic craftsman cottage, the former home of Bend pioneers Clyde and Olive McKay, and their son, Sen. Gordon McKay. Take advantage of the early cool temps to have your morning repast on the outdoor picnic tables. Opt for the slightly more healthy oatmeal pancakes. (62910 O.B. Riley Road, Bend, 541-383-2697)

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HIGH DESERT PULSE • SUMMER / FALL 2009

3. When the mercury really soars in the afternoon, go underground, literally, at the Lava River Cave. The cave is an ancient lava tube that’s now part of the Newberry National Volcanic Monument. Temperature inside is a constant 42 degrees. (Wear warm clothing!) The cave is about a mile long and as wide as 50 feet in places. The ceilings are high enough to walk normally through most of it, although there are a few places you’ll have to crouch. The tube crosses beneath the highway, but don’t worry, the ceiling is 50 feet thick. Lava tubes like this began as rivers of lava that flowed in open channels just like a normal river. A crust of solidified lava grew from the cooler channel walls out over the flowing lava. Eventually the two crusts from each wall joined in the center to form a roof over the lava river. When the eruption that produced the lava stopped, the lava drained out of most of the lava tube, leaving the cave you can walk through today. Rent a lantern ($3) because it’s pitch black once you get away from the entrance, and flashlights or headlamps aren’t usually bright enough.

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Be there by 3 p.m. to allow enough time to explore the cave before the 5 p.m. closing. No lanterns are rented after 4 p.m. (From Bend, 12.5 miles south on U.S. Hwy. 97, one mile south of Lava Lands Visitor Center, 541-593-2421; $5 day pass per vehicle)

Mio Sushi in the Cascade Village Shopping Center at the north end of Bend. A children’s meal with chicken teriyaki, miso soup, salad, rice and a California roll costs $6.95. This happy meal doesn’t come with a toy, but kids will love trying to master the chopsticks. Adults’ meals average about $8 to $15. The family-friendly restaurant caters to sushi lovers and non-fish eaters alike. (62455 N. U.S. Highway 97, #35, 541-306-3486) • DEAN GUERNSEY

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Cover story | MEDICAL MARIJUANA Continued from Page 11 despite its reported medicinal properties, scientists still don’t understand exactly how the drug works.

A dearth of data Dr. Donald Abrams is a cancer specialist and director of clinical programs at the Osher Center for Integrative Medicine at the University of California in San Francisco. He’s also one of a handful of scientists to perform research on medical marijuana and have his results published in major medical journals, including the Annals of Internal Medicine. “There’s definitely a stigma attached to marijuana studies. It’s not easy to build an academic career on it,” he says. Few groups are willing to fund marijuana research. Drug companies have little motivation because it is almost impossible to patent a plant. The National Institute on Drug Abuse only funds studies that look at marijuana as a “substance of abuse.” Two of Abrams’ studies have qualified for NIDA funding because they examined the physical effects of mari-

juana in a way that could be applied to both abuse and medical use. The University of California established the Center for Medicinal Cannabis Research in late 2000 and funded some of Abrams’ research before running out of money. “I don’t know who’s going to continue to fund studies,” he says. Abrams is wrapping up one study of chemical interactions between cannabinoids and opiates — ingredients in marijuana and opium, respectively. “There’s some evidence that cannabinoids boost the painkilling effects of (opiates such as) morphine or OxyContin,” he says. “So the idea is that people who are in a lot of pain, who are already taking opiates, might be able to enhance their effect with cannabinoids.” To get approval for a clinical trial, Abrams had to present the study to eight regulatory bodies, including the FDA, NIDA, the Drug Enforcement Administration and the Research Advisory Panel of the California Department of Justice. In contrast, a medical study that does not involve marijuana usually requires approval

REASONS OREGONIANS REQUEST MARIJUANA CARDS A patient may have more than one diagnosed qualifying medical condition. Rank Condition

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Severe pain Persistent muscle spasms, including but not limited to those caused by multiple sclerosis Nausea Cancer Seizures, including but not limited to epilepsy Cachexia, or loss of weight, muscle and appetite HIV positive/AIDS Glaucoma Agitation related to Alzheimer's disease

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“If you believe that there are that many sick people who cannot be treated without marijuana, I’ve got a bridge for sale.” Mike Dugan, Deschutes County district attorney Page 32

from just one agency: the university’s institutional review board. “Once you do the study, people are not absolutely eager … to have medical marijuana research published in their journals,” Abrams adds.

Marinol: Part of the solution In the 1980s, a pharmaceutical company called Unimed Pharmaceuticals conducted clinical research with the National Cancer Institute on a synthetic form of delta-9-THC, a primary component of marijuana. In 1985, the FDA approved the drug. Solvay Pharmaceuticals, which owns Unimed, holds the patent for Marinol. On its Web site, the DEA touts Marinol. “Medical marijuana already exists,” the page reads. “It’s called Marinol.” But according to Abrams, that’s not entirely accurate. “Marinol is not the plant. Marinol is a synthetic form of the single active (component), delta-9-THC. In marijuana, there are at least 70 other cannabinoids,” he says, referring to the substances that are unique to marijuana. “In addition, (there are) about 400 (other components) which probably also have some beneficial effects, and which also sort of balance the effects of the delta-9-THC.” In Marinol, the active medicine is dissolved in sesame oil, which is absorbed at different rates depending on the individual. “When you smoke, you usually reach or achieve a maximum concentration in the bloodstream within two minutes, which then rapidly declines over 30 minutes,” Abrams says. “Marinol takes two hours to reach a peak, and it takes much longer for the concentration to decline.” Marinol is recognized by the medical community as treatment for chemotherapyinduced nausea and to control nausea and stimulate appetite for AIDS patients. But the drug is sometimes prescribed for patients with other diseases, too. Once the FDA approves a drug for prescription use, doctors are legally allowed to prescribe it for off-label uses, or conditions other than those it was developed and approved to treat. Dr. Robert Boone, a cancer specialist at Cancer Care of the Cascades, still remembers the first patient for whom he prescribed Marinol. The man was a cancer patient who threw up on the way to his second chemoHIGH DESERT PULSE • SUMMER / FALL 2009

“This is not minor back pain. (Martin Halsey) is in a lot of pain and he deserves access to whatever medication gives him the best quality of life.” Dr. David Stewart, Halsey’s rehabilitation specialist

“I don’t need that much of it. And I have a life. I have things that I want to go do during the day.” Martin Halsey, a medical marijuana user

therapy appointment. “He got sick while signing in for chemotherapy,” Boone recalls. “He hadn’t even had the chemotherapy yet, but he had what is called anticipatory nausea. It’s a form of anxiety. He had a bad experience with chemotherapy and he was nauseated by the idea of going to get tortured again.” Marinol, he says, helped. Still, Boone estimates that he prescribes Marinol for less than 5 percent of his patients. Other drugs are cheaper and more effective for most chemotherapy patients. Boone says that most of his cancer patients who request medical marijuana are baby boomers or younger and have used marijuana

recreationally in the past. “The 90-year-old that asks for medical marijuana is pretty unusual,” he says. When a patient brings up marijuana, Boone runs down a list of benefits of taking Marinol instead of smoking the plant. “It keeps them from buying it on the street and it keeps them from having to smoke it,” he says. But Marinol comes at a high cost. Literally. “I don’t know the street cost of marijuana,” Boone says, “but it’s probably not as expensive as Marinol.” At local pharmacies, Marinol costs about $23 for one 5-milligram pill. A typical prescription is two 5-milligram pills per day. That means a 30-day supply costs $1,380. A generic form of the pill, called dronabinol, costs about $12 for a 5-milligram pill, or $720 for a 30-day supply. Other medications that treat chemotherapyinduced nausea or stimulate appetite cost as little as $2 per pill. Still, doctors say they are more comfortable prescribing Marinol than signing a medical marijuana form.

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Cover story | MEDICAL MARIJUANA With marijuana, “you’ve got an unregulated substance, potentially coming from an unknown source, that the patient’s going to use in an unknown way,” Stewart says. “Are they going to use it once a day before bedtime? Are they going to use it all day long? Are they going to sell it?” Oregon’s medical marijuana program allows patients to grow their own marijuana or designate a proxy to grow the plants. The number and size of the plants is limited, but patients have a constant supply that does not have to be refilled by a pharmacist or reviewed by a doctor. “With most drugs, you prescribe a very specific amount, to be taken at a specific time, for a specific reason,” Stewart says. But Boone points out that prescription drugs are sometimes abused, too. “One of the tough things about being a physician is that your intentions aren’t always played out the way you wish they were,” he says. “In truth … you’re not really in charge of a patient’s health. The patient is.” •

MARIJUANA LAWS IN THE NEWS In 13 states, including Oregon, Washington and California, medical marijuana occupies a strange legal niche: State law permits it, but federal law prohibits it. Beginning in 2001, Drug Enforcement Administration officials arrested dozens of medical marijuana users, growers and sellers in California. Most of the prosecutions involved large-scale growing operations and dispensaries in California, where state laws permit the sale of marijuana for medical purposes. Earlier this summer, the owner of a marijuana dispensary in California was sentenced to one year and one day in federal prison and four years probation. By contrast, Oregon does not permit the sale of marijuana for any use, and no individual may grow marijuana for more than four users. In 2005, the U.S. Supreme Court ruled that federal drug laws trump state laws, and the DEA can legally prosecute medical marijuana users and distributors. But President Barack Obama has said that under his administration, unlike under George W. Bush’s, federal officers will not actively pursue prosecution of medical marijuana users or growers who are in compliance with state laws. Here in Oregon, medical marijuana is the subject of frequent debate within the Legislature. Oregon’s Medical Marijuana Program was first formed after voters passed an initiative in 1998. It is administered by the Oregon Department of Human Services. In the past couple of years, the Legislature has considered several bills to protect the rights of employers to fire an employee who uses marijuana, even if he or she has a medical marijuana card. This year, a bill was proposed to prevent recreational marijuana users from obtaining medical marijuana cards to avoid the threat of arrest.

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HIGH DESERT PULSE • SUMMER / FALL 2009

Beyond medicine | END-OF-LIFE PLANNING

PETE ERICKSON

A room in the Hospice House, part of the hospice services at Partners in Care. People who are admitted to Hospice House have opted for comfort care measures rather than continuing treatment.

TIMES HAVE CHANGED. SO HAS

Continued from Page 20 Though that local medical culture is helpful, it is by no means a guarantee that an individual’s wishes will be respected at the end of life. Patients and their physicians still must make sure, for each individual, that wishes are known and honored.

RETIREMENT

Getting doctors to talk The key to having a person’s values and wishes respected at the end of life is communication of those values and wishes. Though that may seem common sense, these conversations happen too few times, experts say, for a variety of reasons. “Everyone should be having end-of-life discussions,” said Holly Prigerson, director of the Center for Psycho-oncology and Palliative Care Research at the Dana-Farber Cancer Institute in Boston, who has done much work on end-of-life care. “The problem isn’t awareness of importance. The problem is that no one wants to have them.” Many physicians do not speak to their patients about the end of life. In a study by Prigerson of more than 300 patients with advanced terminal cancer, only one-third had end-of-life discussions with their physicians. “Two-thirds not having them at that point is almost criminal,” she said. Sometimes doctors just don’t know how. Older physicians in particular were likely not trained in how to have end-of-life discussions. Talking to a patient about the end of life, said Tolle, “is a learned skill.” It is now taught at OHSU, said Tolle, though only this year became a part of clinical rotations, when students deal with actual patients. Many doctors wait for patients to initiate the conversation because they don’t want to shock patients, said Tolle. “It is hard to get that conversation going, when people are still hoping there’s a little more time, hoping it really isn’t this bad, hoping you have another option for treatment. And sometimes these conversations take a little more time than you might have allocated on your HIGH DESERT PULSE • SUMMER / FALL 2009

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Beyond medicine | END-OF-LIFE PLANNING

“I’ve been to many codes (resuscitations) at the hospital, and the question is, why are we coding this person? I mean, she’s dead.” Dr. Robert Boone, Bend oncologist

schedule. So maybe you take the easy way out and decide you’ll do it on the next visit.” Patients vary in how they react to endof-life discussions, doctors said, with some resigning themselves, and others not ready to hear that news. Boone, who cares for cancer patients, said he has had patients who seemed almost grateful for his bringing up end of life, and others who were not ready for that discussion. Some people, he said, say thank you and let him know they’re packing their bags for a larger cancer center. Though patients feel differently about how heroic they want their physicians to act in caring for them, studies have shown that patients who discuss end-of-life care are more likely to request less aggressive endof-life treatments. In Prigerson’s study, patients who had end-of-life discussions with their physicians were less likely to be put on ventilators or resuscitated and more likely to enroll in hospice earlier. The patients who had more aggressive care reported worse quality of life on a survey that asked about physical health, support and symptoms. Both groups survived for the same amount of time. The upshot of the survey is that patient preferences can change. While there are cerPage 36

tain people who will want aggressive treatment to the end regardless of who talks to them, and others who know they definitely do not, many are waiting for a physician or another person to guide them through the process. It is the same principle in end of life that applies to other types of decisions, said Prigerson. “If preferences weren’t modifiable, there’d be no advertising agencies.” From a policy perspective, shifting toward less aggressive care has economic benefits. Each year, somewhere between one-quarter and one-third of all hospital-based Medicare costs are spent on a person’s final year of life. That costs Americans between $59 billion and $79 billion per year, much of that on aggressive hospital interventions in the last weeks of life. The total cost is much higher; those numbers do not include doctors’ fees or prescriptions. As health reform efforts focus on costs, the amount spent at the end of life — and whether it benefits people — will become a central part of the discussion. Communication seems to be a key in this area as well. A study published in March by Prigerson found that having end-of-life discussions could significantly lower a person’s health costs in their final days. In the study, patients who engaged in end-of-life discussions had about $1,900 of medical costs in their last week of life; without the discussions patients had about $2,900 in costs.

“Sometimes you just have to arrive at the conclusion that death is a part of life.” June Stewart, widow of Dale Stewart

“When a patient doesn’t prepare ... they don’t do as well. There’s more suffering and it’s harder on the family.” Dr. Stephen Kornfeld, Bend oncologist

Given the benefit and importance of endof-life discussions, patients are wise to be certain they occur. There are resources for support — hospice being the best known — but patients or their families often must initiate the discussion. “When a patient doesn’t prepare, in my experience, they don’t do as well,” said Kornfeld. “There’s more suffering and it’s harder on the family.” Those who leave the decisions to family members, experts say, may be disappointed. Families often disagree. Starr, the chaplain at St. Charles Bend, said she is often called into situations where a person’s adult children are arguing about how their mother or father would want to die. Often, siblings disagree, leading to strife at an already stressful time and a delay in getting care they eventually decide is right. Tolle said those situations happen often when patients’ wishes are not known and they cannot speak for themselves. “If you have one person out there yelling, ‘Dad’s a fighter,’ then you will spend a lot of time in the ICU, even if that’s not what you want.” The best remedy, Tolle said, is to communicate with family and doctors, no matter how hard. “There are individuals who have great difficulty talking about the end of life. They are HIGH DESERT PULSE • SUMMER / FALL 2009

never going to get the conversation going,” she said. “Or they may be willing, but their adult children can’t.” But, she said, it is crucially important when the time comes. “Often the families who go through the most hell are the ones who said nothing.” Patients who are terminally ill should make sure their advanced directives — legal documents specifying the type of end-oflife care a patient wants — are in their medical records and, if they have POLST forms, that they are easily accessible. POLST forms should be on a refrigerator or in some other visible place, not in, say, the bottom of a dresser drawer. Sometimes, said Tolle, patients do communicate their wishes, but in the heat of an emergency, their paperwork cannot be found to communicate those wishes to emergency personnel. For June Stewart, accepting the death of her husband came gradually but certainly. She realized that the medical system was there to treat him, but found that at some point, the interventions needed to stop. There was no drug, no therapy, no doctor that was going to help Dale live forever. “Sometimes you just have to arrive at the conclusion that death is a part of life.” •

Put Life Back in Your Life Living Well with Chronic Conditions NEW! Workshops Begin This Fall in Deschutes, Crook & Jefferson Counties If you have chronic conditions such as diabetes, arthritis, high blood pressure, heart disease, or other ongoing health issues, the Living Well with Chronic Conditions program can help you take charge of your life. The sixweek workshop and book “Living a Healthy Life with Chronic Conditions” costs only $10. To register and for more information, please call

322-7430

www.deschutes.org/livingwell Living Well is brought to you in partnership by: Deschutes County Health Services HealthMatters Central Oregon PacificSource Health Plans Oregon Department of Human Services

END-OF-LIFE PLANNING • Advance directive forms are available through the state’s Senior Health Insurance Benefits Assistance Program (www.oregon.gov/DCBS/SHIBA/ advanced_directives.shtml) • The POLST program’s forms are available on the program’s Web site (www.ohsu.edu/polst)

Shoulder Strain

• Information about hospice can be found at the Oregon Hospice Association (www.oregonhospice.org) • Hospices in Central Oregon: • Partners in Care: 541-382-5882 (www.hospicecenterbend.org) • Hospice of Redmond-Sisters: 541548-7483 (www.redmondhospice.org) • Newberry Hospice, La Pine, 541-536-7399 • Mountain View Hospice, Madras, 541-475-3882 x2310 • Pioneer Memorial Hospital Hospice, Prineville, 541-447-2510

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Arthritis

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Laughter | THE BEST MEDICINE

Bragging rights T

here comes a time for many of us when the topic of conversation turns to a comparison of scars. Some scars are impressive and carry tales of traumatic, heroic events. There are the scars to be shown off, and those that are hidden. And some scars are related in an off-hand manner, played down like a Monty Python sketch, “Only a flesh wound.” My life, however, has a tendency toward the absurd, and my scars get no respect. Scrapes and cuts, broken fingers, baseball bonks and tree tumbles haunted my childhood like an accident-prone moose. For example, the scar above my left eye is where a classmate clocked me with a rock at recess for running off with her Burnt Sienna crayon. We were both startled by her marksmanship, as she was a prissy girl whose only claim to fame was that new box of 64 Crayolas. I now use a grown-up Burnt Sienna eyebrow pencil to fill in the scar. No glory in that. I hoped when I got older ignominious accidents would cease, that any scar I accrued would be something to display with some semblance of dignity and deserve the respect of my peers. Alas, just inconsequential scars hide behind makeup or clothing, like where the curling iron slid across my neck, skin sizzling, as it took off the top layer. But nothing beats absurdity like the miniscule, half-circle monkeybite scar on my left hand. Painful as it was at the time, my story of a friend’s pet monkey dangling from my hand, sinking his sharp, tiny teeth into my flesh, only became more hilarious as I attempted to re-enact the drama of the situation. I got no respect, only increased laughter as they envisioned big old me doing battle with a scrappy little monkey. Then my big chance at scardom came as the result of emergency surgery. Rushed to a hospital in the middle of the night, wheeled into the operating room — stat! Last thing I remembered was being surrounded by a cadre of white-masked faces. When I awoke, the nurse told me the operation was a success, and not to worry about the 12” incision. SUBMISSIONS Not to worry? At last, a scar worthy Do you have a funny of bragging rights! She assured me it health story you’d like to would heal nicely as the dentist had share? Send 500 words done a good job. or less to pulse@bend Dentist? My gall bladder had been bulletin.com. Editors will removed by a dentist! I was in a select one submission teaching hospital and he was schedfor each edition. uled for advanced surgical training, but still, the disparate fields of medi-

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cine hardly made sense. In fact, it was nonsensical. My bragging credentials were blown! Trying to make the best of both worlds, I sighed, and asked the nurse if I could have my gall bladder. “What on Earth for?” she scowled. “Well, I’d like to put it under my pillow tonight and see if the tooth fairy will bring me some money.” She didn’t get it. As I said, my scars and I get no respect. • — BONNIE BURNS

Burns moved to Bend in 1998 from Silicon Valley. Now retired, she pursues her love of writing, with works appearing in Green Prints, Adams Media and Random Acts of Kindness. She also does research and writes for the Deschutes County Historical Society.

HIGH DESERT PULSE • SUMMER / FALL 2009