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GERD: Treatment Options

GastrEsophagealRefluxDisease (GERD) is a very common problem that I treat everyday. I am posting a 20 minute talk that I gave at the YMCA last year. I had posted it previously; but, I had some technical difficulties and am redesigning the site slowly. In the past year there has been quite an emphasis on the most popular medication for the treatment of GERD, PPIs or Proton Pump Inhibitors such as Prilosec, Nexium, Protonix and Prevacid, and others. Alarming side effects have been reported; bone fracture secondary to impaired calcium absorption, chronic kidney disease, dementia, and aggravation of pulmonary conditions are examples. The data suggests that there may be some weak associations, and some of the alleged side effects have more data than others.
The primary goal is to control GERD with the least amount of medication. The reported side effects of the PPIs are dose-dependent, so a low-dosed PPI is much less significant than a high-dosed PPI. If medications do not work, or if a patient is dependent on high-dose PPIs, or a PPI-dependent younger patient, then surgical options could be explored.


Stone landscaping a garden on a slope, between a fence and a waterfall: it is done–really done.



Today, I added the paver-lock sand, which is pretty much magic as far as I’m concerned. I’m sure there must be a use for it in the OR if I just think hard enough. And I was right about the river rock around the cobblestone, I don’t think the granite would have looked proper.

Cobblestone circle



I am now ready for winter and all is done, mainly. I only fell down once, in the rain garden, when I twisted my ankle on a rock while levering the 20′ ladder against the roof to put up the heat tape in the roof valley’s. Awesome view up there, but a little scary in a precarious sort of way. I’d much rather stumble on the ground than on the roof.



Time for something new now, and it has to do with warmth, interior environments, and mental stimulation, as opposed to the physical stimulation of hard labor that has so occupied these past three months during my back-breaking work of staggering genius.

Time for me to poke the monster in the eye.

Stone landscaping a garden on a slope, between a fence and a waterfall: it is done, and so am I.


I feel like John Merrick of The Elephant Man as he places the last piece on his puzzle of St. Phillip’s; “It is done.” Fadeout.

Although, when I saw The Elephant Man a few years ago, played brilliantly by Joe Faust, the script was modified slightly from the original English text: “It is done; and so am I.” Then John/Joe lay down and quietly died from asphyxiation. Conversely, I still breath easy, effortlessly even; nonetheless, I have this sense of completeness to the point, as happens from time to time at the completion of a major task or operation, of wondering if this was the meaning of my life, my special purpose as it were, and all that follows is rather anticlimactic, a lame-duck life remaining. I hope not. I guess the morrow will tell if I awake.

I’m ready for something different.

Stone landscaping a garden on a slope, between a fence and a waterfall: Part Two (C): Planting a Tiger-Eye Sumac

Aerial view of garden

Tiger Eye Sumac


Tiger Sumac








As I lay my 70th or 80th concrete block today, I recalled Mark Antony’s soliloquy from Julius Ceaser:

“The noble Brutus hath told you Caesar was ambitious:

If it were so, it was a grievous fault,

And grievously hath Caesar answer’d it.”


I only knew it because I memorized it in high-school for Sister Hugo. It must have made quite an impression because I can rattle at least half of it off on the spur of the moment. It’s the one beginning with, “Friends, Romans, countrymen, lend me your ears…” And that’s only one of several that have stuck with me all these years; To be or not to be, that is the question whether tis nobler in mind to suffer the slings and arrows of outrageous fortune…; Fie ‘ont fie, tis an unweeded garden that goes to seed, things rank and gross in nature possess it dearly…; What a piece of work is man, how noble in…;

Anyway, in this case, I felt like, in retrospect that my little project to be accomplished in evenings and every other weekend, was far too ambitious, and grievously hath I answer’d it.

For three weeks now, I’ve had a Tiger-Eye Sumac sitting in the driveway, slowly dying despite my ministrations and today it finally found a home:

It will have a mature height of 5-6′, and there is a matching Sumac across the head of the waterfall that is three years old, and of the approximate size of the one I just planted.

At least I haven’t had any more leg cramps. On the third night of my “vacation”, during which I logged four consecutive days of hard physical labor, I awoke at two in the morning with an ice-pic sticking in my quadriceps muscle from the front side and sticking out the hamstrings on the back side. I could barely get out of bed. When I did, the pain was so intense couldn’t tell where the doorway was to the bathroom or to the living room and I stumbled around, dizzy and not sure if I was dying or not. I couldn’t even say I was leaving the world with a sense of satisfaction, given my sadistic suffering torture I’d subjected myself to in the garden–my only consolation that came to mind was that it would soon be over. But then I found the door, then the kitchen, and chugged down a  bottle of Gatorade; and slowly, the ice-pic was withdrawn like the door of an iron maiden opening and I was made whole.

Three weeks or so into this, I am happy to say that everything seems to be lining up so perfectly that it is as though I drew up a plan with carefully measured elevations and laser site lines and so on and so on; but of course I did not. I laid those first rows of blocks and poured 1500 lbs. of concrete with a wild abandon and nothing more than a vision in my head. As it turned out, they are exactly where they need to be and of an elevation not off more than a quarter inch, easily withing the margin of mortar (type N). I can’t believe it. It’s a goddam miracle, and thank God for miracles, which I don’t doubt in the least having experienced them personally a number times, notwithstanding this last.

Stone landscaping a garden on a slope, between a fence and a waterfall: Part Two (C): Passing through doubt

Aerial view of gardenI lead a simple life. I get up in the morning, make the exact same thing for breakfast, drink 8 cups of coffee (I’m sure they’re small cups–it’s just what it says on the coffee pot when it’s just past half full), go to work, come home, work on the project at the work site on the south side of my house, make the exact same thing for supper (I ran out of the “same thing” so tomorrow there will be some change), read Great Expectations, sleep; then repeat.

It was a difficult week for me, plagued by doubt. What I had started with, what I suppose I would describe as great expectations, became, seemingly, a futile exercise with an endpoint so distant and so uncertain that I could do nothing but stand in the middle of my chaotic muddle and wonder what in the hell had I done with my garden. My trenches and concrete block that seemed to make so much sense when I dug them, placed them and then concreted them in for good were to my eye now unsightly and something arranged slightly less than random.

The shadow of doubt moved across the field of my enlightened vision four afternoons ago after I had spent a number of hours cutting stone for a section of the walkway/floor. It looked like this:

stone paversOf course I loved it; but, then, when I propped up the same stone against the concrete block, it all seemed too too monotonous. It was definitely too monotonous, and would not do. I think if I would have only vomited that I might have felt better. I had to do something different with the walls, but what–stucco was the only thing that I could think of, but how much more would that cost, and how in the F*^& do I do that. I still don’t even know how to be a stone mason.

After some consultation with a designer (thanks Honey), it was obvious that I would need to change the floor from stone to something else, and what better than the river rock that we already have around the pond that I was going to replace anyway; and that is what you see in the aerial view of the leading image. The river rock is constrained by the stone and flush to the top of it. It has all of the colors as the stone I’m sticking to the walls.

Lower entrypath






There. That’s better. I haven’t yet laid the concrete block at the top of the work site. I had intended to do all of that first, as part of my Part Two; but then I entered the winter of my doubt and thought I’d better figure this out before pouring another 1500 lbs. of concrete.

A second doubt-shadow invaded my consciousness three days ago when I mortared the back of a stone, stuck it against the concrete block wall, and it fell down. I wanted to vomit again. Faced with somewhere between 50 and a 100 concrete blocks, not so expertly laid with neat joints, etc. that needed covering with stone, I found myself mightily disheartened. This was shortly after my revelation of monotony. Clearly, I was doing something wrong, and most likely, to my thinking, it had to do with the mortar.

Now, I don’t know who’s the genius that came up with the instructions for pre-mixed mortar and concrete; about mixing a few ounces of water into each 60 pound bag of dust, but they must surely be short a few cards in the proverbial mental deck because it takes a hell of a lot more than what they say, by at least a factor of 2. When I hung my first stone, I thought I’d be exact, and I mixed and I mixed, and I mixed the 60 pounds of dust with a few ounces of water, and it was dry–but I followed the directions dammit. They were wrong.

Now I know that you add water until it is right. You make it a little drier if you want to roll it or do joints, but it can be a little wetter for the veneer application. Type N mortar will work for anything. Type S mortar is not sticky enough for vertical application. And by now, of three things I am certain; it is impossible to cut anything other than a straight line in Door County limestone, limestone dust doesn’t smell half bad, and, I’m going to need more rock.

Ornamental treeThis ornamental tree is at the top of my garden on a slope. The entry into my terracing project will be just to the right of this tree. I’m going to lay some fabric and then black rock around the tree.




Now that I am aesthetically okay with what I have done below, I can now lay the rest of the block above. I have a six foot pillar of 30 blocks sitting in the driveway between the garage doors where I will be less like to back into them. I hope there’s enough.

I’m exhausted. Some people play the piano; some paint pictures; others golf or fly planes or drive boats; me, I prefer something much more self-flagellatory.


Stone landscaping a garden on a slope, between a fence and a waterfall: Part One

In an effort to decrease my yard maintenance in my out years; I’ve decided to expend a tremendous amount of energy in my ?in? years, or, at least while I have the requisite muscle mass. I am converting a sloping garden on the side of my house to stone–the Medusa-Gardner. All that will remain are 2 trees, three grapevines against the fence, and a few pots for tropicals; therefore, I may kill anything not tree-like, vine-like, or outside a pot :^). I win. Finally.

I’ve planted so much there these past eight years that I fail to recognize anything not white, with a yellow dot in the center; or yellow, with a black dot in the center. The picture below is from two years ago, before the weeds fully established themselves due to my not realizing they were weeds.


The first day, I cut everything down. This took two hours. I used a machete, not because it worked extremely well, but because it was black and big and made me feel perhaps more manly than I usually do. It worked best for stems held under tension, with the weight of the blade chopping down and rather horizontal.Machete I didn’t even cut myself, although I did come close on a few occasions.

The only thing that survived were the two grape vines. I have a third that I’ll be planting in the remaining space.



For the past week, I’ve been hauling loads of stone from a local quarry. My pick-up could only handle half a pallet at a time (1500 lbs), which I unload, one by one, stacking them in stone walls here and there while they await their final resting place.

Cut stone









The thick-cut stone will be used for edging pathways and patios that will be filled with quarry wash (gravel) and the thin-cut stones, which are actually fairly thick. The thick stones weigh from 40-80 lbs.

On the second day, I worked 4 hours in mid-day, in 90 degree weather. I drank two gallons of water and didn’t have to visit the restroom once, which was really very convenient. I excavated 1/4 to 1/3 of the lower garden and set the base blocks for the second to lowest level in the corner. I will wrap and cap the concrete walls with the thin-cut stone.

ExcavationYes, the concrete blocks are level, front to back and side to side.

I’ve taken the root balls of the flowers, and I’m sure a few weeds, and replanted them between trees on the margins and other places bare.