The Second Pressing - Pour Pause Pay Attention 2

Cyndi Marlowe is a careful woman. She photographs the pill organizer every Sunday. She logs every observation. She tracks everything. But tracking everything and understanding everything are not the same thing. As Christopher's recovery enters its second month, patterns are emerging that Cyndi can no longer file under variability. Épisode 2 of Pour. Pause. Pay Attention. explores what caregivers miss when they are managing too much to truly see — and what the science of traumatic brain injury and pain medication never quite gets around to telling families until it is almost too late.

Transcript

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Welcome back to Take Care Time, the Tales and the Exhales of Caregivers. I'm your host, Beverly Nance. Before we go back to Napa, before we return to Cindy's garage and her fermentation log, and the quiet that has started to feel less like peace and more like a held breath. I wanna take a moment. Last episode, we met a woman who builds things with her hands to survive the weight of caring for someone she loves. She started because she grew to love the hobby of wine making. We met her husband, a man who fell from a scaffold and landed somewhere. Neither of them expected, and we heard something that every caregiver knows, but rarely says out loud that managing everything and seeing everything is not the same thing. Today we go deeper into the fermentation. Today we start to see what Cindy has been explaining away. Come on, stay with me In wine making, the second pressing is where things get complicated. The first pressing the free run juice is the easiest, the most elegant. It flows without force. It carries the brightest expression of the fruit. The second pressing requires pressure. The grape skins, the seeds and pulp, the palmas are tightened into the press, squeezed harder, pushed further than they want it to go. What comes out is darker, more tannic, more complex, sometimes bitter, some winemakers discard it Others. Believe the second pressing holds everything. The first one couldn't reach. Cindy was in her second pressing. She just didn't know it yet. It was a Tuesday in mid-December when Cindy first noticed the count was off. Not dramatically, not obviously just off. She had developed a system in the weeks following Christopher's discharge, the pill organizer she had purchased at the pharmacy, sat on the left side of the kitchen counter nearest the coffee maker, where neither of them could miss it. Each compartment was filled on Sunday evenings. Each compartment was photographed with her phone before she closed the lid. It was the kind of system that a person builds. When they need to feel something, at least one thing is under control. On that Tuesday morning, she reached for the organizer to confirm Christopher had taken his morning doses. The Wednesday evening compartment was already open, empty. It was Tuesday. She stood at the counter for a moment holding the organizer, turning it slightly in her hands as though the angle might change what she was seeing. Then she sat it down, opened her phone, checked last Sunday's photograph Wednesday evening had been full. She made a note in her log, two words, check Wednesday, and then made Christopher's coffee, sat it on the counter beside the organizer. She went to wake him for his physical therapy appointment because that is what caregivers do they note. They file, they continue and they tell themselves that there is probably a reasonable explanation. That evening, Cindy went to the garage. The grenache she had labeled November was entering its secondary fermentation. The conversion, where the harsher maleic acids soften. Into rounder lactic acids, a transformation that happened slowly, almost invisibly, lest you know what to measure, she drew a small sample and held it to the light. The color was deepening a good sign. The clarity was still slightly hazy. She expected at this stage, she tasted it tart a little tight. Something underneath the tannins that was trying to resolve itself, but hadn't quite got there. She wrote in her notebook, still working through it, not ready to give up, give it more time. She was not entirely sure she was writing about the wine. The Cabernet Franc was further along, deeper settled. She had bottled six of the 12 planned bottles the previous weekend and labeled them carefully in her small, precise handwriting. She had not yet named this batch. Names came when the wine told her what it was. This one was still deciding. For those familiar with home wine making, it is worth pausing here to understand what Cindy was actually doing in that garage. Micro batch wine making, sometimes called home wine making or amateur viticulture is the practice of producing small quantities of wine, typically between one and 10 gallons per batch outside of a commercial setting. In California, a home production of wine for personal use is legal. Under federal law, households are permitted to produce up to 200 gallons per year for personal or family use, not for sale. The process mirrors commercial wine making in most essential ways. Primary fermentation converts sugar to alcohol over seven to 14 days. Secondary fermentation. The Malo. Lactic conversion. Cindy was monitoring, refines the acid structure over weeks or months. Then comes aging clarification, bottling patience. What separates the experience. Home. Winemaker from the novice is not equipment. It is attention wine does not forgive inattention. A single week of neglected monitoring can allow a contamination to take hold, an ox oxygenation to set in a fermentation to stall the product of months of careful work can be compromised in days. Cindy understood this intimately. She had learned it about wine. She was about to learn it about something else. The pain management physician who oversaw Christopher's care was a measured, careful man named Dr. Reyes. He had been in practice for 22 years. He was not cavalier about opioids. He was also not withholding of them. When the clinical picture warranted their use, Christopher's picture warranted their use. Two fractured ribs, a wrist fracture, significant soft tissue damage to the left shoulder, and a neurological component. A frontal lobe injury, which introduced variables into the pain experience that were difficult to isolate. TBI patients frequently report pain amplification. The injured brain processes pain signals differently, sometimes more intensely, sometimes in ways that don't correlate with observable degree of physical injury. In simpler terms, Christopher May have hurt more than his injuries alone would suggest, and the medication helped. This is important because the story of opioid dependency, the story most people know, the one told in documentaries in courtrooms and congressional hearings and tends to, begins with villains. A reckless doctor, a predatory pharmaceutical company, a person who made a choice. Christopher's story did not begin that way. It began with a man in genuine pain. It began with a medication that worked, and it began with a brain that had been structurally altered in ways that made it more vulnerable than even Christopher and Cindy have been told. The relationship between traumatic brain injury and opioid dependency is one of the most under-reported intersections in caregiving education. Research has documented, elevated rates of substance and misuse among TBI survivors compared to the general population. The reasons are neurological,, not merely behavioral. The frontal lobe, the region most commonly affected involves governs impulse control. Risk assessment and the regulation of reward seeking behavior when it is damaged. When it is damaged, the brain's ability to self-regulate is compromised Simultaneously. Opioid medications act on the brain's reward system by flooding it with dopamine, the neurochemical. associated with pleasure, relief, and motivation in a healthy brain, the frontal lobe can moderate this response in a damaged frontal lobe, this moderation is impaired. The relief registers, the cravings follow, and the person experiencing it may not have the neurological resources to recognize what is happening, let alone stop it. This is not weakness. This is injury. By the end of December, Christopher was having what Cindy privately called, good evenings and difficult mornings. The pattern was consistent enough that she had adjusted the household schedule around it without consciously deciding to do so. Physical therapy appointments were moved into the afternoon. Phone calls from business partner Denny were redirected to after lunch. Morning hours were quiet hours. She did not examine the pattern too closely. TBI Recovery is nonlinear the discharge paperwork had told her, expect variability Expect good days and difficult days. That was variability. That was recovery. This is recovery. This is expected. And what she did not connect not yet was the difficult mornings consistently followed evenings when Christopher seemed especially settled and the especially settled evenings consistently followed. Doses taken earlier than scheduled. The pill organizer told a story. Cindy had all the chapters in her log. She had not yet read them together. One evening in early January, Cindy Came in from the garage to find Christopher awake in the living room. This was unusual. He had been sleeping by nine most nights. He was sitting in the chair, nearest the window. The television was off. He was looking at nothing in particular. She set her notebook on the kitchen counter You okay? He looked over at her for a moment, something moved through his expression, something she didn't have a word for. Not pain, exactly, not sadness. Something older than either of those. Can't sleep. He said. She sat down across from him, the shoulder. He shrugged the way people shrug when they don't wanna comment to a yes, but can't bring themselves to say no. Everything just feels tight, he said. Like something is wound up and cannot be let go. Cindy nodded. She had read about this post TBI, anxiety autonomic dysregulation. The nervous system stuck in a low grade state of alarm. Did you take your evening dose? She asked. It paused. Yeah. He said earlier she noted the word earlier. She noted the way he said it, not as a confession, but as information. How much earlier she asked an hour, maybe it was a rough afternoon. Cindy held that moment carefully. She wanted to say, that's not how it's supposed to work. She wanted to say. The schedule exists for a reason. She wanted to say, I have been tracking this, and the pattern concerns me. She said, okay, try to get some sleep. Because she was exhausted, because she did not want to make him feel worse than he already did because she told herself it was an hour, just an hour, and because she was not ready to name what she was beginning to suspect. The refill came earlier than expected. The prescription had been written for a 30 day supply on day 23, Christopher mentioned casually over breakfast between sips of coffee that he was running low. Cindy sat down her mug. She did not react visibly. She had learned that the way you respond to information determines how much information you continue to receive, react too strongly, and the source goes quiet. Stay neutral and you stay in the room. I will call Dr. Reyes' office in the morning. She said Christopher nodded, looked at the coffee, said nothing else. After he moved into the living room, cindy stood at the kitchen counter. She opened her log. She scrolled back through the entries. The missed Wednesday evening, the earlier than scheduled doses, she had noted three separate times. The evening she had marked settled early, which she now understood to mean medicated beyond the prescribed timing. Seven entries over 32 days, each one explainable on its own. Together they form something she could no longer file under variability She did not call Dr. Reyes that morning. She sat with what she knew for a full day first because calling would make it real. Because real would require action, and action would require her to say out loud to a medical professional the thing she had been arranging evidence against, saying for more than a month. I think my husband has a problem with his pain medication. This is one of the most critical moments in the caregiving experience. And one of the least discussed, the recognition phase before the conversation, before the intervention, before the medical appointment, or the treatment plan or the difficult, family meeting. This is the moment when a caregiver, the person with the most information and the most at stake knows. And she has to decide what to do with that knowledge for caregivers managing a loved one who is recovering from illness or injury and taking opioid based medication. These are the behavioral signs that warrant a conversation with a medical provider. Not a confrontation, not a accusation, a conversation using medication earlier than the prescribed schedule, On more than one occasion, running out a prescription before the refill date and increasing pattern of request to take medication when pain seems inconsistent with activity level, mood changes that correlate with dosing, timing, notably agitation and restlessness in the hours before a scheduled dose. Increasing sedation or unusual calm shortly after taking medication, withdrawal of interest in recovery, activities, therapy, movement, engagement outside of medicated windows. None of these signs alone constitutes a diagnosis. All of them together constitute a reason to call the doctor and the caregiver who has been keeping a log, who has the dates, the times, the observations is the most important person in that conversation, not the enemy. The witness that night. Cindy went to the garage later than usual.. It was after 11. The house was quiet. Christopher had gone to bed early, another good evening. She noted without comfort. She checked her wine first. The conversion was nearly complete. The haziness was clearing. She drew a sample and held it under the work lab. Deep Garnet, almost translucent at the edges. A clarity that had taken weeks of invisible work to arrive at. She tasted it. The tartness had softened. The tannins were still present, but no longer combative underneath them, something round, something that had been acid was now almost velvet transformation. She set the sample glass down and stood in the garage for a long time. She thought about the log on her phone, the seven entries, the pattern she had spent weeks explaining away. She thought about Christopher in the living room chair at midnight looking at nothing. She thought about something wound up that could not let go. She thought about a brain that had been struck against the side of a skull and told to keep running. She thought about the medication that was doing two things at once, relieving pain and creating a want that had nothing to do with pain. She picked up her notebook. She opened it up. To one of her wine batch pages at the top of the page. Weeks earlier, she had written things drift when you look away. She read it twice. Then below it, she wrote the name of the batch and she called it Pay Attention. I wanna speak directly to you for a moment. If you are a caregiver for someone recovering from a serious injury or illness. Who is on pain medication. This episode was for you not to frighten you, not to make you suspicious of your loved one or of the medical team managing their care, but to give you something that Cindy did not have when she was standing in the kitchen counter staring at the empty the Wednesday compartment information. Because here is what I know about caregivers. We are observers by nature. We notice things, we track things. We keep logs on our phones, in our heads, and in the margins of notebooks. We are also protectors and protection. Deep, fierce, long driven protection can sometimes look like willful blindness. We explain away what we see because we cannot bear what it might mean. We file the entries and close the notebook because opening it fully feels like betrayal of the person. We are trying so hard to help. But here is the truth that wine making taught Cindy and that caregiving teaches all of us. Eventually, you cannot correct. What you refuse to see, the contamination that goes unaddressed does not stay in one barrel. It spreads. And the caregiver who waits too long to name what they are observing is not protecting the loved one. They are paying the cost of that silence and the most personal currency imaginable if something in Cindy's story felt familiar today, if you recognize the pattern, the explanations, the closed notebook, I want you to hear this. You are not betraying your person by calling the doctor. You are being the witness they need and your log that careful, detailed, loving record that you've been keeping. It is not evidence against them. It is a map back to them. Next time on Poor Pause, pay attentions makes the call. Dr. Reyes listens and Christopher, the man who builds things, who called her at lunch every day just to hear her voice begins to understand that the fall at his job site was only the first thing that broke. The wine labeled pay attention is cleared for bottling, and Cindy finally names the Cabaret Franc. It will be the most honest label she has ever written. Today's episode was heavy. I know that. And I also know that if you are a caregiver, especially one managing a loved one's recovery and medication, you are carrying something significant right now. The Take Care Time Respite Box was created exactly for this weight. Not to make your weight disappear, but to give you a moment, a contained, intentional. Yours and yours alone moment to set it all down. The spring flowers box is available now on our website@takecaretime.com. And in honor of this episode, beginning in May, we will have our Pour and Pause wine related take care time, respite box. You deserve that. Not after you finish caregiving right now. While you're still in it, you can visit. Take care time.com to view both of those boxes. Have you ever been in a moment like Cindy was in standing at the counter, holding the evidence, trying to decide whether to name what you are seeing? Your story matters, and it may be exactly what another caregiver needs to hear. Contact Me at podcast@takecaretime.com. We would love to feature your story. Every story shared in confidence will be treated with care. Please note that this episode features reenactments and dramatized details. While in most cases the exact verbatim dialogue may not be known, all dramatizations are grounded in thorough research and crafted to honor the stories shared. To respect the privacy and confidentiality of the individuals involved names and some identifying details have been changed. The information shared in this episode is Educational in nature and is not a substitute for professional medical advice. If you have concerns about a loved one's medication use, please contact their healthcare provider directly. Until next week, take care.