Me and My Unstable Adrenal Insufficiency - Part 2 My Life With AI

 In a previous post, I gave a general overview of adrenal insufficiency, and in this post I'm going to write about my personal experiences with AI.  

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My AI Origin Story and History

Through as series of medical mistakes, misdiagnoses, and misadventures, I was put on high doses of steroids that I didn't actually need for several months in 2017.  This confused my already fragile hypothalamic-pituitatry-adrenal axis into slacking way the hell off.  I had a minor surgery for a congenital defect in my neck and had the joy of experiencing my first adrenal crisis the next day when my cortisol suppressed body couldn't cope.

My body's reaction to stress

  Adrenal crises are always scary, but this one was especially so because I didn't know what was going on.  It felt like I was going crazy and had the worst flu ever and a was in a horrible dysautonomia episode.  Luckily I had enough brain cells still firing to pitifully whisper, "adrenal issues" over and over again in the ER and my mom took over explaining my complex medical history from there.  I got the meds I needed, a 5 day hospitalization, and a shiny new diagnosis of secondary adrenal insufficiency (SAI).  I went home very weak, but stable.  Ish.      

I thought I'd be good to go after that and would wean back off steroids like I have dozens of times in the past.  No such luck.  It took me months to recover from that first adrenal crisis.  Months of weakness, gaining tons of weight, and feeling generally sick.  I found I was unable to stop the steroids, but at least through trial and error found a (relatively) stable daily basal dose of steroids.   

Some people are able to take a few pills of steroids a day and go on with life as usual.  I am not one of those people.  I've never found managing my AI easy.  I am more often too high or too low than just right in the steroids department.  

Things did get better when I learned about some unconventional treatment options from an AI support group.  In 2019 I switched from oral steroids to injectable steroids.  It helped a ton, but there was an even better option.  After exhaustive research, advocacy, and appeal letters to insurance I got an insulin pump that I could use to deliver the steroids.  I could program the pump to deliver cortisol 24/7 and at the rates of a normal cortisol day curve.  I could updose in minute increments in response to symptoms or activity.  Big meal?  Have a little updose.  Get the flu?  Easily increase my daily dose by 30%-50%.  Stressful day full of doctor appointments?  Here's a little bit of a bigger updose.  It became much easier to mimic a functional adrenal gland.  

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I got so flipping healthy that I started volunteering in vocational rehabilitation with the intention of going back to work.  Though I still found AI difficult to manage perfectly, I was doing pretty ok for a while. 

In September 2021 my (relative) stability slowly degraded for as yet undetermined reasons.  I went from going over a year without an adrenal crisis to having one every other month...then every month, then I was giving myself emergency injections a couple times a week and was in and out of the hospital.  My yo-yoing between high and low cortisol symptoms became pretty extreme.  My doctors think the AI instability is due to an infection somewhere in my body since I do get stable anytime I'm on strong antibiotics.  (I also have wonky blood tests that suggest a chronic infection.)  It could just as easily be any of my other health issues causing too much stress on my body though.  Yay medical mysteries! 

Not as fun as Dr. House made it out to be. 
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So that's where I am now.  Prophylactic antibiotics have helped cut down on the instability, but not completely.  I was just in the hospital with a crisis a month ago and am currently battling one at home.  I'm seeing lots of specialists trying to figure out various other health issues with the hope that addressing some of them will help the AI become more stable.  

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Symptoms

Most people who know me know that my "adrenal issues" cause frequent hospitalizations and make me feel sick, but I usually don't talk a lot about what the actual symptoms are.  Because I'm unstable, I have both high cortisol and low cortisol symptoms depending on the situation.

The high cortisol symptoms are slower to develop and usually less intense than low cortisol symptoms.  They are more likely to happen as I come out of an adrenal crisis and am slowly weaning back down to my usual daily dose.   

It's not fun to be on high doses of steroids.  They impact your mood, skin, weight, hunger, energy, pain, etc.  The general picture of high steroid me is a grumpy, tired, very weak, hungry person who feels like they have the flu.  

And that super sexy steroid moon face.
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It's also really hard to maintain adequate potassium levels, so I get a lot of nerve pain and other weird neuro symptoms like wonky vision and ringing in my ears.  Usually I become so weak that I literally feel and move like I'm walking through jello instead of regular old earth air.  The weakness has been a truly humbling experience.  It's wild to have to rest between each step of getting dressed, for example.  I need a lot of help to do pretty much everything when I'm that weak. 

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Occasionally, I'll have the pleasure of going a bit crazy from the steroids.  Once when I was accidentally given 6x the dose every 3 hours for a few days due to a dosing equivalent miscalculation I even needed IV calm down meds.  While terrible at the time, I now find my reenactment of The Exorcist  hilarious.   When I sheepishly told my doctor about it, he said I was lucky.  He has had patients strip down naked and run/crawl through the halls of the hospital from steroids.  I'm glad that all I get is fidgety and irritable.  In my last round of the high steroid crazies I became very offended if anyone dared to speak to me.  I'm sure I was a delight to be around.      

Now I'm thinking that like 80% of horror movies are just people overmedicated with steroids.
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 The hunger is something else too.  It's not like a fun kind of, "I'm craving cake," hunger or even the, "Hey it's about dinner time, let's eat," hunger, but this exhausting, never ending need to get out of a hypoglycemia episode where my hands are shaking, my vision is blurry, and my heart rate increases 15-20 beats per minute.  And it's not even fun to eat because steroids give me a terrible bitter taste in my mouth.  Where is the justice in that, I ask!  

In addition to these fun things, high doses of steroids are going to cause a lot of problems in my future.  I'll be much more likely to experience osteoporosis, type II diabetes, hypertension, obesity, cardiovascular disease, and frequent infections.  Lifestyle choices can help mitigate this, but even with pretty healthy habits, I'm already slipping down this road in my mid 30's.  I'm choosing to cope with this picture of my future by a combination of denial, living in the moment, and banking on medical advancements to fix me up in the future.  So just like everyone else, basically.         

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Even with a lot of high cortisol symptoms being pretty uncomfortable and unhealthy, I much prefer it to low cortisol symptoms.  These ones can come on quickly, are more extreme, and more imminently dangerous.  

The worst part is that I go a bit bonkers.  High cortisol me is grumpy and sleepy, but low cortisol me is a brain bathed in panic juice.  I can't settle down at all and nurture that Impending Sense of Doom doctors tend to actually take pretty seriously as it often precedes things like heart attacks.  Pain is bad.  Nausea sucks.  But hours or days of panic...that's the worst.  I thank my lucky stars that it's temporary and once treated, I get to go back to my regularly scheduled balanced brain chemicals.  

Actual footage of my brain chemistry during a crisis.
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As my body starts to freak out and shut down, I'll have unstable blood pressure, a very high heart rate, GI cramping, nausea, electrical heart issues, lots of trouble breathing, rapid loss of blood volume, and moderate to severe pain.  I also get...kind of dumb?  It call it adrenal dementia and basically I just sort of forget how to do things.  I'll be just as likely to lay down on the ground and stare off into space as get myself emergency meds.  Or if I do get myself emergency meds, it will take me forever to sequence the steps and I am likely to make bad dosing decisions.  The result of this is a loss of independence.  I generally need people nearby to get me help if I start drifting off into la-la land.   

I'm getting much better at catching low symptoms early and when they are more mild, which is great.  I recently got a fitness tracker which has been providing some good data and advanced warning when things start slipping.  I also have a very wonderful and attentive alert dog who will headbutt me or start aggressively licking my legs if I'm heading low.  And my parents are almost as good at my dog at recognizing low cortisol symptoms.  I have a good team supporting me.

My little hero

The sooner I can updose and get stable, the better because things usually escalate on an exponential scale once they get going.  

To give you a picture of how bad I look by the time I get to the hospital, I usually am rushed through triage and into a room no matter how crowded the ER is.  Once I even got to "cut" in line ahead of the guy who just came in on an ambulance with a heart attack.  Yikes.

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Impact

   As you can imagine, this has had a major impact on my life.  It's really pushed me into an existence of minute by minute living.  I have to be on constant alert for any change in symptoms.  Since it's rare to have AI this out of control, I don't have as much help from doctors as I'd like.  I have to make high stakes decisions without sufficient data, education, or experience.  Which I find very stressful.  And tiring.  I swear, like 8 times a day I just sigh and say, "I'm just so tired."       

  I'm limited in what I can do because I can't really be alone and I have to stay close to local healthcare resources who are familiar with my treatment protocols.  Even more than usual, I have to cancel plans last minute or not make them in the first place. I have great days and sometimes even a good week or two here and there, but most of the time I'm either recovering from or heading into an adrenal episode or some other health issue.  

I've adapted by pursing more hobbies that I can pick up and put down easily.  I'm taking online classes and continue to work a bit from home.  I miss the in-person socializing, and just doing stuff in general, but whatever I can do from bed is a better fit for me right now. 

The good news is that I don't expect things to be this difficult forever.  I continue to follow leads and chip away at my health issues.  Each thing that I can address gives me that much more stability.  I am so far from exhausting all my resources.  When I am overwhelmed wondering what the next steps should be, I remind myself that's a good thing because I still have options.  

As a charmingly forgetful little blue fish once said...

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Me and My Unstable Adrenal Insufficiency - Part 1 (The Basics)

 One of the most difficult health issues I've struggled with in the past few years is one most people don't know that much about*.  I thought it would be a good idea to write a post about my experience with unstable adrenal insufficiency (AI) so my friends/family can have a better idea of what I have going on, and for anyone who may find this helpful if they are in a similar situation.  

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This fist post is a general overview about adrenal insufficiency.  Stay tuned for part 2 where I'll talk about my personal experience with AI (which, spoiler alert, is super chaotic and abnormal.  Yay.) 

What is it? - The physiology

First, forgive me, but I need to go over some boring hormone stuff.

Hormones are chemical messengers that help the body regulate and function.  There are a bunch of different kinds and many of them work together in groups called axes.  If something goes wacky in how your body creates or responds to hormones, you're gunna have a bad time.  

In adrenal insufficiency, something in the hypothalamic-pituitatry-adrenal axis get's messed up and the body stops producing enough cortisol.   Which is a bummer.  Because you absolutely need cortisol to stay alive.  

Something can go wrong at any of these levels.   So much opportunity for hormonal mischief!  

  There are different types of adrenal insufficiency which all have similar-ish end results.  There is primary adrenal insufficiency, also known as Addison's Disease*.  This is where the adrenal glands - the cute little pyramids above your kidneys - stop producing cortisol.  The lazy bums.  Then there's secondary adrenal insufficiency where the pituitary stops sending messages to the adrenal glands to produce the cortisol.  And there's tertiary where the hypothalamus slacks off on it's job communicating to the pituitary which impacts the adrenal glands. 

   

What are the symptoms?

So you are unlucky enough to have stopped producing enough cortisol - what will that look like?

Symptoms can start suddenly, usually if there is a major trigger like surgery, or it can come on slowly over time.  

Without enough cortisol, you can enjoy entries from the delightful menu of fatigue, GI upset, POTS,  weakness, and mental health disturbances, among many other things.

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That's just the kid stuff though.  That's just the baseline of not feeling very well.  Some people go years without being properly diagnosed in this state if they are still producing some cortisol.  

The big scary stuff happens when you don't have enough cortisol to meet the demands of your body and it sets off a cascade of horrible known as an adrenal crisis.  

This is very hard on the body and a medical emergency.  If you don't get urgent treatment, you will (most likely) die.   

The symptoms of an adrenal crisis are more extreme versions of the above menu, with some extra fun thrown in.  

Symptoms might include vomiting, fever, hypoglycemia, severe pain, cognitive decline, lethargy, heart rhythm issues, trouble breathing, and, my personal favorite, the overwhelming sense of Impending Doom.   

Basically your body is going into shock and shutting down.   It's not a fun process.   In fact, I'd go as far to say it's the worst thing I've ever experienced.  And that's saying something as someone who woke up from neurosurgery without any pain meds due to an IV malfunction.  Twice.  

Adrenal crises can look like a mental health crisis, a stroke, appendicitis, hypoglycemia, drunkenness, and a lot of other things.  This confusion can lead to adrenal crises not being caught and treated in time.  In fact, if you survive your first adrenal crisis, congratulations, your life expectancy just skyrocketed!  

What is the treatment?

Anyone with adrenal insufficiency needs to replace the cortisol that their body would normally produce.  That is their base biological dose.  They need to replace this dose in a way that mimics what the body would do if it was working correctly.  In functioning bodies, cortisol is released at different rates at different times of the day known as the cortisol day curve.  So both the amount and timing of daily steroid replacement is important.   

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In addition to this daily base dose, people with AI may need to increase their dose (called updosing or sick dosing) if their body is stressed by illness, injury, or abnormally high activity.  If there is a severe emergency or adrenal crisis, they will need to get a large injection or IV dose of steroids.

So people with AI:

1. Have a basal dose they take each day.

2. May need to updose in response to illness, injury, or stress.

3. Need to carry an emergency kit with injectable steroids in case of severe illness, injury, or adrenal crisis.

Most people get their steroids through taking 1-3 pills each day.  Some people do great with this, have a fairly normal life expectancy, and are basically asymptomatic.  Them lucky ducks!

Like this guy.  A very lucky duck in the AI area.  Not so much in other areas. 
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  For everyone else with AI, figuring out the exact dose and timing of meds can be difficult.  People digest, absorb, and utilize steroid meds at different rates.  We can't test our cortisol levels at home, so we have to do this based on symptoms, past experience, and...I dunno, sometimes it feels like I'm just making it up as I go along.  Even if we could test cortisol levels at home like people can test blood sugar, that wouldn't be very helpful because the amount of cortisol your body needs at any given time varies.  Because of this, we are only ever cosplaying as an adrenal gland and can never get things quite right.  It's probably more common to be a little high or a little low in cortisol replacement than in the just right range.  

Speaking of cosplay...potential Halloween costume this year??? I'd just need a little triangle hat.
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Some people don't tolerate the pills or they need more control of their steroid dosing.  If these people happen to be privileged with excellent healthcare and are strong self-advocates, they may be able to switch to sub-cutaneous injections of steroids.  

Look at those beautiful life giving little soldiers. 
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  Some very lucky people who respond well to injections may be able to sweet-talk their doctor into prescribing them an insulin pump that they can use to get a continuous dose of steroids.  This pump is programable to more closely follow the cortisol day curve, can handle minute changes in dosing, and is as close as anyone is going to get to a bionic adrenal gland.  In my opinion it's the best option by far and I hope someday it becomes standard of care.  

My beloved pump.  Built like an old school Nokia and deliverer of the elixir of life. 

   Depending on the type of AI and various comorbid conditions, some people may need to take additional meds too.  But these are usually much easier to manage and I'm not going to go over them in this post.

In the case of an adrenal crisis, treatment becomes more complex and involved stabilizing blood volume, electrolytes, blood sugar, controlling pain, etc. in addition to providing large amounts of IV steroids.  If caught early, some people can be stabilized in the ER and then go home, but often an adrenal crisis results in a hospitalization and a long recovery.    

What is the prognosis?

   The most dangerous time to have AI is before you are diagnosed.  If you survive your first adrenal crisis, things look much better for you.  After that, it depends on how easy your case of AI is to manage, how good you are at taking care of yourself, and the quality of healthcare you have access to.  It's pooooooossible to recover from secondary (and maybe tertiary?) adrenal insufficiency, but in general, it's not something that can be cured or reversed.  You're stuck with it.  

  Some people have pretty normal lives once they get on a good treatment regimen.   Unfortunately, many (citation needed) people seem to have at least some symptoms and negative side effects from the steroids.  Things like fatigue, obesity, and type II diabetes are common.  If you go by population statistics, life expectancy is less if you have AI, but it really depends on the person.  

It's a pretty bummer disease, and it can be dangerous, but it's not a terminal diagnosis.  

*Other random notes:

  Adrenal insufficiency shouldn't be confused with "adrenal fatigue."  Adrenal fatigue is a made up thing that is not supported by current science.  It's a concept perpetuated by snake oil salesman and dodgy figures spouting dangerous health advice.   If you have AI and anyone tries to tell you to stop taking steroids and switch to supplements or magic crystals or whatever, run away as fast as you can.  

  I've over-simplified some things in this post for the sake of accessibility.  If you want to get a full picture of adrenal insufficiency, I highly recommend Congenital Adrenal Hyperplasia: A Comprehensive Guide by Peter C. Hindmarsh (Author), Kathy Geertsma (Author).   I've read it cover to cover and it's a great resource.  

  When I introduced this post, I mentioned that it's not a very well understood condition.  By that I mean that even doctors, even endocrinologists, even the best endocrinologists at major research hospitals don't really know that much about it.  Though the basics are something you can learn in intro college biology, management of difficult cases can get very complex.  If you don't respond well to taking a few pills each day, no one really knows what to do with you.  There's a lot of controversy surrounding use of injections and pumps, and a lot of dangerous advice against updosing.   

Nothing in this post is meant to be medical advice.  Please consult your doctors for that.

Thanks for reading!    

  

  

Fifteen Years

I posted this on facebook on the actual day and wanted to post here too.  Fifteen years...quite a landmark!  

15 years ago today I got a chiropractic adjustment on my neck that went very wrong and I see it as the turning point of when I officially became sick. Though I was born with Ehlers Danlos Syndrome, I didn't know it at the time, and still managed a pretty normal life going to school, playing soccer, traveling, and dreaming without many of the limitations I have today. I had a very different life envisioned for myself.

Because of that neck adjustment, I had a stroke and tore some ligaments in my neck. I was lucky that I had a good neuro recovery from the stroke. I learned to walk again pretty quickly and got used to reading at a slower pace. But since that day, I've never been healthy.

I developed POTS and learned to live with a resting heart rate in the 90s-110s. It's exhausting. The chronic pain I'd had since I was 9 years old became a much bigger issue. I've had spinal cord injuries because of the instability in my neck, developed some seriously strange allergies, stopped absorbing many nutrients, had SO many huge surgeries... the list goes on. Literally for pages! More recently I've been struggling with unstable adrenal insufficiency and CSF leaks. It's been extra rough since 2016. Each piece of the puzzle that's figured out takes months or years of doctors appointments, tests, and lots of "are you sure it's not just that you're a weak woman?"

One thing I can say for myself is I never stopped living. Yes, I need to rest a lot, and I have to do things differently, and I'm pretty uncomfortable most of the time. But with lots of hard work, support, and an increasingly amazing healthcare team, I do have a life. While the last 15 years hasn't been what I'd expected, I've done some amazing things, met so many awesome people, and most of the time I'm pretty happy.

I made it through college on the slow path, even studying abroad (after two previous failed attempts). I went to grad school on the other side of the country and became an OT. I lived in NYC, and even though I had to move back home, it was everything I thought it would be while I was there. I got over a needle phobia and faced my fear of public speaking to raise funds and awareness for causes important to me. I've lobbied congress for better healthcare and helped create local support networks for people with chronic illness. When I couldn't find accommodating work, I started my own OT practice so I could continue in the career I loved. I found so many tiny ways to celebrate life and go on little adventures when I can't manage the big ones. I have so much time to devote to hobbies and lifelong learning. I've found over and over again resilience as challenges piled up. I have a closeness with my family and friends that grew from my extraordinary circumstances and my dependency on others. I have a lot of love in my life and truly know how lucky that makes me.

It's not the life I expected or wanted, but I think little me would be proud of what I've done in the past 15 years. I think I've done pretty well with the cards I've been dealt. So many opportunities have come out of adversity and I am very much grateful for that. I wake up each morning happy to be alive and excited about the day. I know that alone makes me one lucky duck.

To everyone who had been here with me, I truly can't thank you enough. It takes a village and I have an exemplary one.

Just like everyone else, I'm not sure what the future holds, but I'm always hopeful and always looking forward to it.

So happy "sickiversary" to me! It's been a crazy 15 years full of the best and worst times of my life, adventure, adversity, joy, and perseverance. Thanks for sharing the journey with me.

I'll be adding some photos with captions in the next couple of days. More good times then bad!

10 Years On

 

It's been ten years since I first stepped foot on the MV Explore, a ship that would be my home for an amazing four months.  My time traveling the world with Semester At Sea was truly transformative in terms of who I am and how I see the world.  I wanted to celebrate by posting a collection of some of my favorite photos and moments.  

Technically, I hadn't embarked yet in this photo, but it's important because it's when I first realized that I was actually going to make it on the ship!  My pining for a SAS adventure started a couple weeks before I had my stroke and there were an awful lot of health and logistical barriers to overcome to make the dream a reality.  I really have to thank my parents, doctors, and SAS staff for opening up this opportunity to a slightly medically unstable but determined student.  This picture is at a zoo in the Bahamas shortly before embarkation.  

I did it!  I'm on a ship!  And repping my alma mater.  Embarkation was a dizzying blur of happiness, paperwork, and some nerves too.  

I had many thrilling encounters with wildlife beyond my wildest imagination.  I was a little afraid to touch this guy because of the bright colors, but like a lot of situations during SAS, I chose to YOLO it.  

The Stairs were my nemesis in port.  It took me a lot of time and energy to get up and down these (this was pre spinal fusion, so my legs weren't working well) but everyone was always very patient with me.  SAS was the most supportive environment I've ever experienced.   

This picture is during my infamous hike through the Amazon Rainforest.  It's infamous because I use it as a marker for how well my pre-trip medical treatment worked.  Three months before this photo was taken, I was mostly bed bound.  Here I'm hiking several miles through the incredibly hot and humid rainforest.  (Shoutout to my cooling vest!  That was a lifesaver!). Also, .5 seconds after this photo was taken, I realized there was a spider bigger than my open palm right near my right cheek.  It still shows up in my nightmares.  *shudder*  

 

This is one of my favorite photos from the trip.  I'll always be captivated by monkeys.  So human...but not quite.  

It was pretty rad to study on the 7th deck.  I mean, look at this.  This is the life.  Any study location after this would obviously be a disappointment.  

I met so many amazing people and made some friends for life on the ship.  We called ourselves The Family and we specialized in Shenanigans.   Some examples are as follows...

Loved the dances on the ship!  

One of my favorite memories was shooting some hoops in the middle of a storm as we crossed the equator.  I played wheelchair basketball in a college PE class, and it was cool to get a taller perspective on the court.  

Ah yes, the Passover meal that would change my life.  The food was good and the spirituality moving, but that's not the reason it was life changing.  I ate way too much of the "bitter herb" and so started my extreme allergy to a range of spices.  This time I was lucky and it was only full body hives, but over the next year it escalated to anaphylaxis.  (I just started a regiment to try to desensitize to these allergies this week.  I'm hoping to put well spiced meals back on the menu in time.) 

Roomie and I during Sea Olympics

The food on the ship wasn't quite bad...but there was an awful lot of cream sauce and pasta.  So when it was a special day like Taco Tuesday, there was much rejoicing.  Pro tip, bring your own peanut butter because there were fixings for PB&J at every meal, but the peanut butter served on the ship we are pretty sure was actually soy butter or something weird.  My fav place to restock was in India.  They had the best peanut butter by far!  (Also, I got in trouble trying to "smuggle" some into the flight to Tibet.  I tried to argue that it wasn't a liquid, but a non-newtonian fluid so it should be allowed.  Security and my guide were not amused or persuaded.  Oh well.)

Mealtimes were peak shenanigan time.

More dances! 

And a fancy formal night. 

Those "Running to the ship because we got lost and it's almost time to leave port" vibes.

More dancing! 

I signed up to be part of a ship family and these are my Ship Parents.  They were a great source of support and travel tips and we still keep in touch!  In fact I saw them the day before my last surgery and it was great to catch up!

More mealtime shenanigans.  My favorite times where during heavy seas when we would fall out of chairs and spend 80% of our time trying to catch things before they fell off the table.  

COVID was not a thing, but we still had "plagues" on the ship.  Norovirus got me and I had to spend a few days in quarantine.  I felt very sorry for myself and pretended to be in the movie Castaway during my time of deprivation.  

Did I mention the shenanigans????

We started on our chains of 1000 paper cranes several ports before Japan.  It was common for us to sit around folding cranes and gossiping.  As ya do. 

The Fam <3

Oh hey, now we're in Ghana!  This was during the welcoming dance where I had my homestay.  Couldn't dance then and can't dance now.  But that really, really didn't matter.  

May I introduce my Homestay Mom and my two youngest Homestay Siblings.  I got to learn how to do some of the kids' daily chores, play games with the family (card games and soccer), and woke up in the morning to the youngest braiding my hair.  Such lovely, open, and patient people.  I committed so many cultural goofs, and they just laughed it off and taught me the proper way to do things. 

     

Still one of my favorite brands!  They make beautiful purses, ornaments, jewelry, and clothes!  You can catch some of their pieces at the Smithsonian stores in Washington DC, or shop online.  

This photo made the round on a few accessible travel blogs back in the day.  My poor spinal cord got quite a jostle, but it was worth it, of course!  

This is one of the happiest moments of my life when my fourth grade dream of "meeting" a cheetah came to reality.  Just as soft and magnificent as I'd thought!

The safari I splurged on was truly magical.  The animals regard the jeeps as just part of the scenery so they would get pretty close!

Our fearless leader!  Here he is trying to convince us to eat some elephant poop.  In my defense, I was dared to and I can't back down from a dare.  Tasted kind of like...sandy arugula.  Not bad, honestly.

More of my cherished animal encounters.  These were semi-domestic free roaming elephants who were very cheeky.  My bio professor on the trip really opened my mind to why I felt the need to meet and touch so many animals.  Was is good for the animals?  Was I supporting humane treatment?  Was I being safe?   That's a lot to think about for a girl who wants to snuggle every creature she meets.  

Now to India!    I snapped this photo from a boat on a river cruise.  Chatting and laughing with the girls over lunch is universal.  

If you don't think of seafood when you think of India, you are missing out!  I had some of the best seafood in my life in and around Kochi.  These are some of the fishing nets that provided said magnificent seafood. 

Getting my obligatory henna tattoo in Singapore.  I wish we had more time in that port!  There was so much to do and see and the shopping was top notch!  

Oh hey another childhood dream this time in the form of visiting the Great Wall of China.  It was a heck of a hike for this wobbly-legged, dysautonomic girl, but so worth it!  I'm wearing the panda hat my Ship Grandma got me to celebrate me getting into OT school.  I found out on a skype call the evening before.  

"Don't eat the street food" is horrible advice.  I ate everything I could get my hands on and only stopped short of flat out drinking tap water at some of the ports.  

Tibet was a magical, oppressive, fun and frightening place.  So many rules, so much propaganda, so little oxygen, and so much blatant oppression that even our carefully curated tours couldn't hide.  But also so much natural beauty, amazing architecture, and the people were funny and genuine (when we managed to sneak a conversation).  Here I am riding a yak...as ya do.

One of the Sacred Lakes I visited.  Just absolutely breathtaking!

In 7th grade social studies class I watched a documentary about Tibet and always dreamed of visiting Potala Palace.  I had to finagle a loophole that waived the need for a physical to travel there, and I may have lost some brain cells from going to such high altitude, but it was so worth it!  

This is where my guide gave me the tip that wearing a mask in cold, dry air was great for asthma!  It honestly works better than any inhaler I've tried.  I just had to wait several years for the western world to adopt this practical accessory.  

I spent a great day cruising down a river in Vietnam.  I ate some truly amazing food, met lots of dogs and cats, and saw some cool factories.

Market dog bringing good luck to his family.  Made me miss my pup back home!

Oh man, this kid!  I spend a couple days at his school learning Vietnamese Sign Language and going on fun field trips.  He was such a pistol, always pulling pranks, telling jokes, and pushing my chair far faster than it was made to go.  We had a blast! 

In high school I learned about the Vietnamese war tunnels and I always wanted to see them in person.  I was pretty scared to squeeze through such tight spaces and tunnels, but I'm glad I did it.  Truly humbling that people lived and fought from these small spaces.  The tone of the tour was oddly humorous and uplifting considering the setting.

Children's' art at the War Remnants Museum.  

This is one of my favorite photos from the trip snapped from a bus window as we drove through rush hour traffic.  

On to Japan!  I was pretty exhausted (and needing neurosurgery) by this point in the trip, but there were still many fun times to be had!  We had a great day visiting a Spring Flower Festival and taking in a rainy baseball game.

For reasons I can't articulate, this is my favorite photo from the trip.  

It was surprisingly hard for me to find sushi in the port town.  It took me half a day to find some to-go that wasn't at a fancy sit down restaurant.  It was worth it though!  Delicious!  

And here is where I realized I had a super power!  I don't feel temperature in my feet!  (Came in handy during Boston winters!)  This moment brought to you by me being severely underdressed for a trip up Mt. Fuji.    

After many fun filled gossipy hours working on my paper crane chain, I got to leave it at the peace monument in Hiroshima.  I still love folding cranes and leave them everywhere I go for random people to find.   With every fold, I wish for peace.  

The toilets in Japan were something else!  Once you've had a toilet with a seat warmer that plays music and gives you a dainty shower, you really are disappointed to go back to regular old porcelain.  I know that many of the professors and life long learners shipped one back home because they knew they'd never go back.  

This is what my cabin looked like shortly before disembarkation.  So many memories and mementos!  I'm honestly not sure how I fit everything into my suitcases to come home. 

SAS taught me so much about Home.  Home is with humanity.  Home is on a ship with the family you created.  Home is coming back to the people you love.  

SAS will always mark the point in my life that separates everything into "before" and "after."  The lessons I learned are enduring, the people I met are family, the changes I've made are for the better. 

Happy 10 years!