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Night wrestling

I am ten days out from my total knee replacement and there are many stories and experiences to relate. But first I wanted to begin not with the first event but one a few days after getting home, because it is funny, ironic and reveals much about the brain during dream sleep.

One of the most wonderful machines used in post surgical care is the ice water cooler. it is basically a small cooler that holds ice water, a pump which cycles the water through a hose to a pad that is placed over the surgical area. The point is to remove the heat generated by the inflammation. Not only does it provide comfort but it helps with circulation, and swelling.

So on the night in question I set myself up for what is hopefully going to be a good night’s sleep. I have an insulating layer on the knee then the cooling apparatus then several elastic wraps holding everything in place.

Soon I am in a horrible dream, fighting for my life against a huge boa (snake!). I am thrashing around trying to pull its coils off my body. However every time I grab it I feel it to be ice cold and can’t hold on to it. It is an Ice Boa! a rarely found subspecies of the snake. In my dream I think how odd it is that the snake is so cold but I am more distressed by how I am unable to remove its coils.

Of course I wake up fighting with the cold hose from the cooling machine with my foot and hands trying to rip the thing off.

It took almost half an hour to recover from the fright. But the strange interpretation that my sleeping brain gave to normal things lives on. I have enough distance from it a week later to see the humor. But I wish the surgery associated nightmares would end.

04/02/2015 at 10:08 AM Leave a comment

night of anxiety

I am waiting to lay down for an attempt at sleep. Tomorrow morning at 5.30 i will arrive at the local hospital and get ready for an appointment with a bone saw. Fortunately for me, the saw will be used by a skilled surgeon. When i wake up, part of my knee will have been removed and some high tech metal and plastic will be inserted in its place.

I will wake up numb from my waist down thanks to a spinal block and probably not too groggy from the twilight anesthesia. Most traumatizing to me will the be the role change from provider to patient. Then the therapy will begin. I abhor that this is necessary. It makes me feel vulnerable, dependent, and possibly even human. That last one is rather strange to me, and I don’t mean human as opposed to god like, but human as used in the terms (human error, or we are only human after all). if pressed I  might admit to feeling weak, perhaps even of failure. but since i am not being pressed I won’t admit to such things.

I know that I will wake up at 4.45 get a quick shower with the special antimicrobial soap they gave me, dress in loose clothing as instructed, arrive on time  or a bit early as is my habit with my id card and insurance card. I will be pleasant and undoubtedly joke  with the staff until they shut me up with drugs. But inside I will want to pull the iv out, grab my clothes, run for the parking lot, and take off in my wife’s car to the airport, buy a  ticket to which ever flight is leaving right then and keep on going. Wouldn’t that be a hoot, instead of runaway bride it would be runaway doc.

I have never cared for alcohol in any form, preferring to eat my calories rather than drink them, and now would not be a good time to start, but I can begin to see the appeal of shutting the brain from thinking too much. it is late and I need to go to bed.

D.

03/22/2015 at 10:04 PM Leave a comment

Lack of Focus

This man in his late 50’s came in the other day for two small problems. Both of them rather trivial; not so trivial that they did not require attention but trivial compared to what I discovered.

During the visit I noticed a lump/mass/tumor in his neck below and slightly anterior to the ear. “Oh yes, that has been there for months! But it is nothing, see I can push and poke on it and it doesn’t hurt”

“Oh my” how do i tell him that lack of pain is a bad sign not a good one, and that three months is not a good sign either.

He goes further, “and the other reason I don’t worry about it is because it is not just a little lump but actually I can feel it way back here below the ear and all the way to the jaw bone.”

“double Oh my” another bad sign.

The sense of touch is amazing, we can detect the slightest contour, the slightest subtlety in hardness. there are clinical words for these things. If you have a ‘bad’ lymph node the term you don’t want to hear is ‘rubbery’, another word you don’t want to hear is hard, irregular, fixed in place. His was definitely rubbery, irregular and fixed in place. The other thing you don’t want to hear is large and his was large.

So now i have a late middle age, smoker, who is full denial of the seriousness of his problem. All through the visit he kept trying to steer me to the reasons he came in (actually I forget what they were for my focus became rather narrowly focused at the time)

On careful palpation I noticed that the tumor was pulsating. Clearly it was near the carotid artery and it could just be that it was transmitting the normal pulses but it was more than that, it was inseparable from the carotid as if it had enveloped it. For a second i worried (hoped?) he might have an aneurism or something serious but non malignant . However the mass was hard not the soft feel of a large vessel, even a calcified one.

It took some effort to keep the patient focused on this issue. I first of all had to deal with his two minor issues, then insist that he get a soft tissue CT of his neck right away. I consulted with a surgeon to discuss the best approach to diagnosing this mass and depending on what the initial test shows we will either go directly for the biopsy by either a surgeon or interventionist Radiologist, or get a contrast MRI. Without tissue we cannot make a definitive diagnosis and therefore cannot give a prognosis. Although there remains the possibility that it is an odd, non malignant growth it is not likely and  but even then it would cause interference problems. Another worry is that the tumor could erode the wall of the carotid artery, which to say the least, is not a good thing.

Now we just have to check up on him to make sure he gets the test. Then somehow break through his lack of focus regarding the seriousness of this problem.

Ideally i would simply call a family member to guide him through the process, but the only legal way to do that is to have him come in with someone and discuss it together. I cannot reveal his information without his permission stated or implied. (which, by the way, is the way it should be–IMHO)

03/22/2015 at 8:29 AM Leave a comment

Difficult success

This elderly lady came in after recent back surgery. More than that, after her 6th back surgery!! For any one that knows about medicine that is a daunting thing. The success rate of back surgeries drops exponentially with each surgery and after the second or third the success rate is hardly measurable. At any rate that was not the problem. The problem was overwhelming pain two weeks after surgery. Pain so bad that she could hardly survive, could not rest, was in constant misery and nothing gave her any relief.

I entered the situation when the significant efforts of her surgeon became pointless and he sent her to my office. I was shocked (and it is hard to shock me) that she was already on oxycodone 15 mg and she was taking them every 2 hours! That is a hefty dose for someone as big as me, much less a 77 year old lady. Moreover it was barely helping at all, it was not even sedating her. She could not sleep, could not eat, and the pain was effecting her thinking. It took significant effort for her focus on questions, the pain was so intrusive.

I talked with the surgeon to make sure I was up to speed on what he had done and discovered that this was the upteenth surgery on her spine! Ouch! I had the huge advantage of knowing the patient and her husband for decades. They worry enormously about each other and in fact her husband has lost nearly thirty pounds because he cant eat, he is so worried ( and he is very thin to begin with). She constantly worries about his heart and that he will not be able to handle the stress of her problems.

Knowing that narcotics have not helped the pain is a great help, it narrows down the scope of what could be wrong. She felt miserable and complained of pain ‘all over’ so I had to push her to focus on where the sever pain was (started). I finally found an area two inches to the left of the incision where I could feel a series of muscle spasms and she reacted to light presure with significantly increased pain– A trigger point. I decided that the problem we were not dealing with was two fold, tremendous anxiety and worry plus the muscle spasm ( imagine a charlie horse in your back, one that you cant straighten out and relieve). Muscle spasm are nearly impervious to narcotics, I dont know why but that is they way they are.

I first injected her with a hefty dose of Valium. One of the world’s best drugs. Extremely safe when used appropriately, a great anxiety reliever and a very strong muscle relaxer, all in one. I waited 10 to 15 minutes while I prepared a Cortisone injection and then I placed it all around the tender spastic area. All the while assuring her that I would do everything I could to prevent one more sleepless pain filled night.

Within ten minutes her entire demeanor changed, she was not constantly fidgeting, she stopped fretting about the pain, she began talking about how hungry she was, the turnaround, although, significiant was not complete.

There were two additional things, she was worried the pain would return and she began to focus on other issues. I realized that her overall issues were 50% enormous pain 50%anxiety and 50% insecurity. I had only dealt with the pain and some of the anxiety.

Over the next day I continued with the valium, talked to her on the phone to reasure her I was not abandoning her, saw her again the next day and injected a less tender spot that was masked initially but most importantly told her how good she was doing. I pointed out  everyone of the pain based behaviors she had stopped and the abilities that she had not regained. She was standing unaided adjusting her dress! She walked out without discomfort!

Once I got her focus on her improvement and that I would be there for her, She completely morphed into her old self. She had needed to be shown that things were better.

I am happy that she is so much better and now we have a plan of attack should the problem recurr ( and no narcotics!) but it took nearly every bit of learning and experience I have had over the past 20 years, good thing I was on my game that day.

12/20/2014 at 5:56 AM Leave a comment

Natural, schmatural

What is it with this ‘Natural’ thing anyway? I have so many people simply assuming that natural must be better, as if it is a given, nothing to question, as fixed as ‘breathing is good’. This despite the overwhelming evidence against it. Furthermore, people are totally willing to believe that if it said to be ‘natural’ it therefore must be.
Nobody in this money driven society would ever consider lying about such a thing, surely that is taboo.
These are intelligent, educated thoughtful people. People that would never even hesitate to delete an email from a Nigerian prince. So why swallow such a bunch of hooey about ‘natural’?
The best answer I have heard in thirty years is that it is a holdover from the ’60’s back to nature movement and perhaps it is, but it sure should be wearing thin by now.
After all, consider the following:

Natural encompasses:

a hard difficult life full of tragedy ( think many childhood deaths) followed by an early death

Small Pox, Typhus, Malaria, Polio, Tetanus– the scourges and killers of untold millions before ‘unnatural medicines/ vaccines’ came to the forefront.

Performing labor manually, living by ‘the sweat of ones brow’ if you will, being hot in summer, cold in winter. No way cars and electricity are ‘natural’

Natural vegetables and staples before they were augmented/domesticated provided meager sustenance and did not allow for much storage, which meant cycles of famine.

Going to the bathroom in the open, the world smelling of a toilet.

Give me engineering and human modernity anytime. Certainly i won’t be the first to try something new but hey, were are a very bright and curious race and I enjoy and fully take advantage of all the fruits of scientists’ labor, whether it be transportation, Air conditioning (!!!), a robust infrastructure or advanced medicines.

A year ago I was routinely tested for immunity to a variety of diseases (Hep B, Polio, etc.) and was found to have no immunity to ChickenPox. How in the world is that possible ? I don’t know but I can tell you, I could not wait to get to the office and get a shot followed by a second one in six weeks.

12/13/2014 at 3:22 PM Leave a comment

iceland summer

A patient brought his adorable 12 year old daughter today for a sore throat, etc. I noticed, apropos of nothing, that he had a sweatshirt from the Reykjavik University, a rarity in these parts. It turns out that his best friend went there and regularly says it is rather brutal there.
“even in the summer” i countered.
“This year, it was on Thursday” he responded.
😉

12/05/2014 at 8:31 PM Leave a comment

slowly and clearly please

I am on call this weekend and received two pages at the same time. the only thing they had in common was that when it was time to leave the phone number to call back, they sped up their speech as if in a speed reading contest. this I do not understand, after spending many minutes giving a long and mostly unnecessary history, when it comes time for the most important part of the message, they lose control of their slow deliberate speech and run through the number.

I listened to the first message four times and could not hear the right phone number. i was shure of 4 digits, pretty sure of one more and had no idea of the other two. I had to wait until they called back, which was sad because it sounded like she needed some advice.

the second call did the same thing but had the addition of a crying baby in her arms. is it really that hard to realize that if you cannot hear yourself think because of the crying that I won’t be able to hear the message? I have been a parent with crying kids and i went to another room with the door closed to make a call.

I do want to call people back, a little help would be great. Short, to the point messages, give the phone number first thing and last thing on the message. Slow down for the number and enunciate.

11/19/2014 at 1:01 PM Leave a comment

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