Ooey, Gooey: the Revenge of the Nosebleeds

Today, the cliff shall be unhanged! It's a little anticlimactic, since we're not talking about horrible tumors or immanent death, but it's kind of gross.

As I wrote on the night of the 12th, I was to see the amazing neurosurgeon who had tried to plug my nosebleeds and then see a very well-respected neurologist and stroke expert whom I will call Lord Strokes (This is not at all fair. He's a very nice guy who, in no way resembles the evil overlord of the First Order.)

So, on Friday, the 13th*, Kathleen and I drove downtown to the O'Hair Medical Center for the appointments. First, we saw Lord Strokes.


Meeting with Lord Stokes

I hadn't seen Lord Strokes since 2006 when I had my first stroke, so we had a lot of catching up. I had sent him one of my own patients recently, and we discussed that too. The good news is that there has been a big study comparing doses of aspirin from 50 mg to 1300 mg per day for the prevention of stroke. There was NO difference except that the incidence of stomach ulcers and kidney damage increased with dose. So I can get by on a low dose which will cause less of a risk of nosebleeds.

Then, it gets complicated. There are two likely causes of my strokes.

One of them is absurd amount of radiation to my head I got for my cancers. Sadly, this was not ruled out when the neurosurgeon found no narrowing of the arteries of my head. The effect of the radiation is on microscopic vessels called arterioles. This is not visible until you cut the patient's head open and collect some tissue. I'm not really up for that. But I think this is the most likely cause. I received so much radiation that radiation oncologists practically faint when they hear about it. Also, the two strokes were located close together within the radiation field.

However, that still leaves the issue of the little hole between the top two chambers of my heart (patent foramen ovale, or PFO).** It is possible that a small blood clot found its way from the right side of my circulation, through the PFO, into the left side of my circulation, and to my brain. Even if it's not the case, with a PFO, my risk of stroke is 1.5 % a year. If I get the PFO closed, that risk drops to half a percent per year.

Closing the PFO is relatively easy. They spike my crotch again (which is getting to be routine), and another catheter is threaded up, this time through the veins, and into the the right side of my heart. There, they would open a little umbrella-like device which would block the hole. I am in no hurry to get this done, but I expect I will get it some day.


Meeting with the Neurosurgeon

So, finally, the time came for the follow-up with Dr. Crotch-Spiker (provisional, inappropriately disrespectful nickname for a doctor who is at the very top of his sub-sub-subspecialty and is a good man). We told Dr. Crotch-Spiker (whose parents' last names were Crotch and Spiker) that I was still having nosebleeds. He shook his head sadly. The intense headaches and fevers I had after the procedure meant that he could not repeat it without risking permanent damage to the tissues. I am going to have to live with the nosebleeds.

That said, it's not so terrible--a lot better than it was before the procedure. Instead of erupting with gushing bleeds in the middle of patient appointments and having to rush to ENT for cauterization, I have a slow trickle that does not even come out until I have gone a few hours without rinsing my nose.*** I just have to remember to rinse in the middle of the day to avoid sneezing bloody goo in the afternoon.

And that's the end of this particular adventure. Another annoyance, but not the end of the world.


Be well,

Tom


* No, I don't believe that means bad luck. If there were truly an unlucky date/day-of-the-week combo, it would be Monday, the 13th, wouldn't it?

** See Tumoriffic, original blog, August 7, 2007 for more on that: http://www.tumoriffic.org/Part%20III.htm

*** Technically, this procedure is known as a 'nouche,' for nasal douche. It is done with a squeezable 8 or 16 oz bottle filled with salt solution. I do it at least 4 bottles at least twice a day and a lot more when I have an infection.

You too can nouche. I strongly recommend it for anyone with sinusitis or cold. The bottles, made by Neilmed, are available at most drugstores. You should use distilled or boiled water and mix it with a little bag of salt and sodium bicarbonate formulated to match the salt in your own blood and snot. (That way, it doesn't sting when it goes in. Pure water really hurts.) Neilmed makes these bags, but CVS, at least, now sells their own bags, which are much cheaper. You don't have to do it as much as I do, but it should help with cold symptoms, help prevent colds from becoming bacterial sinusitis, and make your bacterial sinusitis go away faster. Happy nouching!

This bird never gets bloody noses.

Flashback: When to Ignore Meningitis Symptoms

This is going to be a confusing post. My last post was on the evening of July 12, just before the follow-up appointment to my June 6 procedure. But I still haven't told you about the procedure itself and what happened over the following days.

Rewind to Tuesday, July 6. (For context, look at my post of June 5.)

That morning, it was time to get my second spike in the crotch. Kathleen drove me downtown to O'Hair Medical Center, and we wended our way through a maze of corridors until we reached the Spike-in-the-Crotch Department. Contrary to my childhood memories, the procedure was not as bad as it sounds. I would not want to do it for fun (not that there's anything wrong with that), but, with the right sedatives and pain killers, it's tolerable, and, unlike the week before, I don't remember it at all.

Once again, the neurosurgeon (whom I have yet to give a silly nickname) threaded a catheter up through my femoral artery, past my heart, and into the arteries in my nose. This time, it wasn't just to look around, but to take care of business. Zillions of tiny arteries had blossomed in my nose--far more than I needed for normal nosing. The neurosurgeon released tiny beads that blocked off the extra arteries. I don't remember any of it, but the neurosurgeon told me he had a lovely time.

Once I left the recovery room, I was rolled up in a wheelchair to the neurological intensive care unit. There is a small potential for a stroke after such a procedure, and they thought it would be fun to watch.

If you ever have reason to go there, I highly recommend the O'Hair Medical Center Neurological Intensive Care Unit. Four stars--the fanciest I have ever worked in or stayed as a patient. Unlike the last one I where I was a patient, I wasn't miserable and hallucinating, but there is a lot more to recommend it. It is clean and modern-looking. The rooms are singles, and pretty big. They are closed off completely. (The staff could look in through the window that covered one wall, so it did lack a certain privacy.)

It just to happened that my nurse and student nurse had no other patients that night, so they fussed over me even though I felt perfectly fine. They wheeled me down for an MRI--a fun trip, and we laughed and traded medical war stories. They even went downstairs to the lobby to get me something from the Au Bon Pain (which translates to Oh Bone Pain) because the kitchen was closed. Then, I went home in the morning and slept much of Wednesday.

On Thursday, June 8, I went back to work at the office. I began to get a little ache in my face and a little bit of a bloody nose (which defeats the point of the whole procedure). It wasn't terrible, but it wasn't what I expected. So, near the end of the day, I called the surgeon's office and asked his nurse whether this was normal after the procedure or whether I should go to the Emergency Department. She said I should. I was skeptical, but, after work, Kathleen and I went all the way back to O'Hair.

That visit to the ED was kind of fun, if inconvenient. One of the docs there liked to tell doctor-lightbulb jokes like, "how many psychiatrists does it take to change a lightbulb? One, but the lightbulb has to want to change." The neurosurgery, and ear, nose, and throat staff were unimpressed. Apparently, this was not so unusual after the procedure I had had. They sent me right back home, and, the next day, I went back to work with a little ache in my face. I still don't know why I was supposed to go to the ED in the first place that night.

Then, Friday night, I started to get a really bad headache--the worst I had ever had, and I had a temperature of 103. (Friends not from the US, don't worry. I wasn't boiling alive. In Celsius, my temperature was about 39.) We got a little freaked out and called the O'Hair neurosurgery coverage. They kind if yawned but said I should go to the Emergency Department. They said I didn't have to go all the way downtown this time, so I went to a nearby hospital where I had worked but never been a patient. That's always nice.

They seemed slightly more excited, but once they talked to the neurosurgery coverage at O'Hair, they yawned too. They sent me home, and I tanked up on full dose acetaminophen and ibuprofen (known more commonly by their brand names, Tylenol and Motrin).*

I slept all day the next day and had an even worse headache and a fever. This time, I had neck stiffness, and it was painful to touch my chin to my chest. This was kind of scary, since, when a patient comes to me with these symptoms, I send them to the emergency room, and they get admitted to the ICU.  These are the symptoms of meningitis. So, Kathleen called the covering neurosurgeon. He yawned, but he actually explained things better this time.

Some of the blocked arteries had been doing more than just causing bleeds. They had been feeding tissue that was getting inflamed after losing some of its blood supply. That's apparently something that can happen after the procedure I had, and it can feel like meningitis.  So, I just took the big painkiller combo (with an acid-suppressor--omeprazole--to protect my stomach) for a few more days until everything stopped hurting. It seemed to be a happy ending. But the story was to continue.

Next: Ooey, Ooey, Gooey--the Revenge of the Nosebleeds.





* This is actually a very good combo for severe pain, and I recommend it too my patients. Acetaminophen is unrelated to all of the other over-the-counter pain medications, so it does not conflict with any of them. You can take it in combo with ibuprofen. Just remember that acetaminophen can be deadly for people who drink three or more servings of alcohol every night, and ibuprofen might burn a hole in your stomach or blow out your kidneys if you take it for more than a little while. In clinical trials, they do as well as narcotics.

I met this dog about a month later. He's not really relevant, but he's awfully cute.

Drip, Drip, Drip

OK, first of all, I have had writer's block. Somehow, a chronic nosebleed and the threat of stroke are as funny to me as impending doom from an exotic cancer that ends up being misdiagnosed. Why? I have no idea.

I have a long story to tell, but that will have to wait. I am already staying up too late, and I have to get up early tomorrow. On the other hand, there will be more news tomorrow, and I love a cliffhanger (although, it's really hard to beat 2005's "will he lose his right eye or not" moment)!

Briefly, the surgery did not entirely work. The story of what happened later is a laugh riot for another time, but I have been left with a slow ooze of blood in my nose that gradually builds up and then spills out after a few hours. This leads to such great moments as the other day, when I sneezed bloody snot on my shirt in front of a patient. (He had a story to tell when he got home.)

Meanwhile, I can only take half an aspirin a day if I don't want my nose to be a bloody spigot, and that leaves my vulnerable to another stroke. It might not be the fun kind like the first two. I could be driving or something.

So, tomorrow, for the first time since the surgery, I will see the surgeon again. Maybe he will have another suggestion as to what to do. He will probably want to repeat the procedure. That would mean another two stabs in the crotch followed by all the joys that followed them last time (to be described lovingly in another post). After that, I see the stroke guy and hear what he's got to say. That'll be a real hoot too.

Until later,

Tumoriffic Tom

My friend, Ollie the Gray Seal, says it's all going to be OK.