Nearly A Piece of My Mind

Today started very strangely. Here's some background:

Ever since my surgery and radiation in 2005, I have been unable to blow my nose effectively. So, every morning and evening, without fail, I rinse out my nose with over half a gallon of salted distilled water using a sinus rinse bottles.* I call this process "nouching."

Anyway, as I was rinsing this morning, I felt something hard and sharp behind my nose. I rinsed some more, and spit out a piece of my skull.

Huh?

That's right. A piece of my skull. It's about a third of an inch to a side and more or less cubic. And holy plucking schmidt! It's a piece of my skull! And, it may surprise you, but it does not look healthy. It looks like peanut brittle (though less tasty) or pumice (though less useful for removing corns). I could probably crush it to powder between my finger and thumb. And did I say that it's from my skull?

What does this mean? Is my head about to collapse into a mass of bone powder and goo? Probably not. Although the appearance of a piece of my skull in the bathroom sink was an unpleasant surprise, I know that the big part of my skull between my nose and brain is dead. I'm not sure how that leaves me alive and more-or-less healthy, but my doctors have assured me that I am alive and am in reasonable health. I'm not sure they entirely know why either. 

So, I left messages for my primary care doc, my local ENT doc, and my F'in Famous Cancer Hospital ENT doc. One nurse I spoke to said, "wow. That's different!" To say the least. I've heard back from Dr. Hygiea, Greco-Roman Goddess of otolaryngology, *** and she wants me to get a CT scan. That will have to wait.

See, I am currently spending the week in the British Virgin Islands. I called around. There is one ENT doc in the whole country. He might be able to see me in March. He will be in for emergencies tomorrow, but he'll be away for a week after that. So, if my brain lining rips and my CSF leaks onto my shoes, or if my head collapses onto my spine so that I am a human bobble-head, I'll have to get air-lifted to St. Thomas or San Juan.

I'm actually not really worried. This is just the sort of thing that happens when you have a large chunk of dead bone in the middle of your head. Really, the dangerous part is that dead bone, like a splinter, can fester and cause infections. So, all else being equal, the more of it that comes out, the better. It's like Mom always said, "better out than in." 

Tomorrow, I'll go snorkeling and look for whales.

Be well,

Tom

* By the way, I recommend this wholeheartedly to my patients. If you have a cold, sinusitis, or allergies, rinsing helps clear out the gunk. Do it as much as you can stand. The concept is disgusting, but, sometimes, it can help you avoid antibiotics, and involves no toxic products whatsoever. ENT docs love them. http://shop.neilmed.com/Products/Sinus-Rinse. The salt packets can be expensive, but pharmacies have started selling generic versions which are cheaper.

** I'm certainly not about to carry a giant jug of water on top of my head like some women in Africa. That could get ugly.

*** This is a pseudonym. 

Here's a baby gray whale checking us out in 2013. We're looking for humpbacks tomorrow. I hear there's a newborn nearby.

Well, That Was Fun!

As of last update, I was in the emergency department at Ben and Jerry's Hospital getting worked up for an episode of double vision. After a normal CT scan and MRI, I had to wait overnight for a visit from the eye doctor and for an echocardiogram to make sure there wasn't a big, floppy blood clot throwing off bits and pieces into my brain.

That was the day before yesterday. They put me in a room in 'observation' (part of the emergency room where they keep you if you are there for more than a few hours, but they don't want to admit you). Surprisingly, if you have your own room and are hard of hearing like me, you can sleep pretty well in the ER. You take your hearing aids out, put in earplugs, and it's pretty quiet. There are pluses to bad hearing. K, on the other hand, slept terribly, worrying about me.

Yesterday, late in the morning, a technician wheeled in her ultrasound machine and got an echocardiogram of my heart. This involves the tech rubbing a microphone covered with KY Jelly on my chest. Those of you who have been pregnant may be familiar with a similar experience. It's a rather slimy. To everyone's relief, there is not a great big blood clot flopping around inside my heart waiting to fly off into my brain!

Finally, the ophthalmologist came by. He examined my eyes. I'm always jealous of ophthalmologists. They have all sorts of cool equipment to look into eyes. I only get to use the wimpy kind of ophthalmoscope primary care docs get. It makes me feel inferior. Thankfully, he did not rub it in.

The ophthalmologist agreed that the most likely explanation for my episode of double vision is that my extreme fatigue had amplified the inherent weakness of the muscles that move my right eye.* I had been really tired that day. Not only was there an early-morning meeting at my office, the night before, I had a migraine and had foolishly treated it with caffeine in addition to ibuprofen. I slept terribly that night.

Shortly after the ophthalmologist left, K showed up. I was ready to go home. Sadly, because someone had to put an official read on the echo and various notes had to be written, I had to wait until late afternoon to go home. Still, I had time to take the dog for a walk. It was a pretty short ordeal for a Tumoriffic episode.

That's all, folks!

T





* The muscles that move my right eye (extraocular muscles) are weak due the radiation and surgery I received in 2005. Generally doesn't bother me unless I look down or way to the right.

** I have been getting migraines lately, probably because I just got progressive lenses, and I'm not used to them.

Saying 'goodbye' to the ER and 'hello' to my new friend. 

Embarrassing Update From the Emergency Room

So, the news has been so boring lately, I thought I would spice things up.

Yesterday morning, I was driving to work. Suddenly, there were twice as many cars in front of me as had been there the moment before. Every car had grown a twin. I blinked my eyes, but it was still true. I had double vision. Luckily, if I kept one eye closed, it went away, so I avoided dying in a flaming wreck. After a few minutes, things returned to normal. I went to work, saw my patients, and went home.

That evening, thinking that maybe my primary care doc, Dr. N, should know about this, I sent her a message. Foolish me.

Today, after I had seen a few patients, I got a call from Dr. N. She was laughing. She said, "Tom, what would you tell a patient if they sent you a message saying what you said to me?"

"Um," I tried figure out something to say other than the obvious, but there was no way around it. "I'd send them to the emergency room." And she laughed at me some more.

Reluctantly, I cancelled the rest of my appointments. I grabbed some papers off my desk, and drove home. Then, my delightful neighbor, G drove me here, the emergency room of Ben and Jerry's Hospital. *

After several hours, I have had an unremarkable CT and MRI (by my unique standards). I did not have a stroke. However, I don't get to go home tonight. We still don't know for sure what happened.

The most likely explanation is that Donald Trump. That's right. His fault. Some kind of executive order. Donald Trump.

Another possibility--the one that really seems most likely to me--is fatigue. I was ridiculously tired that morning. My work was holding a meeting at a truly ungodly hour. The muscles surrounding my right eye are weakened from all the radiation, and I think the fatigue just brought this out. This was one of the ways I reassured myself until Dr. N embarrassed me into coming here. I still think it's number one.

Next, it is possible that I had a TIA--a transient ischemic attack. ** This happens when there is a blockage in blood vessel in the brain that is temporary. This could be due to narrowing of the small vessels from all the radiation I had to my brain (a known phenomenon and probably the reason for my two strokes ***). This is quite possible. That was the other way I reassured myself. I'm already on medicine for this, so I am already doing everything that can be done.

But, then, there's the kicker. The other possibility, however remote, is that I have a big, ugly clot in the left side of my heart that just threw off some little bits that travelled to my brain. If that's the case, I'm in for an operation to get the clot out before something really exciting happens. So, I'm here in the ER for the night, waiting for an echocardiogram.

Hopefully, by tomorrow, I'll be home with the wife, the kid, the cat, and the dog.

Be well,

T




* See http://www.tumoriffic.org/LLC.htm.

**  It can also mean other things. According to the Urban Dictionary, a Tia is "a cool, smart-mouthed girl that always has something smart to say to everything. (http://www.urbandictionary.com/define.php?term=Tia) According to the Online Slang Dictionary, it may stand for "thanks in advance," "this is awkward," or "the ignorant ass." (http://onlineslangdictionary.com/meaning-definition-of/tia). It also means 'aunt' in Spanish. Or it stands for "Trump in America."

*** See August 14, 2006 (mislabelled 2007) in http://www.tumoriffic.org/Part%20III.htm and http://tumoriffic.blogspot.com/2012/03/tumoriffic-moves-to-unused-doctor.html. The latter needs a serious rewrite. I haven't looked at it in years, and it's really confusing. Sorry.

Attention: The Inappropriate Guide Has Moved. See Below.

http://drtumoriffic.blogspot.com/2017/01/screen-for-everything-every-day.html

#8 Your Special Specialist

Dr. Tumoriffic's Inappropriate Guide

to Navigating the Medical System

Dear Dr Tumorific, 

How can I know which doctor at the specialist practice to see?

Jay

Dear Jay,

This is a very special question. There are many ways to do this.

For instance, if you would like to use the guidance of the spirits, print out pictures of all the specialists in the specialist practice. Then paste them to a Ouija board. As the paste dries, burn some incense and douse yourself in patchouli oil (at least 5 feet away from the burning incense so as not to light yourself on fire). Clear your mind, and let the spirits of the medico-industrial complex guide the planchette (Ouija piece) to the answer.

If you're less spiritually minded, you could tack that Ouija board to the wall and throw a dart to pick your specialist. Why did you even have a Ouija board in the first place?

Finally, there's the superficial method. If looks can kill, they can also save your life. Peruse the photos. Which one looks most doctorly? Do you prefer red-headed doctors? Are you more comfortable if your cardiologist is ugly? It's all a matter of taste.

But, if you want my real opinion, it's complicated. There are a lot of factors. I am going to interpret the question broadly. I'm not going to talk not just about how to choose a specialist within a given practice, but how to choose any specialist anywhere.

1. This is the most aggravating, but, for many, the most important question to answer: which specialists take your health insurance? More and more, insurance companies are making deals with specific groups of doctors, and if you go to someone outside those groups, you have to pay a higher price, or in some cases, you won't be covered at all. 

Sometimes your primary care doctor can get special exceptions, but the insurance company will then penalize the primary care doctor's organization financially. This puts primary care docs like me in a tough situation. We would like our patients to go wherever they want to go, but if we ask for too many exceptions, we will get in trouble with our employers. But when we don't think an exception is warranted, we end up being the bad guys by telling our patients they can't get what they want, because, let's face it. almost no one reads their insurance contracts, so the fact they can't see their friends 'great specialist' comes as a nasty surprise.

2. Next, where is the specialist located? Assuming you're not a medical oddball like me, convenience may be a good way to find a specialist. Especially if you are elderly and have a hard time going places, Dr. Nearby may be the best for the job.

3. Also, which specialist works best with your primary care doctor? Like all primary care docs, I have a few people in each specialty who see almost all of my patient referrals. I know them, like them, and trust them, and I can get ahold of them easily. There are some who will call me within 5 minutes if I text them. I even bug them about random questions when I'm not sending them patients. And if I am sending them a complicated case, I will call and talk to them about the details instead of just sending them a brief written referral request. All else being equal, ease of communication goes a long way towards quality of care.

4. Finally, how special do you need your specialist to be? Aside from intelligence and conscientiousness, the quality of a specialist for a given problem depends largely on how often they see and deal with the problem.

You don't need to go to a medical Mecca to find a gastroenterologist who is an absolute wizard with a colonoscope, and you do not need to go looking far afield for the world's greatest hip replacement surgeon. There are doctors all over the place who do dozens upon dozens of these procedures all the time.

But on the other extreme, you could be like me and have a type of radiation-induced tumor that is rare even among radiation-induced tumors and in a very difficult to reach spot in the bone under my right eye. In 2005, I could have gone to the highly prestigious Wicked Famous Cancer Hospital in my home town and been operated on by very eminent surgeons who had never before worked as a team, much less done my operation ever before. (No kidding! I was going to be their very first case together!) Instead, I chose to go 215 miles away from home to a team of the F'in' Famous Cancer Hospital who did 50 of those surgeries a year. As a result, I still have my right eye. (See http://www.tumoriffic.org/Part%20II.htm, April 17, 2005, The Clash of the Surgeons, or The Eyes Have It!)

The most common way to locate one of these super-specialists is to know somebody who knows somebody, or to ask your doctors, who hopefully will know somebody who knows somebody; I call this the Medical Mafia.

You or your doctor could also look up who is getting NIH grants in that area (https://projectreporter.nih.gov/reporter.cfm), or research who is publishing articles about their work on similar cases by searching in pubmed (https://www.ncbi.nlm.nih.gov/pubmed/).

So, how to find the right specialist is a very special question. Thanks, Jay, for another good one.

Be well,

Dr. Tumoriffic

#7: The Never Ending Prescription

Dr. Tumoriffic's Inappropriate Guide

to Navigating the Medical System

Dear Dr. Tumoriffic,

Why does it take so long to update my med list in the EMR? I haven't taken that med for 5 years.

Liz




Dear Liz,

The reason is that your medical record is constipated. Clearly, it has not been eating enough fiber. Now, it's paying the price. I recommend you give your medical record prune juice. If that does not work, try giving it Colace. If that does not work, Miralax.

If it's still holding back, desperate measures may be called for. The next step is an soap suds enema. Giving an enema to a medical record is really unpleasant. They tend to struggle, and, if you are successful, it's really ugly. I would wear an apron and put lots of newspaper on the floor.

Finally, you may have to institute the measure of last resort, the manual disimpaction. This is one of the most unpleasant procedures you can perform, both for you and your medical record. You should definitely wear gloves and hold your breath for as long as possible. However, the result is likely to be cathartic for both you and the medical record.

Once your medical record has become regular, it should be able to update itself just fine.

Of course, if your medical record is already regular, there are other explanations. Some systems, like my dearly beloved Epic, do not automatically discontinue medications that obviously should be discontinued. For instance, the short course of azithromycin (after a buttock injection for ceftriaxone) for gonorrhea should, clearly, automatically stop. If the patient needs it again (and I have had patients like that), the patient should at least come in for a stern talking to about condoms before getting a refill. If your doctor is not rushed and thinks of it, they can write in a discontinuation date for the medication, but the fact that they have to do that for obviously short term medications is ridiculous.

Another possibility is that your medication was discontinued by a doctor who uses a different electronic medical record system. As of right now, there is no automatic way for your pharmacy and your other providers to know when a medication has been discontinued by another doctor. As a primary care provider, theoretically, I get all specialist notes, and I try hard to look through them for important details like discontinuations, but it's time consuming.

It's also very dangerous that pharmacies are not automatically notified when a doctor wants a patient to stop taking a medication. Especially with men and older patients, the patient may not know exactly which pill they are supposed to stop. So unless the doctor's office calls the pharmacy and tells them not to refill, the patient may continue taking that medication and continue to get that painful genital rash that it causes.

In the end, it often falls to the patient to know which medication to stop taking and to remember to ask your physician to update the EMR manually. That's not how it should be, and it's highly dangerous, but that's how our messed-up system works. Sorry for the bad news.

Be well,

Dr. Tumoriffic

Getting Your Ducks in a Row

#6: Pills, Pills, and More Pills!

Dr. Tumoriffic's Inappropriate Guide

to Navigating the Medical System

Dear Dr. Tumorific, 

I can't remember the name of the medication I take, it's round and white. Do you know the one I'm talking about?

D

Dear D,

Take this to heart:

One pill makes you larger, and one pill makes you small,
And the ones that mother gives you don't do anything at all.

--Jefferson Airplane


Pills, pills, and more pills. A round, white pill has the blandest of all shapes and colors. I need more information.

Is it a big pill, or a little pill? Is it tasty, or gross? What happens if you give your husband five or six of them? If they're sildenafil (Viagra), you should know right away. If it's a water pill, like furosemide (Lasix), that should be pretty easy to identify this way, too. Still don't know? Give him more! Of course, he may end up in the emergency room getting his stomach pumped, but, sometimes, that is the price of knowledge.

Okay, okay, just kidding. Do not, under any circumstances, take a whole bunch of pills you can't identify, or give them to someone else!*

The sad truth is that most of the time, we doctors have no idea what the pills we prescribe look like.** It's not our fault. Even for a single type of medicine, different manufacturers make pills that don't resemble each other at all. Sometimes, different doses from the same manufacturer don't look similar and may be nearly identical to entirely different medicines.

This can lead to dangerous or amusing situations. For instance, one friend of mine was on vacation and mistook his sleeping pills for his blood pressure pills. He then went to after-dinner cocktails and had a couple of very delicious margaritas. Even though they were small and did not taste strong, he quickly found himself quite soused.

Manufacturers could, theoretically, have some uniform standards for pill appearance (antidepressants could be blue, water pills could be yellow, and so on), but they don't. So I have no clue what your pills look like. But I do get asked questions like yours quite frequently. It happened last week. Especially as they get older and have more medical conditions, patients often don't know what it is they are taking. The complexity of the names of the drugs makes it harder. ***

A couple of weeks ago, I stayed at work quite late, taking 45 minutes to explain a patient's asthma meds to him over and over again. I then called his daughter and explained them again, because the patient seemed a little demented. The patient then came in last week and complained that I didn't bother to explain his medications. There's no pleasing some people. Another patient had been taking a medication I meant for him to stop, but actually stopped taking a medication I only wanted to change the dose on. I think I explained it pretty well, but it didn't sink in.

Try to remember what it is you are taking and why. If you can't remember the names of all of your medicines, bring the bottles in whenever you go to the doctor. Better yet, bring someone you trust with you to write them down and make a master list of the names, doses, and what they are for, including vitamins and supplements. And if you have a family member who has complicated medical problems, maybe you should volunteer to go with them to the doctor.

Digression: This is part of a larger point I plan to repeat a lot. Try NEVER go to a doctor for a complicated problem without a helper you trust. This is true if you are 93 and having memory problems, or if you are young and have a great memory. It has been true for me during my various Tumoriffic adventures. My wife is always at my side, writing things down and coming up with questions or remembering ones I forget to ask. It can be disorienting and scary to be a patient no matter who you are or how much you know. Here endeth the lesson.

So don't pay too much attention to whether your pills are red, white, or blue. Learn their names, and try to remember what they do. Yes, it is my responsibility to do my best in the limited time I am given to explain them to you. But ultimately, no one can pay as much attention to your own health as you and your family can. Know your pills.

Be well,

Dr. Tumoriffic



* Strangely enough, there is a thing called a pill party. People will come to the party and drop a bunch of pills in a jar and mix them up. Then, party-goers will just take random pills. I'm sure I could break such a party up pretty quickly if I brought a bunch of laxatives.

In other crazy pill lore, there was a rock star in the 70s who would accept random pills from his adoring fans and take them immediately. I don't think it was a member of the Grateful Dead, but it could have been. Please tell me in the comments if you know.

** A major exception would be the occasional generic Adderall pill one might find around the call room during residency.

*** The names of generic drugs are often purposely difficult to pronounce and remember. That way, the doctors and patients will have a comparatively easy time remembering the brand name when the patent runs out, so they are more likely to prescribe the brand rather than the less expensive generics.

Ginny says, "know your pills!"