Archive for the ‘Medicine’ Category

TRYING TO AVOID PITFALLS

September 26, 2020

A recent article in the medical section of the Times told the story of a man with chronic buttock pain who ended up with being diagnosed with Crohn’s disease with sacroiliac arthritis. 

It only took 10 years. The cause was discovered by accident when the man had a colonoscopy and an alert GI doc noted that the ilieocecal valve was scarred. He passed the scope further into the distal ileum and found inflammatory changes consistent with Crohn’s disease. The patient has since done well with strong anti-inflammatory agents. He had never had overt symptoms of Crohn’s. So many of the things I once learned in medicine have been shown not to be true, or to be different from what I originally had learned. So many of the conditions that were once untreatable now are. 

I remembered from medical school being told that a barium enema (which is how we imaged the colon back then) had to reflux into the ilium or the appendix to be able to say it was complete. It’s not enough to say the cecum—the beginning of the large bowel— was viewed.  What looked like the wall of the cecum in one instance was a large tumor. Had one not looked for the appendix, which was impossible in that situation, or the ileocecal valve, which was very difficult to find, the tumor itself might not have been appreciated.  Cecal tumors themselves are difficult to pick up.  I learned that lesson.

I thought of the good specialists who told us medical students about conditions in their field we didn’t want to miss. That bailed me out in my internship the night I examined a scrub nurse in the ED with a scalpel wound to the palm of her hand.  Everything looked fine; she could move everything and feel everything, and there was minimal bleeding.

I called the hand surgeon anyway. I had learned that puncture wounds of the palm were dangerous.  He came in, thanking me for calling him.  A few weeks later, I happened by the nurse, who took me aside and thanked me for saving her hand.  I was surprised and asked her what happened.

“I had a significant hematoma drained,” she said. “Had nothing been done quickly, I could have lost significant function and might not be able to work. Thank you.”  I had forgotten about that day.

Or the patient who complained of something in his eye where nothing was found. I either had to find the object, find a corneal scar, or call an ophthalmologist.  Something was wrong until proven otherwise when a person complains of a sensation that something is in his eye.

Or the Fireman 1/c on board my ship, who had a red eye that might have passed for conjunctivitis, except the inflammation encircled the iris. He had acute iritis, and I had to treat him with steroid eye drops. Iritis is not something one wants to miss. I would never see another case. But I found that one.

Or the patient with progressive loss of vision that was felt to need glasses.  The only problem was that the pupil had a very poor reaction to light on that side, but reacted briskly when light was shone into the other eye.  This meant the optic nerve was compromised, called an afferent pupillary defect, since the afferent pathway is involved.  In this instance, the patient had a meningioma compressing the optic nerve. Another trick to screen for optic nerve disease is to look for red desaturation, have the patient compare the degree of redness with each eye. The afflicted eye will not see the red nearly as bright.

It can also work in reverse.  Many with poor visual acuity may have remarkable improvement looking through a pinhole, which can be easily made. When such improvement occurs, the visual problem is always refractive, for visual defects of optic nerve origin do not improve by looking through a pinhole.

Or the man I saw in the Morenci, Arizona clinic, 3 hours’ drive from Tucson, whose neurological exam was fine, but he had a soft lump on his cheek. These look like sebaceous cysts that should be drained, but I was taught well about parotid gland tumor presentation, and the one thing one never does with parotid tumors is stick a needle into them, for it will enhance spread. He was sent to Tucson where a surgeon cured him.

Hoarseness?  The patient has two weeks to get better before one must do a laryngoscopy looking for vocal cord paralysis due to recurrent nerve injury perhaps due to a condition like a malignant lung tumor.

Possible pneumothorax?  Get an inspiration-expiration film, where the difference is sufficient to show air where it does not belong. I can still remember what room I was in at Denver General Hospital when I saw a case on a Saturday morning, the second month of my internship, 46 years ago.

When I was in practice, a patient with a cerebellar infarct was admitted to the floor. I put in a call to a neurosurgeon, because while at the time the patient was in no distress, the affected brain can swell and compromise the lower brain stem quickly, leading to death.  Potentially enlarging cerebellar lesions are dangerous and deserve respect.  I asked the nurses to “check frequently,” without needing to take vital signs, which saved them time and underscored the need to watch the patient often. The next day, I found the patient post-op in the ICU, awake. The swelling had become significant, the brain stem was becoming compromised, and the swollen, infarcted cerebellum was removed. He made an excellent recovery.

My wife had two cases where there was a clearcut breast malignancy on the mammogram but nothing found by either the surgeon or pathologist.  In the former, missing the malignancy led to a second mammogram—uncomfortable to go through post-operatively—and a subsequent change in the hospital system, so that X-Rays were required to be taken of the specimen before closure, to ensure that the lesion was in the specimen and not still in the patient. In the latter instance, the pathologist was told he had to go back and find the cancer, because it was in the specimen, and it was cancer. It was found.

On the psychiatry rotation I learned never to be shy about asking about suicidal ideation, and I asked about it scores of times in practice, to evaluate depression. Not one person was ever angry with me for asking. Virtually all had thought about suicide; very few had gone to the next step, which was determining how they would do it.

Or, the routine physical exam which I did on a sailor before he left the Navy. I felt his abdomen, something I had done hundreds of times, and the large mass I felt surprised me. The sailor had been unaware of it. He would turn out to have lymphoma.

While I have long forgotten the details, I remember calling in consults to orthopedic surgeons using words like “valgus” and “varus,” rotational deformity, distracted or overriding, and discussing vessels, skin, nerve, tendon, joint, and muscle, for that was how I was taught. 

I learned that when I argued with myself about whether I should do a spinal tap, just do it. More than once, I discovered something that was useful. Sometimes, one had to get the spinal fluid a different way. I had an obese diabetic with a stiff neck at 2 am in the ED one night. A spinal needle could not reach her meninges through the back, so I punctured the skin just below the base of the skull, “walking” the needle down the occipital bone, until I reached the cisterna magna, finding white fluid indicative of a bacterial meningitis. She did survive.

I hope along the way some of my teachings may have been useful, like checking level of consciousness by “What does it take to arouse them?” “What do they do when they are aroused?” and “Are they getting better or worse?”  The last was an attempt to remind people that being medically stable requires at least two observations, not one. I don’t know if the same approach is used today in teaching medical students, but I hope they do finish training knowing not only the potential pitfalls in their specialty but many of the ones in other specialties, too.

DIFFERENT QUESTIONS

April 29, 2020

The other day, a woman called in to Doctor Radio wondering when there was going to be a cure for Covid-19.  Her voice was peremptory, as if this were something we should all be expecting by now.  Americans are impatient, and while I am impatient, I have inhaled a dose of reality.  I know there are many drug trials, at least a dozen, with results due anywhere from next week to late September. That’s good. What isn’t so good is that if we had any trial stopping event—like polio vaccine, which was so powerful the drug trial was halted and the vaccine being given—we might know that by now. Something that pulls someone off a ventilator overnight, or ECMO, or empties an ICU is a big deal, and I haven’t heard of that yet.  I don’t expect to.  

But, we have something now. One Remdesiver trial showed the time for half the patients to recover was 11 days with the drug and 15 days without. The death rate was 8% in the control group vs. 11.6% in the treated group.  That is a 31% difference with a p-value of 0.059. The time to recover was significantly shorter; the death rate statistically not significant (want p-value under 0.05, which is the probability if chance were operating and nothing else, we could have seen this result or one more striking), but with a larger study, I suspect we would see a value under 0.05, which is an artificial construct but generally used.  Study two compared length of time efficacy; 5 days’ treatment is as good as 10 days, good news. 

From Oxford, a genetically modified MERS virus vaccine stopped Covid in macaques, a control group of whom did not survive similar doses of the virus without the vaccine. This study needs to be watched. 

But for the moment, let’s look at reality: how quickly we are going to return to whatever will be normal.  And those last four words to me are key. Sports, concerts, flying, cruise ships, restaurants, road trips, and schools aren’t going to be normal for some time, in my view, a lot longer time than many think. I have cancelled two trips this spring; I don’t expect to canoe in September, and I am not expecting to see the eclipse in December. 

Certainly not on a cruise ship.

Some wonder whether it is worth getting the virus and getting it over with.  Given the number of anecdotal cases of young and middle aged people having severe disease, I don’t think that is a wise choice, especially if one has diabetes, is obese or smokes, which are not rare in society today.  I correspond with people overseas, and one in Asia told me the whole family just got clinical Covid.  Two have anosmia, mild in the scheme of life, but people complain bitterly about it.

There are additional issues with the virus either causing a coagulopathy, where the blood doesn’t clot, or attacks the blood vessels directly.  Coronavirus myocardial damage is known; coronavirus encephalopathy and involvement of the thalamus in the brain is known, and the virus been found in the kidneys.  One third on ventilators have significant kidney disease. That should bother anyone.  I sure don’t want that at my age.

We also don’t know whether there will be after effects of pulmonary scarring, congestive heart failure, or chronic renal failure. Again, I don’t want to get this virus. 

I look at a lot of numbers and have noted from the beginning that Washington State never had a big problem after the initial attack in the nursing homes.  I expected California to explode with cases like New York, but it didn’t. Florida had people on beaches, and it had cases, but not like New York’s. I have wondered whether the population density of susceptible people mattered, and I think it does. The media does mention that “cases are rising xx per cent,” but they are rising from a smaller number.  What is clear is the numbers of cases in the mid-continent haven’t yet started to fall, whereas they have on the east and west coasts.  That concerns me, but to say the numbers are rising at 10% a day means a doubling time of 7 days, and NYC started with doubling at 3 days and continued that way for awhile.  Oregon is going to allow elective surgery.  That makes sense, because elective surgery is often biopsies and fixing things that we all have come to expect with surgery.  I think social distancing worked; we need to remember that there is a two week delay when people start moving about before we will know if there are new infections.

For those who are saying we never had to do anything, that this virus wasn’t all that bad, keep in mind that the purpose of public health workers is to prevent things. We don’t have many cases of measles; if people vaccinated, we wouldn’t have any.  It’s not that measles is gone; it just doesn’t have a home here. We social distanced and we cut the number of Covid-19 cases.  Not enough, and the numbers are well past the number of deaths from influenza that people quote every year.  I suspect they will be more than 100,000, the low end of the original estimate. We are already 11,000 over the estimate for 1 May that I read two weeks ago.

The other issue is testing, an important catchword, and we need to also know how good tests are,  Recently several were checked; three were good.  It turns out, (proof below),  a test that is 90% specific (one has the disease, test is positive) and 95% sensitive (one doesn’t have the disease, test is negative) and the disease is relatively uncommon (5% of people), a positive test has a 50% chance of being false positive.  It is the difference between “if I have the disease what is my test?” and “I test positive, do I have the disease?”  The more common the disease in the underlying population, the more likely a positive test is true.  It’s why public health people did not require AIDS testing for wedding licenses. The disease was uncommon enough that a third of the positives were true and the other false. 

5% prevalence of disease


Test PositiveTest NegativeTotal
Disease positive (has it)45550
Disease negative47.5902.5950
Total92.5907.51000




This is sensitivity of 90% (45/50) and specificity of 95% (902.5/950).  Positive test has (45/92.5) or 49% chance of being a true positive, even when the specificity and sensitivity are both 90% or more.

Same with a 20% prevalence in the community would make false positives only 18%.

So, I wear my mask, take my walks, and wait. 

Maybe next year we will do a lot more, but not soon.  We don’t yet know for sure whether people are immune to the virus after having had it or can get it again. There is a bit of national denial in thinking that sports will start soon. They won’t until or unless there is a vaccine or an anti-viral better than Remdesivir. Additionally, we don’t know what it will take to get a vaccine, or whether a vaccine will even be effective, let alone for how long and what side effects are present. People want something, but vaccines can backfire and overstimulate the immune system, which is a huge problem with this virus.  Indeed, many medicines are in trials to see if they can turn down the immune system.  In the meantime, beware of those who are pushing strengthening our immune systems.  Stay in good health and let your immune system take care of you.

We are finally doing random sampling in various cities to get a sense of how many asymptomatic infections are present.  The evidence we had from China was that few were asymptomatic.  That is not true. We need more information about relative risk, not that 2/3s of the deaths are over 70 but what the risk of a 70 year-old or more, without chronic disease, surviving. That’s a different question.  We need to give the risk to people in various decades of life with and without chronic disease as to what their risks are—to be asymptomatic, to avoid hospitalization, to avoid ventilators, and to avoid death.  

If public health professionals are doing their job, people will complain that they were too strict. 

It’s nice to be still alive to complain.

THE FOUR PART DAY, COURTESY OF MIDAZOLAM.

January 29, 2020

It was really all my fault: it was I who suggested to my cardiologist about a year ago that maybe I should be screened for abdominal aortic aneurysm.  I didn’t think I had one, but I’m old, male, and have a waist size that is borderline large for my height.  I don’t think the cardiologist agreed that I had any risk factors, but he scheduled me for a CT Angiogram in a year. He was in no hurry.  He  first wanted to get a CT of my heart, looking for calcium in the vessels, 

That exam showed almost no calcium, good news, but a small hiatal hernia, a fairly common finding, but which I could have done without.  A year passed, I had the angiogram, and the aorta was normal.  That was the good news.  The bad news was that I had diffuse esophageal thickening, which is always abnormal, and which required evaluation. The likely possibility was reflux esophagitis;  maybe I had Barrett’s esophagus, where the lower esophageal lining changes and appears more like the stomach’s, Esophageal carcinoma was a fortunately more remote possibility.  

I initially didn’t think I had significant reflux, but three years earlier, I had a nagging cough that went away dramatically when I started an H2-blocker for acid reflux, again confirming what we know about one cause of chronic cough: reflux.  And when I started thinking about it, I did have some symptoms of reflux, especially if I did some bending over activity when working trail.  I had such reflux up the Aufderheide last August in the Waldo Lake Wilderness that I upchucked, fortunately with nobody else on the crew’s noticing.  Barfing on the crosscut saw would have upset everybody.  Anyway, It’s like my body is trying to tell me that my heart Is doing OK, deal with my esophagus.  

So that is how I found myself one dark morning in the GI lab, about to get an upper endoscopy (EGD), at least with half my clothes still on me, including my shoes.  I was hoping I would only have to ditch the shirt for the study. Given what was going to happen later, I could have walked out of the hospital nude and not been aware of it.

The nurse told me what medicines I would be given, and I heard something I wasn’t sure I heard right, and I didn’t really want to hear it, but I asked her to repeat what she said.

“Versed.”

“Oh,” I replied. “I did have that in 2001 for a colonoscopy, and afterwards, the nurse asked me how I felt, and I said fine, so they let me leave the lab.  Unfortunately, they didn’t ask me if I knew where I was, because the next thing I knew, I was wandering around the hospital parking lot, fortunate enough that my wife, in the car, found me before someone ran me over.” I had no recollection of walking out of the GI Lab, leaving the hospital, and ending up in the parking lot. The hospital later heard about my experience and promptly changed the system to require all patients to leave in a wheelchair, accompanied by a staff member.  The next two colonoscopies I had were done with Propofol, and I did just fine. I actually woke up in the GI lab, rather than leaving the hospital without a clue as to what county I was in. Such a relief.

Just sayin’ be careful with that stuff with me, and don’t believe much I say when I come out of it.  The nurse laughed.  I was serious.

The last thing I remember before the procedure was telling the Indian-born doctor that I really liked the birding at Bhartapur in India, when I was there in 1995.  Incredible place.  Saw 30 species that day.

The next thing I vaguely remember was trying to read the report and understand the pictures from my study, but as I tried to turn the pages, I couldn’t do it. The feeling was like one has in a dream where simple things just can’t be done, and words don’t quite make sense.  The next thing I remember in this induced dream/reality was making my breakfast at home, hearing my wife saying that the bag of blueberries I had picked and frozen last summer had a hole in it. I then remember eating, reading the paper online, and doing some writing.  I even read my report.  I looked at the clock and was surprised it was 1050. The last time I had seen was 0800. Nothing else surprising happened for the next hour, when I had lunch and then let the heater service man in the house to take care of the annual servicing. The gap in my morning was still a gap, and I still wasn’t aware of it.

That afternoon, 5 hours after I got Versed, I took a walk.  I felt fine, but only then did I realize I hadn’t a clue what happened earlier that day.  There were four parts to this particular day, and so far, I had only been aware of two: right now, and before I had the procedure and acting normal at home.  The third part was being at home, eating two meals, and having lunch, but not being aware I had had a deficit. That deficit itself was part four, when I was able to remember anything.  I did not remember the doctor’s talking to me after the procedure, my getting dressed, walking out of the hospital, to the car, riding home, getting out of the car, and going inside.  None of it.  

I walked for nearly an hour, came home, to where my wife had some concern that my note “Took a walk” didn’t include the needed comment, “I really know who I am now.”

This loss of memory is known with Midazolam (Versed), and a friend of mine had a similar problem after a colonoscopy, although hers was more like Transient Global Amnesia, a disorder of unknown cause, that typically lasts about 12 hours, or Global Amnestic Syndrome, which typically follows a significant head injury.  The way I would test for these two disorders was to tell the patient my name, then leave the room, and come back in a minute later (or even after 30 seconds) and ask if they knew me.  With the above conditions, they would not know me.  

Once again, we are fortunate in our house to have medical knowledge. I don’t know what an older couple would do if they suddenly heard their partner ask over and over again where they were.  My wife knew that I would eventually return to the world of memory, but she didn’t know exactly when. 

I didn’t turn in my smiley evaluation to the GI lab, because I when I left the lab, didn’t know who I was, let alone where the box was to turn in the evaluation. I felt like the man in Blazing Saddles, who woke up in jail, so maybe I need an “in jail” smiley. My review will be the one of my favorite lines in response to the black sheriff’s asking, “Are we awake?”

“We are not sure. Are we black?”

“Yes, we are.”

“Then we are awake.  But we are very puzzled.”

KNOWING IS BETTER THAN NOT KNOWING

April 13, 2019

I stood up as a very tall young man walked into the examining room, didn’t introduce himself, shook my hand, and as he sat down, his booming voice uttered one word:

“Questions?”

Interrogative.

It reminded me of the time in 2006 I was in Grand Marais, Minnesota, the night before I went to Isle Royale National Park.  I was at the casino eating dinner, since that was the only place open, and the waiter walked up and uttered one word.

“Walleye.”

Declarative.   

I remember repeating the fish’s name, interrogative, and he replied that it was the special. I’m not sure if I decided to have it, but I do remember his introduction.  

I went to the urologist’s lab a week prior to get my annual PSA test.  I am more concerned about my PSA than I should be, but I remember the adage that the probability in percent  of a man’s having at least microscopic prostate cancer is equal to his age.  In addition, my father had it, and he took an expensive medication to control it.  My only biological brother doesn’t write me often and may not have been checked in years, so I don’t know anything there. 

I arrived at the office for my appointment 20 minutes early to check-in, the check-in line out the door, and only one person working.  I joined a few old people there, and while waiting, I heard a daughter ask her mother-patient questions that the latter needed to have repeated and wasn’t sure of the answer.  The receptionist had a problem couple she was helping, and explaining the iPad check-in took time.  Life is sometimes difficult for those of us digital non-natives.

Eventually, it was my turn, and fortunately, I was checked in quickly and given two pieces of real paper on which to write down my medications.  Before I even got to the third line, I was called: “Michael?”  

While I usually introduce myself to younger people by my first name, I don’t like being called it in public by people who are a third to half my age and don’t know me.  It wasn’t worth saying anything, but whatever happened to basic formality? Perhaps if we were more formal in our speech and treatment of each other, we Americans might be less polarized.  Or not.  Just sayin.’

The nurse told me that “James” would be seeing me.  I didn’t know a James, and I started running through my head my doctor’s first name.  On my way to the inner sanctum, I had to get weighed, so I took my phone and wallet out of my pocket, stepped out of my shoes and got on the scale.  I lost 13 pounds two years ago, kept it off, and am proud of it.

I was put in a room to wait for “James,” saw my doctor’s first name (David) on a business card, and within a couple minutes, the tall man entered.

I was so stunned by the start, I couldn’t think of anything to reply to  “Questions?”  

I should have asked, “Who are you?” But, I read the “PA” on his badge.  I could have then asked, “Where’s David?” But obviously I was going to be seeing a PA.  I stammered, much like Ralphie does in the movie “A Christmas Story,” near the end, on Santa, he clams up and finally says, “A football?”  with my version of the pigskin:  “What was my PSA?”  

Tappety tap, mouse clicks.  Then, “When was it done?” Answer—with plenty of time for it to have been sent here and written on a piece of paper that you could have taken in your large hands in here and given me the result immediately instead of tappety, tap.  I stared at the wall and finally learned it was a good 1.8.  

I liked my physician, David. He’s a major player in the local and state medical community plus being a principal investigator for the practice.  I was once a player in my local and state medical community but never a principal investigator, although I tried to get my colleagues to investigate errors, but that didn’t work out.  

I have called the office and been on hold, where I heard about the great cutting edge, literally and figuratively, care is given.  It’s truly impressive, as is the information given to patients, hearing, “Knowing is better than not knowing.”  But, I didn’t know why I wasn’t seeing David but a PA.  I realized that being a retired physician counts for little these days, either in a medical office or outside of one, where first responders, nurses, and therapists carry the day and docs are good for ….well, let’s face it—being donors, bashed as a group, or occasionally being asked to give a curbside or trailside diagnosis. I had several questions, and while some were answered, it wasn’t the same.  I got my exam and some recommendations.  David told me a lot more.

The next thing I knew, I was walking out of the office, aided by a sign pointing to the exit, which was needed, because I needed to be in the left lane or else walk into somebody’s office. I remember thinking that the sign needed to be permanent, because it was necessary and the temporary one looked tacky in this 21st century office.

I had been looking forward to telling my urologist that I was off diazepam, that I had both discovered and used it successfully for a nasty condition. I tapered it myself, after one internist suggested as I got older I had more of a fall risk taking it, which was true. I tapered it faster when my next internist ignored my refill order. Don’t get severe pain today, because physicians are scared of the feds coming down on them for opioids and other controlled substances scripts, even when diazepam is not an opioid.  We went from pain as a 5th vital sign to don’t ever give opioids. I’ve been on this pendulum before.

I never got to talk to my urologist about the fact that some of my issues arise from other medications I am now taking.  This stuff happens at 70. I wanted to talk to him, because “Knowing is better than not knowing,” unless one is an old man with a stable condition and can be put off on a mid-level practitioner, rather than the physician.  I never did that when I was in practice.  I saw people, I returned their calls myself, I gave mountains of free advice and care, and I was a chump in another era.  But I was available, for better or for worse; for worse, if I were sleep-deprived, which was often. My office didn’t require people to make more than two 90 degree turns or walk more than 10 meters from the waiting room.  We didn’t need signs showing how to leave the sanctum sanctorum.  

It’s a different world.  

I wrote David and said I had missed him and had looked forward to seeing him.  I never got a reply.  That hurt.  It takes 24 seconds to send a polite blow off email.  I timed it once.  I sent an email to James deciding to take the medication we discussed, and several days later screwed up logging in to my patient portal, getting my account locked.  I waited and sent a couple of emails, and nothing happened.  A call finally settled everything, and I was told an email for me was on the portal, except it wasn’t.  Three days later, I got a three emails giving me a password to my account. Not being a digital native, I just thought it was a bad system, but digital is always better.

I thought that the bill would be less because I saw the midlevel and didn’t have a urinalysis, which I wanted to have.  It is, after all, a urology office.  One colleague told me that my bill would be the same. We were both wrong. It was $150 more than the prior year, when I saw the physician AND had not only a urinalysis but an ultrasound. My followup care charges in 1992 were $35. By medical inflation, they should now be $90. It was $350 for what I described above. We’ve lost something in 21st century medical care.  We are arguing as a nation as to who should and should not have care and how it is paid for.  Fair enough.  We need to do more, in my opinion.

But how the care is delivered is not unimportant. Knowing is better than not knowing.  And there is still important magic given by physicians who actually take time to see patients. That time matters.  Knowing matters. Laying on the hands matters.  I didn’t fully understand that when I was in practice.  I do fully understand it now.

And we have yet to fully address quality of care.  That’s for the 22nd century.