Yesterday I was thinking about alcohol. I saw A who has Alzheimer's. But she drinks. She's always been a heavy drinker. Her daughter and son-in-law were here with her yesterday. They mentioned that they would find alcohol bottles in the apartment. There is nothing that can be done about this. She is still independent and goes to the store. She lives alone. But alcohol, especially heavy use, is very bad for the memory.
I have another patient who thinks he has Alzheimer's. He came yesterday afternoon. He has alcohol-related memory loss. I can tell the difference between the two, but he and his wife like to think he has Alzheimer's. His son, I think, believes me that it's from too much alcohol. He drinks two glasses of bourbon each evening. Each glass is about four to five ounces of bourbon. So that's a lot of alcohol. That's what he's had every day for over forty years. So it adds up.
I've seen him for a while now. But it was yesterday that he told me he drinks because of "marital discord". He actually said that his wife is "mean". He has a difficult time having to be with her. It came up because I've actually gotten him to cut down on his drinks from two to one recently. I gave him xanax to take, which is not a great trick but often works. It's a different way of calming down. In any case, it's worked well because he lost eight pounds in a month (the weight is killing him, and that's another reason I need him to drink less - it's about 800 calories per day of bourbon). But he complained that now he has to listen to his wife more. They've been married for forty three years.
I see people who have challenging relationships. There are marriages that are mutually destructive. The psychiatry people like to use the word "co-dependent". I suppose that's a useful concept. But I like the concept of "co-destructive". People hurt each other. Then, they withdraw from each other. During the withdrawal, they seethe in anger. Then they hurt each other again. It's a cycle. They think there's love in there somewhere, but it gets very hard to get in touch with it. It wears people down. They adjust, but something just slowly slips away. Year after year they lose a piece of their strength.
I've been in a situation just like that. So I know how it affects a person. But I don't have a solution. I'm in a different place now. I'm married in a way that makes me grow. Every day my wife is there to care for me. Of course, every once in a while, I get hurt by something that she does. But that's more likely my overly-sensitive nature than anything that she's actually done wrong. She is very dedicated to making sure that I'm well in every way. I do the same. So we're in a mutually helpful relationship: "co-growing". It makes life wonderful. It makes me strong and happy. Being in both situations, I can't say that I'm able to survive well in the co-destructive marriage. So I empathize with him.
Alcohol used to reduce pain from this type of situation is not going to be easy to cure. After forty-three years of hurt, I doubt that healing is much of an option. Some patients are hard to treat, after all.
My other patient, A, is newer to me. I don't even know what's led to her alcohol use. So she is even harder to treat.
Wednesday, October 31, 2007
Tuesday, October 30, 2007
Aphasia
Yesterday, I saw P. She is in her seventies. She saw another physician, who had diagnosed her with Alzheimer's. Actually, she doesn't have that. She has progressive aphasia. Aphasia is when you lose language. She can't find the words that she wants to use. Alzheimer's patients also develop aphasia. But they develop other thinking issues. They have "global" cognitive decline. So this is different. Words that we need get put into a filing cabinet. Then, when we need them we go and retrieve them. P has lost the ability to find the files for the words in the filing cabinet. Her repetition, comprehension, and reading abilities are normal. It's a very interesting illness. It's rare. It's "expressive aphasia". Aphasia actually comes in different forms. Most often, there is loss of most of the language functions.
It's hard to imagine this particular problem. There is normal thinking. What one wants to say is there, but it won't come out. So it's essentially the same thing as just having your mouth taped shut whenever you go to speak. Unfortunately, expressive speach through other means is also impaired. So there isn't a way around it. Usually, these patients can't use sign language to express themselves; they can't write to express themselves (they can copy, but not write original thoughts). They're "mute" but not deaf. She was happy to not have Alzheimer's. She can drive, and do all of her checking, and shopping. She lives alone and gets everything done just fine. That won't go away.
I like expressing myself. I like communication. Most of us like to speak. People speak just to hear themselves talk, sometimes. I guess that everyone has a thing that they would hate to lose. Most of us, I guess, would hate to lose most of our functions. To me, it seems especially hard to lose speech.
It's hard to imagine this particular problem. There is normal thinking. What one wants to say is there, but it won't come out. So it's essentially the same thing as just having your mouth taped shut whenever you go to speak. Unfortunately, expressive speach through other means is also impaired. So there isn't a way around it. Usually, these patients can't use sign language to express themselves; they can't write to express themselves (they can copy, but not write original thoughts). They're "mute" but not deaf. She was happy to not have Alzheimer's. She can drive, and do all of her checking, and shopping. She lives alone and gets everything done just fine. That won't go away.
I like expressing myself. I like communication. Most of us like to speak. People speak just to hear themselves talk, sometimes. I guess that everyone has a thing that they would hate to lose. Most of us, I guess, would hate to lose most of our functions. To me, it seems especially hard to lose speech.
Tuesday, October 23, 2007
Expectations
I think a lot of illness is related to expectations. I used to have a plan to only do three things every day. I suppose I still have that plan, although I usually forget these days. These are the three things we should do every day: 1) wake up (for obvious reasons); 2) find just ONE thing to be thankful for; and 3) handle just ONE difficulty with grace. No one can appreciate all of the wonderful things that occur every day. We're not that talented. We don't stay that focused on the positive things. How often do we appreciate the absence of our stroke, the absence of our tooth ache, the absence of our blindness? These are wonderful things. Then, of course, there are the flowers, the rain, the trees, the air and all of those things that we usually take for granted. Most of us forget to be thankful we have food. Then, we also can't expect that we're going to perform well at every difficult event. No one can do it. So how many things should we appreciate? How many difficulties should we handle elegantly? We have to set our own goals. If we set them too high, we're going to surely fail. This will create unhappiness with ourselves. Our expectations will be unachievable. So I came up with one of each.
This is how it works. Wake up (one thing done). Get out of bed (which may be hard to do - two things done). Take a shower and be thankful for running water (three things done). Then, we're done for the day. It was a successful day. There is nothing else that truly has to be done. So we can just sit back and enjoy what comes. If there are some things that we fail to enjoy, it's OK. The shower covers us. If there are challenges we don't measure up to, that's OK, we're covered by getting out of bed elegantly. This makes life easier.
The expectations we have of others are the same. If we expect others to do more than wake up, get out of bed and shower, we're being unreasonable with them. They have to be allowed to be human and fail. They have to be accepted that way. We need to make sure we don't get too upset about their weakness, since that's human.
This practice, I think, is the only way to really get through disease. There's that "one day at a time" saying. It's a good plan, because it tries to avoid creating ideas about tomorrows (which are expectations). Expectations aren't different from fears. They're the same thing. They are both thoughts about the future. One is future desires, the other is future non-desires. But either way, they are entirely out of our control. The ultimate non-control is death and it's twin brother disease. We can certainly (and should) exercise and eat well. But this only avoids some of the man-made diseases. It doesn't eliminate nature. So disease and death come. They are unpredictable at every turn. Like when people "suddenly drop dead".
In the chronic illness situations there is great fear. There is expectation about recovery and treatment effectiveness. There is expectation from the family for a certain measure of support (which may not come, since they may not be able to provide it). But perhaps one of the most challenging is the expectation that our health will be with us. It's not realistic. Some day, it's got to go (unless we're one that dies all of a sudden). We must make sure to let go of this expectation. Otherwise, when the inevitable comes, there is great disappointment. Most of the patients with illness struggle with letting go. They still expect their health. The fact that it isn't there seems terrible. It seems that they were "robbed" of the health they had. But in reality, they are only experiencing the inevitable. We all have or will go through it. It's not that it's enjoyable to be sick. Of course it isn't. But when we see what is naturally going to happen, it's easier. We know that the flowers on the plants will go with the season. But it doesn't make us that sad. It has to be that way.
We really aren't different than flowers at all.
This is how it works. Wake up (one thing done). Get out of bed (which may be hard to do - two things done). Take a shower and be thankful for running water (three things done). Then, we're done for the day. It was a successful day. There is nothing else that truly has to be done. So we can just sit back and enjoy what comes. If there are some things that we fail to enjoy, it's OK. The shower covers us. If there are challenges we don't measure up to, that's OK, we're covered by getting out of bed elegantly. This makes life easier.
The expectations we have of others are the same. If we expect others to do more than wake up, get out of bed and shower, we're being unreasonable with them. They have to be allowed to be human and fail. They have to be accepted that way. We need to make sure we don't get too upset about their weakness, since that's human.
This practice, I think, is the only way to really get through disease. There's that "one day at a time" saying. It's a good plan, because it tries to avoid creating ideas about tomorrows (which are expectations). Expectations aren't different from fears. They're the same thing. They are both thoughts about the future. One is future desires, the other is future non-desires. But either way, they are entirely out of our control. The ultimate non-control is death and it's twin brother disease. We can certainly (and should) exercise and eat well. But this only avoids some of the man-made diseases. It doesn't eliminate nature. So disease and death come. They are unpredictable at every turn. Like when people "suddenly drop dead".
In the chronic illness situations there is great fear. There is expectation about recovery and treatment effectiveness. There is expectation from the family for a certain measure of support (which may not come, since they may not be able to provide it). But perhaps one of the most challenging is the expectation that our health will be with us. It's not realistic. Some day, it's got to go (unless we're one that dies all of a sudden). We must make sure to let go of this expectation. Otherwise, when the inevitable comes, there is great disappointment. Most of the patients with illness struggle with letting go. They still expect their health. The fact that it isn't there seems terrible. It seems that they were "robbed" of the health they had. But in reality, they are only experiencing the inevitable. We all have or will go through it. It's not that it's enjoyable to be sick. Of course it isn't. But when we see what is naturally going to happen, it's easier. We know that the flowers on the plants will go with the season. But it doesn't make us that sad. It has to be that way.
We really aren't different than flowers at all.
Thursday, October 11, 2007
Simple Procedure
I'm seeing M in the hospital. I was called to evaluate him on Sunday due to problems with thinking. He was in a near coma. He went to the hospital for a simple procedure. He needed a very large kidney stone removed. He developed some bleeding. He got acute renal failure. He went into severe liver failure. Then, he developed problems with brain function. His blood ammonia level was too high. That's what happens with liver failure. The liver gets rid of the ammonia in your blood. So he couldn't think, which is what happens because the brain can't work with too much ammonia. His thinking has improved somewhat, but he's far from his old self. He can't walk more than 250 feet. He has trouble moving around in the bed, from pain which is all over. In order to get his ammonia levels down, we used lactulose. This produces VERY severe diarrhea. So he had a diaper. The nurses weren't on top of it (they're always very busy) and he was sitting in a dirty diaper a lot. His wife isn't doing well. She's very frustrated.
A few years ago, I had a patient who went for a rotator cuff surgery. That's another simple procedure. They called me because she was in a coma after the surgery. I never really understood what happened, but she ended up dying after about one week in the ICU. My guess is that this was from a bad reaction to the anesthesia. I'm not really sure, though.
If you're going to have a simple procedure, you need to understand that these things happen. I'm not fear-mongering. We have to do what we need to do. Obviously, these things are rare. But that doesn't matter when it's happening to you. Things can happen without simple procedures, of course. People slip and fall in the bathroom and die from hitting their head. I've seen that happen. I've seen someone fall off a bicycle and get brain damage. I had a patient who was hit in the head at work by a scissors lift that suddenly collapsed. So we don't need any procedure at all for things to suddenly turn into catastrophe. But we need to be aware of the possibility. I'm not putting in a plug for the insurance industry. It's about feelig lucky. We're lucky if we didn't have a simple procedure, or a fall, or a piece of large equipment falling on us. It's good to remember to feel lucky. I send money places. There are starving children and there's genocide. There are women in Iraq who have turned to prostitution to feed their children (husbands killed, no work). Sending money helps alleviate the suffering a little, but it also makes me feel lucky. That makes it a lot easier to be there for the people who want me to be there for them.
A few years ago, I had a patient who went for a rotator cuff surgery. That's another simple procedure. They called me because she was in a coma after the surgery. I never really understood what happened, but she ended up dying after about one week in the ICU. My guess is that this was from a bad reaction to the anesthesia. I'm not really sure, though.
If you're going to have a simple procedure, you need to understand that these things happen. I'm not fear-mongering. We have to do what we need to do. Obviously, these things are rare. But that doesn't matter when it's happening to you. Things can happen without simple procedures, of course. People slip and fall in the bathroom and die from hitting their head. I've seen that happen. I've seen someone fall off a bicycle and get brain damage. I had a patient who was hit in the head at work by a scissors lift that suddenly collapsed. So we don't need any procedure at all for things to suddenly turn into catastrophe. But we need to be aware of the possibility. I'm not putting in a plug for the insurance industry. It's about feelig lucky. We're lucky if we didn't have a simple procedure, or a fall, or a piece of large equipment falling on us. It's good to remember to feel lucky. I send money places. There are starving children and there's genocide. There are women in Iraq who have turned to prostitution to feed their children (husbands killed, no work). Sending money helps alleviate the suffering a little, but it also makes me feel lucky. That makes it a lot easier to be there for the people who want me to be there for them.
Wednesday, October 10, 2007
A Happy Life
Today I saw S. He is about 70. He was in great health, playing tennis several times a day when he just slipped. He was in a grocery store where there was a wet floor. He landed right on his sciatic nerve. It was seriously injured. He had very intense pain for a few months, but that resolved. Now he is left with pretty severe weakness. It's been a year already. He can walk, but not quite right. He certainly can't play tennis. It's frustrating for him, because all of a sudden, for no good reason you can't do what you used to do. The very abrupt onset of things is hard enough. What makes it worse, though, is the completely ridiculous nature of the injury. It was preventable and it was caused by pure stupidity (making the floor wet). He's going to sue the grocery store. He's really upset with them. I hope his nerve is going to heal. It could be two years before he has full recovery. But there is a reasonable chance that he won't ever be quite right from this. The good thing, I think, is that there isn't any pain with this. He was worse off when he was suffering with that really severe nerve pain.
I saw MW. She is going to be 80 in two weeks. She is very seriously obese, and has neuropathy and strokes and severe fatigue, and (I think) sleep apnea. She was very happy today. She usually is very happy. Her husband is a patient of mine because he has CIDP which is a severe form of neuropathy. He also has severe heart disease. He has a lot of weakness, and he can't walk very far. They aren't going to do anything fancy for her birthday. I told them that they need to go to Las Vegas (she likes it there). But I don't think that they will.
MW told me that a lot of the people at the nursing home where they were have no sense of humor. They're just not happy. She thinks it's because they didn't have a good life. They aren't happy with the way it worked out. She asked me if I'm happy with my life and my children. Because if I'm not, then I should change it. S. doesn't talk about that, because he's a business man who has little time for that sort of talk. But he leads by example. He just acts like it. Everything is there for the living. He loves his work, so he works a lot.
I don't think that we should be happy and enjoy things to avoid regrets in the nursing home. That's because there are sometimes sudden changes. We may not make it there. Not everyone gets to be eighty. In fact, not everyone gets to be ten. But we do have an obligation to make sure that we're making ourselves happy. Some religions stress the importance of service and sacrifice as the path to holiness. Most have some emphasis on ascetism, or at least charity. It's not that I think we should be hedonistic. But clearly happiness is essential to health. It's essential to the ability to tolerate illness. I don't think that it's unholy to be happy. We just need to provide service and eschew hedonism within the path of happiness. It makes me happy to see some of my patients. I provide them with a "service". At least that's what everyone says. Still, they certainly provide me with a service of at least as great a magnitude.
I saw MW. She is going to be 80 in two weeks. She is very seriously obese, and has neuropathy and strokes and severe fatigue, and (I think) sleep apnea. She was very happy today. She usually is very happy. Her husband is a patient of mine because he has CIDP which is a severe form of neuropathy. He also has severe heart disease. He has a lot of weakness, and he can't walk very far. They aren't going to do anything fancy for her birthday. I told them that they need to go to Las Vegas (she likes it there). But I don't think that they will.
MW told me that a lot of the people at the nursing home where they were have no sense of humor. They're just not happy. She thinks it's because they didn't have a good life. They aren't happy with the way it worked out. She asked me if I'm happy with my life and my children. Because if I'm not, then I should change it. S. doesn't talk about that, because he's a business man who has little time for that sort of talk. But he leads by example. He just acts like it. Everything is there for the living. He loves his work, so he works a lot.
I don't think that we should be happy and enjoy things to avoid regrets in the nursing home. That's because there are sometimes sudden changes. We may not make it there. Not everyone gets to be eighty. In fact, not everyone gets to be ten. But we do have an obligation to make sure that we're making ourselves happy. Some religions stress the importance of service and sacrifice as the path to holiness. Most have some emphasis on ascetism, or at least charity. It's not that I think we should be hedonistic. But clearly happiness is essential to health. It's essential to the ability to tolerate illness. I don't think that it's unholy to be happy. We just need to provide service and eschew hedonism within the path of happiness. It makes me happy to see some of my patients. I provide them with a "service". At least that's what everyone says. Still, they certainly provide me with a service of at least as great a magnitude.
Thursday, October 4, 2007
Showing Up
I saw AM yesterday (Nice initials, I think). He has a parkinsonian like disorder that can't really be treated. He looks like a person with parkinson's: can't walk, move very well, speak well. I saw another person like that in the hospital last week, also. The medications for Parkinson's don't work for them. AM comes in every four months. I'm not sure why he does that, since there's no treatment for him. I've already tried everything that there is. He went for a second opinion to Hopkins. They told him what I told him. Once, I told him that he could come back on a PRN basis (whenever he wants to, but we don't make an appointment). He came back in two months. There wasn't anything new, really. He had fallen, but not any worse than all of the other falls. (He falls often.) So I decided to have him come back in three months. Then, I changed it to four months. I kind of know that if I change it to PRN again, he'll come back in pretty quickly. He is getting slowly worse.
I saw J yesterday. She has severe back pain. She gets injections every three months. Then, she can walk around the house, and even a little outside. She uses a wheelchair for any distance. After about two and a half to three months, the pain worsens and she can't walk around the house. She's been to pain management, but they didn't really help her that much. She had gone through a big depression when she went to the ALF place. Her and her husband hated it. They moved back to their house. Now they're doing a lot better.
I saw S too. She's 27 and had a brain tumor taken out last year. She saw me for pain, also. I gave her Lyrica, because it's nerve pain. She's doing very well now. She has just a touch of pain at this point, but it's very tolerable. She had a miscarriage, right before the brain tumor diagnosis. She's doing well. The surgeon told her she can go back to work. I told her she can back to work also. It turns out she didn't like her job at the hospital though. So she's going to find another job.
AM and MM didn't show up yesterday. RS rescheduled.
Some people show up. Some people don't show up. One time, someone somewhere said that showing up is 90% of it. I don't think that's right. I think it is really "Being there is 90% of it." People can show up and not really be there. That shouldn't count. A lot of people say it's "hanging in there". I don't really think it's that, either. That's more like "showing up" than it is like "being there". I respond "Well, that's better than falling out of there." It is better than that. But it's not the best of all. If you're really there, then you can make the best of it. That's how I grouped those three: AM, JH, and S. They are really there. They are making the best of what it is.
I saw J yesterday. She has severe back pain. She gets injections every three months. Then, she can walk around the house, and even a little outside. She uses a wheelchair for any distance. After about two and a half to three months, the pain worsens and she can't walk around the house. She's been to pain management, but they didn't really help her that much. She had gone through a big depression when she went to the ALF place. Her and her husband hated it. They moved back to their house. Now they're doing a lot better.
I saw S too. She's 27 and had a brain tumor taken out last year. She saw me for pain, also. I gave her Lyrica, because it's nerve pain. She's doing very well now. She has just a touch of pain at this point, but it's very tolerable. She had a miscarriage, right before the brain tumor diagnosis. She's doing well. The surgeon told her she can go back to work. I told her she can back to work also. It turns out she didn't like her job at the hospital though. So she's going to find another job.
AM and MM didn't show up yesterday. RS rescheduled.
Some people show up. Some people don't show up. One time, someone somewhere said that showing up is 90% of it. I don't think that's right. I think it is really "Being there is 90% of it." People can show up and not really be there. That shouldn't count. A lot of people say it's "hanging in there". I don't really think it's that, either. That's more like "showing up" than it is like "being there". I respond "Well, that's better than falling out of there." It is better than that. But it's not the best of all. If you're really there, then you can make the best of it. That's how I grouped those three: AM, JH, and S. They are really there. They are making the best of what it is.
Tuesday, October 2, 2007
American Health Care
It turns out that we spend more money on health care in this country (per person) than anywhere else. We spend a lot more. Now there is great debate about SCHIPP. This is the program that provides health care for children who are too wealthy to receive medicaid, but who "need" some sort of coverage. The different states have different ideas about how much money your family can make for you to qualify. Bush doesn't think that it's fair for children to receive federal and state money to help pay for their health insurance, especially if some of them will no longer use private health insurance. We have the highest infant mortality rate in the "developed" nations. We rank 54th in overall health care quality. We have the highest amount of uninsured people. People over the age of 65 qualify for medicare. They receive government subsidized care regardless of their wealth. There are now some provisions being placed to increase the amount that people pay based on their income. That way, the people whose income is over ten million dollars per year don't necessarily get free health care if they are over 65. The thing that is strange is how we decide that those under 18 are different than those over 65. Both of these groups are vulnerable to inability to care for themselves. I think this is more so for the children. I would personally rather see us pay for the children and eliminate the medicare. At 65 you have a much better shot than at 5. 5 year olds have no chance whatsoever of gainful employment that is sufficient to generate income that will pay for health care. A social safety net should consider that issue. Perhaps the five year old is the responsibility of the family more so than the sixty-five year old. I don't really know, though. We are supposed to take care of our family. This includes parents and children. Before medicare, families stuck together and took care of each other. If an elderly parent couldn't work, the kids would take care of them. Now, the government does. But if they take care of my parents, why not my kids? If the interest is in taking care of the American population, it would be all of the vulnerable parts. I see people who are 98 years old in the intensive care unit for three months at a cost of at least $500,000. Their life expectancy is probably less than one year. So we're spending that to keep them alive for a few more months. If we can do that, then we can take care of health care costs for an awful lot of kids who can't even see a pediatrician. Whole Foods has HSA insurance, where the workers get a "savings account" to pay for health care. It dramatically reduces costs, because when it's "my money" I don't want to spend it. People tell me all the time that they'll do it "as long as medicare pays for it." They won't do it, though, if they have to pay for it. In fact, they won't even do it if they have to pay a significant portion of it. But if they behaved like it really was their money, then we could afford to cover all of the people who aren't insured. The insurance companies waste an incredible amount of money. As far as I'm concerned, about 100% of their profits are a waste of money. They should all be mutual companies. It's not a risk sharing pool the way it's structured right now. It's a "business". They're in the business of taking money and not paying health care costs. The better that they are at it, the greater the share of the pie that they take out of health care. It just doesn't make sense. It's a guaranteed increase in cost with no benefit. They don't increase efficiency in any way. The only way to increase efficiency is to have the patients (the consumer) involved in the spending (like with the savings accounts). I don't understand why we can't seem to get this right. It's not complicated, really. It's just that no one wants to be honest about the fact that we have to limit our consumption (as health care consumers) and take more responsibility for what we're spending. If we were all shopping around carefully, we would look at the whole thing. We would also look around more carefully at the Insurance companies. They aren't under the kind of pressure to perform that retailers are. It's easier, for sure, to see what a shirt costs at different stores. We can also assess shirt quality somewhat easier than health care insurance quality. But we're not challenged to do it. So we don't do it.
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