CS died. He was a patient of mine for about seven years. He had a stroke that had damaged his "motivation center". He had severe apathy. He was very pleasant, but always sort of "blank". He didn't try very much. He didn't walk. He was very overweight. He just basically didn't care about anything. I liked him. I like most of my patients. I like people and I like patients. I will miss him.
JM was in today. Her son is in hospice. He is dying from a brain tumor. She is very sad about it. I can't help her. She has Parkinson's disease, which is why she's my patient. Her Parkinson's is doing well, but I just had to stop her Azilect. Her blood pressure is high, and I think it's from that. That's too bad, because her Parkinson's will get a little worse.
There's been a lot of dying this week.
I saw BS today. He fell in a grocery store. It was a "slip and fall". He fell in just exactly the right way to completely crush his Sciatic nerve. I think he fell around the end of 2007, so it's more than a year, maybe close to a year and a half. Anyway, his nerve isn't going to heal so he has permanent pain in the leg. He has such an upbeat attitude for a person with nerve pain. I like him because I think he is one of my happiest patients. I have several people in the practice who have constant chronic pain every day but they are happy. It is very important.
People don't understand that there are different things that are "unpleasant". There is the simplest form: "noxious stimulus". Even a single-celled organism (ameoba) can move away from something. But it can't really experience "pain". "Pain" doesn't happen until there is a fairly advanced nervous system, nearly a "brain". Jelly fish don't really experience "pain". Pain (in humans) happens at the level of the thalamus. Then, there is a higher order of experience called "suffering". This is a critical distinction. "Suffering" happens at the cortex. It's not in the thalamus. They are different experiences that happen in different parts of the brain. This is why there can actually be "masochism". That is where a person "enjoys" a "painful" experience. The translation from thalamus to cortex doesn't prouce suffering, it produces joy. If we could "induce masochism" we would turn pain into pleasure. It would be a very good treatment for chronic pain.
I saw MM today, who has chronic pain that creates enormous suffering. She is a complete "anti-masochist". No one can figure out why she has all of this pain (including me) and she won't go to Mayo Clinic even though I keep asking her to (I don't think they're going to figure it out either, I just want to check). However, her pain makes her suffer greatly.
Anyway, CS never really cared about anything. So he didn't really have the ability to "suffer". He didn't care enough about the hurting leg or the hurting arm. BS doesn't suffer that much because he refuses to let the pain in the thalamus become suffering in the cortex. It's like there is a block. JM doesn't have pain right now, but she will because she is having such great depression over her son that her transmission from the thalamus to the cortex is going to be enhanced. And MM has actually augmented her transmission of pain in thalamus to suffering in cortex.
I had lunch today with my wife. We don't have lunch that much anymore, because it's not really in the schedule. We were talking about how much can people change themselves, change their brains. CS had a stroke that robbed him of all motivation. So she wanted to know how we can be upset with the people who are homeless in the streets but aren't motivated to get themselves going. (She is always sticking up for the poor and the wretched.) What if they have a "weak" motivation center in their brain? Still we all try to change ourselves and to some extent succeed. We have some limit, of course. I can never be totally different than me, I can only change me a little. Of course, if I'm persistent a little change at a time adds up after a few years.
I think that too many people don't realize that they have the power to change themselves. They don't even realize that there are these huge differences in people's perceptions. People think that the pain and suffering they have is similar to the pain and suffering that others have. But everyone's pain and suffering is different. Everyone is different and they experience different realities.
Friday, February 20, 2009
Thursday, February 19, 2009
Losing Things
WM came yesterday. I haven't seen him for months. He has MS, but a very mild form. His wife died, and he's been grieving. RS has also recently lost his wife. Wife-losing is a very difficult thing. BP just came back down from Ohio, she lost her daughter (esophageal cancer). Daughter-losing is also a difficult thing.
If the bank can take "my house" then it isn't really "my house". It was always the bank's house. They bought it. Their money bought it. I borrowed the money. If I pay off my mortgage or if I buy my house with cash money,then the bank can't take it. Nobody can take it except the government. They can take it with "eminent domain". So even if I "own" it, I only own it provisionally. It is mine as long as the government says it's OK for it to be mine because they don't really need it right now. These days a lot of people are losing "their" house (which wasn't really theirs).
If somone else can take the thing that it is "rightfully" then it isn't really my thing. It's on loan. People are on loan. They can be rightfully taken by nature or God, whatever you want to call it. We forget that. We forget that these people are just a temporary loan. They get taken back. It's so hard because we don't want it to be like that. We want them to be ours because we have no connection to what's not physically here. We don't develop those connections. Then we have too much loneliness.
I can't really imagine getting through days without my wife or my children. I see a lot of people who do it. They really don't know how they're doing it. I think it's important to go through the exercise of reminding ourselves that our people are on temporary loan. It helps to appreciate them while they're here. It helps us to deal with their "loss" better because we know they were never really ours. More importantly, we need to know that when we "had" them we never forgot their value, their impermanence. We do way too much of not being aware of how near death is to all of us. It can be here in a moment.
If the bank can take "my house" then it isn't really "my house". It was always the bank's house. They bought it. Their money bought it. I borrowed the money. If I pay off my mortgage or if I buy my house with cash money,then the bank can't take it. Nobody can take it except the government. They can take it with "eminent domain". So even if I "own" it, I only own it provisionally. It is mine as long as the government says it's OK for it to be mine because they don't really need it right now. These days a lot of people are losing "their" house (which wasn't really theirs).
If somone else can take the thing that it is "rightfully" then it isn't really my thing. It's on loan. People are on loan. They can be rightfully taken by nature or God, whatever you want to call it. We forget that. We forget that these people are just a temporary loan. They get taken back. It's so hard because we don't want it to be like that. We want them to be ours because we have no connection to what's not physically here. We don't develop those connections. Then we have too much loneliness.
I can't really imagine getting through days without my wife or my children. I see a lot of people who do it. They really don't know how they're doing it. I think it's important to go through the exercise of reminding ourselves that our people are on temporary loan. It helps to appreciate them while they're here. It helps us to deal with their "loss" better because we know they were never really ours. More importantly, we need to know that when we "had" them we never forgot their value, their impermanence. We do way too much of not being aware of how near death is to all of us. It can be here in a moment.
Friday, February 13, 2009
Our Community
Yesterday I saw two new patients RM and CT right after another. They were both very difficult. RM is an 85 year old man with blindness from macular degneration and dizziness who was sent ot me for peripheral neuropathy. He has been telling his doctors for years that he has a great deal of pain in his feet, in his back, and in his neck. No one seems to be addressing it. He tells them about it and they tell him that he's old. It was depressing. I can help him, and in all likelihood I'll get rid of his pain. But I was upset about the past: about his previous neglect.
CT came right after him. She is a 44 year old who can't walk. She lost her walking ability fairly quickly for unclear reasons. Her mother is a double-amputee diabetic, so her daughter, who is 17 years old, dropped out of school to help take care of the two of them. She has no medical insurance (of course). I don't think I'm going to be able to make her walk. I think she has sensory AIDP. I would normally try IVIG therapy on her to see if it works and it usually would. IVIG costs about $15,000. She doesn't seem like the type of person who has that laying around (she used to work at Albertson's before she lost the ability to walk). I was upset about the insurance issue - or lack of insurance issue, to be more accurate.
I know that I shouldn't get upset about these challenges; I am supposed to be optimistic in the face of disease. I try to like disease because of its tremendous positive effects on people. But this isn't about disease. This about the way that people are treated. We aren't treating each other properly. We aren't caring for each other the way that we should. The bonds of our community aren't right. Even doctors are a part of this - the ones that didn't listen to RM; the ones who didn't address his problems but just said, "You're old." What relevance does his age have? There is only one question: "Can I help make this better?" If the answer is no, then there is only one follow-up quesiton: "Who can help make this better?"
I don't understand why we have seventeen year old girls dropping out of school to take care of her mother and grandmother who both can't walk. What chance will she have as a high school drop out? What choice does she have? Why do we put a young girl in that kind of predicament? There were five people in large banks who make over 250 BILLION dollars while they ran them into the ground so we could bail them out. But we can't help this girl. It doesn't really make any sense.
I know I shouldn't be complaining and having a negative attitude. But this just really stinks.
CT came right after him. She is a 44 year old who can't walk. She lost her walking ability fairly quickly for unclear reasons. Her mother is a double-amputee diabetic, so her daughter, who is 17 years old, dropped out of school to help take care of the two of them. She has no medical insurance (of course). I don't think I'm going to be able to make her walk. I think she has sensory AIDP. I would normally try IVIG therapy on her to see if it works and it usually would. IVIG costs about $15,000. She doesn't seem like the type of person who has that laying around (she used to work at Albertson's before she lost the ability to walk). I was upset about the insurance issue - or lack of insurance issue, to be more accurate.
I know that I shouldn't get upset about these challenges; I am supposed to be optimistic in the face of disease. I try to like disease because of its tremendous positive effects on people. But this isn't about disease. This about the way that people are treated. We aren't treating each other properly. We aren't caring for each other the way that we should. The bonds of our community aren't right. Even doctors are a part of this - the ones that didn't listen to RM; the ones who didn't address his problems but just said, "You're old." What relevance does his age have? There is only one question: "Can I help make this better?" If the answer is no, then there is only one follow-up quesiton: "Who can help make this better?"
I don't understand why we have seventeen year old girls dropping out of school to take care of her mother and grandmother who both can't walk. What chance will she have as a high school drop out? What choice does she have? Why do we put a young girl in that kind of predicament? There were five people in large banks who make over 250 BILLION dollars while they ran them into the ground so we could bail them out. But we can't help this girl. It doesn't really make any sense.
I know I shouldn't be complaining and having a negative attitude. But this just really stinks.
Thursday, February 5, 2009
Missed!
I have a "mystery patient". She developed a very strange type of "rash". It's not a rash, actually. She had "purpura". These are little tiny bleeds that occur into the skin for no reason. It has absolutely nothing to do with Neurology. She has a "great" internist. She went to see one of the Oncology (Cancer) people about this, because it can be related to a problem with clotting (usually a platelet problem). She had a bone marrow biopsy, and he gave her a chemo drug, but it didn't help. She also went to an Arthritis doctor because sometimes this is from an auto-immune disease (diseases like Lupus and Rheumatoid Arthritis). She had two skin biopsies and a trip to Moffitt Cancer Center and Mayo Clinic. She came back to see me yesterday, still with no diagnosis.
I told my wife to figure out what was wrong with her. I said it's one of three things: Cancer, Immune problem or drug reaction.
Five minutes later she asked me "Please don't make fun of me. I came up with something, but I know it's really stupid". Then she asked me if it could be from Hydrochlorothiazide.
Hydrochlorothiazide is one of the oldest and most commonly used medications for hypertension. It is practically like aspirin in terms of how well known and commonly used it is. It is right on the list of side effects: "purpura". Not one of the at least ten doctors she's seen who are "purpura" experts has taken her off this medication. Last night, I spoke with a hypertension expert. He said he was shocked. He told me that this is so important that it is a question on every medical boards examination. The first thing that should have been done is to take her off the medicine. He was certain that this is the cause.
I don't know if the purpura is from the Hydrochlorothiazide. I suspect it is. We'll know pretty soon (I told her to stop it). However, even if she doesn't get better and it wasn't from the Hydrochlorothiazide, it's prett scary that this was missed. The really scary part is who missed it. It's really amazing how usually it's the simplest things that people make mistakes about. Everyone forgot to look up the side effects of the medications she was on. It's one of the first things that we're supposed to do. That probably should have been done before the bone marrow, chemotherapy, and skin biopsies.
Things can really get missed!
I told my wife to figure out what was wrong with her. I said it's one of three things: Cancer, Immune problem or drug reaction.
Five minutes later she asked me "Please don't make fun of me. I came up with something, but I know it's really stupid". Then she asked me if it could be from Hydrochlorothiazide.
Hydrochlorothiazide is one of the oldest and most commonly used medications for hypertension. It is practically like aspirin in terms of how well known and commonly used it is. It is right on the list of side effects: "purpura". Not one of the at least ten doctors she's seen who are "purpura" experts has taken her off this medication. Last night, I spoke with a hypertension expert. He said he was shocked. He told me that this is so important that it is a question on every medical boards examination. The first thing that should have been done is to take her off the medicine. He was certain that this is the cause.
I don't know if the purpura is from the Hydrochlorothiazide. I suspect it is. We'll know pretty soon (I told her to stop it). However, even if she doesn't get better and it wasn't from the Hydrochlorothiazide, it's prett scary that this was missed. The really scary part is who missed it. It's really amazing how usually it's the simplest things that people make mistakes about. Everyone forgot to look up the side effects of the medications she was on. It's one of the first things that we're supposed to do. That probably should have been done before the bone marrow, chemotherapy, and skin biopsies.
Things can really get missed!
Subscribe to:
Posts (Atom)