Saturday, October 27, 2012

Big Deep Breath

"Big deep breath...in through your nose, out through your mouth."

     Today's gonna be a good day. It's Friday!!!! Our first case is a "double dip," an EGD--short for esophagogastroduodenoscopy, an endoscopic exam of the esophagus, stomach, and first segment of small intestine--and colonoscopy combo, evaluating a chief complaint of abdominal pain and rectal bleeding. No big whoop. The patient's a healthy 51 year old female; no medications, no allergies, no medical problems, just a little rectal bleeding noted after the endometrial ablation she underwent two weeks ago to alleviate her heavy menstrual periods. "After the surgery, I couldn't 'go,' so I inserted half of a glycerin suppository, and that's when I noticed I was bleeding from my rectum. Maybe I tore a little hemorrhoid?" Sounds reasonable, especially since she's so thin, healthy, and asymptomatic. Aside from having a maternal grandmother who died from colorectal cancer, there's nothing too remarkable in her history. This'll be a piece of cake.

"Big deep breath. You'll start feeling really sleepy in just a few seconds. You're gonna feel that oxygen blowing in your nose a little harder as you're drifting off to sleep, OK? See you when you wake up."

     It's 7:40 a.m., but here in the GI suite, the propofol is already flowing as freely as cheap wine at a house party. After only 80 milligrams of this wondrous milk of anesthesia, my patient's snoring like a true champ. "Wow, she's a lightweight! This case is gonna be a cinch." The scope goes in at 7:41 and comes back out two minutes later. "Her EGD's normal," says my gastroenterologist colleague, Dr. Selleck*, as the procedure nurse and I spin the stretcher around in the opposite direction for the colonoscopy. Everyone in Room One's in a good mood, chatting excitedly about our weekend plans...did I mention it's Friday? We get our patient positioned, and I push a little more propofol as Dr. Selleck performs a standard pre-colonoscopy rectal exam.
     "Oh, FUCK!," he blurts out, his tone unexpectedly grave and serious. "Something's not right. She's got a mass in here." Praying it's only a thrombosed internal hemorrhoid, we all watch silently as he passes the scope a few millimeters into our unconscious patient's anus, collectively groaning, "Oh no..." as the olive-sized, ulcerated tumor comes into view. "It's cancer," he says quietly, his voice heavy with compassionate despair, "and it's a bad one." I deepen the anesthetic, and we proceed with the remainder of the exam.
     Because the tumor is situated so close to her anal sphincter, it can't simply be cut out without affecting continence. "Depending on whether this is squamous cell or adenocarcinoma, she might be looking at a permanent colostomy," he remarks as he takes a few endoscopic biopsies of the now bleeding tumor. "She reported having rectal pain, which is indicative of a more invasive and very likely unresectable tumor. She'll need a rectal ultrasound and CT scans for staging, and we'll go from there." I felt myself starting to become a little undone: "A permanent shit bag? Are you kidding? She's only 51! Jesus Christ! I'm not sure I'd even want to live with an irreversible colostomy." The procedure nurse, a 31 year old woman, nodded in agreement. "Well," Dr. Selleck said, "at least you'd still be alive."

"Hey there, you're just waking up. Big deep breaths for me. We're going to recovery now, and when you're awake, Dr. Selleck will come talk to you about your results."

     Mercifully, the propofol sedation lingered long enough to allow for a peacefully sleeping patient with a no-questions-asked transfer to recovery. I don't think I could have handled it if she'd been awake. People waking up after their procedures always want a confirmation that everything went all right. I was exceedingly thankful that it wasn't me having to deliver such devastating news, especially because I'd already determined that if it were me and I was looking at forty-plus years with a permanent colostomy, I'd probably let the cancer metastasize and die in hospice.
     Just a couple of nights ago, I awoke from a terrible nightmare. It was Thanksgiving, and I was sitting at a long dinner table in the house of someone I barely knew, a conservative woman who appeared to be very wealthy and kept talking incessantly about Jesus. I didn't know anyone else at the table, but they all looked uptight. No one was having any fun. I felt a sense of awkward discomfort, like I was in the wrong place at the wrong time, and I didn't know how I'd gotten there. I ate what was offered, but otherwise kept my mouth shut. Looking across the dining room into the foyer, I could see a bunch of twenty-somethings dressed in garish Halloween costumes clamoring down a large staircase, prompting the hostess to get up and investigate the commotion. Somehow, I knew that they were renting rooms upstairs. That's when I saw Pocahontas and a big fuzzy bumblebee pointing their shotguns, and I knew we were all going to be robbed. There was no time to escape, and that's when I awoke.
     What's it like to wake up as your normal self one morning, only to be informed a few hours later that your days are numbered by a disease, that your body's been invaded by a cancer that will probably leave you disfigured? Although our patient took the news pretty well, her husband was visibly shaken. Instead of heading home with his wife after her uneventful colonoscopy, he was accompanying a newly diagnosed cancer patient to the hospital for CT scans of the abdomen, pelvis, and chest to see if the tumor had already spread to other parts of her outwardly perfect body. Interestingly, the patient disclosed that she'd suspected it might be a cancer. Perhaps her calm demeanor wasn't from the propofol after all; evidently, she'd been discreetly preparing herself for the worst possible scenario.
     I've had a really hard time shaking yesterday's disturbia. I'm turning 50 in a few days, a birthday which nowadays means, "Congratulations! It's time for your screening colonoscopy!" I'm relatively certain that mine isn't going to be normal, either, given the fact that I was diagnosed with Crohn's disease when I was 19, and have endured a lifetime of gut-related misery that I've just learned to live with. I don't like taking medicine, and I don't "do" sick very well. That's been good motivation for eating a healthy diet and keeping myself in excellent physical shape. I value my independence and my intactness. I like my body the way it is, the way it was designed to work. Anesthesiologists are known for our tightly toned sphincters, making it even less of an irony that I find the idea of being surgically altered so unappealing. As yet, I'm undecided about whether or not I'll submit to a colonoscopy.
     Last night, I kept thinking about that dream I'd had, and how uncannily it paralleled my patient's cancer. Like a malevolent uninvited dinner guest, her malignancy had been lurking unnoticed for God knows how long, serendipitously discovered because the rough-edged surface of the glycerin suppository fragment she'd used to treat her post-surgical constipation disrupted a friable time bomb that was ticking away patiently, aggressively straddling her sphincter. It also occurred to me that continuing to sit at a table full of Jesus-talking conservatives is very much like what I do for a living. The practice of medicine necessarily involves a controlled level of hypocrisy. I've given anesthesia to people having all kinds of procedures that I personally would never consent to, with the understanding that although I'm obliged to inform them of risks, benefits, and alternatives of the anesthetic, it's not my place to judge what's right or wrong for them. For some of us, quality of life is what's important; for others, it's sheer quantity. Just how much surgical disfigurement or chemical alteration one is willing tolerate in order to stay alive is a reflection of one's perception of quality, the metaphysics of which are complex and uniquely individual. No two definitions of quality are the same. From an acquired disease perspective, quality of life becomes a matter of adaptation. In contrast, my sons have lived their entire lives with the cruel genetics of cystic fibrosis, and all the pills and therapies and hospitalizations that go along with it. They've never known life without concomitant disease or what it's like to be completely healthy. For them, adaptation hasn't exactly been a choice.
    Doing what I do, and knowing what I know, am I a hypocrite or am I simply being non-judgmental?  Isn't acknowledging that what's right for me isn't necessarily right for everyone else, and vice-versa, the hallmark of self-determination and autonomy, the most inviolable principles of both medical ethics and humanity? Is supporting others who are sick, but not wanting there to be anything wrong with me really such a paradox?  Would any of my feelings change if I suddenly became incapacitated or terminally ill? And, now for the question of the moment: Should I have that colonoscopy?..."Big. Deep. Breath."

*name changed

Physician, Heal Thyself! (a related post)

Sunday, October 21, 2012

The Weirdness of Me

     Fifty. The big 5-0. Half a century. That's gonna be me in just a couple of weeks. For some reason, I thought that by fifty, I'd have my shit together, be a "real" grownup and all, but that just hasn't panned out. On any given day, I feel five or twelve or eighteen or thirty-two. To an observer, my life's curriculum vitae might seem impressive--there's that whole "doctor" thing sticking out like a sore thumb--but that's never been what I'm about. I still don't know what I want to be when I grow up, and lately, that whole idea of "Be all that you can be" doesn't seem incredibly necessary or important.
     Because I keep running into problems with a little thing called society, I've spent much of this last year examining the weirdness of me. Funny thing is, I keep coming up empty-handed. Although I've dabbled in the mainstream from time to time, being a sheeple has never really held much of an appeal. I'm not marching to the beat of a different drummer: I am the drummer. For some reason, this lack of conformity seems to bother people, especially those are overly concerned with superficial appearances and projecting a certain image. Who do they think they're kidding?
     I've never been a good liar. What you see is what you get, and for that, I remain unapologetic. I don't worship the God of Expectation and Disappointment, the one that hypnotizes the susceptible into thinking there's always something else to be achieved, something bigger and better and new and improved, that what we already have to give will never be enough. By definition, isn't enough enough? This consumeristic mentality just isn't my bag; I don't relate to people in terms of what I can do for them or what they can do for me, and for that, I'm labeled selfish, uncompassionate, egoistic, anti-social, and a failure at capitalism. Since when did being interested in people on a deeper level become such a crime?
     Fifty. It's an age that's always sounded so mature and matronly, but I feel more wild and free than ever. Living dangerously is all it's cracked up to be. Although I've learned to tone down some of my more subversive tendencies by flying under the radar, I still don't give a damn what the neighbors think. Life is good, even when it's sucky. Self-acceptance is key to my happiness; at the end of the day, what I think about me matters most, obviating any need to stereotype myself as "weird" or "normal." Sometimes, weird becomes normal. If weird is to normal as eccentric is to boring, though, it looks like I'm in for a few more decades of weirdness.
I see nothing at all weird about using this spoon to stir my Brussels sprouts.
What almost 50 looks like.

Sunday, October 14, 2012

From Poop To Nuts

     It's raining nuts around here, literally and figuratively. I'll try to explain. I live in the former library of a very old elementary school that's been converted into lofts. The library is separate from the rest of the school building: 2500 square feet of open space, 14 foot ceilings with exposed ductwork, huge windows, polished concrete floors, and a metal roof with two large skylights, a visionary repurposing of otherwise ugly industrial materials.  When we found this place back in January, the karma was almost too good to be true. Aside from being the perfect place to start life as a writer, this old schoolhouse is located in an uber-cool East Atlanta neighborhood, one that's currently undergoing the process of gentrification. It's trendy, but still replete with original ghetto charm.
     For the last week, the acorns from the oak trees in the schoolyard have started plummeting incessantly across this metal roof in a maddeningly nutty hail that shows no sign of letting up anytime soon. With the acorns have come the squirrels, whose thunderous rooftop scampering has jangled my last nerve so badly that I'm thinking of taking up residence with any of the mixed bag of human nuts that populate our neighborhood. Let's see...there's the angry sweaty lady with the big hat and pendulous belly who, when she isn't wandering around observing telephone poles and recording her findings in a black notebook, parks herself out on our front stoop, giving F-bomb filled Sunday sermons any given day of the week, completely oblivious to the dog-walkers, bike-riders, and parents pushing baby carriages passing her by. Another lady wearing a hair net rides around on her bike, yelling and screaming into her cell phone, which I'm not sure even has a person on the other end. There's the young guy with dreadlocks and a trucker hat who can be seen either standing on the corner with a baby, or pushing a grill or an empty stroller up and down the street, stopping you on a regular basis to ask for (crack) money. Then, there's the drunk middle aged woman, decked out in Tennessee Volunteers attire, who amuses herself by barking at our dogs.
     I've had my hands full of nuts the last few days, and I'm not referring to the ones here in the 'hood. A couple of weeks ago, I had a patient who presented 30 minutes after her scheduled appointment for esophageal endoscopy and colonoscopy, due to a complaint of abdominal pain. She seemed to be of reasonable intelligence, but come to find out, appearances can be deceiving. In order for a colonoscopy to be performed successfully, one's bowels have to be clean as a whistle. Makes sense, right? It's self-evident that a colon full of poo will obscure a camera's view. Patients are given explicit verbal and written instructions for prepping the colon, which involves a two day ordeal of clear liquids, various cathartics, and enemas. For 24 hours prior to the procedure, there is to be no intake of solid food whatsoever. Doesn't leave much to the imagination, now, does it? After denying that she'd eaten the day before, we took this patient back to the procedure area, got her sedated, and placed the scope in her throat, only to be greeted by an esophagus full of undigested pasta. The procedure was immediately aborted, given the fact that a full stomach in a deeply sedated patient is a potentially lethal combination.
     Because sedation and anesthesia impair the protective gag reflex which prevents food from being upchucked into the lungs where it can cause catastrophic aspiration-induced respiratory failure, NPO (nil per os or "nothing by mouth) guidelines are strictly enforced. Unfortunately, many patients don't seem to take them very seriously. It's almost as if they think they're pulling one over on us, but what they don't quite grasp is that we're going to be looking right into their gullets and bowels with a video camera where all will be revealed. In other words, if you've consumed anything other than plain Jello, apple juice, or broth, we're going to see exactly what you've been eating! Needless to say, upon further questioning, the patient admitted to having eaten a Lean Cuisine the night before. Her inability to comply with simple instructions could have cost her her life. Once again, this patient was given clear and concise instructions for repeating the bowel prep, and this time, she was placed on a clear liquid diet for two full days prior to her rescheduled colonoscopy to ensure that she'd be extra clean. On Thursday, she returned for her procedure, forty-five minutes late. This time, she admitted up front to eating peaches and cream of mushroom soup the day before, so she was immediately cancelled. Whatever belly pain she's been having obviously wasn't sufficient enough motivation to keep this Holly GoLYTELY from indulging in breakfast at Tiffany's (or Waffle House), ruining her second chance at a diagnosis.
     On Friday, I checked into my blogger forum where there's always sure to be an interesting discussion taking place. Medically-related posts never fail to catch my eye. I don't consider myself a censor per se, but with all the nonsense floating around on the internet which lay people misconstrue as science, I feel a bit of responsibility in busting the myths that routinely complicate my clinical practice, the primary example of which is Michael Jackson's illicit use of propofol. Every single day, I'm confronted with some anxiety-riddled version of, "You're gonna give me the Michael Jackson drug?!" I explain that propofol didn't kill Michael Jackson--his own addiction and his doctor's negligence did. I then reassure the patient that propofol, which is an intravenous anesthetic, not a sleeping aid,  is safe when administered by anesthesiologists and anesthetists in a monitored setting. These conversations tack an extra two or three minutes onto my pre-op assessments, time that could be better used in other ways. Thanks a pantload, Michael Jackson!      
     Anyway, I was trying to get my mind off of work, when I noticed a discussion entitled "What Good Is A Cortisone Shot?" Without going into details, it was a wealth of misinformation regarding steroid epidural and joint injections by a Hitler-obsessed conspiracy theorist claiming that patients are misled into thinking cortisone shots are beneficial, when it's really "cocaine derivatives" producing the analgesic effect. I'd never seen this author on the forum before, so I wrote a reply clarifying that although local anesthetics are sometimes used diagnostically in these injections, none of those currently in use are derivatives of cocaine. This guy is a great example of a little bit of knowledge being a dangerous thing. Although some of what he said was valid, namely that the long term use of corticosteroids is associated with immunosuppression, bone demineralization, and derangement of intrinsic hormone homeostasis, his conclusion that these injections have no clinical utility was based on an incomplete understanding of steroid synthesis and pharmacotherapeutics, as well a frightening arsenal of evangelical paranoia-fueled pseudoscientific propaganda. After realizing that he was just another disturbed nutcase, I left the conversation. My guess is that anyone who follows his blog is probably as bonkers as he is, too brainwashed by hogwash to question the verbal diarrhea he's spewing as the truth.
      From poop to nuts, it's been one of those weeks. I'm emerging from a funk of aggravated frustration, heavily infused with snark, which I have to admit I've rather enjoyed indulging in. I'm tired and grumpy, but at least I feel validated. For now, the acorn showers have abated, and the lunatic fringe is strangely quiet, like a knife cutting through peanut butter. Sometimes you feel like a nut, sometimes you don't. Neighborhood eccentrics are whimsical and endearing, militant fanatics and NPO violators, not so much. Life's already a tough enough nut to crack, isn't it? I think I'll be much better off without further help from the peanut gallery.

Sunday, October 7, 2012

When "g" Inadvertently Became a "ɋ"


     She couldn't have been more than six years old at the time, given the conspicuous absence of both bottom incisors, her school uniform itchy and tight about her waist as she sat at her desk, folding a piece of paper over and over on itself, marveling at how it kept getting smaller, wondering if folding it enough times would eventually make it disappear. Defiantly shoved beneath her Big Chief tablet, barely obscuring her assignment's tell-tale red star sticker, lay the ruins of a job almost well done. For a left-handed girl who still wrote her name backwards, penciling row after row of lower case "g’s" without besmirching the sheet of paper had proved an impossible challenge, especially given the fact that Sister Mary Nicholas did not permit the use of erasers without prior special dispensation.
     Only moments before, she'd set about the task of making “g’s,” concentrating intently, determined that today's effort in penmanship would be rewarded with a gold star, not the usual blue or green one. She glanced over longingly at Perfect-Sharon-Carmichael's desk. The tip of Sharon's tongue was already deliberately affixed to the corner of her mouth in typical studious fashion, marching her “g’s” almost mockingly across the page, each letter as crisp and pristine as the typeset in their "Fun with Phonics" workbooks. Pretty, bright, and obedient--the sugar and spice embodiment of a teacher's pet--Sharon was her unsuspecting nemesis. From her stylishly coiffed glossy brown hair to her meticulously polished saddle shoes, Sharon had all the right stuff, including right-handedness. Unfazed by the dreaded yellow subtraction flash cards, Sharon would enthusiastically raise her right hand, righteously illuminating the rest of the class with all the right-minded answers. It just didn't make sense that she was the one who got to use an eraser.
     Two rows of “g’s” down, three more to go. She'd been careful to elevate the sooty pinky-side of her hooked left hand ever so slightly to keep it from dragging and smudging the paper, taking her time to scribe what was certain to be the most exquisite array of “g’s” Sister Mary Nicholas had ever seen. Distracted by the sudden violent scrubbing of Sharon's coveted eraser, her next “g” inadvertently became a "ɋ." Just as she was completing the "o" part of a particularly troublesome “g,” her adversary's convulsive fit of erasure trembled her desktop, peppering it with pink shrapnel, the detritus of which she was tempted to scavenge and roll surreptitiously into a tiny eraser of her own, a delightfully naughty fantasy indeed. Captivated by this wildly provocative thought, she carelessly transposed the "j" which was supposed to turn her "ointo a “g.” Now, she was stuck with “ɋ.”
     Deprived of eraser privileges, and impoverished by her own awkward chirality, she deftly resorted to other means of correcting her sinister slipup. Surely Sister Mary Nicholas, who was thickly bespectacled and had eyes in the back of her drab grey veil, wouldn't notice the little bit of saliva she'd used to coax the “ɋ” into an "α" and finally, into a magnificent “g,” as flawless and unadulterated as one of Sharon's scuff-free shoes...


The Subtle Beauty of Chirality: A Related Post