Posts Tagged ‘carcinoid’

What do do about very bad moments.

May 25, 2015

A note for those who’d be wise

If it comes as a surprise

It’s most likely bad.

The good times you’ve had

You could probably already surmise.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, and finished a couple of assignments in rural Iowa.

Time comes to us, not as a series of days or years, but as an unbroken chain of moments.  Each moment lasts a second or three.  As human beings, when we awaken in the morning we all know we’ll have good moments and bad moments.  Most moments come and go as neutral.

I enjoy saying that if we let the bad moments contaminate the neutral moments we’re giving them too much power, and if we let them sully the good moments we’re missing the point.

Time spent thinking of bad moments that haven’t happened constitutes a misuse of imagination.  The psychiatric community calls it catastrophizing, thinking of sequences that follow from a bad “what if.”

Most of our good moments come to us announced.  Yes, once I really did find a diamond in a stairwell, and the gift of a soprano saxophone in fact rendered me literally speechless.  But my marriage, my children, my graduations, all arrived more or less on time after much anticipation.

In contrast, with few exceptions, the really bad moments come to us as complete surprises, unannounced and unexpected.   Bad medical news, such as my diagnosis of appendiceal carcinoid, and news of our daughter’s climbing accident, for example, came with no warning.   When I think of my lifetime’s 10 worst moments, I have to admit that they ambushed me, every time.

Both Bethany and I had very bad moments yesterday, the kind of moments that, despite all efforts to the contrary, ruin the rest of the day.  We commiserated, we supported each other, and we hugged.  And later, taking my own advice, I put a rubber band on my wrist for self-administered aversion therapy.  When a negative, useless thought intrudes, I pull the rubber band back about 9 inches and let it go; bad thoughts creep in with less frequency as long as I keep the rubber band on my wrist.

In the late part of the day we attended a social gathering, which celebrated Bethany’s last day on her job.  She has done a lot of good work for the last couple of years, and we’re looking forward to spending more time together.

At that gathering, a former patient I hadn’t seen for years, talked to me about a very bad diagnosis.  I listened, sympathized, and told her about my personal experience with carcinoid of the appendix.  But we also discussed our music community, and the person congratulated me on taking saxophone lessons.


Appendicitis on the front lines; drama and irony close to home

December 20, 2010

For the patient who hurts low and right,

And suffers from lost appetite

    Search high and low

    The appendix must go

Would a CAT scan help? Well, it might.

Appendicitis has afflicted so many patients since my arrival that I can write about the disease without identifying anyone in particular.

The classic appendicitis patient will complain of abdominal pain starting near the umbilicus (navel), increasing over the course of three days, and moving to the right lower quadrant, aggravated by jarring, and accompanied by loss of appetite.

I always ask the patient what they had for lunch, and whether they enjoyed it.

People with appendicitis come with a back story and a social context.  Some had serious medical problems before their appendix went bad.  They may use illegal or legal things to excess.  They may have good or bad relationships with their family members; they may have no family members at all.  They may not possess the ability to speak for themselves. 

The physician must rely on the information available.

Eighty percent of appendices live near a spot two-thirds of the way along a line from the belly button to the front point of the hip bone, called McBurney’s point; a patient who points there brings immediate suspicion for appendicitis.

If I call a surgeon, he or she will want to know about rebound (increased pain on sudden release of pressure on the abdomen), psoas sign (pain on pulling the right leg back when the patient lies on his or her left side), bunny hop (pain on jumping on the right foot), bowel sounds (presence or absence of normal gurgling in the abdomen), and guarding (tenseness of the abdominal wall muscles).

None of these signs or symptoms makes the diagnosis by itself.  I have had appendicitis patients come with pain low on the right, low on the left, high on the right, and high on the left.  Some had pain in the leg or the back, and a few had no pain at all.

Not one enjoyed their lunch.

When I worked in Navajoland, my appendicitis patients complained of not being able to eat rather than pain.

CT scans help if the history and physical don’t paint a clear picture but characteristic history and physical trump a normal CT scan.  “I operate on patients,” I heard a surgeon say, “Not images.”

Six years ago, while Bethany and I got ready to go out, I told her about the twinge I’d just had at McBurney’s point.  She asked me if I’d enjoyed lunch, which I had, and if I had pain when I hopped on my right foot, which I didn’t.  I ignored the mild zing which came and went over the next six months while my gallbladder went from bad to worse.  I set a convenient date for its removal, and as I walked to the OR with the surgeon, I said, “Listen, Mike, while you’re in there, take out my appendix.  I really don’t want to get back on this table.”

Ten days later, to my unpleasant surprise, the pathology report showed carcinoid, a low-grade cancer.

More things can go wrong with the appendix than just appendicitis.

Five years after a malignancy, I’m back at the blood bank

November 11, 2010

There once was a nurse named Camille,

Who said, “Gosh, how do you feel?

     For you’ve blown your vein.

     It must be a strain.

Can you come back?  It will soon heal.”

During my oldest daughter’s medical education, a medical ethics lecturer said that one should not be doctor to family or friends, no degree of social contact would be appropriate.  But my family’s youngest doctor grew up here and understands how doctors fit into the community.

At my annual physical this morning I talked with a friend and colleague.  Many have said how great I look, how much more relaxed I am; the same words coming from my doctor mean more.  We discussed the turns in his career, and about how we love the day-to-day, hands-on work of medicine. 

My lab work and exam showed no surprises.

When my gallbladder came out five years ago I asked the surgeon to take my appendix, saying, “I don’t want to get up on this table again.”  Ten days late pathology found carcinoid (a low-grade malignancy) in my appendix. 

The diagnosis didn’t change the way I live, but I was banned from giving blood for five years. 

The VA has done marvelous follow-up; all the CT scans have come back normal.  So today, after the appointment, I went to the blood bank.

Consider giving blood, even if you never have; you can justify 600 calories for every unit.

My wife and children donate blood as often as they can (every eight weeks).  I tell adolescent patients complaining about having blood drawn that the people in my family, mostly female, do it recreationally.

I tried to donate two units of red cells, where machinery takes whole blood and returns plasma, but my vein blew early in the procedure and I didn’t have a good vein on the other side. 

Of course I chatted up the nurses and dropped my wife’s and daughters’ names.  They gave me more sympathy than I deserved.

Afterwards I met my youngest daughter at the Japanese restaurant.  I knew more than half the people there as non-physician health care professionals.  I got to talk about my travels and catch up with their news.

One went to college on a rodeo scholarship; the injuries from that time forced early retirement.   The new-found leisure, she said, would go better if a second career would happen; doing nothing does not suffice.

I love the fact that I can’t go out to eat without running into people I know, and I’ve found the anonymity in my travels the most distasteful part.  

This evening a patient called who had a less than optimal experience with a doctor’s visit today.  Remembering that I respect my non-compete agreement, the question became: which specialist would I recommend under some specific circumstances?  The answer came easily. 

My father, an internist/cardiologist/emergency doctor, always maintained a listed phone number.   I have never had an unlisted number, and I doubt my daughter the doctor will.

Separation anxiety, heat intolerance north of the Arctic circle, and conversations with a sculptor/hunter

July 22, 2010

There’s a way of emotional grieving

When the time comes close for the leaving

     Separation anxiety

     Transcends all piety

Culture, and language, and believing.

The young man I attended gave me permission to write this information.  He came in with his supervisor after an on-the- job injury.  While treating him, we talked.  He’s an apprentice hunter, he holds a steady job, and he’s a sculptor with aspirations of doing animation.  He face sparkles when he talks. 

He makes tiny statues of people that he puts in corners where people do not expect to see them.   His sculptures adorn both home and workplace.

We talked about the artist’s moment; for him it’s watching the face of someone who noticed his art for the first time, seeing the reaction and delight.  For me, as a musician, it’s watching peoples’ heads bob in time to the music, even if they’re ignoring me as a musician. 

As a writer, I would like to think that people chuckle when they read the limerick, and, having been hooked, can’t stop reading till they get to the end.

We also talked about gill net fishing and subsistence hunting.

One of the perks of Barrow hanging out with hunters all day.

At morning conference today we talked about how maternal and paternal alcohol use contributes to schizophrenia later in life.

We exchange a lot of information in morning conference.  We talk about patients by name.  We talk about clinical problems.   I get much education from my colleagues. 

I brought up a particular patient with recurrent right lower quadrant pain whose CT showed a normal appendix.  I expressed my concerns that the image might not have had adequate resolution to show a carcinoid (a low grade malignancy occasionally found in the appendix).  It turned out that everyone around the conference table had taken care of the patient at one time or another and we all agreed the appendix needed to come out.

I am coming to the end of my tenure here tomorrow, and today I developed separation anxiety.

Separation anxiety is a universal human emotion.  It’s the reason roommates fight at the end of the school year or spouses fight just before one goes on a trip.  I knew that I would have it when the time for me to leave came close.   Bethany’s presence buffered the intensity.

Today the weather turned warm (fifty-one Farenheit), the wind stopped and the sun came out.  The heat in the outpatient area became intolerable, and I went to maintenance and complained three times.  I probably wouldn’t have been emotional in my declaration of impossibility of working conditions if it hadn’t happened towards the end of my tenure. 

I think the reason people have separation anxiety is because it softens the pain of emotional loss.  It’s a way of saying, “I have plenty reason to be mad at that person/institution.  So I won’t miss him/her/it when they’re/I’m gone.”