Posts Tagged ‘cholesterol’

Chocolate, tornado, lemonade, ear wax, and a supervisory visit

May 3, 2011

Don’t even try to refute,

For this there is no dispute

     Could I get any closer?

     I tell you, No Sir!

Happiness is a shorter commute

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  After a six-week assignment in Barrow, Alaska, I’m working on the North Island of New Zealand.

I started the day at leisure with a seven-step commute to my office.  I sat down promptly at 8:00 AM and started to review lab work.

In the quiet of the morning, early, before the first patient arrived, I found an alarming erythrocyte sedimentation rate (ESR) with the highest C-reactive protein (CRP) I’ve ever seen; both markers of inflammation throughout the body, I prescribed prednisone.  I don’t prescribe that medication often, and always in the context of getting a specialist’s opinion.

I can’t talk about patients and their medical problems without permission, but I can talk about myself and about medicine.  Yet diseases don’t come to me, people come to me; none of them perfect, each with flaws, quirks, a terrific back story and a family.  Every person who seeks my advice has a unique smell, voice, accent, style of dress and body language.

If a person presents with an ear wax problem, and I take the wax out with a simple instrument called an ear curette, I’ll tell them how to keep the wax problem at bay.  I make sure they’ve never had a hole in their ear drum and I instruct them to start with body temperature water and put in enough white vinegar that it smells like vinegar but not so much it feels cooler.  Then, I say, use a bulb suction syringe to rinse the ears out about once a week.

I saw another person today with appendicitis, making three since I arrived.  At least, I hope I saw the first case of appendicitis I’ve ever seen in a person who had enjoyed their lunch.  I worry that my patient has something worse.

I saw a person with a single distended vein where I’ve never seen one before.

I made referrals the general surgeon, ophthalmologist, urologist, neurologist, and orthopedist.

At mid-morning, I took a tea break.  While the fifteen minute hiatus comes built into my schedule, most mornings I use it to catch up.  Today I walked back through the apartment, picked a lemon from the tree, came back in, made hot lemonade and sipped it while I talked with Bethany, nibbling on some exquisite dark chocolate macadamia nut bark.

When noon came round we lunched while we watched the shocking, driving rain outside.  The first thunder we’ve heard since we arrived made us stop and listen.

The rain continued for the afternoon drive to Wellsford.

In accordance with the Medical Council of New Zealand rules, any doctor new to the system requires supervision their first year.  In this case my supervisor is the clinical director, and we met in the early afternoon.

I enjoyed the interview. 

A reasonable clinical pace.  I told people on asthma medication to quit smoking.   I gave others with high cholesterol levels instructions about diet and exercise.

Driving back to Matakana in the rain, we learned that the same storm that gave our afternoon’s deluge spawned a tornado, so rare in New Zealand that rating came only with difficulty.

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Snow machine excess, cold injury, and wolverines

January 19, 2011

Some people, they smoke and they drink,

Some trap the otter and mink

     But the story’s been told

     That Barrow’s so cold

You can’t open your eye if you wink.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  To avoid burnout, I’m transitioning my career, and while my one-year non-compete clause expires, I’m working in exotic locations, traveling, having adventures, and visiting family and friends.  Currently I’m in Barrow, Alaska, the northernmost point in the United States.

I’ve been back on the job for less than twenty-four hours, here in Barrow.  I’ve seen several cases related to snow-machine use.

In Barrow, one avoids the terms sled or snowmobile in favor of snow machine.   The people here use them, not for recreation, but to do necessary work.  People hunt from snow machines, so that hunting injuries are almost synonymous with snow machine injuries.

Most, not all, caribou migrated south past the Brooks Range when the days grew too short.  Herds of up to five hundred remain, grazing on the tundra.  In temperatures so cold that alcohol freezes, in the Arctic night when the sun doesn’t rise and the moon doesn’t set, subsistence hunters go after them with firearms ranging from .22 magnum handguns to 7mm Remington Magnum rifles.

A lot of parkas here sport wolverine fur on the ruff. Unique in that breath frost won’t stick to its fur, hunters eagerly seek the “skunk bear.”  The creature has such a nasty disposition that it acts like a serial killer, slaughtering everything in its path for fun and eating for necessity. 

The government issued a wolverine fur-trimmed parka to a person I know (not a patient) during the cold war, for work done in the Arctic.  To this day, the nature of the work and the circumstances of issuance remain clouded in mystery.

Hunters also go after wolves; polar bears occur as targets of opportunity.

Most of my clinic load, whether in Iowa or Alaska, has to do with damage from alcohol and tobacco.  Respiratory infections, cough, asthma, depression, fatigue and malaise, hypertension, high cholesterol follow from those two substances.  Counseling people to quit, though a good idea, rarely works.

When the patients come in with fetal alcohol syndrome and fetal alcohol effect, it’s too late.  With irreparable damage I just make the best of the situation.

I won’t say where, but I attended a set of fraternal twins, one of whom had fetal alcohol syndrome and one of whom had much milder fetal alcohol effect.  Some people are more resistant to alcohol than others, and such resistance starts before birth.

If most of what I see in any clinic has to do with drinking and smoking, the majority of the remainder has to do with the unique factors of where the clinic stands.  Barrow’s air is so dry that eczema here runs an order of magnitude worse than any I’ve ever seen.  Yet most people know the cold so well that frostbite comes rarely.

The first case of frostbite here in Barrow came my way today, very shallow damage, but not to fingers or toes.

Death, unconditional love, and a really bad case of enlightenment

October 10, 2010

You know, it’s not that I pried,

 But Bob said, “Last night I died,

    It wasn’t a frightenment

    But a bad case of enlightenment

I was willing to take it in stride.”

My friend Bob almost died last night

Bob controlled his diabetes well for the last ten years, before a disc in his mid back exploded and necessitated surgery about ten days ago.  He faces a very real possibility of paraplegia. Standard of care in these cases includes steroids.  I’ve been in California for the last few days visiting him in the rehab hospital.

Doctors throw the term steroids around more carelessly than two-year-olds throw rice at a Chinese restaurant.  The word refers to any molecule built on a cholesterol skeleton, including testosterone (the main male hormone) and estrogen (the main female hormone).  In this case, “steroids” mean things like cortisol or cortisone or prednisone, properly called corticosteroids.  They’re widely used in dermatology, asthma, emphysema, and cancer chemotherapy.

They are the body’s main stress hormone; we use cortisol levels to measure the stress of an episode.

My personal experience with the class of drugs goes back twenty years, when my rheumatologist decided to treat my flaring ankylosing spondylitis (spinal arthritis related to rheumatoid arthritis) with prednisone.  My back felt great, I felt even better: creative, energetic, and invulnerable.  I talked so fast that my wife and daughters had to tell me to slow down.  I slept four hours a night and awakened rested.  I wrote another novel.  But steroids exact a price, I started to get irritable, I could hear repetition in my speech, and I lost so much strength in my shoulders I couldn’t string my bow.  My rheumatologist tapered the dose down and started methotrexate (a very nasty drug); I’ve not been on prednisone since—I found it too seductive.  In retrospect, it put me into hypomania (a state near mania, part of bipolar disorder), a known side effect of the drug. 

Steroids like prednisone powerfully inhibit the body’s inflammatory response.  Post-surgical swelling in the area of the spine can put enough pressure on the spinal cord to strangle it; thus the corticosteroid therapy.  Predictably, they wreak havoc with blood sugars, but not in a linear fashion, and physicians play a balancing act trying to avoid the adverse consequences of sugars too high or too low. 

Bob has been on Decadron or dexamethasone; compared to prednisone it’s a steroid, well, on steroids.  The doctors on the case have been appropriately prescribing insulin, but corticosteroids bring chaos to diabetes.  His sugar crashed last night.  His blood pressure, blood sugar, and oxygenation fell below levels that sustain life.

He doesn’t remember seeing white light or darkness, and he calls the experience “a really bad case of enlightenment.”  He no longer fears the pain of death.  He loves his freedom.

But he’s alive today and better than he was yesterday.  He has minimal movement in the left leg and a trace on the right.  Between the steroids, motion in his legs, and his new-found freedom, his spirits are soaring, his thoughts are racing, and he relishes the feeling of unconditional love he has for the people around him.

Frost heaves and bear maulings

June 4, 2010

The docs tell the stories of bears,

Of the pilot who shouldn’t, but dares

     Of the planes that turned round

     Or crashed into the ground,

And the problem of bootleggers’ wares.  

 Morning rounds start at 8:00 AM here; the doctors meet and we discuss problems and cases. 

Alaska medicine is not like medicine in the lower 48.  The doctors and the patients deal with immutable physical realities.

 Permafrost is very real and it governs the architecture and the roads.  No matter how warm the summer gets it never thaws more than a few meters deep.   When springs warms past the melting point the permafrost starts to heave.   Pavement becomes problematic, and, in cases, impossible.  During the spring, the dirt runways in the four outlying villages are not safe to land planes.  If the wind blows too hard, the helicopter can’t go either.

I think the only pavement in an area the size of the state of Washington is the Barrow runway.

I listened this morning to the stories of patients mauled by bears; the conversation moved on to stories of extreme weather, when planes could take off but not land, or land but then couldn’t take off again.  Sometimes the airplanes got diverted or returned to base.  There were harrowing stories told matter-of-factly, when you couldn’t leave the village for weeks at a time, and how sometimes the ability to get an aircraft was a matter of life and death.

I had a luxurious morning clinic, spending as much time as I needed with each patient.  I got to tell the story of my back pain, and the story of Bethany’s untoward reaction to the statin drugs (things like Lipitor or Crestor, which reduce cholesterol).

A lot of people still smoke, or perhaps I should say that a lot of our patients still smoke.   The local word for cigarette is “roll,” as in, “I’m cutting down, I only smoke 4 or 5 rolls a day.”  Just like in Sioux City, I ask the patient if they want to quit.  If they do, I ask if they want help, if so I prescribe Chantix.  If they don’t want to stop smoking, I tell them about the risk of death and disability, and, when they’re ready to quit to go cold turkey and if they can’t do it by sudden withdrawal to make an appointment for medication which will not help if they don’t want to quit. 

Then I get out my calculator.  A pack of cigarettes is almost $10.00 here.  Two people each smoking a pack a day comes to a lot of money.

I talked to someone today whose consumption of soft drinks, moderate by Iowa standards, costs almost $5,000 yearly. 

Alcohol sales are technically illegal here, though possession is not, making the criminal status of marijuana and alcohol, properly, equivalent.

It’s Friday afternoon.  I have had an absolutely glorious week.  I can’t give the details of the clinical triumphs out of respect for patient privacy, but there were several.  I have learned to say yes, no, good morning, thank you, and hello in Inupiak; I also properly pronounced the name of the village Atkusuk (there’s a click in the middle).  I am not on call till Sunday, and then it’s only 12 hours and not during sleep time.  While I was writing this, the sun came out for the first time all week and cast a shadow stark enough to frighten a groundhog, and for a moment the world was dazzling in the brightness of sun on snow.

Against cholesterol hysteria

April 15, 2010

Ever since that class that I sat in

If  patients of mine start to fatten

Exercise

And diet I prize,

I don’t just reach for a statin.

At the Care Initiatives Hospice meeting this week we discussed a new patient.  Metastatic cancer, emphysema, and a massive stroke justified the patient’s terminal care.

“Well,” I said, “Let’s look at the med list…(Pause)…Is there any reason a person in their mid 90’s ought to be on a statin?”

The very next thing we sent a message to the attending physician asking, politely and respectfully, if it would be OK to stop the cholesterol lowering agent, seeing as how it would do nothing for comfort.

We haven’t heard back yet.

I don’t buy into the cholesterol hysteria.  (By way of background: cholesterol is a waxy substance, triglycerides are fats, just like olive oil or lard.)

After a lecture on the evils of high cholesterol in the early ‘80s a naysayer in the back of the room asked why changing the cholesterol doesn’t change all-cause mortality.  The lecturer, a nationally known figure, waited an embarrassed moment and then said that yes, for every one we save from heart attack and stroke we lose one from homicide, suicide, car accidents and respiratory infections, BUT…

The audience laughed, because the association sounded so improbable.  The same data came across the next year at the same education event and we laughed but not as hard, and the third year we didn’t even chuckle.  To this day we have dozens of studies that fail to show that cholesterol therapy lowers total death rate, but only a couple that show it does.

Before the statins (which are more properly called HMG co-A reductase inhibitors), my approach stayed pretty mainstream.  I’d check the thyroid, then I’d say, “Well, your cholesterol is high.  Eat less, exercise more, and come back in 3 to 6 months.”  Of course, half of them didn’t come back.  At the follow-up visit I would say either, “Look how well you’ve done, keep up the good work and come back in three to six months,” or “You really do need to eat less and exercise more, come back in three to six months.”  Once again, half wouldn’t come back.  Which meant that I didn’t have to treat a whole lot of high cholesterol.

After all, the guidelines say that lifestyle modification, mostly diet and exercise, remains the first line of treatment.

Cholesterol hysteria’s grain of truth lurks in diet and exercise.

Exercise can become its own reward, and you don’t have to wait for years to get the payoff.  Yes, it pays off in the long term, and it has to do with fewer fractures, less depression, sleeping better, delaying dementia, and a better sex life.

Obviously food tastes better when you’re a little hungry, and essentially any weight loss diet will leave you a little hungry.  Most people who overeat ignore rather than enjoy their food, and truly don’t realize how much they eating.

Few patients listen when I give them advice about weight loss, and the ones who do live longer, happier lives.

Nowadays I still check everyone’s thyroid and testosterone in men, but I also check vitamin D.  I still tell them about diet and exercise, but by now most of my patients know me pretty well and that advice hasn’t worked yet, and it’s not likely to in the future.  So I start people on fish oil and niacin.

I have many reasons to recommend fish oil, mostly to do with mental vigor and joint resilience, unless you’re going to surgery.

A well-known family practice lecturer asserts that any patient who takes a high enough dose of a statin for a long enough period of time will ache so badly they can’t exercise.  I agree.  Just recently I got an elderly patient out of the wheelchair and back walking by stopping that drug.

Still I live in the real world. Any physician who flies in the face of the standard of care risks law suits. So I prescribe statins when the other things fail, enthusiastically when the patient has known heart disease.  Unless the levels are very abnormal, I am ambivalent about treating the number, rather than the person.