Posts Tagged ‘steroids’

When the surgeon advises no surgery

March 1, 2018

From Galveston we drove in the rain

To discuss a tumor of brain.

To our great relief

And we love the belief

That surgery would be in vain.  

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. I’m taking some time off after a month of part-time (48 hours per week) work in northern Iowa. Right now we’re in Texas visiting our married daughter, her husband and their new baby. Any identifiable patient information has been included with permission.

MD Andersen could lay claim to the title of America’s Premier Cancer Hospital. The exam room at the Brain and Spine Center on the 7th floor of Building 3 held more than a century of education.

I have had 27 years of formal education; my wife has 20 years of schooling including a bachelor’s, a master’s, a year for her Certified Medical Assistant, and another for advanced educator training; our oldest daughter, a Family Physician in her own right, has 23 years. The two neurosurgeons have at least 27 years each.  Including Anya, our 12 day old granddaughter, the average number of years in school came to 21.

But the two neurosurgeons spoke directly to the patient, my wife Bethany. A routine MRI in the summer of 2016 found a meningioma, a non-malignant thumb-sized brain tumor growing out of the floor of the skull just behind the left eye.  She had radiation therapy that August and has remained symptom free since.

But follow-up MRI in Sioux City showed mistiness suggesting possible tumor growth, and we came to Houston for another opinion about proposed treatment.

Actually, we came to Texas to visit the new grandchild. Jesse arranged for a consultation and drove us through the pouring South Texas rain, up from Galveston.

I listened in while the neurosurgeons explained the findings on the scans. The tumor itself shows a clear-cut outline or capsule; the haziness around it does not connect with the meningioma proper, and probably represents radiation necrosis, that is, death of brain tissue from the radiotherapy.

To our great relief, they strongly recommended against surgery, and prescribed a quartet of drugs: steroids to take down inflammation, Vitamin E as an antioxidant, pentoxifylline to make the blood less viscous, and pantaprazole to prevent an ulcer from the steroids.

We all felt relief flood the room. And I’m sure little Anya, who knows nothing cognitively but stays locked to her mother’s emotions, felt it too.

I had my work calendar cleared out because of worst case scenarios. That night, while thunder rolled over the Gulf of Mexico, Bethany I and snuggled in the darkness and talked about Where To Go Next.



Croup treatment has and hasn’t changed

December 21, 2017

With a cough like the bark of a seal
And the kiddy so good doesn’t feel
There’s no way to avoid
A dose of steroid
Croup must be treated with zeal.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.
I had cause to contemplate how things do and don’t change in medicine. Consider, for example, croup. If a virus swells a child’s narrow airway, a barking cough, much like a seal asking for a fish, follows. Death can ensue if the airway narrows to the point of closing, or if the child stops breathing out of exhaustion.
The pediatric ward in the hospital where I did my residency had two outdated features for treating croup when I arrived.
One consisted of a tiled room that could be filled with water vapor; a large cloud chamber that could sleep 8. During my tenure its only use was storage.
But the spacious balcony on the other side of the nurses’ station told a different story. It had sliding glass doors and space for 6 cribs. In a bad croup year, the nurses bundled the children up, to sleep with their faces uncovered in the cold, dry Wyoming air.
It worked for most of the kids, and I still recommend that strategy, saying, “Now if the spasm of croup doesn’t clear in 3 breaths you’re already headed to the ER.”
Treatments have come and gone and come back. Antibiotics, we found, did no good. Theophylline (a close cousin of caffeine, and found in pharmacologic amounts in chocolate) helped, but not much, and had a lot of side effects so has since been completely displaced by the albuterol (in Canada, salbutamol) updraft.
Every winter, during the peak croup season, I’d ask my pediatrician friends if we’d gotten anything new for croup, and every winter they’d shake their heads.
We used to use inhaled adrenaline (also called epinephrine). It has come and gone in five year cycles. A year and a half ago I thought for sure that I’d never use it again when I heard a study showed it did no better than inhaling saline (salt water).
We used steroids a lot and stopped for a while in the 90s, started again just before the millennium, and continue to this day. Controversy remains regarding dose, and method of administration.
But croup has changed. The really, really bad version, where the epiglottis (the flap valve between the airway and the swallow tube) swells has disappeared with modern immunizations for diphtheria and Hemophilus influenza. And with the decreasing smoking rates we don’t see nearly as much as we used to.
I had cause to research croup treatment recently, finding, to my surprise, that all my internet sources recommend inhaled epinephrine and steroids. Just like 1982.

Six clinical triumphs and a tornado

March 17, 2017

I had me a wonderful day

I was keeping the blindness at bay

And I helped stop the shakes

Oh, the difference it makes!

To start steroids without a delay.

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I can’t write about particular patients but I can write about clinical trends.

Sometimes I suspect Parkinson’s in the first 60 seconds after I meet a patient. I note a shuffling gait with arms that don’t swing, a face with limited movement, and a quiet voice lacking in music.  After the patient finishes their concerns,  I ask about shrinking handwriting size and loss of sense of smell.  Then, if the patient lacks the characteristic resting tremor, I’ll hold the patient’s hand.  If I feel the muscles between the thumb and forefinger quivering, I strongly suspect the disease.

No single sign or symptom serves as a gold standard. Without a lab test for Parkinson’s, the diagnosis frequently relies on response to the medication Sinemet, (levodopa and carbidopa).

Parkinson’s always progresses, but the rate varies. No matter what stage I find the patient in, I tell them that we have no medication that will slow disease progression, but we have a whole sequence of drugs for the symptoms.  Most elect to try the meds, a few don’t.

I love seeing a person in the hour or two after their first Sinemet dose, especially if I find the family close at hand. It really deserves the term, awakening, the title of the Oliver Sachs book and Robin Williams movie about the development of the drug.

I have picked up more than one case per week here.

I’m also finding an inordinate number of people with polymyalgia rheumatica (PMR), also called giant cell arteritis or temporal arteritis. For unknown reasons, worse with advancing age, occasionally a person’s body will attack the arterial lining with very large immune cells.  As a result, people feel terrible, lose strength in their shoulders and hips, and get severe morning stiffness lasting more than an hour.  The symptoms can sneak up over the course of months, or ambush over the course of days.  I ask if their jaw gets tired while chewing.  I feel the arteries over the temples; once in a while I feel hot, ropey spots on the scalp, where the blood vessel pulses .  We use two non-specific blood tests, the C-reactive protein (CRP) and the erythrocyte sedimentation rate (sed rate or ESR), which help make the diagnosis.  The conclusive test is the temporal artery biopsy, but only if it’s positive, which it never is.

Blindness ranks as the most feared complication of the untreated PMR; the artery that supplies the retina can clot off. Thus if I have strong suspicion I start steroid therapy promptly.  A quick response helps make the diagnosis.

Last Tuesday I had the wonderful experience of seeing more than one Parkinson’s patient and more than one PMR patient in their initial positive response to therapy.   Bethany picked me up at the hospital, and in the time it took for me to walk out the front door and get into the car the sky darkened so fast that the street lights came on.  As we drove to the gym I started to recount my day full of successes, but halfway there our phones interrupted with the announcement of a tornado warning.  We continued on, but the noise of the hail drowned out my words.  Three blocks later we arrived at the gym just as the tornado sirens started.

We sat on a bench inside and watched the vacant pool while I finished recounting my 6 clinical triumphs in one day.

Hearing loss and moose hunt

October 15, 2016

There’s a ringing I have in my ears

I sure hope that it clears

Perhaps on its own

Or with prednisone

For deafness is one of my fears

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

We first spotted the moose on a hill about 170 yards from the lakeshore. He moved just before I pulled the trigger.  The guide started to call, and the moose came to us, his antlers swinging at the level of the boreal forest tree tops.

With my crosshairs on the bull’s sternum, I pulled the trigger when the distance closed to 60 yards, and my ears started to ring.

Age-related hearing loss runs in my family. My mother and her mother needed hearing aids before they reached my age.  But neither of them stood in front of the drummer playing sax for an R and B band, hung out in discos, nor had anything to do with firearms.  I could still hear bats at the age of 26, but the highs gradually faded.  I started hunting in my 30’s and after the first few years of firearms use I got conscientious about hearing protection.  Later I bought occlusive hearing aids with a limiter circuit, so I could hear a pheasant taking off or a deer approaching, but nothing louder than 85 db would transmit to my ears.  The devices worked fine hunting pheasants in January.

But they failed to protect my ears from the blast of a 7mm Remington Magnum.

The death of an animal, even a mouse in a trap, always hits me spiritually. I have never killed a moose before, and when he crumpled he left a palpable hole in my universe.

When the moose stopped moving I found my hearing had fled.

Over the next couple of days my hearing improved. As soon as I got home I contacted the audiologist.  He found I’d lost 20 db on the left and 10 on the right.   He adjusted my hearing aids and talked to me about vitamins.

Luckily, I’d already ordered an electronic stethoscope.

The next day I went for acupuncture. But on a physician’s social media site, I posted a question about treatment for acute noise-induced hearing loss.  More than one doc said it served me right for killing such a majestic creature, a thought I had already had.  But a few mentioned steroids.

I never self-prescribe; I called my ENT, and I started steroids today.

I hope they work. I’m not done listening.

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.

Three critical patients and two planes

June 17, 2010

By now I really should know

If a morning is starting out slow

     I won’t get a break

     To finish my steak

Working nine hours in a row.

Euphoria opened my morning.

My stack of lab results started with a hypothyroid, a hyperthyroid, and a testosterone deficiency.

The thyroid gland is mainspring of the time clock at the plant: it tells the whole show how fast to run.  Thus most hyperthyroid patients can’t sleep, can’t tolerate heat, and lose weight.  Hypothyroid patients may gain or lose weight, but they can’t stand cold and they can’t get going in the morning.  Both conditions lead to lack of energy.

Thyroid problems are very gratifying to treat; I get to save the patient’s life for pennies a day and make him or her feel better.

Testosterone deficiency is much more expensive to treat, but the patient always feels better.

Morning walk-in and emergency clinic was slow and enjoyable but I was the only doc there.

A call from an outlying village elicited my advice to send the patient by commercial plane to Barrow but the patient didn’t arrive till after six.

I got to go to lunch early but I was called back to an emergency just as I was sitting down.  I bolted part of my lunch and threw the rest away. 

The afternoon waxed progressively frantic.  

In Barrow as in Sioux City infidelity leads to divorce, and divorce leads to health problems rippling through the family.  People come to me with ailments, and I can prescribe things like amoxicillin and hot soaks, nicotine and alcohol cessation.  To ease the real pain all I have are the ability to listen and words of wisdom. 

At quarter to six I realized that if I didn’t get to the cafeteria I’d miss supper and I was already ravenous.  I scurried down the hall and grabbed a Styrofoam box with what would have been a decent steak.  I bolted the cookies on the way back to ER.  Over the next three hours I managed to whittle away half the steak, a third of the potato, and all the vegetables.

I dealt with three life threatening situations at the same time.  A patient in town had developed a sudden compromise of a major organ system.  The patient from the outlying village had arrived with alarming physical findings.  A different village called in with information about a potentially salvageable patient. 

With three patients to transport and two planes I had to prioritize.  The in-town patient ranked highest; the outlying patient whom I had never seen got a plane directly to Anchorage.

I called Alaska Native Medical Center (ANMC) about the patient who had flown in at six.  The proper doc on call dialogued with me; with the recommended whomping dose of steroids the patient improved enough to keep in Barrow for the night.

Each Medevac transport south costs between $30,000 and $80,000 and as a result involves a number of hoops that must be jumped through. 

Two of my colleagues came through while I jumped through hoops and organized data; one because of call and one to be supportive.  The cozy outpatient area hummed with activity: two Medevac transporters, three docs, three nurses, a pharmacist, an X-ray tech, two patients with a total of six relatives, and a medical records tech.

I got back to the apartment at nine, put the steak fragment in the fridge and got out my saxophone.  I worked thirteen hours, the last nine without a break.

What had started off slow and clear and solo finished frantic and ambiguous and supported.

Contrast is still  the essence of meaning.

Almost dead on a Friday afternoon

March 20, 2010

When a fictional patient had died

I worried, I paced, and I sighed.

     The little white spheroids

     Were pills that were steroids

The adrenals had shriveled inside.

Flash back to 1979, when, fresh out of medical school, I was studying for the Boards.

Back then there were no computer based learning programs; an “interactive” program involved using a disclosing highlighter on pulp paper. The name of the book was Clinical Simulations; it gave a clinical scenario, and a series of decision choices. At each decision point I would use the supplied highlighter and printed information would appear where blank space had been, directing me to turn to a new page.

The hypothetical patient, a fifty-four year white female with rheumatoid arthritis, took some “white pills” she got in Mexico for her joint pains, but she came in with right lower quadrant pain suggestive of appendicitis. I asked for more information and found out she smoked, she drank, and worked as a highly paid executive. Labs came through that looked OK, and I continued leafing through the book. I picked the page that let me order IV fluids and send the patient to surgery. As I ran the felt tip yellow marker across the page I read Your patient dies on the operating table. I dropped the marker and the book in shock.

At the time I had little clinical experience and no clinical confidence. A week later I discussed the case with my father, a cardiologist. He didn’t seem at all surprised. He talked about steroid dependency and the need for steroid support when people get sick.

Fast forward to yesterday.

Friday afternoons are always chaotic in doctors’ offices. People getting sick try to get in before the weekend, and I don’t blame them. But people who work in the office also would like to have a long weekend, and frequently the place runs short-staffed. For a long time I have tried to maintain a policy of not scheduling any appointments for Friday afternoon before the switchboard opens on Friday morning. Especially with a crowded schedule, I’ve tried to keep slots open for established patients, and not take new patients on Fridays. As a short timer, with weeks left in my tenure, I shouldn’t get any of the new patients.

Especially not on Friday afternoon.

Yesterday I walked cheerfully into the exam room to greet a new patient, and a relative, for the first time. The two together were a family fragment, a piece away from the context. The problem was cough.

In short order I’d found out about the colon cancer and the ileostomy as well. The patient confirmed status as ex-smoker, and I ordered a chest x-ray. The films showed the battlefield where lung tissue had fought a losing battle against smoke for a very long time.

“Your chest x-ray looks very bad,” I said. “Have you ever been told you have emphysema?”

The patient said yes. I started writing orders for antibiotics and steroids, at the same time I reviewed the medication list. I stopped in mid-prescription. “Why do you take Florinef?” I asked.

One adrenal gland wasn’t functioning when the other one was removed because of a benign tumor.

I clicked on the Vital Signs section and found a blood pressure of 60/40. “Are you feeling OK?” I asked.

The patient felt light-headed and dizzy.

I vividly remembered the yellow highlighter on the grey paper and the words Your patient dies on the operating table. I opened the door and asked my nurse to call the ambulance, and I turned back to the patient and relative. “Your adrenal glands,” I said, “Make steroids like cortisone.” They already knew that. “When you get sick,” I continued, “you have to have more steroids to keep your blood pressure up. If you don’t have adrenal glands to make more steroids your blood pressure can go so low you can die. And right now your blood pressure is dangerously low.”

(President Kennedy had Addison’s disease, where the adrenal glands fail slowly, and by the time he died he had no cortisone of his own manufacture. Back then treatment included injections of testosterone, which puts the Cuban Missile Crisis into a different perspective.)

The nurse came in to ask about what to tell the ambulance. I asked, “What injectable steroids do we have here?”

“Depomedrol and Kenalog,” she said.

“As soon as you can, give forty of Kenalog IM,” I said. “Please.”

I took out my cell phone and called Mercy’s ER to connect to a doctor I’ve known for a decade. I explained the situation, essentially an Addisonian crisis. I apologized that the best steroid I could lay my hands on, on a right now basis, was Kenalog, not the best choice but would hopefully keep the patient alive till the ambulance could get her across town. The doc accepted the transfer.

I’ve never had a patient in an Addisonian crisis before.

The patient and relative asked about continuing care after the hospitalization.  I told them the briefest version of my upcoming departure.  They expressed disappointment.

When the ambulance pulled away I apologized to other patients for my lateness.  I was too busy to breathe a sigh of relief.