Another clock and my father.

     On 1/24/13, I wrote a piece about a clock and its behavior in a family event. I always intended to tell here another story about a clock, time, and dying, that will go into our family lore. Here writing in January, 2014 is that other story.
     My father had the genetic curse that ran through his family -- a very low HDL (the good cholesterol) so that even though his total cholesterol or even bad cholesterol were not extremely high, his HDL was low. Even though they were not able to measure these levels in the past or provide medication to alter these bad actors, I am sure that many family members on his side of the family had this problem. His father and all of his father's 6 siblings died of heart disease in their 60s. And my great grandfather also died of heart disease as did his father my great great grandfather who died in his 50s.
     My father had had a myocardial infarction, a heart attack when he was in his 60s. Then over time, there apparently was further loss of heart muscle. When he was in his mid 70s he began to really feel short of breath, and he was having angina, ie chest pain with the least bit of activity. He had a catheterization and was found to have some blood vessels blocked. Though his cardiac output was down suggesting not good muscle function, he decided to take the doctors up on their offer of a bypass. We knew that this bypass would be more risky than the usual because his cardiac function was so low. But he still wanted to try it. The alternative would be to let the arteriosclerotic process go until he had another heart attack, which would mean more damage and he probably would not survive that heart attack. Surprisingly with the help of a pump assist to the heart he survived the surgery and the bypass circulation gave him another two years of relatively good quality life.
      But then gradually there was more damage, no big heart attack, but a slow deterioration in heart function. He became very short of breath, very fatigued, and unable to do much activity at all. His quality of life plummeted. Nowadays he might have been a candidate for a heart transplant but he was 78. That would not have been offered even today to a man at his age. He did receive a drug called dopamine intravenously for several days on several different occasions. This medication stimulates the heart muscle and he was able to have a few weeks each time of better quality of life. But finally he was hospitalized for the final time. He had developed complete heart block--a rhythm disturbance of the heart where the heart rate slows down so much that the heart can't do the pumping necessary to keep the brain alive. This occurred on a weekend and the cardiologist on call didn't know his case. Therefore as an emergency she had placed an external pacemaker. I headed to that hospital to provide whatever advise or decision making that would be needed.
      It happened that this had occurred on July 1. My father's birthday was July 4th and that day had always been very important to him. He always loved to celebrate and he always said that the whole United States celebrated his birthday. Just like that song, Yankee Doodle Dandy, he was "the real life nephew of his Uncle Sam, born on the 4th of July." So I felt even though we would not be putting in any permanent pacemaker because of Dad's poor quality of life which the pacemaker would not improve, perhaps it was fine that the temporary one had been placed. It might let him make it to his birthday.
     July 3rd came. All of the family had gathered at the hospital. But Dad had become worse. He was going in and out of consciousness. Even with the pacemaker, his heart was not functioning well at all. As the doctor daughter, I was trying to work with the nurse to regulate the morphine that he was needing for better comfort in breathing. My middle sister, herself a nurse, was basically almost collapsed in tears at his bedside.  It was getting into the afternoon. I spoke with my younger sister. We decided that we better celebrate his birthday right then and there. We drove to a nearby grocery store, purchased a birthday cake, paper plates, plastic utensils, candles, and balloons. As my father opened his eyes he looked at the round clock that hung on the wall at the foot of his bed in his room. I knew he was keeping track of the time. He was trying to make it to his birthday. But he was suffering and we were suffering with him. So during one spell when he lost his lucidity, we took the clock off the wall. We put the balloons where the clock had been. We pulled the room's shade. We lit the candles on the cake and served up some pieces on the paper plates. The next time Dad came to, we told him, "Happy Birthday, Dad. You made it to your birthday." We even each ate a bite of cake and gave him a little of it also. You could see him trying to see that clock and he looked toward the window. But it wasn't long and he lost consciousness again and this time he was able to let go. He died at about 8 PM on the eve of his birthday. Yes, we faked him out. But I think he would forgive us our little fake birthday party. Maybe he thought he could have made it, but we were all suffering so much with him that it was questionable if we would have made it. That was in 1995. He would have been 78 years old on July 4th of that year. We all still miss him. But we were all there to send him off with a birthday celebration. He had begun to talk about his wishes for his funeral. He said he wanted to be carried out of the church to a John Phillip Sousa march. We arranged that. And some of the organ interludes included an organ version of "Yankee Doodle Dandy."
      

Medical benefits: the Didgeridoo

My fine instrument -- the didgeridoo
 

  Who would have thought it? This week I attended the Medical Grand Rounds at CSM, the hospital where I practiced. The topic of the lecture was: Sleep Apnea: a Complete Look at Advanced Diagnosis and Treatment.

       The speaker, a pulmonologist who specializes in sleep medicine, sited that learning to play the didgeridoo using what is called circular breathing actually can help people with sleep apnea and can decrease the number of sleep apnea episodes. Now I haven't read this article from the British Medical Journal, but I assume this would really only help those who have fairly mild sleep apnea. It is presumed that this activity helps by strengthening the muscles that support the tissues of the throat and that surround the airway, letting those muscles work to keep the airway open better during sleep.

An ethical dilemma? Measles vaccine or not?

     Andrew Wakefield is a former British surgeon and medical researcher who published articles which he said related Measles vaccine as a cause of a new form of inflammatory bowel disease he called autistic enterocolitis. Medically there is not such a disease recognized. He also said that the MMR (Measles, Mumps, and Rubella) vaccine may have caused autism in children who received it. There is absolutely no evidence that such is case. Multiple blinded medical studies have been done and there is no evidence of any kind of a causative relationship. Others have suggested that the mercury (thimerosol) used in some vaccines as a preservative and antiseptic could be toxic to infants and might play a role in causing autism. Again multiple studies have been done looking for such a connection. None was found. Now thimerosol is only used in tiny amounts in influenza vaccine. It is not used in an other vaccines that are given routinely to children
     Multiple lawsuits have been filed in all directions. Dr. Wakefield's article which was found to have tampered with results, unethical recruitment of study patients, invasive and harmful tests performed on study patients without approval of ethics committee among other more minor but still significant problems with the data. There was even evidence suggesting that Dr. Wakefield was paid by a legal group to produce this article, that he had applied for a patent for a single Measles vaccine which he stood to make money from should MMR become suspect and be withdrawn, and also a test kit for this supposed new form of inflammatory bowel disease.      .

     Wakefield's conclusions were broadcast in the media worldwide and resulted in fear of children's vaccines and a drop off of the vaccination rates. It is estimated that MMR vaccination rates in Britain dropped from 92% to 73% in the late 1990s after Wakefield's press conference raising the concerns about MMR which he raised in his article in Lancet, the British medical journal. The effect was less in the US but it is still estimated that as many as 125,000 children born in the late 1990s in the US also were not vaccinated due to this scare. Many children therefore got sick and some died from complications of measles. The lawsuits have subsided. Lancet retracted the article and 10 of the 12 coauthors of the original Lancet article withdrew their support for the conclusions. Wakefield left England after losing his medical license to practice there. He is still trying to do research in the US and is still claiming that his research was honest, that there was no deceitful data changes and that there is still a reason to be concerned about the MMR. He still has a small group that supports his conclusions. But the greater medical and scientific community agrees that he is a fraud and there is absolutely nothing to fear with MMR and a bowel disease or autism or any developmental behavioral problems.
     What does all this mean for society? How can one man and at best a very bad medical study, at worst a completely fraudulent publication perpetrated in order to make money have such a broad effect on medical care world over? I recall a few years ago when my grandson started daycare, my daughter in law was concerned. She knew there were some parents of children at the daycare who were not vaccinating their children because of just these fears. She then had concerns about her own infant who would be at this daycare and subjected to exposure to these children and their possible illnesses before our grandson's own vaccinations would have had a chance to take effect. It does become a personal issue when a family member might be involved. This is sort of like the Ponzi scheme of medicine. It doesn't affect people's wealth but instead may affect children's lives. It is true that every area of human endeavor has its bad people who don't care about doing harm to others, whose self interest outweighs any concern for others. However, it is particularly heinous when that person is in the field of medicine. People generally tend to trust their own doctor and by inference the medical profession at large. They would normally believe these allegations coming from a researcher and printed in a prestigious journal like Lancet. Of course, they would react with fear concerning their own children. The legal system and the medical self policing system (British Medical Council, Lancet) and the media itself have more or less shown Wakefield for what he is, but there are still concerned parents out there who don't know the whole story and still wonder. What else could we have done? We are limited in a free and just society in order to protect the rights of the innocent. But I sometimes wonder if the rights of the fraudulent and the criminal are protected too strongly in our Western democracies. What do you think? Send me some comments. Let's get this comment section going!

The Aesclepion, Bergama, Turkey

     Two posts ago you learned what an Aesclepion is. If you missed that post: http://renraeretire.blogspot.com/2011/07/medical-symbol-confusions-cadusis.html
I can show you an Aesclepion first hand. We visited Bergama while traveling in Turkey. In that modern city are the ruins of the ancient city of Pergamon, and in that ancient city is one of the largest if not the largest Aesclepion in the world. This is a fascinating place in Turkey, that was a total surprise to me. Since returning home, I have learned more and found this history even more fascinating.


A drawing of the way the Aesclepion appeared in 2nd century AD.



The Hippocratic Oath and the White Coat Ceremony

    Has anyone ever wondered what exactly your doctor has sworn to do? Did he take the Hippocratic Oath? And if he/she did, what exactly is the Hippocratic Oath?

     Well, here are several versions ranging from the original to a much more modern one which has been changed to reflect how medicine is practiced today.

Medical Symbol Confusions: Caduceus versus Staff of Asclepius

    Many posts ago (11/10/10 -- Obituary Tells a Story http://renraeretire.blogspot.com/2010/11/obituary-tells-story.html), I promised you an explanation of the origin of the symbol of Medicine, the Caduceus. There is only one problem: I had the Caduceus mixed up with another symbol, the Staff of Asclepius which is the true symbol of Medicine. So if a doctor doesn't even know the symbol of her own profession, I thought that this might be an opportunity for education, as I educate myself. 

                                                                               
                                                                                 OR

     Which is the symbol of medical care? Confused. Don't feel bad. I am a doctor and I didn't know the answer. I have certainly seen the first used to symbolize different forms of medical care, but had only a vague recollection of seeing the second symbol. The origin and use of these two symbols is quite interesting. Like most things that are very old, their story is long and convoluted, and many beliefs contribute to what is now accepted in the modern world.

Physical Therapy

     As my readers can see, I have not posted a new article for over a month. Yet I am looking over the new flags that made hits on my website and also where some of these viewers came from. I feel I owe you a posting, so I decided to write a little about why I have been delinquent.

     I have been accessing the medical profession again from the consumer side of the desk. My elbow has been continuing to have daily pain from my melanoma surgery. I have had various types of strange pains starting about 2 weeks after the surgery. At first it was, I think, a nerve pain with hyperesthesias (extreme sensitivity to normal touch) over the area, and allodynia, which is accentuated pain from stimuli over the area. I saw a physical therapist at the Hand Clinic at the Medical College of Wisconsin. But she really didn't have much to suggest and showed me a couple exercises to try to stretch the nerves, and slapped some corticosteroids cream on the site and gave me an ultrasound treatment. But she said she was not allowed to get the ultrasound head very close to the relatively new incision so she couldn't really get to the area that was bothering. Even so I found the vibration of the ultrasound to be very annoying, accentuating the pain.

     This was very similar to therapy years ago for my knee and mostly what was done was modalities ie ultrasound, and electrical stimulation. That time zapping my quadriceps muscles with electrical stimulus while I was voluntarily contracting them was I thought extreme torture. And I did not complete that session. My knee slowly got better on its own.

     Since my pain is persisting and some of that hyperesthesia is better, but now I am having deep pain with motion and with hanging my arm down, I have decided to try therapy again. It is after all three months since my surgery. A friend from my Spirit Mind Body group gave me a name of a therapist at the Sports Therapy clinic near my home. After the first visit with him, I was very optimistic. I now think there are therapists and then there are therapists. He was great, treating my whole body, found some things that I didn't know could cause me trouble. Very thorough. and astute at picking up on what I told him about the nature of my pain. He found a lot of tightness in my neck and shoulder, and at the acromioclavicular joint in the shoulder. He also said I was lacking about 40% motion when turning my head toward the surgical arm. He said one of my vertebrae was turned on the other because of that muscle tension. so he took it upon himself to strengthen this out and release those tight muscles. Just with the first two sessions I was felling somewhat better in the arm.

     But then he started working on my surgical site and that elbow. He was probably too vigorous that first time. Within a day or two I began to recognize the pain; it was no longer strange or a stranger to me. I now had lateral epicondylitis, or tennis elbow. Somehow all that manipulation of the elbow had centered the pain and inflammation right on that lateral epicondyle. I had experienced tennis elbow before from playing tennis, but this one was created with the help of a surgeon and a physical therapist and it was a wing-dinger. But at least I knew what to do for this. I purchased a fresh new tennis elbow band and wearing it brought some relief. I have been wearing it much of the time since. My physical therapist was bummed out that he had caused a lateral epicondylitis, and stayed away from the elbow until about my 7th or 8th session. He continued to work on my neck and shoulder girdle. He is good, he identifies the muscles and performs maneuvers and asks me to move certain ways against resistance while he is isolating those muscles. My grip strength is lagging and seems to have plateaued at about 30% down from normal. We are able to record increases in neck range of motion, and arm range of motion after these sessions.  But then the next session, I have lost all that range of motion and everything is all tightened up again.  I have learned that therapy is an example of the cliche: Two steps forward, one step backwards. In fact it may sometimes be one step forward, two steps backward. Once I seemed to get a flare up of the arm pain after attending an Imax movie -- looking up. Once when I seemed to have moved backwards, the therapist took a history of my activities and we decided it might be me working a lot on my laptop, writing blogs and, -- I admit it, playing solitaire, or mahjong on line. So I have limited my computer time or else tried to steal the desktop machine which is more ergonomic from my husband, which is not always easy. So, indeed, you have not seen any blogs for a whole month.

     I am still occasionally taking steps backwards. I went to water aerobics on Saturday and had a different and very young teacher. Of course, the moves were different because of the different teacher and she did a lot of arm work with buoys in the water. I stopped using my bad arm about 2/3 of the way through when I saw this, and I iced it after, but still I was pretty sore the next day. My therapist says I must stay positive, so I will try. Thank goodness for tennis elbow bands! And I will get better; I know it. It is just a slow process.

     In the middle of this whole therapy thing, I did go back to see the plastic surgeon who operated on my arm. First let me go against rules and generalize that I think many surgeons (my son excepted) do not deal well with postoperative pain, particularly the pain that is different or more than expected.  He was not very interested in the neuropathic pain I was reporting to him when I returned to get the sutures out. This 3 month follow up was just as disappointing. He really didn't address the location, nature or degree of my pain. He put his finger on a spot on my forearm which was slightly tender, and brought up a diagnosis that I had never even heard of, called a radial tunnel syndrome, and he suggested I was creating it by wearing my tennis elbow band too tightly. He also criticized my therapist implying he was treating me appropriately.  He was otherwise showing off for the medical student that was with him. He also was critical of the report that my oncologist had sent him because she had decided that the total depth of my melanoma was only 0.48 mm which is very superficial. This depth would probably not justify as wide an excision as I had and would not justify a sentinel node biopsy. So he told me that we still do not know the depth. He still said we can't be sure and add up the depths, which of course would be 0.48 mm and 0 since nothing was found in the wide excision specimen. Just to make sure his student knew the degree of surgery was justified, he told me that we still had to be paranoid about this melanoma, that it could come back. Then he said,"Now, if you ask me do I think it has spread, I would say 'No.' but I do think we will never know the depth of this lesion, so I would class it as more advanced class of tumor than your oncologist did." OK, that's going to make me feel good and confident. Needless to say, I found this appointment very disappointing.

     In an unrelated experience, I wanted to write another tale of a medical interaction. Amazingly, my husband had a nevus removed from the bottom of his foot about a week after I had my melanoma surgery. A dermatologist in my clinic had been watching this lesion on the bottom of hubby's foot for about 6 months and just could not live with it there anymore. He was going to do a very shallow biopsy of it, but knowing how my depth was disturbed by the shave biopsy, my husband insisted that at least 1 mm of tissue be removed in the biopsy. The dermatologist said he was uncomfortable about doing this and so wanted to send my husband to a surgeon. He called me into the exam room to explain this to both my husband and me at the same time. But then he began speaking to me about my amelanotic melanoma. He related that he made the same "mistake" that my dermatologist made and shave biopsied an amelanotic melanoma on a young woman. He felt bad about this, but then he said: "But it really didn't matter, because her melanoma had already metastasized and she died of a brain met." Yes, he said that to me and I was still wearing the big bandage on my arm from having my melanoma removed. This was an example of the doctor talking with the doctor and his being unable to view me as a patient. He was in truth not very sensitive to the situation. I told this story to my water aerobic lady buddies, and they thought it was terrible. They wanted to know his name, but I refused to give it to them, because this dermatologitst was a good doctor. He was just having trouble telling between the patient and the doctor.

Bathroom Wars

     The proverbial war of the toilet seat up or down goes on.
      Our war has some extras that add fuel to the fire. Our large house has 5 bathrooms, 3 of them downstairs where we live most of the time. The one that is part of the master bedroom suite has always more or less been mine so I would usually find the toilet seat down. My husband when he got up to go at night would usually walk to the other end of the house and use the back powder room near the laundry. I don't know why he always walked so far--maybe because he usually left that seat up and so it was ready for him. There is the guest powderroom that is right outside his bedroom door, but that one is special. It contains my Kohler :Wildflowers of the Prairie pedestal sink. Also both of us got in the habit of not flushing because we didn't want to wake the other person, but then we would forget the next day and this is not good for the porcelain toilet bowl or for the welcoming odor of the home. Finally we both agreed to flush even at the risk of waking the spouse. But this still leaves us with the "seat up or down" battle.
     As time as gone on and we have both aged, various things have happened to our bladder musculature. My husband has had prostate issues and subsequent radiation treatment that leaves him with nocturia (medical term for getting up at night to urinate too often). He may also have some urgency, I don't know. (Term that means you have to rush to urinate to avoid an accident). I have definite urgency to a significant degree and perhaps some degree of overactive bladder in addition to the sinking musculature that contributes to this. Both of these factors in the two of us sometimes necessitate us using the other's designated bathrooms. For example, I come home and have that urgency the minute I step in the door that leads me to use the back powder room near the laundry. Hence, seat stays down on husband's bathroom. My husband again avoiding the "special" guest powder room , uses the one in the master suite. Hence I find the seat up and I am having urgency. Those few seconds needed to put the seat down in the middle of the night might be all it takes to prompt an accident. Neither one of us have commented to each other about these issues because they are beneath civilized conversation in the living room or over coffee in the morning.
     What do we do? Write Ann Landers? I think she is no longer doing a column. I think her sister is, but should either of us communicate with her? See our respective doctors and medicate ourselves further than we already are medicated? I for one don't want any more medication. Wear one of the several brands of panty liners and/or with time a Depends type of product? I have already tried the former and it helps, but I doubt I could get my husband to do this. Anyway how would this help under dire circumstances? What should we do, just let it rip? Fill the product, so to speak. Seems rather uncouth, don't you think? I did do some research on the Internet on this issue. Some suggestions for toilet bowl etiquette suggested that both parties lower the seat and the lid each time. Then both parties would be equal when they approach the toilet bowl and can choose which way they want the set up. Each would be subject to the same delay -- certainly an equitable solution. There is also the question of closing that lid on germs and just the general site of the open toilet while washing your hands or brushing your teeth. Before we have company, I always go around and close all the toilet lids, so there is something in me that thinks the closed seat and lid is more esthetic.

     To add further analysis to this question access the following website. You will see an analysis on work units starting with two different schemes pertaining to the position of the toilet seat after use. Convincingly there is less work if the toilet seat is simply left in the position in which it is found. But the level of kindness to the female is at least perceived to be higher if the seat is left down even though it takes more work units to accomplish this. Access this website to see the statistical analysis: funny!  http://www.speech.sri.com/people/anand/toiletseat/index.h  Or google toilet seat up or down etiquette and you will find this site listed.

     I guess after my husband's encounter with prostate neoplasm and mine with melanoma, the urgency and nocturia problems as medical problems go are rather diminutive. Just another sign of aging and another deficiency to deal with. Maybe some day there will be a toilet seat reader that reads an implanted chip on the butt of the urinator and automatically raises or lowers the lid. Wouldn't that be something?

Post surgical stories

     I have to write one more story about my little surgical/medical excursion with melanoma. And there is a chance for you to tell me about your surgical pain experiences. Below is a neuropathic pain scale to use to assess your own pain levels at various times of the day. This might be useful to your medical care team. Read on below to learn more about my experiences and medical studies that sometimes document poor postsurgical pain control.