Allergic

I chuckled as my patient explained that a highly respected, but recently retired local dermatologist once told him he was allergic to his own sweat. He has suffered for many years from many different skin disorders, including psoriasis, eczema, seborrheic keratosis. He even required excision and a skin graft for a squamous cell carcinoma of his groin. Now he was complaining of dry, itchy skin in both of his groins and around his anus. I recommended some ointment with zinc oxide in it.

I went to the hospital to make rounds. The patient I was seeing had a severe exacerbation of ulcerative colitis. This chronic inflammatory condition of the colon had been well controlled for two years with anti-inflammatory suppositories. When my patient fell ill with a virus that she caught from her daughter, she grew severely dehydrated from vomiting and the symptoms of her colitis flared. She had days and days of uncontrollable bloody diarrhea. Being a firm believer in alternative medicine, and convinced that her symptoms had been allayed for two years by herbal remedies and acupuncture, she drank Gatorade, swallowed vitamin supplements and refused to go to the hospital.

When she grew so weak she could not get out of bed, her husband called an ambulance and brought her to the Emergency Room. She was admitted to the medical service, resuscitated with IV fluids and started on high dose intravenous steroids. Her severe electrolyte imbalance was slowly corrected, but her diarrhea continued. Even after a week of steroids the inflamed lining of her colon forced out bloody, watery, mucoid stools seven to ten times a day. She grew weaker, afraid to eat. Her blood count dropped. Her legs swelled as her nutritional stores were depleted. She was incontinent, unable to get to her bedside commode to meet her explosive stools. She asked me to pray for her.

My partner tried to insert a central venous catheter into her subclavian vein so we could pour high protein, high calorie liquid nutrition into her system to try to make up for all the food she could not eat and all the fluids she was continually losing. His bedside attempt was unsuccessful. We relied on the interventional radiologists who were able to thread a catheter into place using fluoroscopy.

Now it was time to start talking about surgery. Because of the drastic nature of the surgery to correct this disorder, it is usually reserved for the most severe, life threatening cases. It would involve removing the entire colon and rectum, leaving her with either a permanent ileostomy, where the small intestine is brought to skin level and waste exits the body into a bag on the abdominal wall or a connection between her small intestine and her anus. Neither of these options would make her completely normal. Her stools would always be frequent and loose. Any lesser surgery would leave her at risk for persistent inflammation and cancer.

My patient was in better spirits as I entered the room. Not quite as weak, tolerating some soft, bland foods, perhaps seeing the prospect of surgery as a light at the end of the tunnel. She wondered out loud why this was happening to her, how all the herbal supplements, the vitamins, the acupuncture and her family’s prayers could have failed her.

I sat on the edge of her bed and began to explain, “It’s almost like you are allergic to your own stool…”

Overheard

("Rhetoric is heard," said Yeats. "Poetry is overheard.")

Dad

Love ~ George

Dad

My favorite person

The person who helps me battle

through the battles of baseball

He's the most honored and trustworthy person

of my very life

He teaches me the very things

in life's little mysteries

He helps me to the top

He is my person who will show me

the way through life

He is the person who

will protect me

He will lead me though life

He is the person that will make me happy

just the way I want it

and I will make him as happy

as he wants

Faith and the Faithful

“Your faith has saved you. Go in peace.” (Luke 7:50)

I suddenly felt myself in the middle of a Terry Schaivo case. I was asked to evaluate a patient for surgical insertion of a feeding tube. The gastroenterologist who called on me was a friend, who recently lost his mother to Pancreatic Cancer. He had tried unsuccessfully to place the tube percutaneously. The patient he needed me to evaluate was a young woman, 45 years old when she was first diagnosed with colon cancer five years ago. She had refused surgery at first, being of such faith as to want to leave things “in the Lord’s hands.” She finally agreed to surgery, which my associate performed, to uncover an advanced rectosigmoid colon cancer which had spread to multiple lymph nodes. He recommended she see a medical oncologist for further treatment. She refused any chemotherapy or radiation, wanting again to leave it in the Lord’s hands.

Now, five years later, she allowed herself to be admitted to the hospital, without an appetite, and unable to eat. There were two other people in her room, who introduced themselves as her husband and her sister. Each time I tried to speak directly to the patient they would call out, interrupt, ask me to be careful what I say, assure me that this patient was “at the end of her race,” although they were still “hoping for a miracle,” and seeking some way to provide her with the nutrition she needs. They complained about the medical doctor who had been assigned to her case, about the service and how paltry her meal trays were. They asked me about other surgical means of providing nutrition, central intravenous catheters and venous access ports. They even tried to take me aside to impart more of their insight into her plight when finally the patient called out, “Wait! I want to be in on this, please.”

Immediately I pressed to her side. Her face was gaunt, her cheeks hollow, her belly protuberant with a cancer—filled liver sitting like a loaf of bread at the upper part of her abdomen. I could see now why my GI friends had had such trouble placing a tube through the wall of her stomach. I wondered why they even had tried. She lapsed in and out of drowsy conversation. I asked her what she wanted, how she felt. She explained that her mouth was so dry, she could barely speak. I asked her to try to swallow, to try to eat. Her husband swabbed her mouth with a small blue sponge on a plastic stick . She said she would do her best. I told her I would, too.

I went out to the nurses’ station to write a note in the chart. I called my friend to tell him what I thought. I wrote in the chart that I did not believe that any further surgical intervention should be pursued. I reiterated that her prognosis was extremely poor. Her medical doctor had given her less than a month. I ordered her some high protein and calorie oral supplements in case she couldn’t tolerate anything else on her trays, and stressed that she should be kept as comfortable as possible and be seen by the hospice service. I inferred that she should be discharged home and allowed to die with dignity.

A beleaguered nurse (aren’t they all, lately?) approached me to find out what we were doing to her next. I explained my position, and she seemed relieved. “So, they are starting to get it?” she asked.

“No, I’m not really sure that they do.” I answered.

“Well, I’m not even sure who they are,” the nurse replied. She proceeded to describe the strange dynamic of her patient and her visitors. They had rearranged the bed and furniture in the hospital room so the patient would be facing a wall, where they had hung a large banner. I had noticed the banner and recognized the words as from the Bible’s Book of Psalms. I hadn’t noticed a picture, that the nurse described as strange and somewhat disturbing, although she had herself been raised in a Christian family she said it was not something she recognized as belonging to any particular Christian denomination. She said that the patient’s visitors were sometimes many and that they would stand around her bed and chant to heal her. The one woman who had introduced herself to me as the patient’s sister had even approached this nurse once and laid her fingers on her head and pushed her back with some force. She had questioned the nurse several times both about the patient’s food and her attending physician. Once, when the patient had refused to take a stool softener that was ordered, because she anticipated having trouble swallowing it, the visitor insisted that she need it and that the nurse should be more forceful with her patient.

The strangest part was a phone call this nurse received that morning. It was from a woman who introduced herself as a physician’s assistant and explained that she lived in California. The nurse said this woman was grief—stricken on the phone, sobbing that SHE was the patient’s sister and asked if “they” were there. When the nurse mentioned to the caller that her patient had many visitors, the caller sobbed some more and stated that “the Group” had not allowed her to communicate with her sister for many years, and that she had only just found out now that she was ill and that she was in the hospital. She said that she understood that according to HIPPA laws the nurse would not be allowed to discuss the patient’s condition with her, but she requested that if “they” were there, not even to mention that she had called.

I agreed with the nurse that this was truly an unusual situation and that the patient’s visitors were equally insistent with me. I told her how important it would be for her to continually remember who her patient was and to respect her wishes and anticipate her needs above all else. I closed the chart, left it with the unit clerk and headed for the elevator. I knew the nurse would try her best. I had faith that my patient would do her best. I believed I would, as well.

Medicine: "And the survey says..."

My husband answered a survey online last week that helped him realize how much he knew about fuel efficient driving habits and how his driving fit in with those around him. My brother answered a personality quiz that told him he was most like the character of the boa constrictor that swallowed an elephant in Antoine de Saint-Exupery’s The Little Prince.

Surveys are used in research and medicine all the time. I use questionnaires such as the Cleveland Clinic Constipation Score, the Fecal Incontinence Severity Index, and the Fecal Incontinence Quality of Life Survey to measure patients’ response to specific treatments and procedures. Market researchers use surveys to understand a product’s performance.

Any reader of women’s magazines such as Glamour or Cosmopolitan will tell you that we can use surveys and quizzes to learn more about ourselves as well. Who hasn’t glanced at results of quizzes on sex or relationships to see how they measure up?

March is Colorectal Cancer Awareness Month. Please visit the American Society of Colon and Rectal Surgeons’ website to take a quiz that could save your life. Let me know how you did!

Science: Tangled Bank

For an exciting glimpse into the latest and greatest blogging on science and medicine, check out the Tangled Bank #23, hosted by grrlscientist, on her blog Living the Scientific Life.

Medicine: Family History

A 61-year-old retired nurse came to see me in my office. She had an ascending colon cancer, and I scheduled her for a right hemicolectomy. The frightening thing was the circuitous route that she took to end up in my care. The only thing that had ever really bothered her was her knees. She retired several years ago to care for her husband, who died just last year from complications of diabetes. These last three years, spent mostly at her ailing husband’s bedside, she gained a tremendous amount of weight, and the arthritis in her knees grew worse and worse. Now, as a widow, trying hard to move on with her life, she was finding it difficult to get around at all. Her average 5 foot, 6 inch frame was no match for her 278 pound body. She consulted an orthopedic surgeon who recommended both knees be replaced.

In preparation for her knee operation, she was found to be anemic (low red blood cell count). The orthopedic surgeon started her on Procrit, a medicine to help boost her body’s ability to make fresh blood. Her internal medicine doctor insisted she have a workup to rule out any source of gastrointestinal blood loss, and sent her to a gastroenterologist. The gastroenterologist did an upper endoscopy and found some minor gastritis (stomach inflammation). The same day he did a colonoscopy and found her cancer. The gastroenterologist sent her to me.

I spoke with my patient’s family after her operation yesterday. I met her two sons, her daughter and son-in law. I explained how her size had made the operation more difficult, and how important it would be to have her up and out of bed as soon as possible. They thanked me for all the hard work, and for taking care of their mom, and explained that it was truly her knees that saved her. In the past ten years, her youngest son had had some benign polyps removed at colonoscopy, her daughter had polyps of a premalignant nature removed, and her older son had actually had a cancerous polyp removed endoscopically. Their mother, so busy caring for their father, had not gone for a colonoscopy in fifteen years, and never, never would have gone for one again if it had not been for her aching knees.

A family history of colorectal cancer is a serious risk factor for colorectal cancer. Your risk is higher when cancer occurs in primary relatives, which include your parents, your brothers and sisters, AND your children. For more information about colonoscopies, colon cancer screening, and what you can do to decrease your own risks of colorectal cancer, visit the ASCRS website.

Medicine: The Slide Show

One of my favorite uses for my digital camera is its ability to be connected to a television and play a slide show of all the pictures stored on the camera at that time. I availed myself of this feature on Tuesday night at my sister-in-law’s house, to give my mother-in-law, Joe’s sister’s, and their families a glimpse into our lives of late.
We sat and enjoyed images of our new house, clothed in the first snowfall of the season, a cat show that we took in at a local convention hall, a late Christmas present exchange we had with my side of the family upon my father’s return from a visit to the Philippines. Suddenly, the images changed. On my sister-in-law’s widescreen HDTV was a gruesome image: a fungating, friable, nearly obstructing rectal cancer.
I yelped an apology, jumped up from my seat and started fumbling with the buttons on my camera. Images, taken during a colonoscopy, which I had loaded onto my camera in preparation for a power point presentation I was going to give at Tumor Board conference, flashed on the giant screen behind me. My audience was mesmerized, and begged me to leave the pictures running.

Then came the questions:
Ø What is that yellow stuff?
Ø Which part is the cancer?
Ø How old is this patient?
Ø Is she going to live?

Clumsily at first, then with a confidence and clarity that must have come from giving a similar talk in November at our hospital’s Colorectal Cancer Symposium, knowing this patient’s history well, and dealing with colon and rectal cancer on a daily basis (now, it seemed, even when I was on vacation!), I answered their questions.
This patient is a 43 year old hairdresser from Poland who came to me for rectal bleeding. She smokes a pack of cigarettes a day, and spends most of her day on her feet, styling hair. She has no family history of colon cancer and assumed that the bleeding was from hemorrhoids.
I found the cancer on flexible sigmoidoscopy, in my office. The rectal ultrasound, which I also did in my office, showed how invasive the cancer was through the rectal wall, and that a lymph node in the area appeared suspicious for metastatic disease. Her CT scans showed some cysts on her ovaries, but no evidence of other organ involvement.
She is currently undergoing intensive chemotheraphy and radiation therapy, which I will follow in 6 – 8 weeks with her surgery, a low, anterior rectal resection. She will spend 5 days or so in the hospital after her surgery, and recover over the next two to three months at home. Her other doctors and I will watch her very closely for two to five years, looking for signs of distant spread or recurrence (return of the cancer). Once she is five years disease-free, her chance of recurrence is very slim.
My family was blown away. Not even the pictures of my adorable son at the vineyard that we stopped at on our way out that day could dampen the intensity of the story they just heard, the images they had just seen.
March is Colorectal Cancer Awareness Month. The word is out in my family. How about yours?

For more information about Colorectal Cancer Awareness Month, please visit:
Ø The American Society of Colon and Rectal Surgeons
Ø Preventcancer.org
Ø The National Colorectal Cancer Roundtable

Family: Brotherly Love

Is it at all possible to do so much? Is it possible to be a surgeon, a mother, a wife, a poet, a friend, AND A BLOGGER? Perhaps it is the thinness of the hour that feeds these fears, these doubts. Or the vastness of possibility in this newfound medium, so easy to set up, I'm set before I'm ready.

We drive to Philadelphia in the morning. To visit with my mother-in-law, recovering from treatment of a microscopically metastatic breast cancer. We all can't wait to see her, to touch the peach fuzz that must be growing back by now, to banter about social security and health insurance, to drag her to A.C., her old stomping ground, or back north with us to our still-new home, a house she helped us buy, yet hasn't been able to visit since last summer.

So I must post, with haste, my first post on my first blog. For in the morning we visit the City of Brotherly Love. Is it at all possible to do so much? I am grateful for the opportunity to try.