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Sun, 31 May 2009

Four Pills A Day

I was watching a rerun of Saturday Night Live not too long ago, featuring Steve Martin as the host. One of the sketches had Martin playing the title character, "Theodoric of York, Medieval Barber". A parade of people with various maladies were brought to him, and in each case, Theodoric impressed the crowd with his advanced knowledge of the healing arts: "Once we would have believed that this man's afflictions were caused by being cursed by a troll, or a witch. But now we know that it is instead caused by an imbalance of humors in the blood," for which the inevitable prescription was leeches and bloodletting. The audience roared as each hapless victim was led away to cut and bled.

A funny bit, but one that also got me thinking of the progress in medicine since Theodoric's day, and my own interactions with our health care system.

I should mention that in my family we do have something of a medical background: my mother was a Registered Nurse at a large Boston hospital, and my grandfather (mom's father) was a surgeon in the town in western Massachusetts where they lived. So if one could be somehow genetically predisposed to be favorably inclined towards doctors and medicine, I was certainly as good a candidate as any. But instead, for as long as I can remember, I loathed doctors and all things medical.

Even when I was very young, I found all these things distasteful -- often in the case of medicines, literally so. The various elixirs that were spooned into us were in no way meant to be palatable, except to the extent that they were not so vile that they would be regurgitated on the spot. I dreaded each and every spoonful.

I also managed to develop a healthy dislike for doctors. Again, from a very early age, what I mostly remember about going to the pediatrician (usually for my annual school physical) was that the visits would end with one or more immunizations, and I just did not tolerate getting shots very well. I cried and complained, and always asked Mom if I could get them "later", but that never worked. With Mom on one side of me, and the doctor closing in from the other, I would have to submit to the inevitable jabs and stings of the needles.

Eventually, I developed a kind of coping technique for shots and other kinds of painful procedures -- I would literally turn my head away from whatever spot was the intended target, and close my eyes, not wanting to watch the syringe approaching, preferring the surprise of actually getting stuck to the anxiety of seeing what was coming. This helped, but it did not completely alleviate my fears. The only thing I could think of that could possibly be worse than getting shots would be being admitted to a hospital and getting an IV stuck in my arm: the shot that doesn't end. The very notion of it filled me with dread. I resolved then and there (probably around age eight) that I would never let myself get sick enough to need hospitalization and an IV, that I'd rather tough it out with whatever my condition was than allow myself to be subjected to that.

We delight in thinking of ourselves as primarily rational beings, usually confident that in most cases, our thinking brains will predominate over our baser instincts. Yet sometimes, no matter how hard we try otherwise, we find ourselves taking counsel of our fears. Even at this early age, I was old enough to know that IVs could not possibly be so excruciatingly painful as I feared, and that thousands and thousands of people received them every day and managed to survive. So somewhere in the back of my mind, I knew that my feelings of fear didn't make much sense. But that didn't mean that I didn't believe them.

Around this same age, I developed a running series of ear infections, which, the doctors feared, might lead to permanent damage to my hearing if nothing was done. A long treatment with bitter, goopy antibiotic liquids weren't helping very much. Finally, Mom and Dad brought me to an EN&T specialist, and his conclusion was that I was suffering from tonsillitis, and that the chronic infection in my tonsils was migrating back up the tiny tubes that connect the middle ear to the back of the throat and giving me the recurring ear infections. His solution was simple -- those pesky tonsils of mine would have to come out. He would have some time available later that afternoon or evening, so why didn't we go across the street to the hospital and get me checked in right away? I wasn't really up to speed on exactly what was happening, and my parents didn't go out of their way to really explain it to me. All I knew was that, after some waiting while my parents filled out paperwork, we went across the street and had me admitted to the hospital; after getting me into my bed, my parents left me to whatever awaited me there.

The procedure itself wasn't so bad, although I do remember that, instead of being given general anesthesia administered by injection or by inhaling gas, a nurse held a filter paper cone above my nose and mouth, and dripped ether onto it from a small brown bottle. It smelled like gasoline, and I found it unpleasant and nauseating. (To this day, the slightest whiff of gasoline fumes when I'm filling the tank brings back memories of that day.) I also stupidly thought I could show how "tough" I was to all the doctors and nurses by not giving in to the dizzying effects of the ether and instead tried to fight the stuff as long as I could. All this meant was that I inhaled much more of the ether than normal, so that when the operation was over, I spent much of the night and a good part of the next day vomiting it all back up. I did not know that ether fumes not only went into your lungs, but would condense in your throat and be swallowed as well. But at least I had managed to avoid by worst hospital fear -- no IV was needed. (And I did score a pretty cool flying model plane from my parents when they finally checked me out and took me home, which eased my distress some.)

After the tonsillectomy, my major medical history entered a fairly long holding pattern. My fear of shots and IVs extended itself to an unwillingness to let our family dentist pull a tooth when I was ten -- those big pliers were even scarier to me than the hypodermic needles, but fortunately, we only had one confrontation like that, the rest of my teeth coming out due to natural causes (bubble gum, falling off my bike, getting punched in the mouth by my brother, etc.). I did suffer a couple of fractures of various bones, but these only required momentarily being maneuvered into awkward positions by the X-ray technician, and didn't require hospitalization. I also got my fair share of cuts which occasionally needed stitches. The stitches themselves weren't so bad, and I was able to put my turn head/close eyes technique to good use when they moved in with the shot of Novocaine before the stitching started.

Then, when I was approaching age 30, I had my first "serious, long term" encounter with the medical system, and the things I feared most about it.

It all started innocently enough. I had been feeling a little bit unwell for a few days -- tired, uncomfortable, what felt like a very mild fever using the back-of-the-hand-on-forehead measurement technique. I had been sticking it out at work, taking Tylenol every four hours, and expecting that, whatever this was, it would get better over the weekend when I had a chance to rest and recover. Instead, I got even more tired and achy. Things were so bad and I was so uncomfortable in bed that I got up in the middle of the night and went to lay down on the bathroom floor, because I thought it would help cool me off. Of course, my finance happened to come into the bathroom later that night and found me lying on the floor; to this day she it convinced that I "passed out" in there, although I know it was a quite deliberate decision on my part. In any case, we were off to the doctor the next day, and, after the requisite poking, prodding, and blood tests, it was determined that I had an "hot" (inflamed) appendix, and I would have to check in to the hospital to have it removed. It was just like the tonsils all over again, with no time for deliberation, and no other alternatives available. While I reassured myself with the thought that appendectomies were simple, straightforward procedures which left only small scars, I also knew that I was about to face my biggest medical fear.

After the usual bout of insurance paperwork at the admitting desk, I was eventually taken to my room, and started to receive the standard hospital prep work. Finally, after a couple of hours spent fooling myself into thinking that they had somehow forgotten, the nurse came in with a bag of saline solution and the requisite tubing. It was time to hook me up to my IV.

I explained to her that I had never had an IV before, and that she shouldn't be surprised that I didn't watch her install the thing. In turn, she offered to show me the equipment, and particularly to show me how the IV line worked, but I declined. All I wanted was to get this over with as quickly as possible. With her promise that after a while I would pretty much forget the IV was there, I turned my head and she began her task. There was the usual jabbing sensation as the needle went into the vein in the back of my hand, and it was unpleasantly unnerving that she had to muck around for a minute or two getting everything in place and taped down. But then she announced that everything was done, as she attached and hung the pouch of saline to the line that now fed into my hand. And truly enough, while I could not honestly say that I was able to forget that it was there, there was no real pain involved with having the IV running.

Early that evening, I was wheeled down to the operating room. Unlike my tonsillectomy twenty-some-odd years before, this time I would be getting anesthesia through my IV line, ether having been dispensed with as somewhat unhealthy for doctors and patients alike, as well as being a distinct fire hazard. Also this time I did not try to "fight" the anesthesia (remembering the bad effects of having done so from last time), but instead meekly closed my eyes after reaching something like 95 in the count backwards from 100, quietly slipping into a dreamless sleep.

I awoke in the recovery room feeling distinctly uncomfortable. There was a good deal of pain in my abdomen whenever I moved the slightest bit, and there seemed to be more tubes going in and out of me that were present when I came into the operating room. I talked briefly with the nurse, who said I was okay, and that I would be brought back to my room once I had thrown off the anesthesia completely. I drifted in and out of sleep until finally being wheeled back in the wee hours of the morning.

Later that morning, the doctor came by to check on me, and, now that I was fully awake, he explained to me what had happened. Not just inflamed, my appendix had swollen with infection to enormous size. Normally, he explained, an infected appendix would be about the size of your little finger. After making the initial incision, he could not even see all of mine. So he kept enlarging the incision, longer and longer, wider and wider. "It was the worst appendix I've ever seen in all my years as a surgeon," he explained. He said mine was as large as a hot dog, and, far worse, the end of it had already burst, allowing the infection to spread all over the inside of my abdomen. The team flushed my abdominal cavity with sterile solution several times, and then hooked up a pair of suction hoses to help pull out any remaining badness (which were still there, sucking away). He said that if I had waited much longer, there would have been nothing they could have done for me, and I almost certainly would have died of the massive infection. Fortunately, they got to me in time, and, while I would be in the hospital a while until the infection was gone, I was going to be okay. Besides the two drainage tubes, my incision (from my right hip nearly to my navel) was not stitched shut, and would instead be left to heal on its own. I had visions of my entrails spilling out of my not-yet-healed incision onto the bed, and I therefore resolved to move around as little as I possibly could.

And so began my battle with sepsis. At first, I had four other bags attached to my IV line, each with a different and potent antibiotic. I was getting the "full treatment", the most powerful medicines available to stop my infection. (The downside was, of course, that if they didn't work, there was nothing else that could be done for me. I didn't dwell too long on that prospect.)

I wound up spending nearly three weeks in the hospital before my infection was under control. I found out that some of these powerful antibiotics had uncomfortable side effects, that they were capable of causing painful inflammation of my veins. I learned to tolerate (but still never quite got used to) having blood drawn for testing twice a day, noticing that the skill and technique of the phlebotomist made a huge difference in how much discomfort was involved in the procedures. And I noticed that doctors have a tendency to speak in euphemisms when it comes to doing unpleasant things to their patients: "You may feel some discomfort," my doctor said, as he pulled out my drainage tubes (which had adhered to the sides of their holes); what this particular phrase actually meant was, "This is going to hurt quite a lot." Finally going home after three weeks, I had learned a great deal about the medical system and how it worked -- and I had learned that some of the things I had feared so much, like IVs, were, in retrospect, the very least of the things I should worry about when in the hospital.

Another ten years or so passed. I was getting regular, annual checkups, and everything was fine, until after one visit when my doctor finally said that my blood pressure was running a bit high. That was true enough -- my systolic pressure was always about 10-15 points higher than it should have been. I always attributed this to "white coat allergy", an anxiety reaction caused simply by being in the doctor's office. But it had been just high enough for long enough that he decided it was time to do something about it. At first we tried diet (not that hard to change -- cutting salt, mostly) and weight loss (harder for me), but when things didn't really change, he put me on a diuretic and an ACE inhibitor. These were the first two pills I would take every day for the rest of my life. But they had the desired effect -- my blood pressure came promptly back to normal, and has stayed there ever since.

My next major medical event turned up about two years ago. My annual physical included routine blood work, and my doctor noticed that by blood sugar level had been slowly climbing for several years. While still in the "high normal" range, the climbing trend concerned him, and we monitored things more closely. Quite abruptly one time, the readings jumped up out of the normal range, and the next test six months later came back higher still. Again, diet changes and exercise helped, bit not enough, and I added another pill to my daily regimen. And again, fortunately, my sugar levels quickly returned to normal and have stayed there since. So far I have managed to avoid any of the negative side effects associated with having diabetes, and expect that it should remain so as long as I can keep things under control.

Finally, a year or so ago, I heard a report that a study showed certain diabetes medications raised one's risk of having a heart attack. Even though the specific medication I was taking was not one specifically mentioned in the study, it was in the same general class of medicines, and I was concerned. I talked with my doctor, and we agreed that, while I would probably be okay in any case, it wouldn't hurt to take a child (81 mg) aspirin a day as a precaution against heart attack and stroke, which became the fourth pill of my daily regimen.

And so I reflect on my experiences with modern medicine, and all the good and bad things that have happened to me with it. What have I learned?

I've learned that childhood fears can be generally quite overblown. I've found out that the things I thought I needed to worry about turned out to not be important at all, and things that I hadn't paid much attention to turned out to be the most important after all.

A hundred years ago, conditions like diabetes usually meant a slow and lingering decline, its victims often often succumbing to some of the inevitable side effects. High blood pressure often resulted in a premature death due to heart attack or stroke. Certainly my ruptured appendix, before the age of modern antibiotics, would have meant almost certain death. All in all, I have enjoyed reasonably good health. I did have one serious brush with problems when I hadn't realized my appendix had burst, but other than that, I haven't had to deal with truly serious conditions like cancer or heart disease. In fact it's quite remarkable that my high blood pressure and diabetes can now be managed by nothing more than having to remember to swallow four pills a day.

Posted May 31, 2009 at 19:43 UTC, 3121 words,  [/richPermalink