creepy cat

(Sunday, July 29: Updated with NEJM link)

This was just too odd to pass up. My father raised my siblings and me with what’s best described as an unhealthy sense of skepticism. Such unwillingness to ever suspend disbelief might make for being a good scientist but I’ve seen that over application can result in a somewhat annoying human. I often find I want to believe…but I’m always held back by skepticism, usually right from the outset. So on reading this story (excerpted below), my tendency is toward the assumption of a non-causal or at least not directly causal relationship between death and the cat.

I think that the article does a reasonably good job of keeping the report on the up and up though. Most likely because the doctors referenced in the article do.

When death comes calling, so does Oscar the cat

PROVIDENCE, Rhode Island (AP) — Oscar the cat seems to have an uncanny knack for predicting when nursing home patients are going to die, by curling up next to them during their final hours.

His accuracy, observed in 25 cases, has led the staff to call family members once he has chosen someone. It usually means the patient has less than four hours to live.

“He doesn’t make too many mistakes. He seems to understand when patients are about to die,” Dr. David Dosa said in an interview. He describes the phenomenon in a poignant essay in Thursday’s issue of the New England Journal of Medicine.

pain in the ass

I read an interesting post over at Musings of a Dinosaur called Drug Seeking in Primary Care. In it, the writer discusses encounters with different types of pain med seeking patients. He makes an excellent distinction between “the patient legitimately seeking to form a new doctor-patient relationship for management of a chronic condition requiring controlled substances” and what are traditionally called “drug seekers” (but which more properly could be called “drug scamming addicts”).

While looking over the responses to his post, I came across Cathy’s Place, and her recent post describing a visit to her doctor’s office where they had recently hung a sign in reception stating “Do Not Ask for Pain Medication”. Cathy’s initial response to the sign is similar to what I think I myself would experience were I to find myself face to face with such a notice. Reading her post made me consider how pain has been handled in my medical history.

Here’s a patient perspective on just some of the problems presented by “drug seekers” (that is the “drug scamming addicts” kind). They take up time and resources which should more appropriately be used for patients who have a legitimate medical complaint or concern. Their habits, narcotic and interpersonal, can serve to establish or confirm any underlying health care provider approach of doubt or suspicion of patient complaints and patient interactions. In short, their behavior creates risks for compromised care of all patients.

But Cathy’s post raises an interesting point. Given the acknowledged dangers (for providers and patients alike) of creating or feeding a narcotic addiction, it seems the general tendency would be towards caution – either zero tolerance type caution of a type the “Do Not Ask for Pain Meds” sign suggests or sensible discretionary caution, as seems to be described on Musings, where long term pain medication can be approved but only in limited circumstances, such as when a continuing, confirmed painful condition cannot be otherwise treated. And yet this is not the case. Not by Cathy’s experience and certainly not by mine.

My own recent experiences with this come from both outpatient and ER care. I’ll go with the ER one first.

I have migraines, had them since I was in my 20s. They had been mostly menstrual, and I had been taking Frova in what is apparently an off label manner premenstrually to keep them at bay. Last summer, they changed in frequency coming any old time of the month and sticking around for days. I made an appointment to see the doctor for a reassessment, and he increased the frequency of the medication. Then they changed in character. In addition to the photophobia and over sensitivity to sound, I had tingling in part of one hand, near blindness in one visual field of one eye, some creepy cognitive changes, and one episode of vomiting. I took my migraine meds and rested, waiting. It seemed to abate some a few hours later, so I got up and started making dinner. The usual dull rotten feeling of the pain came back and brought with it a novel sensation of a series of sharp lancing pains in the occipital/temporal area which were so intense they left me gasping for breath. I went to the ER. I went because I have the misfortune to have studied stroke patient case histories in my grad neuropsych courses, I’m over 35, I smoke, and I have a family history of cerebral vascular disease. Hence, I felt the smart thing to do was to make sure this wasn’t something worse than a migraine.

In the ER, I got an IV, and antiemetic, and an offer of pain meds. They offered morphine I think, but remembering something about this possibly raising intracranial pressure, I asked for something else. I can’t remember what they gave me, not morphine but possibly also not something which was a non-narcotic. What I didn’t get was any imaging, which I found a little troubling.

Then there’s the GI doctor. Good old fired GI guy. I came to his service under one of his colleagues after diarrhea and post-prandial intestinal cramping cost me about 20 pounds in less than a year. For a while, levsin and loperamide got the symptoms controlled enough that I was finally digesting the food I ate, regaining weight, and not in so much pain. Then the symptoms started getting worse again. I started losing weight. I went for a re-evaluation and ended up with the now fired GI guy. Fired GI guy’s response was to prescribe Ultram. “Isn’t that addictive?” I asked. “Oh no” he assured me.

Meanwhile, he worked me up as if I were a 50 year old man and found nothing which would explain the symptoms. Had I remained under his care and his recommendations, I would have been taking Ultram for the pain, a higher dose of loperamide and levsin for the the diarrhea and apparently quite rapid transit of food through my gut, something else for the nausea that I inevitably had when on a higher dose of levsin and loperamide, and possibly another drug for to increase my appetite so I would want to eat more even if eating anything caused pain and nausea.

Now to me, these treatment plans and decisions don’t sound like they come from people who are worried about perhaps unnecessarily creating a drug seeker. The ER doc? How about a head CT? I know at the weetiny-ville community hospital I went to that night they may not have been able to do an MRI that night, but a CT could have happened. Instead I got “treat it and beat it”. The GI doctor never took into account that endometriosis might have been causing or exacerbating an underlying irritable bowel. Rather than allowing himself to think of my whole body (or even proximal organs) in an attempt to find (and treat) a probable cause for the symptoms, he retreated to a diagnosis where the only option is to treat the symptoms.

In both of these cases, I went in looking for answers, looking for identification either to rule out something terrible or to ultimately (hopefully) treat of the cause of the symptoms. In both cases, happy drugs were the only answer I was offered. Sometimes the only choice is between the lesser of two harms – harming someone by allowing chronic pain to go unchecked or harming someone by making them dependent on a narcotic. This choice should be a last resort, one weighed only when other means or options have genuinely failed.

What I’m realizing in thinking about these cases in the context of the drug seeking patient issue is that too many times I’ve not had the assistance of doctors in ensuring that we’ve exhausted the other options. I’ve managed to skirt treatment which could result in my being labeled as or in my becoming a drug seeker (in the nicer or less nice sense) only by being a total pain in the ass – that is only by insisting on a higher standard of practice than these doctors were willing or able to give.

Puss

As the in house linguistics major, I was sometimes called upon for word and language references when I worked as a unit secretary. My least favorite was the time a nurse asked me to use my extremely out of practice Italian to communicate with one of our frequent fliers who spoke nearly no English. “Hai dolore al petto?” I asked tentatively (and, I think, incorrectly), only to be rewarded with his barrage of fluent Italian, of which I caught about every fourth word. I felt totally unhelpful and we were none the wiser for the nurse’s having recruited me in her efforts to communicate with her patient.

But my all time favorite was puss – or more specifically – the adjectival form of that word. On more that one occasion I was fed the line which began “How do you spell…” And I would answer merrily “Exactly how you hope it isn’t spelled.”

I asked my mother about this one time. Without batting an eye, she rattled off “p-u-r-u-l-e-n-t”. Damned English major RNs.

diurese this

I noticed two recent hits on this blog from people looking for the same topic. I mean exactly the same. Both were referred from Google searches for what the lay person’s term for diuretic is. Two different IP addresses even. How odd. I find myself wondering if someone referred to a diuretic in a House rerun or something.

Anyhow, since two hits count as a significant portion of the site’s traffic, and since I’m a sucker for language, I’m giving my vote on this one. I’m going with “water pill”. It’s delightfully old fashioned, isn’t it? Sort of like “the vapors“.

I feel…

Not so great at the moment. I’ve got a substantive post in the works, but for now we’ll just go with a fun YouTube.

They say laughter is the best medicine, right?

“you can tell me”

with coffee spoons

The Spoon Theory by Christine Miserandino is an excellent, I mean truly excellent essay about “what it’s like to live with sickness or disability”. While reading it, I thought of T.S. Eliot’s Prufrock measuring out life with coffee spoons.

The essay is linked through But you Don’t Look Sick, (oh another great name) which I just discovered was founded by Ms. Miserandino. Well done Ms. Miserandino!

For anyone who is interested in knowing what it is like to live without the luxury of good health in a world which presumes all are well (or well enough), I offer more words from the poet as advice. Do not ask what is it. Let us go and make our visit. Read the essay.

medical record

When my former primary was leaving her practice, I was told there wouldn’t be a charge for my record if I decided to go to another office for primary care.

Today I was told that the people who took over the practice (Mr. and Mrs. Doctor) do intend to charge me to obtain a copy of my medical record.

I questioned the fee Mr. Doctor wanted to assess and was told this is what Mr. Doctor charges for copies of “his” notes.

Prior to this, I’ve only ever had one doctor’s office charge me for copies of records and that was the unbelievably jerky guy I saw for a couple of months back in 2002/2003 (the one who assumed I thought I had “chronic Lyme”).

While the cost is less than a buck a page, which sure doesn’t sound like much, little charges add up when you’re as broke as I am (I make $125 a week right now. In the Fall, if I’m lucky, that’ll go up to about $250 a week).

On a whim, I looked up cost, medical record, my state name, and law. It took very little time to find out that although it’s perfectly legal for a provider to charge fees to cover the cost of copying and paper, there’s a cap on the amount which can be charged to a patient. This varies by state, but in CT it is 30% less than what Mr. Doctor is asking.

From Georgetown University’s Center on Medical Records Rights and Privacy – Connecticut

And from the source itself, CT statute – Title 20, Chapter 369, Section 20-7c

my new favorite t-shirt

I had been thinking of making one myself. Tonight I did a quick search and found the folks at the California Lyme Disease Association have gone and done it for me. I hope they don’t mind my uploading a picture of their “Ticks Suck” t-shirt.

How great is that? I’ll tell ya how great. It’s super great with great big sprinkles on top. I love creative education/awareness tools. I still have a PSA in the works for my local radio station (hoping to find someone to do a spanish version too), and now I’m planning on getting me one of these snappy t-shirts as well. And maybe some as Christmas presents for a few of the many folks I know who have or had Lyme.

Oh yeah, and one for my advisor, who has had to live with MY Lyme Disease and the effects of it on my progress as her PhD student. I went from having two very productive years which resulted in contributing to 3 publications, and now I’m barely inching my way towards a dissertation proposal draft.

blogging nurse(s)

Celtic Rose at First Do No Harm examines the issue of “Patient vs Client” in an excellent post.
I work in the ICU, these are not clients, these are not customers, they have not chosen to be here. They would give anything NOT to be here.