To treat… or not.

My dad was diagnosed with prostate cancer on his 82nd birthday. I expected it when his PSA test started increasing. He had a biopsy.  I couldn’t attend the appointment for the results but asked my mom to make sure she found out his Gleason score. When she called me on his birthday, I heard it in her voice before she said the words.
Cancer.
It’s considered an intermediate- risk tumor.  There is no metastasis. But given his advanced age and other co-morbidities, namely the Alzheimer’s, surgery is not recommended.
At his age, hormone therapy and radiation is recommended. Without treatment, he has perhaps 10 years.  But that means the tumor will get larger, he’ll have more lower urinary tract symptoms of obstruction and likely bone pain from metastasis.   Radiation is not easy.  It involves daily trips to the hospital for weeks;  20-39 radiation visits. That’s 20-39 days that my mother has to drive him to and from hospital and pay exhorbitant fees in parking. My mom went through  radiation treatment for her own breast cancer 15 years ago. She still remembers how hard that was on her. How difficult now will this be on my dad? He asks her several times a day what the next doctor’s appointment is for. Because he forgets. How difficult will this be for my mom to take him to the hospital day in and day out,  in his already semi-frail and de-conditioned state?  Is it cruel to put him through treatment? Is it cruel not to?
After meeting with his radiation oncologist and learning about a new treatment protocol involving only 5 weekly visits for radiation therapy, it looks like we will be embarking on treatment for my dad.  He seems to understand the side effects of treatment and that it means weekly visits to the hospital.  Of course, he’ll ask many times why he’s going but that is okay for now.  Five weekly visits is going to be much easier for my mom.  If and when it gets to be too much, we’ll make a decision to stop.  But for now, he/we are going to fight this.

Let’s Talk

January 25 is Bell Let’s Talk Day.

One day a year the world comes together to help end the stigma of mental illness.

One day a year, a large corporation donates $0.05 for every tweet and hashtag that says “#BellLetsTalk” towards funding mental illness.

Meanwhile the province I live in is underfunding mental health across the board.  I can’t get a delusional/psychotic patient timely access to a psychiatrist without sending him to the ER or placing him on a Form 1 (ie involuntary 3 day hold).  I can’t get the chronically depressed and suicidal middle-aged woman a psychiatrist to follow her and manage her 3 psychotropic medications.

So yeah, let’s talk about mental illness.

Why don’t psychiatrists actually do what they are trained to do?  Why don’t they follow patients and see those that need weekly psychotherapy? Why doesn’t the Government adequately fund mental health?

How about we talk about mental illness every day of the year and not just one day?

Let’s talk.

The Grim Reaper

December is not a good month to be a family doctor, or any doctor for that matter. I have lost count the number of bad diagnoses I have had to give before Christmas.  What an incredibly shitty way to end a year.

“I’m so sorry to have to tell you this, but that lump in your groin is lymphoma.” 

“The biopsy has confirmed it’s malignant melanoma.

“Unfortunately, your baby stopped growing around 9 weeks of pregnancy.” 

“The lump in your breast is suspicious for cancer.” 

January is sometimes even worse. Who wants to start a new year with bad news?  

Every year I feel like I’m back here lamenting the fact that it’s supposed to be a magical time of year, these “holidays”, and I’m forced to give more people more bad news.  Can’t I just have one year where everyone is healthy? Is that really too much to ask for?

Physician Heal Thy Parent

I was up at the crack of dawn this morning (what else is new?) but this time to take my dad to a specialist appointment. We are the first ones here, even before the receptionist!

Since I have taken over this role of being present at most of my parents’ various specialist appointments, I have come to enjoy watching another physician do a physical examination. It’s a great refresher for me, especially the neurological exam. This was my nemesis in medical school. It is probably the most complex sequence of tests and observations I have ever had to learn and I still feel like I never mastered it.

Today I witnessed a skilled clinical fellow perform a thorough neurological examination on my dad.

I knew everything she was doing and why.  There were tests I had forgotten about, ones that are very specific and others more general.  At the end of the 3 hour appointment, we had some answers and now a few hours later, I have nothing but questions.

I need time to process. I know the road ahead of us. I’ve seen patients and their families go through it.  It’s not what I wanted for my parents, least of all my father.

But this is life.  It is hard. It is ugly. It is rewarding. It is love.

 

Facing the Void

My brother and I had a long talk the other day about our parents.  He has positioned himself to be their power of attorney for finances and I am their power of attorney for personal care.  In the past year, it has become evident that we may need to start exercising our roles.   I can’t tell you how sad that makes me.

Growing up, my father was larger than life. He was a tall, formidable man with a deep voice but he was for all intents and purposes, a gentle giant.

Over the past year or so he’s become impatient, occasionally verbally aggressive toward my mom and is forgetting things.  He was diagnosed with mild cognitive impairment last fall but his condition seems to have deteriorated in the last 3 months.  He has a much shorter fuse now and asks my mom to repeat things several times a day.  He denies feeling depressed but we all think he is. Thankfully his family doctor suggested a trial of a low dose antidepressant and he actually agreed.  

He will be having an brain scan soon. I fear it will be normal.  Why? Because the thought of watching him continue down the road of dementia is heartbreaking. It would frankly be much easier if he was diagnosed with a brain tumor. I don’t think I could bear the day he forgets his grandchildren and then me. I don’t think I can watch him become aggressive and angry and frightened at his memory loss.  I see it already happening with my maternal grandmother. 

And there’s the kicker: dementia on both sides of my family? What does that mean for my brother and me? Are we destined for the same end?

We talked about all of it. Dad won’t want to go into a nursing home when the time comes. Will I have to have him declared  incompetent and take over as POA?  If dad moves into a nursing home, mom won’t be able to stay in the condo; will she live with me or my brother or alone in an apartment?  How long are we going to have to watch him deteriorate? He would never want to live like that. I certainly wouldn’t. 

I fear the road ahead. 

No Breaks.

Day 28. National Blog Posting Month

I am actually looking forward to the weekend. It has been a hellish week at work (see my earlier posts).  I’ve been insanely busy with appointments and double bookings and it seems like everyone’s lab tests are abnormal. I was supposed to have a meeting with my colleagues at dinner last night but I felt unwell all day and had to cancel.  I thought the stomach virus was coming back but I think I just needed some sleep. So this colleague and I have not actually spoken about the issue that came up this week and rather than hang around this afternoon to do so, I am going to get the hell out of here while I still can.  I have no one booked this afternoon, so I am finally going to get home before 6pm which is so nice for a change.

I got to work this morning thrilled that no one was booked after 1 pm and dug in to clear my inbox. And that’s when I found out a patient (60 years old) has had a 20+ point drop in their hemoglobin over the past six months. This patient has other serious problems, a degenerative neurological disease, and really doesn’t need me to call and tell him he’s now anemic and we have to find out why.

For those not in the know – a significant drop in hemoglobin, the molecule in the blood that carries oxygen and is a marker of the bleeding status of a patient, in an individual over the age of 50 is a red flag for a gastrointestinal malignancy until proven otherwise.  This patient has not had any overt bleeding events in the past 6 months.  The bowel pattern has changed but was being blamed by the medications used to treat his neurological condition.  This patient has been declining rapidly with respect to his neurological status but now I can’t help but think there was something going on all along this past year that we are only just now seeing.  Could this patient have cancer?  I fear the answer may very well be yes.

And why the hell does this have to happen on a Friday and a month before Christmas?

Really? What the F—!?

 

 

 

F is for Cancer…. as in .. FUUUUUK, it’s cancer.

I saw my colleague’s patient the other day as I was covering her practice for a few days. It’s haunted me ever since. She was diagnosed with a bladder infection last week and I got the culture report back just before the weekend. I had to change her antibiotics. I spoke to the patient on the phone and told her if she still wasn’t better after the weekend to come to see me.

Well she did. While the bladder symptoms appeared to be improving she also mentioned how light-headed and dizzy she was and “oh yeah, by the way, I’ve lost about 10 lbs in the past month.”

Fuck.

I looked through her chart at her recent blood tests. Hemoglobin was normal but compared to 2 years ago, there’s been a 20+ point drop.

Fuuck.

Upon further review of her chart, I noted a family history of colon cancer in her mother and stomach cancer in her father. Both deceased.

Fuuuck.

Oh and she repeatedly refused to be screened with colonoscopy or fecal occult blood testing.

Fu—-

You get the drift.

She’s got cancer and it could have been caught early with a simple screening test.

Higgledy Piggledy

Higgledy piggledy
Wiggledy wump,
I met a man
Who caught a mump:
With his left cheek lumpy
And his right cheek bumpy –
Higgledy piggledy
Wiggledy wump.

Higgledy piggledy
Sniggledy sneezle,
I met a man
Who caught a measle:
With his chest all dots
And his face all spots –
Higgledgy piggledy
Sniggledy sneezle.
– Alligator Pie, Dennis Lee, 1939

I read this book to the kids the other night.  My daughter loves the illustrations and this one in particular.  She asked me what a mump and measle was.  I explained that they were illnesses caused by germs (viruses) but that most of us don’t get them anymore because of vaccines. She kind of understands what vaccines are, I explained how it’s a needle that she gets that protects her from illnesses like the one described in the story.  She seemed satisfied with that, so we continued reading the book.

But my mind stayed on Higgledy Piggledy, primarily because of the news recently.  There have been outbreaks of measles in a few Canadian cities, mostly in communities where the vaccination rates are frighteningly low.  In the nation’s capital, Ottawa, a young boy contracted measles after returning from the Philippines, a trip he took with his parents.  The child wasn’t vaccinated.  Upon returning home, he became ill and went to not one, not two, but three different walk-in clinics (including an emergency room) before getting diagnosed. Meanwhile, the child was infecting his classmates at school, not to mention a potentially vulnerable population in the ER.  Within a few weeks, another four cases were confirmed.  Another outbreak is also happening in British Columbia.

I’ve written a lot about vaccines.  I’m not going to belabor the point, I believe vaccines work and I believe they are safe.  I don’t believe they cause autism and I believe that, in the end, after all is said and done, vaccines save lives.

Back in 1939, Dennis Lee was born. Decades later he wrote a poem about mumps and measles.  He likely had the illnesses as a child.  He probably recovered.  Not everyone he knew would have been that lucky.

Please vaccinate your children.

A Frightening Trend.

Day 12. This is actually a lot easier than I thought it would be, writing a post everyday.  I actually look forward to it!

And, yes, I’m back, despite my little rant yesterday, which in case you missed it, you can read here.

What’s on my mind today?  Vaccines.  I know, I know, it’s a volatile topic and I’ve discussed it before, but you see, the baby is 8 weeks old today (my goodness, when did that happen?) and he will be going for his first set of vaccinations next week. For me, it’s a no-brainer that he will be vaccinated.  All of my kids were vaccinated.  I didn’t even give it a second thought.  Now, that’s probably because I am a physician and a rational, logical human being.  Okay, that last part was a bit of a dig.  I am just so sick and tired of parents thinking that just because they’ve done their “research” on vaccines (ie. have read about Wakefield, everything that Jenny McCarthy has to say on the subject, and discussed it with their “friends” on countless message boards), does not mean that they understand the science and study behind creating a vaccine.  These parents haven’t seen the devastation that Polio caused, they haven’t seen what congenital Rubella syndrome looks like, nor have they had to tell their son that they may never be able to father children because the Mumps caused orchitis and has the potential to limit his fertility. And let’s not forget the risks of meningitis from certain strains of pneumococcal pneumonia, Measles, and rarely, chicken pox.

I was a resident in family medicine working on the Pediatric ward when a 15 month old girl was admitted with seizures.  She had been diagnosed with pneumonia 2 days earlier.  Blood cultures revealed a particular strain of bacterial pneumonia.  This strain is one that is covered by a vaccination available here, called Prevnar-13.  A review of this child’s medical records showed that her parents declined all vaccinations.  The seizures were eventually controlled, she was diagnosed with encephalitis and a few weeks later was found to be completely deaf.  Totally preventable had she only been vaccinated as an infant.

At least once every few weeks I see a news article about an outbreak of a vaccine-preventable illness.

It’s becoming so common these days, it’s actually starting to scare me a little bit.  If we continue down this path of non-vaccination, herd immunity is going to fail.  We will see the resurgence of illnesses we haven’t seen in twenty or thirty years.  I have never seen a case of measles but I’m sure one day, at this rate, I will.

What’s next?  A North American outbreak of Polio?

100!

I was saving this, my 100th post, for my 2 year blogging anniversary which is on the 12th of September, but I couldn’t wait.

I am 11 days from my booked delivery date.  I have 6 working days left, and yesterday, I, together with a specialist, mutually agreed that our patient could not travel on her European vacation with an obstructed biliary tract from a probable pancreatic tumor.

This is my 3rd maternity leave and I just wanted to leave my practice with no new ominous diagnoses.  Is that really too much to ask? Right before my first leave, a lovely 50-something woman was diagnosed with a pancreatic tumor.  Right before my 2nd leave, a 50-something man was diagnosed with a particularly aggressive prostate tumor, and now, right before my 3rd leave, a 70-something woman is being worked up for pancreatic cancer.

As I mentioned in previous posts,  I have a wonderful physician who will be covering my practice, but it feels awful leaving these people when they need their family doctor the most.  I especially like this 70-something woman as she reminds me a lot of my own mother.  Her husband is wonderful as well and if his wife does have pancreatic cancer it is going to destroy him – he all but told me that at his most recent visit for an unrelated matter.  My heart broke for him.  He really wanted this trip, but he knows full well how bad it might be if she does have cancer.  I wish I hadn’t been a part of taking that away from him. I wish I could be present for them as they navigate through the health care system.  I hope I see her next spring when I return.