MRI
CT
Oncologists at X Cancer Treatment Center –Dr A, Dr B, Dr C
Neuro surgeons from Y Hospital—Dr D, Dr, E
Radiologists from the X Center and Y Center—Dr F, X Center; Dr G, Y Center.
Sunday, 11/14/10, rounds with doctors at Y Hospital neurosurgery section
Dr E, the staff neurosurgeon with Y Hospital, changed prescriptions for anti seizure medication from Dilantin and Lyrica and a third drug to Lyrica only, increased dosage and changed over anti inflammation drug Decadron to pill form rather than intravenous insertion thru Tunie’s portal. The portal had been plugged at the beginning of the day but was finally cleaned out by the staff nurse by mid afternoon. E changed to oral administration on the next shot cycle in prep for her being discharged. He said, based on his visits Saturday and Sunday that Tunie had made progress, did not need her brain wave activity tested, and was ready to be discharged whenever the oncologist released her.
Tunie was disturbed by the changes in Lyrica although she was still recovering from the effects of her brain problems on Friday and largely unable to express herself. �Her concerns were over the impact Lyrica had on her ability to function. Lyrica tended to make her drowsy most of her waking hours and interacted with her metabolism to increase her weight. The medication had been prescribed by Dr H, a physical therapist, as a pain reliever when she was getting rehabilitation for a shoulder operation in 2008.
Tunie was washing in the restroom when E came in and she tried questioning him while standing in the doorway.� He tried to let her get through her issues but, when she was not able to verbalize her concerns quickly, after ten minutes he said he had to leave.
Dr A, the oncologist from the X Center, the center that treated Tunie with chemotherapy and chest radiation in conjunction with the chemotherapy as well as with full brain preventive radiation subsequent to the other treatments, visited later Sunday morning and said she would not be released until Monday at the earliest until they could see how she was tolerating the oral Decadron since she had indicated an allergy to steroids, among which Decadron is classified. He indicated Decadron had been being administered in combination with an over the counter antacid since steroids aggravate the stomach. He said he could not change E’s call for changes in the meds. He said it was the neurosurgeon’s call and not the oncologist’s to prescribe brain medications. �
When Tunie’s mother Pat came in Sunday afternoon, she was upset that the medications had been changed and wanted them re instated. I told her I would not bring Tunie’s medications from home, that she would have to see if the doctor would change them. Pat asked the day nurse to contact the doctor and call her back. Whatever contact was made with him, Dr E did not call back. �
On Sunday, Dr A had said he thought Dr D, the neurosurgeon who had been part of the Y team that had performed the stereotactic radiosurgery on Tunie �on Wednesday, 11/10/10, would see her Monday morning �
Monday morning rounds
Dr B, an oncologist practicing with the X Center, visited about 7:30 a.m. He sat and spoke with us for some time about how Tunie was progressing, about her concerns over Lyrica, and about being discharged. He said it would be upto Dr D to determine when Tunie should be discharged. He asked if the changes in meds had caused her any problems. Tunie said she had not noticed any. (All the information reported here from Tunie is gathered from her halting, difficult, stammering, hesitant recall and not a constant, bright, staccato response to questioning. A good deal of her replies had to be inferred and guessed based on prior experience with her.)
Dr B said the meds could be changed back if Tunie felt any adverse affect. She seemed relieved and satisfied about Dr B’s assurances.
When Dr E visited prior to 9 a.m., he sat for a few minutes, again checked how Tunie was doing from their exchanges, said she was making progress and that, as he wrote in her medical record on Sunday, she was ready to be released on authority of Dr A, the admitting doctor from the X Center. When I asked if Dr D would be visiting Tunie, he said that was out of Dr D’s territory, that he did not make hospital visits.
When I told Dr E about Tunie walking the halls with her intravenous tree and how quickly her energy and her speech dissipated and how she bumped into the wall with the tree regularly, he said that was to be expected with the operation and the disease, that her recovery curve was short duration and would go in spurts, not maintain a consistent level for any length of time.
When Dr E was explaining how Tunie’s problem developed on Friday, he said it was a result of brain inflammation either from the operation or from the nearness of the operation to the area in the brain that controlled speech. He said one of the lesions was very close to her speech center and the operation could have done damage or the lesion could have impacted her brain.
The interesting sidelight to his comment was his partner Dr D did not like the process at Y Center and had at first recommended a different procedure at a facility in Coral Gables, FL.. He said he preferred Gamma Knife surgery because it was faster, more accurate, and more reliable. Both Drs F and G said they had worked with both procedures at M D Anderson in Houston and they were equally well regarded, that it was a matter of choice—although Y Center had only one choice available. �
After E left, I talked with the nurse about getting with the doctors so someone would decide who would release Tunie. She said she would make a note in the records for the doctors to let us know.
Tunie’s mother, Pat, called later in the morning to report a conversation she’d had while on a visit with her family doctor.� Dr I told her he had never heard that Lyrica was an anti seizure drug. �One of them went to Pfizer, the drug manufacturer’s website and it did not indicate Lyrica was an anti-seizure medication. Pat asked me to contact Dr C, Tunie’s primary oncologist, to make him aware of the changes by Dr E and to get his opinion.
By the time I left Tunie in her hospital room about 2 p.m., she had been making wonderful progress in capturing long term memory recollections and reporting them quite fluidly. She recalled a model train board in an apartment in a Munich kaserne where her father was stationed in the 60s. Her brothers Kevin and David used to have train battles that she remembered fondly.
Ditto some water balloon fights when she was in ninth grade in Williamsburg, VA and hanging around on the William and Mary campus with freshmen. She thought those fights were a blast.
That’s where I left it with Pat, asking her to get Tunie to recall other fun experiences from her past that would improve her brain/speech re tracking.
I called Dr C’s office to cancel the appointment on Nov 16 and asked his appointments’ manager to see him. She said she would ask him to call me and he would determine if face time was required on Tuesday.
While I was eating lunch, Pat called to say Dr D had visited. He had increased Tunie's Decadron and delayed her release. Pat has the information on her conversation with Dr D and his reasons for the changes. He did reiterate that he could not change Dr E’s prescribed regimen for meds.
If one were a conspiracy theorist, one could imagine all kinds of theories for why E commented on the possibility that damage had been done by the stereotactic procedure, why the X Center oncologists seem to be taking a hands off response to changing the regimen prescribed by the Y team that performed a possibly damaging procedure, why Drs D and G performed the recent procedure when Dr C, the primary oncologist, said Tunie was too far along and leaving her alone would be as effective as further medical intervention, why Dr E appears to have written a mistaken prescription to for anti seizure protection, whether procedures are determined by who has what equipment where, whether turf battles between prima donnas are appropriate in the treatment of a cancer patient, �and whose experience and judgment to trust in the treatment of patients with small cell lung cancer metastasized to the brain. I certainly do not have the training or the experience or the discriminatory tools to decide who did the right thing. I am not sure any layman does.
It appears that every judgment could be questionable and every expert could have different opinions, leaving the layman to throw up their hands and quit or to rely on the horse that brought them and hope they will do their best. In the case of Tunie’s treatment there are a lot of hands in the choices that got her from X Center to Y Center to the condition she is in now. Maybe most of them have to do with the cigarette industry lacing tobacco with addictive drugs, with Tunie not being able to stop smoking when I nagged her to quit, starting after we were married five years ago, with the urgency of her mother and doctors recommended by her mother’s social network to do something immediately without a second opinion, with her mother’s intervention to accelerate the recent procedure before her primary oncologist had examined her to see if the cancer had developed a critical mass, to a medical system driven to profit from expensive treatment and equipment and drugs, from our need to stave off the inevitable and take risks with people part of the fabric of our lives, that damagex the remaining quasi quality time they have.
Somebody else is going to have to figure out how all those threads have created the mess we are now flyspecking for a better solution. It just brings tears of frustration and anger and despair to me.
I remember when my mother was dying from congestive heart failure at age 86. She had been saved half a dozen times over a couple of years by the docs adjusting her electrolytes and making it possible for her to breathe again. But in the end that was not good enough for my older brother who was racing around the hospital trying to find a doctor who would do a heart transplant for her. Such are the human bonds that make it difficult for us to release those who have done their mightiest to be what we want—and still we want more.�
Did I mention the medical system that functions on the drowning man principle? It offers solutions to often dying people anxious to defeat a deadly disease and willing to grasp at any bit of flotsam to stay afloat.
JM
No comments:
Post a Comment