medical *
**********
Chemo was last Friday. It has been a week
Side-effects began Monday with long bone pain.
Dr. Neal, the Stanford Oncologist, recommended that I try Oxycontin to see if I could sleep through the night. So for the last few nights I took Oxycontin, Doxepin 10 mg, Prazosin 1 mg to help with an expected decrease in urinary stream from the doxepin, and finally 100 mg of Seconal (secobarbital). I used that for a couple of days.
I slept about 7 hours...a really good stretch for me. Although it is more like "coming to" rather than waking up." Usually I'm fully awake when I step out of bed.
Seconal was first manufactured in 1928. In the 1960's I'm sure that it was no more than $.10 a capsule. According to my local Rite-Aid pharmacy, the retail price for 30 capsules is now $500, that's more than $15.00 per capsule. My copay was $45.
Another recent example of anti-market behavior is the colchicine that I have been using. Colchicine is an ages old remedy for Gout. It has been in use since 1500 B.C. It was a very inexpensive drug until the FDA decided that there was not sufficient proof of effectiveness. We can now thank the FDA that dsthe cost a single pill which I take daily has increased from .09 to 4.85.
A few years ago, my Colchicine would cost $2.70 a month. Currently it is costing my insurer (which means us) about $150 per month.
http://en.wikipedia.org/wiki/Colchicine
My wife, Jasmine, just informed me that she had never seen the movie "Conehead." She was looking directly at me. I wonder what that meant?
Most of this current post was written before chemo side-effects kicked in. It has not been possible for me to get anything done since. Yesterday was especially bad, I was in bed for most of the day and when I did get up it was to moan. Why would moaning be helpful?
We were supposed to visit friends for Thanksgiving. I couldn't imagine leaving the house. In a burst of enthusiasm 2 weeks ago, I purchased plane tickets for a trip East the week before Christmas. I was going to call it Cher's Absolutely Final Good-bye Tour. I was hoping to see some folks like my Aunt Ginny and cousin Patsy who have been so supportive.
----------------------------------------
Glendive Montana 1977
I had never lived in the West. My only previous exposure as an adult was a trip across the country where I had spent a week camping around Reno. I loved the lack of humidity, the clarity of vision, the open skies, and the general feel of things--the expansiveness.
On my initial drive from Denver to Glendive, I could see John Deere dealers with inventory appearing on distant hills. They were so far away but so clear that hey looked like child's toys. It seemed you could see everything in the West, even down to the last century of abandoned farm equipment lying about the ranch. In the East, there is such a profusion of vegetation that the past gets buried pretty quickly.
I know that the refrigerator that my father irresponsibly rolled down into a small Maryland creek in an adjacent lot is still there (or at least some of it remains) but it will be overgrown by ground cover. In the West it would likely continue to be exposed and to have less rust.
Even though the West has a less of a past than the East Coast with respect to English speaking settlers, more of the past is visible in the West, particularly unwanted items, trash heaps, abandoned mines and tailings, etc.
Most striking on my initial drive to Glendive was the isolation. There were only a handful of hamlets visible on the interstate for 200 miles. There were few cars on the road and a striking absence of people or other evidence of human activity. It was hard to compare that with the 200 miles from Baltimore to New York City and the wall to wall people.
Geographic isolation. In Glendive in 1977, a woman was 200 miles West or 250 miles East of an obstetrician. General practitioners did most obstetrics. Specialty services were available in Billings or Bismarck as were the nearest airports. Generally we used the Bismarck Airport since tickets from the East Coast were a little cheaper there. The town of Dickinson, North Dakota was about midway between Glendive and Bismarck. With no MacDonalds in Glendive, all trips to the Bismarck airport required a stop at the Dickinson MacDonalds for a cheeseburger fix...generally 20 or 30 to be distributed to family and close friends.
Isolation by weather. Shortly after I arrived I cared for a woman whose 35 year-old husband had frozen to death trying to make it from stuck pickup to his front door. In the winter, you do not pass people who are broken down on the road. Being stranded in the elements can be a death sentence. In my second week there, a body was brought in to town by snowmobile, the only effective means of transportation from an isolated ranch. -40 F is a relatively common night time low.
Need for preparation. You don't leave town in your car without safety equipment. Warm blankets, bedroll, water, candle, matches, flares, chocolate or other dense food, additional coat, hat, mittens, bucket, toilet paper.
Childbirth. There was no obstetrical anesthesia in Glendive. It was all natural childbirth. Unlike the weeping and gnashing of teeth seen in the inner city hospital, the farming and ranching women came to the hospital eager to welcome the next member of their family. Eight and nine pound babies were probably the most common. I've read about the Chinese women back in the fields after delivering in the morning. Those women in Glendive are cut from the same cloth.
The Elderly. This was not West Virginia. Most of the population had retained their mobility and teeth. They lived a very active old age. Despite an environment that included ice covered streets and sidewalks for much of the winter, I didn't see much in the way of broken hips. There were many social functions for the aging couples including dances and parties--much more activity than I had seen in West Virginia.
General Optimism. People seemed to believe that things were going to get better. Granted the state was in a good position with respect to the increasing need for energy and the increase in coal-train traffic from West to East. Four to six of these 100 car monsters came through Glendive each day carrying low-sulfur western coal to power plants in the East.
February 1977
There was quite a bit for me to learn in Glendive. I was entering a long-established medical practice that had been manned by several itinerant Irish physicians during the previous ten years. I had my first exposure to a medical student trained under the British system while I was an intern in Baltimore. He did a meticulously thorough physical examination that would have put most Americans to shame. Likewise, in Glendive I was frequently impressed by the details in the record.
The practice in Glendive had been successful for many years. This was the first opportunity that I had to see and participate in a successful family practice.
What doesn't work in a new practice is being too conservative. A previous post discussed the notion of uncertainty of diagnosis and that by increasing the patient's tolerance for temporary uncertainty, one can reduce the cost of care.
This backfired on me with one of my first cases. A two year-old boy had been wrestling with his sister and had been thrown to the floor. He cried about his shoulder for about 20 minutes. It was Stan's patient, and I agreed to meet the family in the emergency room. By this time the child was quiet and playing with his trucks and using his injured arm to move them. I could not elicit any tenderness over the shoulder or collar bone and I didn't think that an x-ray was warranted. The family seemed okay with that decision, but I got a call from the father the next day. The boy had begun crying the next morning and they had taken him to another physician who ordered the x-ray and determined that there was a greenstick type of fracture of the collar bone. The father was angry and said, "That was a very hasty diagnosis, Doctor." Then he hung up without discussion.
Naturally, you don't want this to happen to you very many times in a county with a population of about 8000. It was my error. I was not established in the community. No one knew anything about me. It would look like a hasty diagnosis rather than an attempt to reduce x-ray exposure in children.
About phones: I had another case that was crucially instructive to me and no doubt saved me hundreds of hours of heart-ache in later years of practice. One early afternoon, a 30 year-old man came to see me for flu-like symptoms. He had a productive cough with discolored sputum. Given the sputum, he was probably a candidate for an antibiotic in 1977 and that's how I treated him.
A few hours later I was sitting down to eat dinner when I got a call from the patient's wife who complained that her husband wasn't feeling better yet. The complaining call from the spouse who didn't come to the medical encounter made me angry. After establishing that he wasn't worse, I told her that it was unreasonable to expect things to happen so quickly. My irritability with their expectations must have come through and she hung up on me. That "hang-up" led to hours of rumination. I finally came to the conclusion that I should never answer a phone call that I am not prepared to take. The answering machine can hold the fort while I'm putting my emotional house in order. A offhand remark during a phone call can produce a mess that requires hours of undoing.
To Work:
The first month was slow but steady. Both Brendan and Stan sent me overflow patients. Without a hospital practice to speak of, I made rounds with Stan every day.
I tried to attend all deliveries of the partners and I was busy studying Eastman's Obstestrics book at every opportunity. I was somewhere between nervous and terrified. I borrowed two different types of obstetrical forceps from the hospital and practiced with them at home. I was fortunate that I could count on Brendan or Stan to bail me out if I got into trouble with a particular delivery. As the person with the most surgical skill, Stan was the C-section man. Just as I had learned minor surgery from Stan in West Virginia, Brendan was in the process of learning abdominal surgery from Stan.
I remember a little bit of a tiff over one of those cases where Brendan had decided that a patient needed an appendectomy. Stan was out of town but was expected back in a couple of hours. There was no need to do an emergency surgery. Brendan asked me to scrub in on the case and it turned out to be a straightforward appendectomy. When Stan returned, he confronted Brendan about the surgery. Although the case went well, what if it hadn't? Neither Brendan nor I were surgeons. What would we have done if the patient had Crohn's Disease or some unusual form of abdominal pain? Stan's point was that the surgeon needed enough skill to get the belly closed safely no matter what the findings. I don't think Brendan bought into that argument.
Molly:
Molly made a decision to come to Montana sometime in mid-February. The West Virginia office was closed and gone--shipped out to Montana. What was left was our home on the mountain which she began to pack up. She was hoping to be able to come sometime in March or early April.
So, I could no longer stay with Stan and Joan...I needed to find a place. In typical Western tradition of banking, I managed to purchase a house in Glendive with $1 down. It was that first house built in Glendive in 1882, the one for the first Railroad Superintendent.
 |
| Original Home Built for First Railroad Superintentdent 1882. Glendive MT |
When first built, the big brick house sat naked on the plains. In the interrim, the town had grown up around it and it was now in the middle of a mature neighborhood on the South Side of Glendive.
The Falling Out:
Brendan and Stan were unable to manage their success. I wasn't privy to all of their dealings and once they began feuding, the source of most of my information was Stan.
Brendan was wealthy but heavily invested and not very liquid. Stan was trying to get on his feet--he had only been there for about a year. He was in a new marriage and had 3 children from his previous one. It could be that Brendan wanted Stan to borrow more money, I don't know. I suspect that both were having cash flow problems.
Brendan worked all the time. As he worked, he required x-ray and laboratory support. This meant that there were supplies to buy and technicians to pay by the hour, especially for any overtime work. Given that he had his own lab and x-ray, it became more common for Brendan to see after-hours emergencies in his office and to use his own equipment rather than seeing a patient in the hospital and having the work done there.
Stan was not a workaholic. He worked hard and long, but liked to come home at some time in the early evening and have a drink, put his feet up, eat a relaxed supper and hang out with Joan. Stan wanted a life and medicine.
You can see that the problem they are going to have is the allocation of expenses for their lab and x-ray departments. What will be the formula that they will use to determine a fair share of expenses? I don't know what they proposed or counter-proposed, but they could not reach an agreement.
This is hearsay: In March of 1977 Brendan and Stan are getting their lunch in the hospital cafeteria. It is packed. From one side of the room, Brendan is alleged to have said, "Stan, you're a fucking liar."
This put me in an awkward position to say the least. I am in a strange country dependent upon two physicians who have guaranteed my income but cannot talk to one another. I have closed my previous practice. I have bought a house. My wife and child are getting ready to come to join me in this new practice..
Was I paranoid? No. As they began to feud, they no longer referred patients to me--they were hunkering down in their own survival mode and were determined to stack money against the future. My workload for the second month was less than for the first. This would not be a sustainable practice. In a place like D.C. or Baltimore, I could hunt around for more work, but not in Glendive, Montana where the nearest city was 200 miles away.
The next step in the drama was the evacuation of Stan and Joan from Brendan's rental house. I don't know the whole story but they called me one day and said they had nowhere to go. So, they came to live with me.
Things were becoming very complicated very quickly.
How I Became A Communist:
It was at this point that Eric Sohr, M.D. became the local face of socialized medicine, a turncoat physician. I needed to guarantee an income, so I went to the Feds and I negotiated a salaried position with the Rural Health Initiative. This made me a Federal physician. The Rural Health Initiative used Stan's practice and the Glendive Community Hospital as a means for providing the funding. This infuriated the local physicians who saw it as unfair competition.
For the next year and a half, I was a social outcast. With one exception, members of the medical staff did not speak to me beyond a nod of recognition should we meet in the hallway of the hospital. My only professional contact in town became Stan and then, a few months later, some newly arriving Public Health Service Doctors. It was very uncomfortable.
As I recall, the RHI gave me a contract for $48K a year. However, they wanted me to transition off of the payroll into a fee-for-service practice. They made it possible for me to acquire an escalating percentage of my accounts receivables based upon time in service. In other words, after 3 months of work, I was entitled to 25% of the accounts receivables. After 1 year of work, I would own 100% of the accounts receivables. It was their hope that after 1 year, the collections from the Accounts Receivables would provide a reasonable standard of living and that I would stay in town.
They did not think through the contract very well, because as they wrote it, there was nothing to prevent me from taking the accounts with me and leaving town. That certainly wasn't their intent but it was quickly becoming mine. The last hospital had gotten the best of me. Maybe I could even the score with this RHI organization.
The Efficiency of Practice:
Big city hospitals allow for nursing specialization. That is not possible in rural areas. Glendive Community Hospital was a 20 bed medical center. There were two cardiac monitoring beds. The same nurses who were watching cardiac monitors one evening might be assisting with obstetrics the next evening. I was very impressed to see the nurses appear to adapt these different roles so effectively.
My medical office was next to the nursing home which was next to the hospital. I could get from one place to another within 5 minutes. It was also a five minute drive or a 20 minute walk to my house.
I remember admitting a child from the office for croup late one afternoon. Within 30 minutes the lab and x-ray were done and the child was in a bed receiving some vaporized medication, and I was on my way home to supper. A few years later, while practicing in Billings, I fondly recalled that case as it took me two hours to achieve something similar in big city hospital for the child of my clinic nurse. There were definite advantages to small town and small hospital practice.
Stan and Joan, Ginger and Shiva:
Stan and Joan were fun to be with. They were still honeymooners. Sometime during the first few weeks, I saw them occasionally shake hands in the morning as they sat down to breakfast. I found out that when they had intercourse on one evening, a handshake was their tradition the following morning. It was cute.
In the meanwhile, Stan was determined to do some hunting and acquired an English setter for pointing birds. This was Ginger. Unfortunately, Ginger was terrified of guns and would sometimes stop along the trail to savor the cow pies that seemed to be everywhere on the range. I recall an incident where Stan was using a fishing rod with a bird wing tied to the end of the line in an attempt to get Ginger to point toward the wing. Instead, Ginger seemed to cower in front of the bird wing. Joan told me later that she had made the mistake of chastising Ginger for bringing her a dead bird. She never told Stan the truth.
Evan Shiva seemed to enjoy watching Ginger's education.
Despite the crowding, these several weeks in the same house were almost therapeutic--united again in a foreign land. As spring came we were enjoying music, cooking outdoors, and sight-seeing this new country.
Obstetrics:
I came to like obstetrics. The relationship between doctor and patient seemed to go to another level of permanent bonding. I became very conservative in my treatments. Enemas were a common standing order for women in labor at the time. The idea was to empty to bowels before the baby came so that you were less likely to be dealing with a baby and feces in the same field. I didn't think enemas worked, so I stopped them on my patients.
I was also a minimalist about doing vaginal exams as the delivery date approached. It was important to know that the baby was coming head first--so important that in our rural hospital we routinely did very low dose x-rays to demonstrate head position. A child coming butt first or legs first would likely need a C-section or a trip to Billings for more specialist care. One would not want to begin to attend the woman in labor and discover an abnormal presentation that late in the game. However, I saw no advantage in doing weekly vaginal exams to determine the condition of the cervix until the patient became overdue or a candidate for an induced delivery. I tried to keep my hands out of there.
I restricted my Obstetrics to low-risk and only took women who were committed to Lamaze training. After a few months I became interested in birth without violence and began using LeBoyer's method for those who were interested.
http://childbirth.me.uk/laboyer.php
Generally the child was born without tears and demonstrated persistent curiosity. It was a very satisfying experience for all.
However, it was possible for me to be comfortable because of Stan's presence and ability to do the C-Sections.
Community Medicine:
Connie, the office nurse,d and I put together a teaching program for hypertension and identified patients whose blood pressures were not under control. We obtained some educational movies and combined these with a blood pressure clinic to serve the patients who were not responding fully. This went surprisingly well. Patients responded very positively to increased education about their condition. It was fairly easy to get them to take on a more active role in the management of their hypertension by asking them to track their pressures on a routine basis.
I also had the opportunity to sponsor a nurse practitioner from the University of North Dakota. One of our local nurses had the opportunity to return to school and qualify. Even though I left town, a new Nurse Practitioner went to work in rural Montana providing primary care services where none had previously existed.
Our Family:
The original reason for the move was the work opportunity, to be able to do a family practice in a supportive community. This is a picture from early winter 1976 in West Virginia that seems to capture some of our tension and depressed mood. Molly has been losing weight and though 5'7" or 5'8" is almost certainly less than 100 lbs here, all due to depression and loss of appetite. At this point it was not clear whether we would separate with the move.
 |
| Fall or Winter 1976 Molly, Eric, Brian. Pulling up stakes in West Virginia. |
It is comforting now to be able to look back and see that things worked out. Whatever slips, bumps, and bruises along the way, Brian and Keith have selected great partners and appear to have the skills necessary for re-affirming their relationships. Things have turned out better than alright.
 |
| Brian with Ginger and Shiva. Glendive 1977 |
Sometime in late Spring or early Summer, Stan and Joan bought a beautiful old house in Rustler's Gulch. I forget the name of the street, but there was a common belief that the original cattle and sheep kings of Glendive had been quick to scoop up the strays on the prairie. Those that made the early fortunes in the cattle business built houses there.
When Stan and Joan left, we had the house to ourselves and more opportunities for conversations about the future. What was clearest about the future was the necessity to avoid a second child which would impose upon us the need for managing another infancy and increase the degree of difficulty in finding satisfying life paths for each of us.
Molly and I went to a Christmas dance in 1977 that turned out to be quite a party. We were both well over our limits of alcohol and were driven home. Rather than go immediately to bed individually we ended up going to bed together. A few weeks later, when Molly decided that she really better get a diaphragm, she learned that it was too late.
I was really surprised. Some part of me wanted to wonder if this unexpected pregnancy was a way of prolonging the relationship, but I knew her better than that. She really did not want a second child at this point.
Having learned the hard way with Brian, we knew that help was required for to prepare for the new baby. Molly's sister, Debbie, agreed to come to stay for awhile. She came and stayed for a few years. Molly is more like a mother than a big sister to Debbie. They both have the Boyle sense of humor. They worked on crafts projects together, did things to beautify our environment, and certainly made my life much easier.
I particularly liked hanging out in the rail yards with Brian on my back. All of the utility cars had dates of creation. I got a kick out of finding cars that had been born in 1912 and 1914 and were still in use. As the pregnancy grew, I remember this 1000 mile vacation trip from Glendive to Lake Mary Ronan. It required two cars. Debbie and Debbie's friend Pam came along. Kristin was there with her friend, Shannon. My brother Kirk was hitch-hiking around the West and he came as well. We rented a large cabin on the lake and had a great deal of rain that forced us inside to play meaningless card games. It was a very relaxing vacation.
My Mother
In 1977 my mother visited us in Glendive. To fully discuss that visit, I have to set the scene. I know that what I am going to say will upset some family members, but it does provide some insight into the nature of her depression.
You will recall that my mother had several experiences that made it more likely that she would suffer major depression. She had early life losses: her mother at age 9, a little sister at age 7, a big sister at 13. She had experienced the transition from comfortable middle class to poverty. She had lost her home as a teenager and was living in a bedroom with sister, Virginia, four years her junior. They were eating meals with another family. In her twenties, my Mom became deaf. Several surgeries at Johns Hopkins in the 1940s were only partially successful and eventually failed.
My mother's academic credentials were a business high school with preparation for being a good secretary. Despite such lack of credentials, my mother read the Wall Street Journal until her 80s. When she died she had saved $500,000. If I had used her to make my financial decisions, I am certain that I would be much better off today.
However, a good business sense and the ability to save is not protection from depression.
In 1968 my father's alcoholism had escalated. Though primarily a binge drinker with 4 to 6 episodes a year, there was more and more intermittent use of alcohol outside of the binges. By 1968, he was dealing with a grown daughter, Suzanne, who was 22. Suzanne was not about to let her drunken father leave the house in a car with the two boys who were now 12 and 9. She might take them into her car and head out somewhere or openly confront him and tell him that she would call the police if he attempted to leave in an auto with the children.
Sometime in March 1968, my father decided to destroy Suzanne's furniture and clothes. He tossed everything into the backyard and built a bonfire. Poof!
The only effective way of dealing with such behavior is through law enforcement. It's crime to destroy the property of another. Alcoholics generally have to be forced into treatment and the law is a reasonable stick. Of course, given the dysfunction of our family, that wasn't done. So a few weeks later, when he was angry at my mother, he decided to burn her clothes in the fireplace in the recreation room. The same can of gasoline that might have been helpful for the bonfire in the backyard was employed in the recreation room with disastrous results.
I was on call with Russ Hicks at the Baltimore City Hospital when I got the call from Mr. Carragher. He told me that he had heard of the fire on the police scanner. When he went by, there was a gasoline can in plain site that he had taken. I called Geoff who was in dental school in Baltimore and we went to our parents' house in Beltsville. The fire company was just leaving. A neighbor had taken in my father who was about to go to sleep. Much of the house was still standing. However, sometime in the next few hours, the house reignited and finished the burn. The fire company responded again. By the next morning, everything was down. It was all a pile of rubble.
Sally and I were living with 1 year-old Kristin in a basement apartment in Laurel, just a few miles from my parents' house. We took in my mother, and my brothers, Kirk, and Dana. My mother was as if paralyzed. She was unable to monitor the activities of the two young boys who were no doubt acting out their own grief as well. For example, the kids insisted on entering and exiting the apartment via windows rather than doors as Mom just sat there.
For the next month, my mother went to the rubble field on a daily basis searching for meaningful connections with her past, such as her grandmother's tea pot and photographs that had survived the heat. About two weeks after the fire, I was home when I got a call from my mother. She said that she was at the firehouse and that a strange car was following her. She wanted me to come and pick her up, which I did. My mother was suffering from a psychosis as a part of her depression. It was the first time that I saw it. However, from then on, when she had a severe depression, my mother was more likely than not to suffer psychosis as well. Often this took the form of a religious delusions, "I am the devil," or "I am the savior." Sometimes, I would just get a call out of the blue. When the ground war started in the first Gulf War, I got a call. "Eric, the retribution has begun." click.
To follow up on the house fire and the separation from my father, they were back together before the end of the year and their marriage outlasted mine to Sally by quite a number of years. Why do abused women have such difficulty letting go of the toxic spouse?
While I was in West Virginia, I had picked up my mother on a few occasions when she was depressed and beginning to espouse paranoid ideas. I would bring her back to our house in West Virginia and let her be--place no expectations on her. She liked to be around us and she used the time to decompress and to regain her bearings. After a few days, she would be more herself and able to return home.
In addition to developing the propensity for having psychotic episodes with her depression, my mother began hanging out with a group of Catholics in the 1970s who were into prayer and healing. When my mother came to visit in Glendive in 1977 she was very much caught up in healing and had begun to believe that God had given her some "power" that could be used to combat illness.
Well, her belief would be heavily tested.
Shortly before her visit, I was working in my office when I saw a child with a high fever who appeared very toxic and had a seizure. The workup included a lumbar puncture to make sure that we were not missing a meningitis, but we still had no diagnosis until 12 hours later when the child began stooling. He had been in a day care center (the one caring for Brian). It turned out that we were on the cusp of a Shigella outbreak that would ravage Glendive for the next month.
Everyone in the Sohr household was affected, including Grandma, who was probably sicker than anyone. The symptoms included bloody diarrhea and a sensation that you were never quite finished with the bowel movement.
No comments:
Post a Comment