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It is Friday Feb 24 as I begin this post. I'm waking up in Las Vegas. About 6 weeks ago I began making plans to see my family for a small reunion of my siblings and their children. Las Vegas offered the most convenient venue for good air service and reasonably priced hotels--bargains if you are not a gambler.
My brother Dana flew out to Morro Bay on Wed and we got up at 2 A.M. on Thursday and drove the RV to Las Vegas. We experienced some engine power problems as we approached the California/Nevada border but managed to make it to a dealer in Las Vegas and had the fuel filter changed out. We'll see today if that was the culprit.
My family will all be here on Saturday. About 25 people will be going and coming for the next 48 to 72 hours.
My CT of the chest on Tuesday looked terrible to me. I know that medical imaging is not my forte but I'm very sure that I see a lot of progression of tumor or tumor effect in my chest. It also appears that my heart is wrapped up in this mess as well. I think that may be a partial explanation for my breathlessness--that my heart is unable to expand to the degree necessary for a good stroke volume. Normally the heart can increase blood output in two ways, by expanding and increasing the filling volume to squeeze out more blood with every beat and by increasing the number of beats per minute.
I am only able to walk about 25 paces on level ground before stopping to catch my breath. At home I am unable to climb the stairs and must rely on the elevator that the builder had installed for his own wife--what a lucky find.
So, my time appears to be very short.
***
It's now about 2:30 PM. There was a lunch buffet at Thai Palace at 935 E Sahara...best Thai restaurant ever...Following that, Robert Granieri, who was my office manager when I practiced in Vegas, and I went to look at comparable office spaces to the building we are currently renting out. Jasmine and I bought the building where I practiced in 2004 (a converted 2700' house). We have been renting it since leaving Vegas in 2007 and the leases come due in September. There are two suites in the building and neither occupant is interested in taking responsibility for the entire building.
***
I'm back in the hotel room and making myself some coffee brought from home. I'm dying for the real thing. While I was boiling the water I had a flashback to Billings in January 2011--staying in a motel room and making coffee when I went to visit Shirley Gunnels who had been told that her breast cancer had involved the lungs and liver. At the time, there were three friends with cancer and lung involvement--I felt connected to them all and was really much closer in some ways that I could have guessed.
Shirley died in late summer but was unable to avoid a spinal surgery for pain 2 weeks prior to her death. She was in her high seventies or early eighties and was active enough to paint parts of the outside of house and to do a lot of cooking and running around at the senior center. There is nothing like cowgirls. We spent the afternoon at the movies. Our choices were Black Swan and True Grit. I would have gone to Black Swan but there was no way Shirley was going to a movie about ballet.
Atascadero State Hospital
The hospital was established in the 1950s and is the city's major employer. The town itself has a very interesting history.
http://en.wikipedia.org/wiki/Atascadero,_California
One of the requirements for working in the hospital is attendance at several weeks of training to teach each new staff member the set of expectations for conduct. A part of this training is physical--to teach the ins and outs of restraining patients safely. All disciplines are expected to participate and respond to alarms that indicate a problem on a ward. When an alarm sounds, staff from neighboring wards are expected to run to the problem and immediately boost the number of staff available to handle the situation.
Physical confrontation with patients was a last resort. Training was focused on identifying situations that were escalating and providing techniques for calming things down.
Alarms are inherently dangerous. People are running at full speed and must get through heavy steel, locked doors that separate the wards from the main corridor of the hospital. Injuries during alarms are common and more likely to be accidental than due to physical confrontation with the patient himself. Staff are more likely to be injured by patients when a punch appears out of nowhere--the patient having planned such an assault and waited for an opportune time.
The hospital has been adopted by the town and vice-versa. It is not unusual to talk to employees who are the third generation of hospital workers.
The State Psychiatric Hospitals are much more dangerous to staff when compared to psychiatric facilities within prisons. The U. S. Department of Justice became involved in the State of California's psychiatric hospitals in about 2002 and there has been turmoil for the last decade. I know that the "consultants" to the state (actually the original inspectors as well ((?talk about conflict of interest)) ), have made a very good living from California.
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I am quickly running out of time and have to prioritize what I think I can actually get written in the next few weeks--so for the time being, I am going to skip away from my work history and focus more on illness-related matters, a summing up and reflection on certain relationships, and my day-to-day kind of progress or lack thereof.
Tuesday, February 28, 2012
Thursday, February 23, 2012
West Again 1997
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It is Feb 21 at 4:30 AM as I start this.
My pain situation is pretty good. I am having occasional left chest pain in the area of the ribs that were irradiated. There have been 2 occasions in the past three days where I took a short-acting fentanyl for breakthrough pain. They come in a tablet that is absorbed through the mucous membranes.
My head has been fuzzy and my thinking seemed slower going back to my last chemo on 2/10. It feels a little clearer this morning and gives me hope that I can write a little bit.
My left ankle and foot have begun to swell. That hasn't been a problem before and may indicate a number of things that I'll take up with Dr. Kolb's office today.
I'm scheduled for a CT of the chest today to "stage" the disease...to see what the changes have been since the last CT done 5 weeks ago.
Going West Again
In the Spring of 1996 I was completing my 2nd year in Albuquerque which left me a year away from completing the program. Dr. Lauriello had tipped me off about Atascadero State Hospital (ASH) in California. The hospital was always advertising for more staff in various psychiatry journals. So, I called the hospital and arranged a recruiting visit. The facility was enormous, something close to 1000 beds, entirely devoted to mental health and criminal justice issues. It was particularly surprising to imagine 25 psychiatrists all living in a county of about 250,000 souls.
The interview process went well and I was given two employment options: a forensic fellowship or a position of staff psychiatrist. Both of them paid the same salary of about $100 K. In addition to the salary, there were health and retirement benefits from the state. There were also opportunities to take call at the hospital and to earn additional money in that fashion.
The fellowship guaranteed more time for learning and reading and I left the recruiting interview determined to start the fellowship in the Summer of 1997.
During my last year of residency, I was also entitled to 4 months of elective time. As soon as I returned to Albuquerque I began to make arrangements to do that elective in California at ASH. My plan was to work my final day in New Mexico in February and move to Atascadero to begin March 1.
Hurdles Leaving Albuquerque
Immediately after my job interview in California, I applied for a California Medical License. This turned out to be a tedious process. Without a California license, I could not be hired at Atascadero. When November rolled around and I remained without a license, I began to look at other options as a back-up plan. Finally I received a phone call to come to California to sit for an oral examination of general medical practice. Three cases were presented to me:
I rented a studio apartment in Atascadero and reported for work on Monday, March 3 1997. There are about a half-dozen pictures preceding this text. A common denominator for them could be roomy, vast, big, expansive. They reflect one of the principal attributes of Western scenery--the immense scale.
Well--here's another kind of immense scale. Below is a google Earth photo of Atascadero State Hospital. If you look sharp, you can see the security fence that appears as a light-colored line around the edge of the central "hunk" of the photo.
I went and marked a red line on the patient yard which is the size of a football field. Notice how this yard is dwarfed by the surrounding structure.
The two-story hospital is divided into "units," a euphemism for "wards." Each ward has a team of professionals that consists of psychiatrists, psychologists, somatic physicians, social workers, nurses, psychiatric technicians, clerks, occupational therapists, nurse practitioners--sorry if I've left anyone out. There are hospital policemen who work in the facility, but they are rarely involved in physical interactions with patients. (The formal role of the hospital police force was never clear to me.)
Each ward may have anywhere from 25 to 40 patients. The hospital has been organized by the particular "forensic" issue, for example, competency to stand trial, not guilty by reason of insanity, California Prison Inmate in need of inpatient mental health treatment, or an inmate paroled to the care of the forensic hospital.
There were also "admission units" where staffing was robust as new arrivals were evaluated with respect to risk of violence to self or others.
The patient uniform was khaki. This meant that khaki and brown colored clothing was off-limits for staff. This is a standard type of rule in many facilities--staff must wear colors different from those of patients.
Staff entry to the facility was through a sally port inside the main administration building. All staff wore badges and these were scanned upon entering and leaving the facility. As the badge was scanned, the security system displayed the employee's picture, name, and data. The security officer checked the live face on the other side of the glass with the face that showed up on the TV screen during the scan.
The sally port emptied directly into the main corridor of the hospital which is about 50 feet wide. On the morning that I started traffic was heavy. Several staff members and many patients in one's and two's were on the move. There may be entire wards of 30 men marching in a formation reminiscent of 3rd grade with 3 or 4 staff in attendance to accompany them. There is a remarkable sense of freedom within the hospital. The appearance of regimentation only occurs when groups are in motion.
My First Case
Sometime in the first week I was assigned to spend a day in the "Admissions Unit" of the hospital. I watched one of the veteran psychiatrists go through the paperwork and the interviewing process for inmates who were being sent from the prison system to the State Hospital for a higher level of care than could be provided within the prisons. After observing two of these admissions, I was instructed to try one on my own.
Everything was very straightforward as I collected the most basic information...date and place of birth, reason for incarceration, medical history, family history, and then the interview got away from me and the patient began describing what had been happening to him in the prison where he had a terrible urge to swallow the hair and feces that accumulated next to the drains in the men's shower in the prison.
Suddenly I knew that I was in a very different place than I may have imagined! It was only later that I learned that in California, three lawyers and two psychiatrists would be required to implement a court order for involuntary medication in cases such as these.
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It is Feb 21 at 4:30 AM as I start this.
My pain situation is pretty good. I am having occasional left chest pain in the area of the ribs that were irradiated. There have been 2 occasions in the past three days where I took a short-acting fentanyl for breakthrough pain. They come in a tablet that is absorbed through the mucous membranes.
My head has been fuzzy and my thinking seemed slower going back to my last chemo on 2/10. It feels a little clearer this morning and gives me hope that I can write a little bit.
My left ankle and foot have begun to swell. That hasn't been a problem before and may indicate a number of things that I'll take up with Dr. Kolb's office today.
I'm scheduled for a CT of the chest today to "stage" the disease...to see what the changes have been since the last CT done 5 weeks ago.
Going West Again
In the Spring of 1996 I was completing my 2nd year in Albuquerque which left me a year away from completing the program. Dr. Lauriello had tipped me off about Atascadero State Hospital (ASH) in California. The hospital was always advertising for more staff in various psychiatry journals. So, I called the hospital and arranged a recruiting visit. The facility was enormous, something close to 1000 beds, entirely devoted to mental health and criminal justice issues. It was particularly surprising to imagine 25 psychiatrists all living in a county of about 250,000 souls.
The interview process went well and I was given two employment options: a forensic fellowship or a position of staff psychiatrist. Both of them paid the same salary of about $100 K. In addition to the salary, there were health and retirement benefits from the state. There were also opportunities to take call at the hospital and to earn additional money in that fashion.
The fellowship guaranteed more time for learning and reading and I left the recruiting interview determined to start the fellowship in the Summer of 1997.
During my last year of residency, I was also entitled to 4 months of elective time. As soon as I returned to Albuquerque I began to make arrangements to do that elective in California at ASH. My plan was to work my final day in New Mexico in February and move to Atascadero to begin March 1.
Hurdles Leaving Albuquerque
Immediately after my job interview in California, I applied for a California Medical License. This turned out to be a tedious process. Without a California license, I could not be hired at Atascadero. When November rolled around and I remained without a license, I began to look at other options as a back-up plan. Finally I received a phone call to come to California to sit for an oral examination of general medical practice. Three cases were presented to me:
- a delirium occurring on the third hospital day which was probably related to alcohol withdrawal after admission to the hospital
- a fungal infection in a young man that was almost certainly HIV related
- depression in a post-menopausal woman
After receiving the license from California, Atascadero State Hospital informed me that when I came for an elective, I would have to be on the payroll of the hospital, not the payroll for the University of New Mexico. The wonderful news was that ASH was going to pay me $8K per month as opposed to $3200 per month that I was making as a psychiatry resident in New Mexico.
The University of New Mexico objected and requested that the State of California pay them the $8K per month while New Mexico continued my usual salary. I became involved in the discussion and pointed out to the University of New Mexico that it should have expected to have been on the hook for my entire salary for the four months of my elective time in California and that my arrangements with ASH were actually saving them $13000 in resident salary, health insurance payments, etc. ASH was also firm and would not negotiate the salary--to work as a resident in the hospital, I would need to be counted as an employee.
At the end of February, I removed all of the seating from my Acura Legend except the driver's bucket. I packed what I thought I would need for few months and I was California bound.
I love the variety of Western scenery between Albuquerque and Atascadero. One goes West past the Navajo Sacred Mountain of the South, Mt. Taylor.
http://en.wikipedia.org/wiki/Mount_Taylor_(New_Mexico)
Forgive me for cheating with the photos...but these are your tourist opportunities as you go West from Albuquerque.
Forgive me for cheating with the photos...but these are your tourist opportunities as you go West from Albuquerque.
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| Mount Taylor: Navajo Sacred Mountain of South: Tsoodził, the turquoise mountain : |
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| In Arizona, The Painted Desert |
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| The Meteor Site in Arizona |
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| Flagstaff, AZ |
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| Needles CA and Colorado River |
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| Mojave, CA: Windmill Farm and Plane Graveyard |
Well--here's another kind of immense scale. Below is a google Earth photo of Atascadero State Hospital. If you look sharp, you can see the security fence that appears as a light-colored line around the edge of the central "hunk" of the photo.
 |
| Red Stipe on Patient Yard which is 320 feet long |
The two-story hospital is divided into "units," a euphemism for "wards." Each ward has a team of professionals that consists of psychiatrists, psychologists, somatic physicians, social workers, nurses, psychiatric technicians, clerks, occupational therapists, nurse practitioners--sorry if I've left anyone out. There are hospital policemen who work in the facility, but they are rarely involved in physical interactions with patients. (The formal role of the hospital police force was never clear to me.)
Each ward may have anywhere from 25 to 40 patients. The hospital has been organized by the particular "forensic" issue, for example, competency to stand trial, not guilty by reason of insanity, California Prison Inmate in need of inpatient mental health treatment, or an inmate paroled to the care of the forensic hospital.
There were also "admission units" where staffing was robust as new arrivals were evaluated with respect to risk of violence to self or others.
The patient uniform was khaki. This meant that khaki and brown colored clothing was off-limits for staff. This is a standard type of rule in many facilities--staff must wear colors different from those of patients.
Staff entry to the facility was through a sally port inside the main administration building. All staff wore badges and these were scanned upon entering and leaving the facility. As the badge was scanned, the security system displayed the employee's picture, name, and data. The security officer checked the live face on the other side of the glass with the face that showed up on the TV screen during the scan.
The sally port emptied directly into the main corridor of the hospital which is about 50 feet wide. On the morning that I started traffic was heavy. Several staff members and many patients in one's and two's were on the move. There may be entire wards of 30 men marching in a formation reminiscent of 3rd grade with 3 or 4 staff in attendance to accompany them. There is a remarkable sense of freedom within the hospital. The appearance of regimentation only occurs when groups are in motion.
My First Case
Sometime in the first week I was assigned to spend a day in the "Admissions Unit" of the hospital. I watched one of the veteran psychiatrists go through the paperwork and the interviewing process for inmates who were being sent from the prison system to the State Hospital for a higher level of care than could be provided within the prisons. After observing two of these admissions, I was instructed to try one on my own.
Everything was very straightforward as I collected the most basic information...date and place of birth, reason for incarceration, medical history, family history, and then the interview got away from me and the patient began describing what had been happening to him in the prison where he had a terrible urge to swallow the hair and feces that accumulated next to the drains in the men's shower in the prison.
Suddenly I knew that I was in a very different place than I may have imagined! It was only later that I learned that in California, three lawyers and two psychiatrists would be required to implement a court order for involuntary medication in cases such as these.
Saturday, February 18, 2012
Albuquerque II
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I'm beginning this on Thur 2/16.
I had my last chemotherapy, Alimta, on Friday 2/10 in Dr. Palchak's office in Arroyo Grande CA. It was a very short infusion--about an hour or so. He convinced me that the Alimta was unlikely to be the culprit from the prior round which whipped me so badly--that it was more likely to have been from the Zometa, a drug that is used to prevent bone fractures.
Dr. Palchak was right. The chemo last week was reasonably mild. On Saturday I was able to drive my RV down to the beach where Archie and I parked in the Sun and watched the activities around the Morro Rock. My friend, Bob, joined us for an hour or so.
By Sunday I was becoming more tired and out of breath. On Monday I slept for 17 of 24 hours. Tuesday was the worst day--no wind and no energy. When I awoke that morning and looked in the mirror I was shocked to see the face of death or at least the absence of life.
There was no hint of any sparkle in my eyes--just a flat brown. I am increasingly aware of how sick I appear. Maybe it's paranoia but I catch people doing double takes--even people I know seem more curious than usual about my appearance. As a result I am becoming more and more self-conscious and would prefer to keep away from others.
These feelings and thoughts were particularly acute on Tuesday. The weather was miserable. There were scattered showers throughout the day but the rain became serious while Archie and I were in the Albertson's Supermarket Parking Lot. I have been wearing Crocs as my full-time footwear and I was concerned about slipperiness and falling, so I grabbed a grocery cart to use as my support and walker. We don't have a KFC or PopEyes in Morro Bay. The closest take is Albertson's fried chicken--really quite good. So I picked up a bag of chicken and wended my way to the self-service checkout line. The store was very crowded and all of the checkout lines were packed. The line for self-service snaked around a bit through a mass of humanity.
So, I'm waiting at the end of this crooked line and a young family of three pulls in behind me. The man and his wife appear to be in their early to mid-twenties. They have a five year old boy who is rolling around on the floor and ignoring their entreaties to do something else. Suddenly, in a loud voice, the young man points out that I am using a full size grocery cart to hold a lunch bag worth of fried chicken.
"The truth is that I'm sick. This grocery cart is my walker. It's holding me up." As I am giving this explanation, I can feel anger welling up that is directed at this blabbermouth. His eyes are opened pretty widely now and he is becoming more uncomfortable. I find that as he appears to be more frightened I feel more angry. Then he hits upon the real magic, "Why don't you calm down?"
Surprisingly, that didn't help. "Why don't you mind your own damn business!" popped right out without thought or restraint.
People are looking at us now. I'm embarrassed. Suddenly a checkout machine comes open and others in line are very quick to point it out to me. So, I go to the machine and I'm determined to demonstrate to the world that I am in control and possess complete mastery of grocery technology in my home town. I scan my chicken. I deposit my $10. My change is $6.01. Cooly I scoop up the penny. I grab the bag of chicken and leave the store and the $6.00 in bills behind!
I've spent the last two days in an effort to refinance our home mortgage to a better interest rate. For those of you who have missed such an exercise in tedium, it involves finding a ton of documents and scanning them into PDF files and then uploading the data to prospective lenders. I know I'll feel better when this is sorted out. Jasmine is working full-time and looking after me by cooking and squiring me to doctors' visits. Doing chores is a normal part of life--and we're still a partnership.
Today was my last scheduled visit for radiation to my spine for pain control. There was a timing glitch and I was asked to wait for a few minutes in a little examining room while the patient ahead of me was processed. While I was waiting, Dr. Stella walked in and was surprised to find me there. This is his medical practice and it was the first time that we had an opportunity to talk outside of a scheduled office visit. Normally I detect a little bit of an emotional distance when we meet, but there was none of that today. He asked me how I was handling all of this and I pointed out that I been lucky to have had so many teachers in the course of a life time of medical practice. He came over and shook hands with me and said that he was sorry that this was happening to me. I told him how much I appreciated all of the help with the back pain. I told him that the pain was much better but wondered if there was more that could be done to allow me to lift my left leg without pain. He pointed out that a lot depended upon the stability of the vertebrae and the amount of strong bone that remained. I enjoyed seeing him this morning when he had his guard down and we met as two people.
Albuquerque II
After my rotation on Dr. Hammond's ward, I moved over to Dr. B., one of the laziest physicians I've ever encountered. At the time, I was 51 years old, exactly one year older than the head of the department. Dr. B was in his thirties and the son of an internist. Dr. B had a very high opinion of his medical knowledge and capabilities. I only saw self-deception.
One of the perks of being in a teaching program is the ability to utilize residents and medical students to do the medical work of the hospital. In return, the attending physicians, like Dr. B., are expected to teach, to guide, to mentor. In addition to being lazy, Dr. B. was caught up in the great frauds of the era--satanic ritual abuse and dissociative identity disorders (multiple personality disorders). Dr. B always had two or three "multiple personality disorder" patients on his ward and he took a special pride in their presence. He spent a great deal of time with these patients reaffirming the "split" in their concept of self. Almost all authorities recognize that this is counterproductive or even destructive.
Sandra
Although diagnosed as having multiple personalities in 1995, the County Mental Health Program had been treating this woman for more than 15 years. The veteran nurses were quick to point out that Sandra's claim of witches' gatherings and torture had only surfaced in the past few years while she was being treated as the long-term therapy patient of one of the faculty. Prior to developing such a popular psychiatric diagnosis, Sandra had been diagnosed with Borderline Personality Disorder with self-injurious behaviors. Halloween occurred during my rotation on Dr. B's ward. Sandra was admitted as a precaution for Halloween.
With Sandra, there was evidence in her own medical records that the diagnosis had expanded from a personality disorder and that she relished the attention and control that she was able to exert as a "multiple personality."
Patient Dumping and Cobra
There were some serious administrative problems in Albuquerque when it came to mental illness inpatient care. In general, hospitals would prefer that the uninsured and poor go elsewhere for care. Otherwise, the hospital itself becomes responsible for providing the care. In the 1980s certain hospitals became quite adept at "dumping," i.e. physically transporting patients to other facilities, typically large, urban public and charity institutions. Congress responded with a bill known as "Cobra" during the mid 1980s which made dumping illegal and subject to fines. Transfers between institutions had to be cleared on both ends and data collected at the first hospital had to be provided to the second one in the path.
Although these regulations had been in effect for more than 5 years nationwide, they appeared not to have made it into general awareness in Albuquerque when it came to mental illness. While working on call at night in the mental health center it was fairly common for ambulances to roll in from other hospitals and emergency rooms without prior notice. Despite complaints to the Department of Psychiatry nothing appeared to have been done about it.
Drawing A Line in the Sand
One Friday I was working on Dr. B's ward. The other resident was either off or sick and this left me responsible for all the patients for the day. Rather than work, Dr. B. decided that he was going to give me some personal instruction in the treatment of Alcohol and Drug Abuse. He had just passed his subspecialty certification examination. (At the time it was possible for a psychiatrist to be labelled an expert in addiction medicine by paying to take an examination and passing it. The pass rates were very high. The process looked more like the exchange of a credential for a sum of money.)
Of course Dr. B's personal experience with drug and alcohol treatment was rather limited. I had done full-time work in the field for more than a year in Baltimore with opiates. While I was in Billings I had been one of the attending physicians at the alcohol detox program. (In Billings, subzero temperatures are the rule during the winter months. One cannot discharge an inebriated patient to the street in severe weather. Therefore, Billings had developed a model alcohol detox program that guaranteed anyone a bed for the night. The sleeping space was monitored by RNs and a physician arrived in the morning to re-examine the patients to minimize the risk that there were medical problems other than alcohol intoxication that contributed to the clinical picture.)
After listening to Dr. B for an hour I went back to work and he disappeared. Since I was alone, I was responsible for all the admissions, discharges, and rounds. It was very busy but doable if I could just keep plugging away at the workload.
The nursing change of shift occurred at around 3:30 P.M. and I was still very busy. The charge nurse identified a problem that she believed I needed to address promptly. I thought it was less urgent than some of what I was doing and I promised to get to it as soon as I could. She bugged me about it again and I firmly put her off again. Shortly after 5 P.M. a medical student approached me with the nurse's request--again!
Rather than just ignoring the nurse's behavior, I took it personally and read her the riot act. I'm sure my face was flushed and my voice was up and I expressed particular displeasure in her manipulation of the medical student.
Gradually my anger passed and I got back to work and walked out of the ward at about 8 P.M. instead of the more usual 5 P.M.
The following week, I was called into the office of the training director, Dr. Morrison. She wanted to know the circumstances behind my outburst. She knew that I had been seeing a local therapist and that I was taking an antidepressant. She asked me an open-ended question. "What's it like working at the Mental Health Center?"
"Generally it is okay during the day. Being on call is very difficult. I feel like I am in a 50 foot hole trying to shovel it out. Over top of me are a series of sewer pipes, each one leading from an Albuquerque hospital. At night the pipes open and it gets flooded in the hole."
"Is there anything positive about working working there?"
"Where else could I learn to create multiple personality disorder?"
This incident contributed to my reputation as a somewhat "prickly" individual.
This was reinforced a few months later when I was on call for the V.A. hospital one evening. I was paged and told that there was a young airman who needed to be involuntarily committed to the V.A. hospital for a mood disorder. I drove out to the V.A. hospital and met the young man and proceeded to do a psychiatric evaluation. The airman was irritable but not disrespectful. He was not suicidal and denied any intent to harm others. He was not gravely disabled. In short, there were no findings to suggest that he met criteria for involuntary commitment.
We began a discussion. The airman told me that his superiors were trying to create "a mental health jacket" so that it would be easier to transfer him on. He pointed out to me that if I committed him to the hospital, I would be violating his rights. He asked me not to do so.
As I thought about it, I had to agree that I didn't have a basis for committing him. As a licensed physician, I was responsible for my own medical decisions. I could not avoid responsibility by claiming that I had been ordered to do something by military authorities. I told the patient that I would have to discuss the case with superiors and that it was unlikely that I would be the physician with the final word on his situation.
I left the airman and called the faculty member responsible for the V.A. for that month and told him that I had examined the patient but could find no rationale for a commitment. The faculty member told me that the commanding officer for the base and hospital had ordered the airman committed-- and I was urged to admit the patient. I told the faculty member that it was my medical license and my judgment and that I could not oblige. I offered to remain at the hospital until some higher authority arrived to relieve me and take responsibility for the patient. I was told to go home.
The reaction among the young residents was interesting. They generally believed that it had been my duty to obey the order and saw my resistance as arrogance.
Kathryn
The case of Kathryn was one of the most blatant that I witnessed. She was a patient of Dr. B. She had a confrontation with a police officer in the parking lot of supermarket. The officer reached into her driver side window to grab her keys. As he did so, Kathryn sped away with the police officer trapped in the window for several feet. She left the parking lot and headed for the Mental Health Center with the police in pursuit.
By coincidence, Dr. B was outside the entrance to the mental health center. Dr. B, Kathryn, and the police all arrived at the same spot at about the same time. Immediately Dr. B began to address "Kathryn" as "Jane," supposedly the "bad-ass" alter and made a commitment to an immediate hospitalization for Kathryn that allowed her to avoid immediate responsibility for her actions with the police. To me it looked like Dr. B showing off to the police and choosing to be an idiot.
Teaching and Peter Thompson, M.D.
I believe that the quality of teaching in New Mexico was very good. The weakness was a lack of overall structure--we were thrown onto the DSM-III and DSM-IV, laundry lists of diagnoses and criteria. One of the rotations was the outpatient clinic at the Mental Health Center. At about 3:30 or 4:00 PM one or more faculty members would come to the clinic and begin to review the cases for the day. Whenever I was available at that time, I attended those sessions and learned a lot.
One of the teachers whom I totally misread was Peter Thompson, M.D. He arrived in Albuquerque at about the same time as I did. There appeared to be a touch of arrogance (and I'm sure that would fit me as well.) A few months later, I was assigned to the outpatient mental health service, where Dr. Thompson was in charge.
It was during this time that I had become interested in John Money's idea of lovemaps (discussed in at least one previous post). A lovemap is a guide to an individual's personal preferences with respect to sexuality and sexual expression. The fact that lovemaps were dynamic was especially stimulating. After all, at age 6 my blonde friend, Nora, was "hot." At age 51, such thoughts of "hot" would be suspicious for pedophilia. So, how did this evolution of lovemaps occur?
One morning I was scheduled to see a young gay female who had been taking prozac for relief of depression and anxiety. She was having some problems with hair loss, probably due to the prozac. The scheduled visit was for medication evaluation and renewal. It was not for psychotherapy. However, I believed that I had established a good rapport with the patient and I decided to talk about "lovemaps." I explained that in my own life, I was aware that changes had occurred from the age of 6. I inquired about the patient's experiences. From the expression on the patient's face, I knew immediately that I had made a mistake. The right thing to have done at that point was to immediately grab my supervisor to try to right the ship. Instead, I just clammed up and wrote the prescription for prozac.
A few weeks later, I received a copy of a letter that the patient had written to the Department of Psychiatry. She apparently believed that I was confiding to her that I was a pedophile and related her recollections of our prior meeting.
Naturally I was mortified. I went to see Peter Thompson. He was wonderful.
"Eric. Everyone in psychiatry has a letter like this in their file. It happens to everyone. It is one of the principle reasons that you go through training programs."
A year later, I managed to get small monograph published, The Difficult Patient. Peter Thompson was the only faculty member who congratulated me on the accomplishment.
The Wonders of New Mexico
I loved my time in New Mexico--the scenery, the history, the culture, and the food--particularly the food. One can go to any little town in New Mexico and eat like a king. The New Mexico question is "Red or Green?" This refers to your preference to green chile or red chile.
Hatch, New Mexico is the chili capital of the world.
http://en.wikipedia.org/wiki/Hatch,_New_Mexico
In the autumn, thousands head out from Santa Fe and Albuquerque to Hatch to gather their chilis for the year, bushels of green chilis of different heats. There is a method for measuring the heat of various types of peppers.
http://en.wikipedia.org/wiki/Scoville_scale
In the autumn, large chili roasters can be found in the parking lots of many supermarkets in Albuquerque. The smells are wonderful. The roasted product is taken home, peeled, and frozen in order to provide the next year's supply of the base material for so many New Mexico dishes.
Used Cars
One of the pleasures of New Mexico was used car hunting. When I first moved to New Mexico, the independent Volvo mechanic called over his two employees to show them what happened to automobiles on the east coast. The rust was amazing to them. The dry climate of New Mexico preserved the past. Along Coors Boulevard on the West side of the Rio Grande there were a couple of areas where cars were parked with "For Sale" signs. I was an enthusiastic follower of this market. During my time there I bought a 1978 4 cylinder Toyota truck for Brian and a 1980 Celica Supra for Keith. I traded one Volvo to my mechanic for work done on the other car and purchased a used Acura Legend with 150,000 miles for about $3000 that I drove for three years. I still miss looking at the used cars.
The Next Step
As the second year of my psychiatry residency wound down, I had to begin to think about my own plans after residency. Much as I liked New Mexico, it would be a hard place to make a living. Almost all psychiatrists ended up in the larger cities, Albuquerque, Santa Fe, and Las Cruces. Salaries were low and there were service taxes for those attempting to work on a fee-for-service basis.
At the time that I had begun looking for a residency, I had thought to return to the Eastern Shore of Maryland and to join the group that included the psychiatrists that I had worked with in the prison.
However, while a resident in New Mexico, I had the opportunity to observe psychiatrists interacting with patients who were felons or standing trial. It appeared that the physicians accepted many statements at face value with very little work exerted to expose weaknesses in the stories. Having spent years dealing with inmate medical complaints in prison, I knew that was terribly naive.
One of my psychotherapy supervisors, John Lauriello, M.D. suggested that I consider "forensic psychiatry" as a career. Forensic psychiatry is the intersection between psychiatry and the legal system and issues such child welfare, competency to stand trial, not guilty by reason of insanity, capacity to handle one's affairs, etc. John told me that Atascadero State Hospital inc California paid a very good salary for those who decided to spend a year training there in Forensics.
When I went to the California map to find Atascadero, California, I was suprised to find that it was within about 15 miles of San Luis Obispo. Curiously, I had spent time there on New Years Day 1995. While living in New Mexico, I decided to spend Christmas 1994 in San Francisco. I got a good price on a great hotel for a week and headed that way. Unfortunately, I had recently traded in my Prozac for Venlafaxine, a relatively new antidepressant. Venlafaxine made me predictably sick each afternoon, but I had no idea of the cause. I had a great hotel room but I was not feeling well-enough to enjoy the wonderful food of China Town in San Francisco.
A couple of days prior to New Years, I started back to New Mexico. The first leg was down the coast through Monterrey and Big Sur. The tight turns in the road made my sickness worse and I checked into a motel at San Simeon in mid afternoon. It was a very mild day with a slight breeze. I'll never forget the sensuous delight of a gentle breeze through my motel room that evening. A couple of days later, I was sitting in an outdoor cafe in warm sunlight in the middle of San Luis Obispo and I was taken by the charm of this mission town.
Atascadero was only a few minutes from San Luis Obispo and only 17 miles from the ocean at Morro Bay. Beginning in the summer of 1996, I started to make arrangements to move further west to Atascadero.
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I'm beginning this on Thur 2/16.
I had my last chemotherapy, Alimta, on Friday 2/10 in Dr. Palchak's office in Arroyo Grande CA. It was a very short infusion--about an hour or so. He convinced me that the Alimta was unlikely to be the culprit from the prior round which whipped me so badly--that it was more likely to have been from the Zometa, a drug that is used to prevent bone fractures.
Dr. Palchak was right. The chemo last week was reasonably mild. On Saturday I was able to drive my RV down to the beach where Archie and I parked in the Sun and watched the activities around the Morro Rock. My friend, Bob, joined us for an hour or so.
By Sunday I was becoming more tired and out of breath. On Monday I slept for 17 of 24 hours. Tuesday was the worst day--no wind and no energy. When I awoke that morning and looked in the mirror I was shocked to see the face of death or at least the absence of life.
 |
| Some Hair is Growing Back |
These feelings and thoughts were particularly acute on Tuesday. The weather was miserable. There were scattered showers throughout the day but the rain became serious while Archie and I were in the Albertson's Supermarket Parking Lot. I have been wearing Crocs as my full-time footwear and I was concerned about slipperiness and falling, so I grabbed a grocery cart to use as my support and walker. We don't have a KFC or PopEyes in Morro Bay. The closest take is Albertson's fried chicken--really quite good. So I picked up a bag of chicken and wended my way to the self-service checkout line. The store was very crowded and all of the checkout lines were packed. The line for self-service snaked around a bit through a mass of humanity.
So, I'm waiting at the end of this crooked line and a young family of three pulls in behind me. The man and his wife appear to be in their early to mid-twenties. They have a five year old boy who is rolling around on the floor and ignoring their entreaties to do something else. Suddenly, in a loud voice, the young man points out that I am using a full size grocery cart to hold a lunch bag worth of fried chicken.
"The truth is that I'm sick. This grocery cart is my walker. It's holding me up." As I am giving this explanation, I can feel anger welling up that is directed at this blabbermouth. His eyes are opened pretty widely now and he is becoming more uncomfortable. I find that as he appears to be more frightened I feel more angry. Then he hits upon the real magic, "Why don't you calm down?"
Surprisingly, that didn't help. "Why don't you mind your own damn business!" popped right out without thought or restraint.
People are looking at us now. I'm embarrassed. Suddenly a checkout machine comes open and others in line are very quick to point it out to me. So, I go to the machine and I'm determined to demonstrate to the world that I am in control and possess complete mastery of grocery technology in my home town. I scan my chicken. I deposit my $10. My change is $6.01. Cooly I scoop up the penny. I grab the bag of chicken and leave the store and the $6.00 in bills behind!
I've spent the last two days in an effort to refinance our home mortgage to a better interest rate. For those of you who have missed such an exercise in tedium, it involves finding a ton of documents and scanning them into PDF files and then uploading the data to prospective lenders. I know I'll feel better when this is sorted out. Jasmine is working full-time and looking after me by cooking and squiring me to doctors' visits. Doing chores is a normal part of life--and we're still a partnership.
Today was my last scheduled visit for radiation to my spine for pain control. There was a timing glitch and I was asked to wait for a few minutes in a little examining room while the patient ahead of me was processed. While I was waiting, Dr. Stella walked in and was surprised to find me there. This is his medical practice and it was the first time that we had an opportunity to talk outside of a scheduled office visit. Normally I detect a little bit of an emotional distance when we meet, but there was none of that today. He asked me how I was handling all of this and I pointed out that I been lucky to have had so many teachers in the course of a life time of medical practice. He came over and shook hands with me and said that he was sorry that this was happening to me. I told him how much I appreciated all of the help with the back pain. I told him that the pain was much better but wondered if there was more that could be done to allow me to lift my left leg without pain. He pointed out that a lot depended upon the stability of the vertebrae and the amount of strong bone that remained. I enjoyed seeing him this morning when he had his guard down and we met as two people.
Albuquerque II
After my rotation on Dr. Hammond's ward, I moved over to Dr. B., one of the laziest physicians I've ever encountered. At the time, I was 51 years old, exactly one year older than the head of the department. Dr. B was in his thirties and the son of an internist. Dr. B had a very high opinion of his medical knowledge and capabilities. I only saw self-deception.
One of the perks of being in a teaching program is the ability to utilize residents and medical students to do the medical work of the hospital. In return, the attending physicians, like Dr. B., are expected to teach, to guide, to mentor. In addition to being lazy, Dr. B. was caught up in the great frauds of the era--satanic ritual abuse and dissociative identity disorders (multiple personality disorders). Dr. B always had two or three "multiple personality disorder" patients on his ward and he took a special pride in their presence. He spent a great deal of time with these patients reaffirming the "split" in their concept of self. Almost all authorities recognize that this is counterproductive or even destructive.
Sandra
Although diagnosed as having multiple personalities in 1995, the County Mental Health Program had been treating this woman for more than 15 years. The veteran nurses were quick to point out that Sandra's claim of witches' gatherings and torture had only surfaced in the past few years while she was being treated as the long-term therapy patient of one of the faculty. Prior to developing such a popular psychiatric diagnosis, Sandra had been diagnosed with Borderline Personality Disorder with self-injurious behaviors. Halloween occurred during my rotation on Dr. B's ward. Sandra was admitted as a precaution for Halloween.
With Sandra, there was evidence in her own medical records that the diagnosis had expanded from a personality disorder and that she relished the attention and control that she was able to exert as a "multiple personality."
Patient Dumping and Cobra
There were some serious administrative problems in Albuquerque when it came to mental illness inpatient care. In general, hospitals would prefer that the uninsured and poor go elsewhere for care. Otherwise, the hospital itself becomes responsible for providing the care. In the 1980s certain hospitals became quite adept at "dumping," i.e. physically transporting patients to other facilities, typically large, urban public and charity institutions. Congress responded with a bill known as "Cobra" during the mid 1980s which made dumping illegal and subject to fines. Transfers between institutions had to be cleared on both ends and data collected at the first hospital had to be provided to the second one in the path.
Although these regulations had been in effect for more than 5 years nationwide, they appeared not to have made it into general awareness in Albuquerque when it came to mental illness. While working on call at night in the mental health center it was fairly common for ambulances to roll in from other hospitals and emergency rooms without prior notice. Despite complaints to the Department of Psychiatry nothing appeared to have been done about it.
Drawing A Line in the Sand
One Friday I was working on Dr. B's ward. The other resident was either off or sick and this left me responsible for all the patients for the day. Rather than work, Dr. B. decided that he was going to give me some personal instruction in the treatment of Alcohol and Drug Abuse. He had just passed his subspecialty certification examination. (At the time it was possible for a psychiatrist to be labelled an expert in addiction medicine by paying to take an examination and passing it. The pass rates were very high. The process looked more like the exchange of a credential for a sum of money.)
Of course Dr. B's personal experience with drug and alcohol treatment was rather limited. I had done full-time work in the field for more than a year in Baltimore with opiates. While I was in Billings I had been one of the attending physicians at the alcohol detox program. (In Billings, subzero temperatures are the rule during the winter months. One cannot discharge an inebriated patient to the street in severe weather. Therefore, Billings had developed a model alcohol detox program that guaranteed anyone a bed for the night. The sleeping space was monitored by RNs and a physician arrived in the morning to re-examine the patients to minimize the risk that there were medical problems other than alcohol intoxication that contributed to the clinical picture.)
After listening to Dr. B for an hour I went back to work and he disappeared. Since I was alone, I was responsible for all the admissions, discharges, and rounds. It was very busy but doable if I could just keep plugging away at the workload.
The nursing change of shift occurred at around 3:30 P.M. and I was still very busy. The charge nurse identified a problem that she believed I needed to address promptly. I thought it was less urgent than some of what I was doing and I promised to get to it as soon as I could. She bugged me about it again and I firmly put her off again. Shortly after 5 P.M. a medical student approached me with the nurse's request--again!
Rather than just ignoring the nurse's behavior, I took it personally and read her the riot act. I'm sure my face was flushed and my voice was up and I expressed particular displeasure in her manipulation of the medical student.
Gradually my anger passed and I got back to work and walked out of the ward at about 8 P.M. instead of the more usual 5 P.M.
The following week, I was called into the office of the training director, Dr. Morrison. She wanted to know the circumstances behind my outburst. She knew that I had been seeing a local therapist and that I was taking an antidepressant. She asked me an open-ended question. "What's it like working at the Mental Health Center?"
"Generally it is okay during the day. Being on call is very difficult. I feel like I am in a 50 foot hole trying to shovel it out. Over top of me are a series of sewer pipes, each one leading from an Albuquerque hospital. At night the pipes open and it gets flooded in the hole."
"Is there anything positive about working working there?"
"Where else could I learn to create multiple personality disorder?"
This incident contributed to my reputation as a somewhat "prickly" individual.
This was reinforced a few months later when I was on call for the V.A. hospital one evening. I was paged and told that there was a young airman who needed to be involuntarily committed to the V.A. hospital for a mood disorder. I drove out to the V.A. hospital and met the young man and proceeded to do a psychiatric evaluation. The airman was irritable but not disrespectful. He was not suicidal and denied any intent to harm others. He was not gravely disabled. In short, there were no findings to suggest that he met criteria for involuntary commitment.
We began a discussion. The airman told me that his superiors were trying to create "a mental health jacket" so that it would be easier to transfer him on. He pointed out to me that if I committed him to the hospital, I would be violating his rights. He asked me not to do so.
As I thought about it, I had to agree that I didn't have a basis for committing him. As a licensed physician, I was responsible for my own medical decisions. I could not avoid responsibility by claiming that I had been ordered to do something by military authorities. I told the patient that I would have to discuss the case with superiors and that it was unlikely that I would be the physician with the final word on his situation.
I left the airman and called the faculty member responsible for the V.A. for that month and told him that I had examined the patient but could find no rationale for a commitment. The faculty member told me that the commanding officer for the base and hospital had ordered the airman committed-- and I was urged to admit the patient. I told the faculty member that it was my medical license and my judgment and that I could not oblige. I offered to remain at the hospital until some higher authority arrived to relieve me and take responsibility for the patient. I was told to go home.
The reaction among the young residents was interesting. They generally believed that it had been my duty to obey the order and saw my resistance as arrogance.
Kathryn
The case of Kathryn was one of the most blatant that I witnessed. She was a patient of Dr. B. She had a confrontation with a police officer in the parking lot of supermarket. The officer reached into her driver side window to grab her keys. As he did so, Kathryn sped away with the police officer trapped in the window for several feet. She left the parking lot and headed for the Mental Health Center with the police in pursuit.
By coincidence, Dr. B was outside the entrance to the mental health center. Dr. B, Kathryn, and the police all arrived at the same spot at about the same time. Immediately Dr. B began to address "Kathryn" as "Jane," supposedly the "bad-ass" alter and made a commitment to an immediate hospitalization for Kathryn that allowed her to avoid immediate responsibility for her actions with the police. To me it looked like Dr. B showing off to the police and choosing to be an idiot.
Teaching and Peter Thompson, M.D.
I believe that the quality of teaching in New Mexico was very good. The weakness was a lack of overall structure--we were thrown onto the DSM-III and DSM-IV, laundry lists of diagnoses and criteria. One of the rotations was the outpatient clinic at the Mental Health Center. At about 3:30 or 4:00 PM one or more faculty members would come to the clinic and begin to review the cases for the day. Whenever I was available at that time, I attended those sessions and learned a lot.
One of the teachers whom I totally misread was Peter Thompson, M.D. He arrived in Albuquerque at about the same time as I did. There appeared to be a touch of arrogance (and I'm sure that would fit me as well.) A few months later, I was assigned to the outpatient mental health service, where Dr. Thompson was in charge.
It was during this time that I had become interested in John Money's idea of lovemaps (discussed in at least one previous post). A lovemap is a guide to an individual's personal preferences with respect to sexuality and sexual expression. The fact that lovemaps were dynamic was especially stimulating. After all, at age 6 my blonde friend, Nora, was "hot." At age 51, such thoughts of "hot" would be suspicious for pedophilia. So, how did this evolution of lovemaps occur?
One morning I was scheduled to see a young gay female who had been taking prozac for relief of depression and anxiety. She was having some problems with hair loss, probably due to the prozac. The scheduled visit was for medication evaluation and renewal. It was not for psychotherapy. However, I believed that I had established a good rapport with the patient and I decided to talk about "lovemaps." I explained that in my own life, I was aware that changes had occurred from the age of 6. I inquired about the patient's experiences. From the expression on the patient's face, I knew immediately that I had made a mistake. The right thing to have done at that point was to immediately grab my supervisor to try to right the ship. Instead, I just clammed up and wrote the prescription for prozac.
A few weeks later, I received a copy of a letter that the patient had written to the Department of Psychiatry. She apparently believed that I was confiding to her that I was a pedophile and related her recollections of our prior meeting.
Naturally I was mortified. I went to see Peter Thompson. He was wonderful.
"Eric. Everyone in psychiatry has a letter like this in their file. It happens to everyone. It is one of the principle reasons that you go through training programs."
A year later, I managed to get small monograph published, The Difficult Patient. Peter Thompson was the only faculty member who congratulated me on the accomplishment.
The Wonders of New Mexico
I loved my time in New Mexico--the scenery, the history, the culture, and the food--particularly the food. One can go to any little town in New Mexico and eat like a king. The New Mexico question is "Red or Green?" This refers to your preference to green chile or red chile.
Hatch, New Mexico is the chili capital of the world.
http://en.wikipedia.org/wiki/Hatch,_New_Mexico
In the autumn, thousands head out from Santa Fe and Albuquerque to Hatch to gather their chilis for the year, bushels of green chilis of different heats. There is a method for measuring the heat of various types of peppers.
http://en.wikipedia.org/wiki/Scoville_scale
In the autumn, large chili roasters can be found in the parking lots of many supermarkets in Albuquerque. The smells are wonderful. The roasted product is taken home, peeled, and frozen in order to provide the next year's supply of the base material for so many New Mexico dishes.
Used Cars
One of the pleasures of New Mexico was used car hunting. When I first moved to New Mexico, the independent Volvo mechanic called over his two employees to show them what happened to automobiles on the east coast. The rust was amazing to them. The dry climate of New Mexico preserved the past. Along Coors Boulevard on the West side of the Rio Grande there were a couple of areas where cars were parked with "For Sale" signs. I was an enthusiastic follower of this market. During my time there I bought a 1978 4 cylinder Toyota truck for Brian and a 1980 Celica Supra for Keith. I traded one Volvo to my mechanic for work done on the other car and purchased a used Acura Legend with 150,000 miles for about $3000 that I drove for three years. I still miss looking at the used cars.
The Next Step
As the second year of my psychiatry residency wound down, I had to begin to think about my own plans after residency. Much as I liked New Mexico, it would be a hard place to make a living. Almost all psychiatrists ended up in the larger cities, Albuquerque, Santa Fe, and Las Cruces. Salaries were low and there were service taxes for those attempting to work on a fee-for-service basis.
At the time that I had begun looking for a residency, I had thought to return to the Eastern Shore of Maryland and to join the group that included the psychiatrists that I had worked with in the prison.
However, while a resident in New Mexico, I had the opportunity to observe psychiatrists interacting with patients who were felons or standing trial. It appeared that the physicians accepted many statements at face value with very little work exerted to expose weaknesses in the stories. Having spent years dealing with inmate medical complaints in prison, I knew that was terribly naive.
One of my psychotherapy supervisors, John Lauriello, M.D. suggested that I consider "forensic psychiatry" as a career. Forensic psychiatry is the intersection between psychiatry and the legal system and issues such child welfare, competency to stand trial, not guilty by reason of insanity, capacity to handle one's affairs, etc. John told me that Atascadero State Hospital inc California paid a very good salary for those who decided to spend a year training there in Forensics.
When I went to the California map to find Atascadero, California, I was suprised to find that it was within about 15 miles of San Luis Obispo. Curiously, I had spent time there on New Years Day 1995. While living in New Mexico, I decided to spend Christmas 1994 in San Francisco. I got a good price on a great hotel for a week and headed that way. Unfortunately, I had recently traded in my Prozac for Venlafaxine, a relatively new antidepressant. Venlafaxine made me predictably sick each afternoon, but I had no idea of the cause. I had a great hotel room but I was not feeling well-enough to enjoy the wonderful food of China Town in San Francisco.
A couple of days prior to New Years, I started back to New Mexico. The first leg was down the coast through Monterrey and Big Sur. The tight turns in the road made my sickness worse and I checked into a motel at San Simeon in mid afternoon. It was a very mild day with a slight breeze. I'll never forget the sensuous delight of a gentle breeze through my motel room that evening. A couple of days later, I was sitting in an outdoor cafe in warm sunlight in the middle of San Luis Obispo and I was taken by the charm of this mission town.
Atascadero was only a few minutes from San Luis Obispo and only 17 miles from the ocean at Morro Bay. Beginning in the summer of 1996, I started to make arrangements to move further west to Atascadero.
Thursday, February 9, 2012
Albuquerque and Psychiatry 1994
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medical
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It is Thursday Feb 9. I'm pain free using fentanyl patches. I have completed the course of radiation on my left ribs with good results. I'm continuing daily radiation for my spine and I'm much better able to lift my leg. My chief problem is shortness of breath. This does not appear related to the amount of lung tissue that I have remaining and is likely the result of some chemical product of the tumor itself.
Dr. Palchak has convinced me to give Alimta another try. I have moved my therapy from Stanford to a town 25 miles away and I will receive chemotherapy there tomorrow.
The weather in Morro Bay is perfect. It is about 70 degrees at 4 PM and I'm about to go sit outside and enjoy the late afternoon.
Dr. Palchak has convinced me to give Alimta another try. I have moved my therapy from Stanford to a town 25 miles away and I will receive chemotherapy there tomorrow.
The weather in Morro Bay is perfect. It is about 70 degrees at 4 PM and I'm about to go sit outside and enjoy the late afternoon.
Albuquerque and
Psychiatry 1994
In June 1994 I
moved from Pocomoke City, Maryland to Albuquerque, New Mexico to begin a
residency in psychiatry at the University of New Mexico. In the five
months prior I had made three trips from the East Coast to New Mexico--to sign
a contract for a house, to do an inspection on the construction, and to move a
car and a few belongings into storage.
It had been 24
years since I had completed my internship--my last formal year of medical
training. I was to begin as a second year resident in psychiatry on July
1, 1994 and the program length was three years. I had always been curious about
the Southwest and had looked forward to an opportunity to live in the region
since the 1950s and 1960s when my Uncle Earl worked as a hospital administrator
for the Indian Health Service. Normally he was stationed in Washington, D.C.,
but when he returned from Albuquerque, he had gone native with the cowboy
boots, the Stetson had, the Indian String ties, and the Turquoise watch band.
Cool!
Perhaps the best decision in my life was to return to a training program in my early fifties. When I had started medical school in 1965, one of my instructors was a psychiatry resident who was 65. He had been a family physician in Frederick Md for more than 30 years. He radiated happiness and enthusiasm. After starting my retraining, I had many wonderful experiences both medical and life experiences. I also learned quite a bit about myself including my interpersonal scripting that had guaranteed problems in relationships with women. Mostly, it was an opportunity to learn by reading and doing. Perhaps the most important force was exposure to the young and really listening to their various takes on the practice of medicine.
Perhaps the best decision in my life was to return to a training program in my early fifties. When I had started medical school in 1965, one of my instructors was a psychiatry resident who was 65. He had been a family physician in Frederick Md for more than 30 years. He radiated happiness and enthusiasm. After starting my retraining, I had many wonderful experiences both medical and life experiences. I also learned quite a bit about myself including my interpersonal scripting that had guaranteed problems in relationships with women. Mostly, it was an opportunity to learn by reading and doing. Perhaps the most important force was exposure to the young and really listening to their various takes on the practice of medicine.
The usual general psychiatry residence programs in the United States require four years of training
before completion. Each of these four years is a "Post Graduate Year"
(PGY). The first year of training is called PGY-1, the second year is PGY-2,
etc.The program at New Mexico promised to get me out of training and back to
work in 3 years by giving me one year credit for my internship of a quarter
century before. I was expected to begin at PGY-2 level rather than PGY-1.
Although the pay
for residents was very bad, about $30K per year, the cost of living in
Albuquerque was moderate. The climate was wonderful. Although I was not used to
spending so much time at temperatures over 100 F, Albuquerque at a mile
altitude, is very dry, and there is generally a little bit of a breeze. I found
that I was almost always comfortable in open shade on the hottest of days.
The low humidity
enabled general use of evaporative cooling for the house and eliminated the
need for expensive air-conditioners on all but 5 to 7 days a year. So utility
bills were reasonable as well.
I was joining an
existing group of residents--primarily the first year residents who had begun
their postgraduate training the prior year--1993. I believe that three of us
were new, one of whom was Roger O, an internist a few years younger than
myself. By coincidence, Roger had practiced in Montana at Butte. Roger and I
are still in touch. He is also struggling with Stage IV Adenocarcinoma of the
lung. I had been attempting to visit him around the time I received my own bad
news.
A week before the
year was to begin, a camping trip scheduled for all newly arriving psychiatry
residents. Most of these folks were the incoming PGY-1 folks, fresh from
graduation from medical school. So, my first contacts with the program were
with these youngest members, a very lively and diverse group. The camping site
was near Los Alamos. The days were spent hiking and exploring Bandolier Park
with cliffside Native American dwellings of the past. As we hiked and camped we
were given an orientation to the residency program.
A big change
for me over the next three years was an enormous increase in the amount of
walking that I did on a daily basis. The parking lot was quite a trek from the
County Mental Health Building. In the evenings I began walking a few miles several
times a week on the mesa west of town, not too far from my house. Hiking
was wonderful in New Mexico. There was a lot of insensible sweat loss which
meant personal evaporative cooling and a sense of coolness. However, the water
loss has to be replaced and ongoing hydration was important.
Albuquerque is
situated at about 1 mile in altitude. The Rio Grande River runs from North to
South through the town. A few miles east of the river, the Sandia Mountains
rise to over 10,000 feet and most of the population of the city lives between
the mountains and the river. On the west side of the river stretches a long
mesa, often depicted in the cable TV show, "Breaking Bad." There are
five small volcanic cinder cones easily visible and running in a line north-south
parallel to the direction of the river.
I purchased a
little house on the West Side of the River. I built a little ramada in my back
yard which had excellent views of downtown and the Sandia Mountains. I spent
many evenings relaxing in my yard watching the Sandia (Sp. watermelon) turn colors during the sunset. Then, at nightfall, I could see the lights
of the tram as it ran up and down the mountain at the North of the city.
The Bernalillo
County Mental Health Center
The county mental
health center was located on the campus of the University of New Mexico and it
was the primary teaching center for the department of psychiatry. There were 4
wards for inpatients including two adult wards, an adolescent ward, and a
geriatric unit. In addition to the inpatient units, there was a psychiatry
emergency room that was open 24 hours a day, and several interview and
conference rooms for outpatient work. Finally, there was office space for some
of the faculty. The Department of Psychiatry had several other teaching assets,
including a Children's Hospital, and a main office building that housed much of the
faculty and residents' offices.
My first rotation
was on the adult inpatient ward of the County Mental Health Center. The usual
census was about 20 patients and the turn-over was fairly rapid. The purpose of
inpatient treatment was stabilization so that treatment could continue outside
of the hospital within the patient's general living situation.
The day started in
the Mental Health Center with a staff meeting scheduled for 8 A.M. during which
all of the admissions since the end of the last work day were reviewed. Each
ward had an "attending psychiatrist" and two assigned residents.
Frequently there were medical students assigned to a ward. All were expected to
attend the morning meetings--generally up to 20 participants.
The morning meeting exposed me immediately to a different concept
of time prevalent in New Mexico. Some of my
friends described it as the "mañana" syndrome, where any specific mention of time
is only a suggestion. The meeting seldom started before 8:10 and occasionally
started as late as 8:20. Some of us out-of-staters were quick to point out that
some of this thinking applied to New Mexico driving habits as well. For
example, the yellow light at an intersection meant to speed up rather than try
to come to a safe stop. We also noted that the common practice of entering an
intersection immediately after the light had changed to red was frequently practiced in Albuquerque under to the dictum of
"fresh red." Our resident Judy complained that the natives used bread wrappers and rope rather than trailer hitches to attach their trailers to the vehicles.
The Locked Ward and Violence
My previous experiences on a locked psychiatric ward occurred in medical school, more than 25 years prior. Then, as a student, I did not have keys to the doors. In Albuquerque we were issued keys to the wards on the first day of residency.
In medical school, I had been assigned to a rather laid-back locked ward and never saw any violence. Things were much rougher in Albuquerque. People were committed from the street with a variety of problems, from acute drug withdrawal to severe paranoia. The staff of nurses and psychiatric technicians were expected to use listening skills, medications, and force if necessary to maintain safety within the ward.
I drew call duty for the county mental health center on the first weekend of July. I was responsible for emergency visits and admissions of patients from Friday night until Monday morning. As I recall things were hopping. Charles, a patient with severe bipolar disease, had been brought to the hospital by police after they arrested him on a golf course where he was trying to run people down with his Toyota truck. While the police were there during his admission interview, Charles had permitted one dose of medication. But after the police left, he refused to continue it. He was scary, being a very large, strong young man who was paranoid and isolating himself in the bathroom. Early Saturday evening, he stripped naked and remained in the bathroom lathering up his body. He was yelling and screaming curses at the nursing staff and daring them to attempt to restrain him.
The nursing staff had to do something about "slippery" Charles. They called for backup and used a mattress to contain him to the point where they could apply restraints. His attempts to punch staff made him a "danger to others" and an immediate candidate for chemical intervention.
The Locked Ward and Violence
My previous experiences on a locked psychiatric ward occurred in medical school, more than 25 years prior. Then, as a student, I did not have keys to the doors. In Albuquerque we were issued keys to the wards on the first day of residency.
In medical school, I had been assigned to a rather laid-back locked ward and never saw any violence. Things were much rougher in Albuquerque. People were committed from the street with a variety of problems, from acute drug withdrawal to severe paranoia. The staff of nurses and psychiatric technicians were expected to use listening skills, medications, and force if necessary to maintain safety within the ward.
I drew call duty for the county mental health center on the first weekend of July. I was responsible for emergency visits and admissions of patients from Friday night until Monday morning. As I recall things were hopping. Charles, a patient with severe bipolar disease, had been brought to the hospital by police after they arrested him on a golf course where he was trying to run people down with his Toyota truck. While the police were there during his admission interview, Charles had permitted one dose of medication. But after the police left, he refused to continue it. He was scary, being a very large, strong young man who was paranoid and isolating himself in the bathroom. Early Saturday evening, he stripped naked and remained in the bathroom lathering up his body. He was yelling and screaming curses at the nursing staff and daring them to attempt to restrain him.
The nursing staff had to do something about "slippery" Charles. They called for backup and used a mattress to contain him to the point where they could apply restraints. His attempts to punch staff made him a "danger to others" and an immediate candidate for chemical intervention.
Dr. Hammond's Ward
I was fortunate to do my first rotation under Lee Hammond, M.D. a bright, sensitive, quiet and competent psychiatrist. He was self-deprecating and spent some of his free time working with the homeless mentally ill at the Salvation Army. He was a very trim man, not an ounce of fat and apparently able to wear the same clothes that he used in college. His pants had a slight flair at the bottom and he wore short sleeved shirts with a tie. His particular academic interest appeared to be neuronal migration and the neuropathology of schizophrenia. I don't recall his specific title but he was acknowledged as the chief of the inpatient services. He was very quiet but the wit would shine through at times in conversation.
I particularly enjoyed watching him begin to establish a diagnosis for new admissions. There are two particular incidents that I recall--I think of them as "birds of a feather" and "he wouldn't have been able to keep the secret."
Birds of A Feather
You might be surprised that an inpatient mental health unit would be of any interest to people without mental disorders. However, it was very common for there to be one or two people on the ward who were hiding from police in the sense that they were avoiding questioning.
There were also addicts and alcoholics who were not interested in specific programs for addictions, but wanted the 24 hour support from an inpatient hospitalization to dry out or detox or even to avoid detoxification. They would generally present as the "suicidal addict," claiming to need help to prevent them from giving in to their overwhelming desire to kill themselves. It was common for their behavior to be motivated by drug seeking.
There were also patients who were totally overwhelmed by their life situation and who lacked the emotional and problem-solving resources to overcome their circumstances. Some of these were too afraid to consider the use of shelters or food lines and preferred the security of an inpatient facility. Sometimes these patients were the ones who would resort to cutting on themselves if not admitted.
The diagnoses were generally sorted out pretty quickly, but some of the difficult cases were the patients whose behaviors were particularly impulsive and self-destructive. For these patients one had to consider severe mood and anxiety disorders as an alternative or accompanying diagnosis.
Dr. Hammond pointed out to us that patients often sorted themselves out by diagnoses. He noted that the two refugees from the criminal justice system were spending their free time together as were many of the patients with personality disorders. It was a lesson that has been useful to me for many years.
He Wouldn't Have Been Able to Keep the Secret
He Wouldn't Have Been Able to Keep the Secret
Kenny was living on social security disability for mental illness. He had a history of many acute hospital admissions for psychosis. During these episodes, he would be stabilized on a medication for his psychosis and eventually released whereupon he would avoid further treatment.
He had been living in a motel in downtown Albuquerque. One day the landlord entered Kenny's room because of a complaint of noises. The room contained 40 tires that had been patiently gathered from around town. In addition there was a large quantity of uneaten and spoiled food neatly stacked in containers around the baseboards of his room. Kenny was very agitated, was screaming at the landlord, and he continued screaming at the two policeman who had been called to the scene.
Kenny was brought to the Bernalillo County Mental Health Center. He was heavily sunburned. His lips were fissured and cracked. He weighed 20 lbs less than on a hospitalization the previous year.
In the first few days after Kenny's arrival, the staff engaged in discussions about his underlying illness. Was it a bipolar disorder with psychosis or was it schizophrenia? If it was bipolar disorder, a drug like Lithium of Depakote was indicated in addition to whatever was required for his psychosis. If the illness was Schizophrenia, he would likely improve with anti-psychotic medications and have no need for the Lithium.
Dr. Hammond's belief was that he was schizophrenia. His argument had to do with the nature of bipolar illness and its effect on relationships. A manic patient is often "intrusive" and may take liberties with the social space of others with unwanted touching or invasion of personal space or the revelation of secrets. Dr. Hammond pointed out that Kenny had managed to bring 40 tires into his hotel room without anyone being the wiser. Since a manic patient was unlikely to be able to manage such a task without telling several people about it, it was more likely that Kenny was best labelled as Schizophrenia.
Kenny and Close Enough
Finally, Dr. Hammond intervened on my behalf in the treatment of Kenny. Kenny had been committed to the hospital with a condition called "grave disability." This leads us into a little discussion of the criteria for "involuntary hospitalization."
In order to take away the right to freedom of movement and to place an adult in a mental hospital, there must be a demonstrable of probable cause that one of the following risks is present:
In the first few days after Kenny's arrival, the staff engaged in discussions about his underlying illness. Was it a bipolar disorder with psychosis or was it schizophrenia? If it was bipolar disorder, a drug like Lithium of Depakote was indicated in addition to whatever was required for his psychosis. If the illness was Schizophrenia, he would likely improve with anti-psychotic medications and have no need for the Lithium.
Dr. Hammond's belief was that he was schizophrenia. His argument had to do with the nature of bipolar illness and its effect on relationships. A manic patient is often "intrusive" and may take liberties with the social space of others with unwanted touching or invasion of personal space or the revelation of secrets. Dr. Hammond pointed out that Kenny had managed to bring 40 tires into his hotel room without anyone being the wiser. Since a manic patient was unlikely to be able to manage such a task without telling several people about it, it was more likely that Kenny was best labelled as Schizophrenia.
Kenny and Close Enough
Finally, Dr. Hammond intervened on my behalf in the treatment of Kenny. Kenny had been committed to the hospital with a condition called "grave disability." This leads us into a little discussion of the criteria for "involuntary hospitalization."
In order to take away the right to freedom of movement and to place an adult in a mental hospital, there must be a demonstrable of probable cause that one of the following risks is present:
- danger to self
- danger to others
- grave disability
In the case Kenny, he was not threatening others or self. However, his sunburn and dehydration indicated that he was not paying much attention to his physical well-being. The spoiled food in his room buttressed this argument and demonstrated that he was not able to utilize food in a safe fashion. He was judged to have "grave disability" and he was placed on a mental health "hold," a commitment to a psychiatric facility based upon sworn affidavits from two mental health professionals. This "hold" provided the legal basis for placing him in the locked facility. Within a few business days he would have a judicial hearing where a the judge would listen to testimony and decide whether Kenny could be held involuntarily for 90 days.
Although patients could be held in the hospital involuntarily for several months, an initial court order for commitment did not allow psychiatrists to administer psychotropic medications over the objections of the patient unless there was imminent danger to self, to others, or grave disability--our familiar criteria.
In the case of Kenny, his admission to the hospital itself had relieved the grave disability. He was being fed three times a day. The sun wasn't shining inside the hospital. Although he attempted to hoard food in his hospital room, the nurses kept cleaning it out.
Kenny was an imposing man. He was about 300 lbs. He was agitated, loud, and religiously preoccupied. He paced the halls at night and got less than 3 hours of sleep at night. His speech was rapid and there was a flight of ideas. He sometimes "dogged" nursing staff and made them nervous.
Kenny was assigned to me as a patient and I was not getting anywhere after a week or so. One afternoon he became increasingly religiously preoccupied and more argumentative when I tried to change the subject. He walked up to me and shouted "My god is going to blind you and kill you!"
Dr. Hammond heard him and ordered the staff to medicate Kenny.
Kenny knew the law pretty well: "I didn't say I would do it. I said my God would do it."
Dr. Hammond: "That's close enough!"
Saturday, February 4, 2012
Status Report February 4
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medical *
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On Thursday I visited Dr. Palchak my local oncologist who practices out of an office in Arroyo Grande, about 25 miles down the coast from Morro Bay. He has been very helpful right along. He was aggressive in persuading me to begin radiation of my my ribs and spine for pain and he has always been straight forward with providing information.
I am a big believer in finding the most experienced, cutting edge physicians and facility for any "bad" illness. I've spent most of my professional life in rural settings. Practice makes perfect. In general, I want the surgeon who has done two hundred procedures rather than the surgeon with ten under his belt. With bad illnesses, I'll opt for the large center that is specialized for the treatment of that particular disease entity. It also makes sense to go there from the start. I was particularly fortunate. Within an hour or two of the CT that showed my tumor, I had an appointment with the thoracic oncology service at Stanford for the 2nd business day.
In my previous posts, I have provided an accurate picture of the wonderful treatment that I have received to date at Stanford and I have been particularly pleased with Dr. Neal.
However, my tumor has not responded to the chemotherapy in the hoped-for manner and the disease is progressing as indicated by the increase in bone destruction from metastases. I have related the very miserable time since my last chemo round and my thoughts about abandoning chemotherapy.
Finally, Stanford is 200 miles away and treatment there is a 14 hour day when the drive is considered. Dr. Palchak is 30 minutes away and treatment done here will be much easier.
The bottom line is that I've had the advantage of treatment at the Mecca (Stanford) and it seems to have made little difference to me physically. However, I am secure in the knowledge that I have received top-notch care and that my failure to respond has nothing to do with the quality of my care and everything to do with the fact that I have a tumor that is minimally responsive or non-responsive. So, I have no residual doubts about my medical care having failed me.
In addition to close proximity by car, Dr. Palchak appears to be in his early 50's. Dr. Neal is in his mid to late 30's. I think it would be hard to find anyone more knowledgeable than Dr. Neal about the science that is being applied in my case. However, I have reached the point where science must take the back seat to my end of life considerations and preparations. So, I want to tap into Dr. Palchak's many years of experience with patients who fail chemo or have particularly difficult times.
I saw him Thursday morning. He reviewed my case and examined the most recent CTs. He was very surprised that I had such a difficult time with Alimta, particularly in view of the mild previous round. However, when we reviewed the medications, I also received Zometa on my last visit to Stanford. Dr. Palchak pointed out that this could have been the real culprit.
So, on Thursday I walked into Dr. Palchak's office expecting to stop the chemotherapy. I walked out agreeing to repeat the Alimta for another cycle on February 10.
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psychological *
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Yesterday I was chopping some onions and dropped a scrap on the floor. I knelt down to pick it up and found that my leg strength was barely sufficient to get me back up. As I look at myself in the mirror I see the loss of muscle mass in my arms and legs. The cancer is consuming me from the inside. I will need to be much more careful about walking because I'm not so confident about being able to get up from a fall.
People are aware of my sickly appearance. I catch them glancing at me sideways. Some smile warmly and even joke at one of my hats that has fake hair. Most pretend to see nothing.
I know that Jasmine is under a lot of stress. She works full time and has been ferrying me back and forth to my appointments. While I am getting radiation to my bones, I have to appear daily at 8:45 A.M.
She never complains. "It's a chance for us to spend time together."
So, I am more aware of things slipping away. For most of my life, the practice of medicine was an essential central theme and provided a sense of meaning. Today I am looking at the renewal paperwork for my medical license in California. Do I want to spend $800 to renew it for another two years?
Thursday, February 2, 2012
Radiation for Pain
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medical *
************
Thur Feb 2. I am becoming even more comfortable pain-wise as my radiation oncology treatments continue. I've had three requests to explain more about this option and so this post will be of a more general nature.
General versus Local Analgesia
When I swallow morphine for chest pain, the morphine will enter my bloodstream and be available to all parts of my body. This is an example of a "general analgesic."
If I go to the dentist who injects novocaine into my lower jaw so that he can do a root canal, the novocaine is being used to block the nerves around the tooth in question--"local analgesia."
In the case of my cancer, it has spread to my bones--both my ribs and my spine. The rib pain has been around since October. The back (spine) pain had been gradually increasing for several weeks until I reached the point a couple of weeks ago where I was unable to lift my left leg without pain in the back.
Since October, I had been managing my pain with the drug Oxycodone and its long-acting form, Oxycontin. Up until New Years weekend, I had been making do with about 50 to 60 mg of oxycodone a day. Suddenly my pain increased markedly to the point where 120 mg of oxycodone was not controlling the pain. At that time, I was put on fentanyl patches. These patches release a steady stream of the morphine-like drug, fentanyl. Although the fentanyl did control the chest pain and did help with the back pain, I was experiencing weakness in my left leg. Pain control did not help with the weakness. Here is an image from a CT of my abdomen in December.
The CT of the Lumbar Spine from December shows a lot of old degeneration--I've had disk disease and intermittent episodes of back pain for almost 30 years. The Lumbar vertebrae are labeled from L1 to L5. In the middle of the L spine, there are two vertebrae where some of the bone outlines have "disappeared." They are labelled L2 and L3. (This may be an error on my part...they may be L1 and L2). However, the essential point is that part of these vertebrae appear to have been replaced by something else...the something else is tumor.
medical *
************
Thur Feb 2. I am becoming even more comfortable pain-wise as my radiation oncology treatments continue. I've had three requests to explain more about this option and so this post will be of a more general nature.
General versus Local Analgesia
When I swallow morphine for chest pain, the morphine will enter my bloodstream and be available to all parts of my body. This is an example of a "general analgesic."
If I go to the dentist who injects novocaine into my lower jaw so that he can do a root canal, the novocaine is being used to block the nerves around the tooth in question--"local analgesia."
In the case of my cancer, it has spread to my bones--both my ribs and my spine. The rib pain has been around since October. The back (spine) pain had been gradually increasing for several weeks until I reached the point a couple of weeks ago where I was unable to lift my left leg without pain in the back.
Since October, I had been managing my pain with the drug Oxycodone and its long-acting form, Oxycontin. Up until New Years weekend, I had been making do with about 50 to 60 mg of oxycodone a day. Suddenly my pain increased markedly to the point where 120 mg of oxycodone was not controlling the pain. At that time, I was put on fentanyl patches. These patches release a steady stream of the morphine-like drug, fentanyl. Although the fentanyl did control the chest pain and did help with the back pain, I was experiencing weakness in my left leg. Pain control did not help with the weakness. Here is an image from a CT of my abdomen in December.
 |
| Sohr L Spine Dec 2012 |
Up until two weeks ago, I was treating my lumbar spine "generally" by taking oxycodone and then fentanyl. However, the pain was continuing to increase and there was an associated weakness in my leg muscle because of the tumor's presence in this area. At that point, I elected to try a local treatment, radiation to my Lumbar spine.
General Principles
Tumors generally multiply faster than ordinary tissues. While cells are multiplying (by dividing) they are very sensitive to radiation, like x-rays. Treatment with direct x-ray tries to deliver enough radiation to the tumor to kill it but not enough radiation to kill the surrounding tissue. You can see where this is tricky. In my case, I want radiation to the bony spine, but I want to minimize radiation to my spinal cord. One way of accomplishing this is to find two pathways to the area to be treated.
The high energy beam x-ray machine fills a room. There is a brownish colored cabinet to the rear of the machine which contains electric motors and controls.
This is the actual machine being used for my treatment.
The front part of the machine is shaped like a block letter C. The top stem of the C is the "gun" that delivers the x-rays. It is labelled "VARIAN" in the picture. The entire "C" rotates 360 degrees so that radiation can be delivered at any angle. The patient remains stationary on the table and this enormous x-ray machine rotates about.
The high energy beam x-ray is too powerful for decent imaging. Above Dale's head there is another x-ray gun that generates low energy rays for imaging.
On my first visit, about an hour was spent aligning my body to the table and to the machine. Several low energy x-rays were taken to hone in on the treatment window--the precise area of the body where the x-ray was to be delivered. Once this was identified, I received a series of tattoos that permitted a much more rapid alignment in the future.
With my current visits, I am placed on the table. The tattoo marks on my chest and abdomen are used to make sure that I am properly aligned to the table and machine. Then a low beam x-ray is taken to demonstrate that the treatment portal is accurate--this is the second check on location. For my spine treatment, I am given about 30 seconds of high energy radiation from the front. Then the machine is rotated 180 degrees and I receive a similar dose from the back. By splitting the total dose into two segments, the surrounding tissues are spared 50% of the dose while the treatment area is treated twice.
These treatments are working very well. I have much better leg mobility than 2 weeks ago and much less pain as well.
---------------------
Later this morning I have an appointment with Dr. Palchak. I am hoping to use his experience and wisdom to lay out a reasonable treatment plan for the next month or so.
Tumors generally multiply faster than ordinary tissues. While cells are multiplying (by dividing) they are very sensitive to radiation, like x-rays. Treatment with direct x-ray tries to deliver enough radiation to the tumor to kill it but not enough radiation to kill the surrounding tissue. You can see where this is tricky. In my case, I want radiation to the bony spine, but I want to minimize radiation to my spinal cord. One way of accomplishing this is to find two pathways to the area to be treated.
 |
| High Energy Beam X-Ray Machine |
This is the actual machine being used for my treatment.
 |
| Adrienne and Dale who do my treatments each morning. |
The high energy beam x-ray is too powerful for decent imaging. Above Dale's head there is another x-ray gun that generates low energy rays for imaging.
On my first visit, about an hour was spent aligning my body to the table and to the machine. Several low energy x-rays were taken to hone in on the treatment window--the precise area of the body where the x-ray was to be delivered. Once this was identified, I received a series of tattoos that permitted a much more rapid alignment in the future.
With my current visits, I am placed on the table. The tattoo marks on my chest and abdomen are used to make sure that I am properly aligned to the table and machine. Then a low beam x-ray is taken to demonstrate that the treatment portal is accurate--this is the second check on location. For my spine treatment, I am given about 30 seconds of high energy radiation from the front. Then the machine is rotated 180 degrees and I receive a similar dose from the back. By splitting the total dose into two segments, the surrounding tissues are spared 50% of the dose while the treatment area is treated twice.
These treatments are working very well. I have much better leg mobility than 2 weeks ago and much less pain as well.
---------------------
Later this morning I have an appointment with Dr. Palchak. I am hoping to use his experience and wisdom to lay out a reasonable treatment plan for the next month or so.
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