Thursday, April 20, 2006

MRI and other torture devices

I never thought I had issues with claustrophobia. I've been in some pretty small places for extended periods of time with no adverse effects. They had to wake me after my PET scans (both of them). I was a Cub Scout den leader for a total of 6 years, so it certainly can't be the volume that got to me. I think it was the pitch - one particular pitch, a pitch that even determined Cub Scouts can't quite manage.

Lack of confidence in the tech didn't help either.

"Does this" she said, indicating inch high red letters stating LATEX ALLERGY, "mean that I need to find some different gloves?"

It was all I could do not to say "Well duh!" Instead I said "Maybe I should just get out my Epi-pen now." She got the gloves.

"Ok, lie down on the platform and put your head in the cradle. We'll be putting a helmet on your head."

It's not exactly a helmet, folks. It's more like a cage. With bars. VERY close to your face.

The first scan took 20 minutes.

The first 18 minutes wasn't too bad. I made the mistake of opening my eyes on the way in. Bad idea.

After that, I kept my eyes closed and focused on breathing. In. Out. In. Out. In. Out. Slower. Slower. Don't hold your breath.

It wasn't too bad until the frequency of the sounds changed, along with the vibration around and under me, I experienced about 2 minutes of sheer panic. There was an overwhelming urge to scream. I'd been warned not to lick my lips. The only thing that kept me from screaming was fear that they'd have to repeat the whole thing if I did.

The tech didn't plan to pull me out between the first and second scans. She just wanted me to stick out my arm so she could inject the contrast. We compromised. I didn't move, but she hauled me out so I could open my eyes and look at the ceiling until I stopped hyperventilating. THEN I stuck out my arm and let her inject the contrast.

Other things I wish I'd known: as with many types of contrast, this one caused an odd metallic taste sensation. It passed within a few minutes, but I hadn't expected that and it was disturbing. It also made my tongue feel thick - but only briefly. That's scary when you're deep in a narrow tunnel and can't even talk because talking would mess up the scan.

Oh and the scan was essentially normal. A few "age-related" scattered ischemic areas, but aside from that, nothing to worry about. Back to the ENT for the diagnosis which is.......Meniere's

Could be MUCH worse. This is treated with diuretics (but I don't tolerate the drug of choice) and a low sodium diet. I whined at first, but since I haven't had any episodes of vertigo since I started cutting back on sodium, I've decided I need to give that up.

A friend helped me locate some low-sodium cottage cheese - funny what you miss when you're told you can't have it. Now if I could just find a low-sodium Caesar salad dressing to go with that, I'd be really happy. Recipes appreciated.

Tuesday, April 18, 2006

Grand Rounds

Grand rounds are up at Fat Doctor She's done a terrific job of organizing and all the links work. I'm impressed, but not surprised.

Thursday, April 13, 2006

IV sites

The largest, most stable veins in infants are in the scalp. Lots of babies are virtually bald, too, making those veins even more inviting when you’re looking for a place to put the IV that your tiny patient needs RIGHT NOW. Unfortunately, parents often find scalp IVs rather intimidating. This leads to somewhat less than positive interactions at times. Usually the parents will take my word that it not only is in the baby’s best interest, but that there really isn’t another option. Other times, I’m just as happy to leave those discussions to the physicians.

One night I was called to the pediatric unit to place an IV in one of their smaller patients. The only veins I could find were in the scalp. The patient’s nurse wanted to ask the mom’s permission prior to placing the IV in the scalp. I’m generally in favor of involving parents in decisions – when it’s appropriate. This time there was only one acceptable answer. No point in presenting options that don’t exist. Mom didn’t seem upset when I explained why I had chosen that scalp vein and assured her that it wasn’t causing the baby any pain. I headed back to the NICU and missed Act Two in which the baby’s father arrived and demanded that we “take that needle out of my baby’s brain.” He wouldn't listen to the baby’s nurse, but the pediatric resident was able to convince him that it 1) wasn’t in the brain, and 2) wasn’t coming out until the baby was better hydrated.

Sometimes we have issues in the NICU too. The day shift nurse had placed the scalp IV in my patient. Mom and grandfather had been in and had seen it. Nobody said anything to the day shift nurse, so we were caught off guard when mom phoned that evening. Fortunately for me, one of my favorite pediatric surgeons happened to be making rounds on his NICU patients when mom called. He asked to speak with her and she apparently passed the phone to her father. This is the half of the conversation I heard:

“Actually, there’s no needle, just a flexible tubing.”

“No, it’s not in the brain.”

“The skull and some tough membranes are between...”

“Those veins are the largest and most stable veins. The IV will stay in longer there.”

“I told the nurse to put the IV in the baby’s head”

“When my grandson had surgery, I insisted that they put the IV in his head.”

I don’t know if his grandson ever had surgery, but this seemed to be the answer that satisfied the baby’s grandfather as the conversation went on from there to other details of the baby’s condition. The statement that most impressed me was his claim that he had told the nurse to put the IV in the head. I doubt he’d had any such conversation, although he would have if she thought she needed to ask. We loved him because he cared for his patients so much – but also because he made the nurses feel like a valued part of the team. He has since retired. I am happy for him, but we all miss him.

Tuesday, April 11, 2006

Sometimes it's not what you say.....

Last Wednesday I saw the ENT about those vertigo episodes I mentioned. Interspersed within the following condensed conversation, there was discussion of history, symptoms, etc, but note the focus.

Dr. M: The ENG report is basically normal. So how long has it been since you've had an eye exam?

Me: About a year, I think. (Thinking "About time to call the doctor, I suppose")

Dr. M: You really should have an eye exam. (looks at report again). How long did you say it's been since you had your eyes examined?

Me: A year. No, wait, I fell down twice in 3 days last fall and thought it was because of my bifocals, so I went to one of those optical places to get some plain distance vision glasses for walking. I had an eye exam in October. (Thinking: "OK, I'll call tomorrow and see my regular Optometrist.")

Dr. M: Well, I think you really should have your eyes examined again. We'll get an MRI of your head to make sure there's nothing wrong in your ears that we've missed, but I think everything is fine. Here's the order

Me: Couldn't hurt. (Wondering now if I should call the Optometrist I've been seeing or make an appointment with an Ophthalmologist)

Dr. M: Let me see that a minute (takes the MRI order back and writes "To be read by Neuro radiologist only". Underlines Only. Twice. Then hands me the chart to carry out to the desk)

OK, so what would you do? The ENT told me 3 times in less than 5 minutes that I needed an eye exam even though I'd had 2 in just over a year. Me? I flipped open the chart on the way out and read the ENG report. I don't pretend to understand those things, but under "impressions" the words "potentially ophthalmic/retinal in origin" leapt out at me.

Then I did what any self-respecting hypochondriac would do. I called the nearest internationally reknowned eye center and made an appointment for the following Monday.

The eyes are normal. The Ophthalmologist at the internationally reknowned eye center was very understanding. He didn't snicker once. He was VERY reassuring, but I have a feeling that when he wrote down the chief complaint it went something like this:

"Acute hypochondria, exacerbated by referring physician."

So is there a tactful way to tell the ENT he needs to tone down his style a little? I understand that some patients need the extra encouragement to make follow-up appointments, but it is possible to scare the pants off the rest of us.

Monday, April 10, 2006

"The good news is that I don't think you have a brain tumor."

The bad news was that the doc didn't know exactly what was wrong.

The worse news was that a brain tumor wasn't even on MY differential diagnosis until he made that smart-ass remark. I was 21 and a nursing student, so I suppose he can be forgiven for presuming that it was. Don't all student nurses self-diagnose? Don't most of us eventually self-diagnose with something terminal? Guilty, but not that time. I was just thinking maybe I had Meniere's I was having dizzy spells that came on with no provocation that I could identify. I wasn't experiencing tinnitus, and the hearing loss was intermittent, not progressive and it was associated with upper respiratory symptoms.

Nine months later when the doc still hadn't come up with a diagnosis after putting me through a boatload of tests, I was really worried that I might have a brain tumor. He ordered one last flurry of tests and a diabetic friend gave me the diagnosis before the doctor came up with the same answer: Hypoglycemia. The high point on my glucose tolerance test was a fasting sugar of 70. It was all downhill from there -- 4 hours worth with a low of 40. It was probably a good thing they quit after 4 hours. No symptoms, but my blood sugar was still on a downward slope. It was still headed down and I had become symptomatic by the time I bumped into my friend. She gave me a snack and her diagnosis. I was able to keep the blood sugar under control by altering my diet and the dizzy spells were history.

I doubt that the doctor EVER made another flippant remark about brain tumors to another patient. I wasn't very gentle when I presented him with my friend's diagnosis for his confirmation. I made sure that he understood just how frightened I had been when he took so long to figure out the actual diagnosis after his off the cuff remark. To his credit, he listened to my entire rant and apologized with convincing sincerity.

Last July I had an episode of vertigo that lasted about a week. My internist didn't find anything to be overly concerned about at the time and prescribed Meclizine to slow things down. It's happened twice more since then. Both subsequent episodes lasted 4-5 days, so at least they're getting shorter. The third episode started the same day I was scheduled to see my ENT about something entirely different. I'm back on the medical carousel trying to figure out what is causing the intermittent symptoms. One thing leads to another and I still don't have a clue what's wrong. My ears check out. So do my eyes, not that visual problems cause vertigo, but the balance test (called an ENG or electronystography) showed a borderline signficant irregularity that was "possibly opthalmic (retinal) in origin", so I was off for an eye exam (normal) this morning. I'm no closer to an answer, but at least this time, thanks to that PET scan I had in December, I'm the one making the smart-ass remarks about being pretty sure there's no brain tumor.

I have an MRI scheduled for Wednesday and another visit to the ENT the following week for the results which will probably be normal. I've determined that my blood sugar and blood pressure are normal during these episodes, so that eliminates a few possible causes. The current ENT wants to see me when the vertigo recurs. I'd just as soon it never did even if that means the puzzle doesn't get solved. I'm determined not to engage in Googlology. I'm afraid I'll find out that there are things I really should be worried about and I just don't have the time for that.

The better choice is to make an appointment with my internist and let her put the rest of the pieces of this puzzle together. If there's an answer, I'm sure she'll find it.