Category: Medicine

Posts that are specifically tailored around the practice of medicine.

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Being human Medicine Reflections on Life, Being Human, and Medicine Updates on my health

Green Bananas, Two Years Negative and Keep Going On With Life

Two years ago I had a kidney stone. That brought me to the ER. Late that night, an ER doc that I have known for many years came in with a very somber expression. He opened my CT scan on the screen and showed me my 10 cm left adrenal mass. That was followed by another CT scan, labs, then surgical resection, radiation and the chemotherapy mitotane. Adrenocortical carcinoma (ACC) was the pathological diagnosis. ACC is a rare cancer with only about 300-500 cases per year in the United States.  ACC can recur despite the best efforts to get rid of it. The protocol then is to do CT scans every 3 months so that if it comes back, we could respond and treat it.

In May 2020 I had some enlarged lymph nodes in my chest. Just when I was regaining confidence that this was going to be behind me, the reality of it all came home. We spent some tense days and weeks of wondering if it was back. My August scans showed the lymph nodes as being smaller. On November 1, 2020 I had my two year scans. Those scans now show the same trend (lymph nodes getting smaller) and thus provide clear reassurance that those are not likely cancer.

Good news.

It does have implications, however. It means it is ok to buy new shoes. I sometimes reassure my patients by joking that they can buy “green bananas.” The idea is that they will be around long enough to have them ripen and enjoy them. New shoes also implies that you will be around long enough to wear them enough to justify the expense. 

What it really means is figuring out how to go on with life.

I joke with my patients about this but it is not a joke. It is an important part of their treatment. They have to change their thinking. They have to start thinking about how to go on living. They have to do this even if they have ongoing symptoms.

We all have to do this even if the world is not behaving how we want it to.

We all have had to deal with this in 2020. In late March we locked ourselves in our homes to get through the storm of COVID 19. We treated it just like we do a blizzard. We made sure we had supplies. We found books to read or shows to watch. We set up a card table and started doing puzzles together. We could stop life because it was a crisis. We were excused from a lot of what normally makes up our lives.

I can remember in late April when I saw the COVID projections extending into 2021. A pit formed in my stomach. This whole thing was losing its novelty. We were going to be stuck dealing with this for far longer than any of us would like. We had to come up with different strategies. For my part, I wrote our governor. I pleaded with her to consider pulling together experts to consider sustainable models for social distancing and control of COVID 19. It was time to move beyond shutting down everything and holding our breath. It was time to think about how we could live with new patterns for 1-2 years.

All of us have had to come to some sense of understanding of how to live in an era with COVID 19. It is not what we want. We want to be together. We want to hug our friends and have big get togethers with our family and friends. We want to go and linger at our favorite restaurants and sit in coffee shops for hours on end. 

On top of this, 2019 and 2020 have brought really hard things for many of our family and friends. I find my prayer list growing and growing and growing. Life is hard. There are things that cannot be fixed.

For me, my CT scan result means accepting my current symptoms and learning how to live in the body that I have. I have been left with adrenal insufficiency. With this comes a variety of unexpected issues and limitations. It means that I am not normal. I have another blog that I have written about this and will share it soon. That will go into more details. 

In brief however, in June I started to feel crummy again. I worried it was a cancer recurrence draining my energy. I was waiting for the other shoe to drop. I would somehow just muddle along with fatigue, muscle aches, and dizziness until I had to go through the next wave of treatments for cancer.

It isn’t cancer. 

That means that it is not something that will get a lot worse. It also means that there is not necessarily a clear path through it to get better. It means that it is something that I am going to have to figure out how to live within. Some days I come home, and I just want to collapse. I think by and large I do a good job of hiding it. My wife can immediately see it. I don’t want to distress her by it. She is just too perceptive. 

I am now on more hydrocortisone. I have learned to push fluids and to have a high sodium (salt) diet. I have learned also to understand my limitations. I am also experimenting with exercise. All of that seems to be helping. I am doing better than I was in June.

What does this all mean?

  1. I don’t have any evidence of residual or recurrent cancer.
  2. I do have symptoms that are not magically going to go away. 
  3. I am going to have to learn how to manage my symptoms, live within them, and live for all the good things that I can do.

What does it mean for you?

  1. I am sorry for all the pain that 2020 has brought. COVID 19 and its limitations and implications have brought pain for everyone. On top of this it has been a year of enormous grief, pain, and loss for more friends than I can ever remember. 
  2. We do not have a magical cure. I cannot make COVID 19 go away quickly. I cannot also take away the pain from my friends, no matter how much I want to and no matter how earnestly I pray for them. 
  3. We go on. We live. We do what we have to do. We try to make the best choices and decisions we can but mostly we just have to go on with life.

This morning my body ached all over. I got up because it was at least as good to be up as it would be to be aching in bed. I took my hydrocortisone and plopped in a chair with my computer and my coffee. I waited for my body to warm up and get ready for the day. I would love to have a magical cure. Maybe I even secretly hoped that the scans would show cancer or something that would be a way to explain my symptoms in a way that could be fixed. I didn’t really want that, however. I am very pleased with my results. It just means that I need to get up, keep moving, and keep living.

This is what all of you have had to do. In spite of COVID-19, in spite of elections and election results (whatever they may be), and in spite of horrendous losses that can make both of those look trivial, you just get up and decide to live. Go ahead. Buy some green bananas. Treat yourself to a new pair of shoes.

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Being human Medicine Reflections on Life, Being Human, and Medicine

I am a Goldblatt Dog – Or – Lessons from Harry on How to Learn in Life

It was 1916. Harry had graduated from medical school and was doing his residency in general surgery. He took care of all sorts of patients, but one changed his career. One patient, and one physician who asked questions, provided treatment for millions of patients – including me.

Harry’s patient experienced a tremendous tragedy. 

The patient had his kidney removed because of a cancerous tumor. After the kidney had been removed, the surgical team realized too late that the patient only had one kidney. It was years before the technology was available that made hemodialysis possible. With no technology to replace the missing kidneys the patient was doomed to certain death. Harry was tasked with taking care of this patient and doing whatever he could to help him. The patient died 6 days later. But as Harry took care of him, he found a surprise. The patient did not develop high blood pressure.

Harry had seen many patients die of kidney failure before. Each and every time the patients developed tremendous elevations of their blood pressure. His patient who had no kidneys did not develop any high blood pressure. Harry reached an interesting conclusion: the kidneys must be responsible for causing high blood pressure.

Harry got called to serve in World War 1. In 1924 Dr. Harry Goldblatt returned from the war to Western Reserve University. There he began to research his theory that the kidneys were the cause of high blood pressure. He developed a clever technique of applying clamps to the renal arteries (the arteries that supply the blood to the kidneys) of lab animals. He found that by restricting the blood flow to the kidneys he could cause the animals to develop high blood pressure. Once he developed this consistent reproduceable model of high blood pressure, research was able to move forward. Eventually this led to the understanding of the renin angiotensin aldosterone system. 

In October 2018 I went to surgery for resection of a large mass near my left kidney. At the time of the surgery they noted that my cancer shared a blood supply with part of my left kidney. My surgeon called a urologist to the operating room to discuss options. They clamped the artery and waited. The kidney looked ok. It is not unusual for our organs to have collateral (duplicate) blood vessels. This means that the organ can have two different blood supplies. They concluded that I might have enough collateral blood flow to protect my left kidney. They tied off the artery to the cancer and removed it. They didn’t really have any choice and it looked like it was not going to cause a problem. 

I went home from the hospital two days later. Three days later I developed progressively worsening back pain along with shaking chills and fever. I had my wife bring me back to the hospital. In the emergency department I told the physician that I thought I might have a renal infarction (death of part of the kidney due to impaired blood supply). They gave me some morphine and took me to the CT scanner. I was right. The upper half of my left kidney was dying. 

I was like a Goldblatt dog. Like Harry’s dogs, part of the blood supply to my left kidney was blocked off. I had never had high blood pressure before. Would I get high blood pressure I wondered? 

I went to the pharmacy with my wife and bought a blood pressure cuff. I started monitoring my blood pressure. Just as consistently as in Harry’s experiments my blood pressure starting rising. The next week I was going to have an appointment with Dr. Hammer at the University of Michigan. I became worried that if I showed up with my very high blood pressure they might end up hospitalizing me. I called one of my colleagues on a Saturday and asked her if she would be willing to prescribe a high blood pressure medicine for me. She phoned in a prescription for amlodipine and I started on it right away.

Amlodipine works by acting directly on the arteries to cause them to dilate (enlarge). It is a safe and effective high blood pressure medicine. But it does not directly counter the activation of my renin angiotensin system.  The amlodipine helped but it didn’t completely control my blood pressure.

A few months later a vender for a new home monitoring system for heart failure patients was meeting with us. Their device included a blood pressure cuff. To demonstrate the system, they put the cuff on me. The machine registered a blood pressure of 205/115. I laughed that maybe I had a little too much caffeine that morning. I reassured them that I was fine.  After the meeting I went up to the clinic and measured my blood pressure again. It was 185/105. That was a little bit better but still not good enough. My amlodipine alone was not doing the job. 

I called my primary care physician. I asked if he would consider prescribing an angiotensin converting enzyme inhibitor for me. He put me on lisinopril. That medicine blocks the hormone that Harry discovered in his dogs that would cause high blood pressure. 

I tracked my blood pressures. Within a few days my blood pressure was trending down very nicely. Eventually my blood pressure was low normal. I talked with my PCP again. He told me to start reducing my dose of amlodipine while I continued to monitor my blood pressure. Eventually he had me stop the amlodipine and my blood pressure remained in good control. Later I changed to the medication candesartan (an angiotensin receptor blocker). This is another medicine in the class of medicines discovered because of Harry’s work with the dogs. I continue to take candesartan to this day.

The other evening, I was taking my evening pills. As I grabbed my bottle of candesartan it occurred to me. I am like a Goldblatt dog. I laughed and wrote it down and promised myself that I would someday write a blog post about it.

  1. Because of an inquisitive mind that asked questions, Harry Goldblatt concluded that high blood pressure must come from the kidneys.
  2. Because of his clever techniques, Harry proved his theory with his special clamps on the arteries of lab animals.
  3. Later Harry isolated a chemical from the kidneys of his lab animals that later led to the discovery of the system that drives a lot of the cases of high blood pressure.
  4. Because of all of this work, and dozens of clever scientists, I have one tiny little single pill that effectively and consistently controls my blood pressure.

I am like a Goldblatt dog. Thank you Harry Goldblatt for what you did. You would have never realized that your work would change the life of a cardiologist become patient in 2018.

But why do I write this post? Is it just about the one tiny pill that controls my blood pressure? There is more to it than that.

Because Harry was curious he did a tremendous amount of good. He was bothered by the one thing that didn’t fit. 

Let me explain more. 

When I was in medical school we had huge amounts of material to learn. In class we would take notes. Later I would go through the notes studying. When I did I would look for the things that I didn’t know. There were things that made sense, things that I had already learned or things that I could determine by common sense or logic. But the things that I hadn’t remembered or seemed to not make sense or surprised me, those were the things that I needed to learn. I developed a technique of taking notes off of my notes. As I went through the all the material I would end up with just a few pages of things that I really needed to learn. I could then go through those notes again and again and even once more just before the test.

That is a valuable principle in life.  Look for what surprises you or doesn’t fit. 

We can spend our lives only looking at what fits nicely and comfortably into what we expect. But if you look for what doesn’t fit – that is when you will learn and grow.

In medical practice we look for abnormal labs or test results. The important ones are often the ones that don’t fit or make sense. When we see those, they can drive us to look harder. It might be the key to finding the problem that has been missed.

When I study the Bible, I look for things that surprise me or catch me off guard. This then drives me to start digging deeper and asking questions. When I do I am rewarded with insights I would not have gained if I had just read looking for only what made sense to me. 

You are sitting at coffee with a friend. They are telling you about something they have done. I would encourage you to look for things that surprise you or don’t quite make sense. Tease those things out. When you do I suspect you will be nicely surprised with wisdom and insights that you might have otherwise missed.

Harry noticed what didn’t fit. His patient didn’t develop high blood pressure. He asked questions. Because he did, my blood pressure is nicely controlled on a single tiny little pill. 

Thank you Harry Goldblatt!