Thursday, April 12, 2007

i don't want to say 'i told you so'

right after my brother was first hospitalized for 'possibly dying', he rechecked with a primary care physician. the doctor, Dr. N we will call him, basically took the history, said, 'hypertension, right' and scheduled him for a recheck in a month. when Dr. N told me his 'plan,' an extended dialogue ensued that went something like this: [NOTE: You can skip to the bottom of the blockquote to minimize your pain if you have difficulty substituting Charlie Brown 'WAA WANH' for medical jargon.]

Dr N: I set an appointment for your brother to recheck in a month.
Me: You what? I'm sorry. Maybe I am missing something. You aren't going to check him for microalbuminuria, consider advanced imaging or run any blood work?
Dr N: He said he is feeling fine now and his BP is much better.
Me: How is 156/86 much better than 146/80?
Dr N: Well, one of his diastolics was over 120 so it is much better.
Me: When was it over 120? The highest number I was provided was 111.
Dr N: Well, I don't have the actual numbers or records, but... He says he feels fine now. So it obviously responded to the medication.
Me: What about the episode 3 weeks ago that resolved without treatment?
Dr N: Um. Oh.
Me: So you think it is okay for him to be driving around and climbing on rooftops when we don't know what happened or if it could just hit again?
Dr N: Well, the patient needs to take some responsibility. If he has symptoms, he shouldn't climb on a roof.
Me: So if he has advanced knowledge of impending acute onset of symptoms, he should divine not to get on a roof?... You are not going to even run a microalbuminuria assay to determine whether the hypertension was truly significant enough to cause encephalopathy? Or whether he should start ACE inhibitor therapy?
Dr N: I'm going to do it next month.
Me: ... when you won't know whether a normal test means the beta blocker is helping or whether it means hypertension was not relevant to the initial symptoms? I'm sorry. I am really not trying to be difficult but I must be missing something...
Dr N: I really don't think it is justified to run thousands of dollars of tests when we don't know what is wrong.
Me: The urine assay is cheap and will at least tell us whether this makes sense as a cause of his signs.
Dr N: But what if its positive? Then what am I to do?
Me: [long pause] Well, I don't entirely know right this second. But... no offense but...

Inability to develop an appropriate follow-up diagnostic plan does not justify inaction.

this went on at length until i could have screamed. finally i decided to just tell my brother what tests he needed so we could make sure nothing jumped up to bite us in the collective patoot later.

Dr N wrapped up (quite stuffily) with 'I will convey your concerns to your brother.'


i called my bro and, in the interim, Dr N spoke to a human renal specialist who agreed with me [like that is a surprise]. Dr. N called my brother and volunteered an amended plan.

where am i going with this?

well, he had the urine test, which was positive, so they started him on ACE inhibitor therapy. they also scheduled an ultrasound of his kidneys for yesterday to stage blood flow etc. i approved wholeheartedly and my brain phased into chronic hypertension management but...

Dr. N called today to say that they may have found a possible mass/cyst/item on/in/near his kidney. they will be doing a CT on Monday to evaluate the area further and determine if there is a mass and, if so, what is involved. this is a test i almost convinced them to run when he was still hospitalized, since a type of adrenal tumor (pheochromocytoma) can cause intermittent severe hypertensive episodes and we do not really have a compelling history of essential hypertension in the family. once we discovered my brother was accidentally spiking his blood pressure by using an OTC nasal spray, i put the possibility of an adrenal mass out of my mind. now, given the ultrasound findings, it is back.

this may very well be nothing...

but it may not...

i find myself thinking over and over and over again, 'There isn't supposed to be anything. The tests are supposed to shake out as Essential Hypertension with iatrogenic exacerbation. Dr. N is supposed to think, "It all came out fine. That will show his pain in the ass sister... but it is better medicine this way and I will sleep better knowing the answers." He is not supposed to have to hang his head and order more tests dammit. I DON'T WANT TO BE ABLE TO SAY "I TOLD YOU SO!!!!"'

it doesn't make sense to borrow trouble. if there is something to worry about, it will be here soon enough. if there is not, it is silly to have wasted bits of life worrying about nothing.

not too surprisingly given our recent family history, i have not had much luck today with not worrying...

1 comment:

Denise said...

Jacqui, if I'm ever sick I want you in the doctor's office with me. Seriously.

I think this scenario is more common than not, unfortunately. Your brother is very lucky to have you to advocate for his care and that you have advanced (!) medical knowledge.

I wish I had some excellent advice on not borrowing trouble by 'running ahead' with your thoughts or on how not to worry, however since I'm only too good at that myself I can only empathize and ask you not to worry too much.

take care