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Thursday, August 28, 2014

In the Chemo Room

By Jay Ellis, MD

Editor's Note: This is the third in a series of articles written by San Antonio anesthesiologist Jay Ellis, MD, a member of the Bexar County Medical Society Communications/Publications Committee. The series, published monthly in San Antonio Medicine, examines the physical, emotional, financial and spiritual burden of life-threatening illness. Check out part I, Dealing With Cancer, and part II, Getting Ready for Chemo.

I doubt anyone was as relieved to start chemotherapy as I was. It was my best hope for recovery and relief from the scourge of the abdominal pain that tormented me nightly. My wife, Merrill, prepared for my first chemotherapy session with a proficiency and precision reminiscent of the logisticians of Desert Storm. She packed enough food for a regiment, assembled what looked like a year’s worth of reading material, and packed a bag full of sweaters and blankets in case I felt cold, or decided on Arctic travel. Carrying all these bags into chemotherapy reminded me of the Clampetts arriving in Beverly Hills.

Greg Gulley saw me that morning to review my lab work and treatment plan. It was comforting to see him. I did complain that I had only 54,000 platelets and everyone seemed to want to draw my blood and take a look at them. He responded by giving me an article from the New England Journal of Medicine confirming that patients are often phlebotomized into anemia. OK.

EGALITARIAN GATHERING PLACE

The chemotherapy room is a great egalitarian gathering place, like the DMV or divorce court. Cancer is an affliction that crosses all social barriers without prejudice. We were the first ones there, and Merrill staked out a plum position, then began making friends as others arrived. While we were in chemotherapy we would meet other professionals, laborers, little old ladies, little old men, and too many young people. Everyone is there for the same purpose and everyone asks your diagnosis, not unlike being in prison and asking, "What are you in for?"  It is a mutual support society. There are even moments of humor, such as one man who spent his entire treatment session standing and yelling, “I'm not sick. I don't know why I'm here. I don't need this," all the while hooked up to his infusion.

The chemotherapy nurses are caring, professional, and they inspire confidence. They reviewed each medication with me. I did have memories of CHOP (Cytoxin, vincristine, doxorubicin, prednisone) therapy from my medical student and resident years. I can still recall the hemorrhagic cystitis, heart failure and peripheral neuropathy experienced by my patients. I had vivid memories of the intractable nausea and vomiting they all developed with each session of therapy and for days later. The specialty of oncology should be commended for improving this bleak picture. First, I received several premedicant drugs to minimize my symptoms and risk for side effects. I experienced mild nausea, but not the intractable vomiting so starkly remembered. In addition, I would get the CHOP-R version with the addition of the monoclonal antibody drug rituximab. Unlike the old days where chemotherapy was an applied exercise in selective toxicology, I now had the “magic bullet.” Rituximab would be specific for the lymphocytes of my lymphoma, sparing me from many of the side effects of the old CHOP regimen.

After I finished my premedication, the rituximab infusion began. My bride is a great doer, but not good at sitting and watching. I can tell when she is getting fidgety and asked her to go and get me a Starbucks coffee. Soon after she left things got strange. I started getting the rigors/shaking chills I once had with pneumonia. They started small, but began to crescendo in intensity and duration. I raised my hand like a school child and the nurses quickly recognized my problem and descended on me. I became the center of attention in the chemo room, not a distinction I wanted. The nurses rapidly went through the algorithm to treat symptoms they saw often. One nurse stopped my infusion. One covered me with blankets and another brought the diphenhydramine and steroids to treat my symptoms.  My symptoms became worse. I was shaking uncontrollably and wondered if this is what seizures felt like. The muscles in my neck began to contract, and my head bent to the left with a strange, torticollis-like position. I had never felt so helpless in my entire life. I had no control over my body, and I thought I would vibrate myself right out of my chair. Fortunately, after some meperidine, my symptoms subsided. I was exhausted. I doubt the whole episode lasted more than 10 minutes, but I felt like I had been exercising for hours. The combination of the medication and the physical exertion of the shaking chills left me exhausted. I fell asleep and woke later with Merrill sitting next to me with a cold cup of coffee. The nurses slowed my infusion rate. It took the entire day to finish my regimen, and we left late that afternoon.

SMOLDERING EMBERS

I woke the next morning feeling is if someone had lit a fire throughout my body. It wasn't the flaming inferno of the forest fire. It was a low, smoldering sensation like the last embers of the campfire as it consumes the final ounce of fuel. I felt the smoldering most intensely in my back at my biopsy site. I wondered if it was my tumor shrinking away from the effects of chemotherapy, but quickly extinguished that thought as the silly wishes of a desperate man. I was tired, in pain and just felt awful. Merrill began what soon became our thrice-daily ritual. She would prepare something for me to eat, and I would refuse to eat it, lacking any appetite and certain that ingesting food would result in catastrophe. She would respond by first persuading, then cajoling and finally insisting that I eat. I only made the attempt because I knew it was important to her. I'm convinced that had she not been there I would not have eaten anything that day, or for several days after. Friends called and sent text messages of encouragement. I tried to respond to everyone, but fell asleep. Merrill swiped my phone and answered the messages for me so that I would rest during the day.

The next day the diarrhea started. The smoldering now became a hot torch centered in my rectum. Every time I tried to lie down the diarrhea would return. The burning sensation in my rectum was accompanied by spasmodic contractions of the viscera of my abdomen. It was misery. I began to pray to God fervently for relief. I was afraid to be more than a few steps away from the bathroom. The designer who placed three commodes at different locations in our downstairs now seemed like an architectural genius. By the next day these symptoms passed as well, and I went from being severely distressed to just miserable. Then I noticed something remarkable. My abdominal pain was gone. I hadn't touched any pain medication for 24 hours. The stabbing torment in my abdomen vanished. The distress I felt over the previous days seemed like more than a fair trade. There was hope that the chemotherapy was working.

After five days, I tried to go back to work. I overestimated my recuperative powers. The walk from the parking garage to my office took every morsel of physical energy I possessed. I sat at my desk, completely exhausted. After two cups of coffee and a 30-minute rest, I began to rally. As always, work was a tonic, and I survived the day. My office staff could not have been more supportive. They made little changes to make my work easier and my life more comfortable. Their concern increased my resolve to get through the day. I did finish my schedule, but when I arrived home I was exhausted. I was too tired to argue with Merrill about whether or not I would eat. After I ate, I just went to bed. I would repeat this routine for several days, but as the days went by my strength seemed to grow and my stamina increased. I certainly wasn't well, but I had hope that I was moving in the right direction.

ROUND TWO

I approached my next chemotherapy with some trepidation. The nurses were a great comfort, telling me that by slowing the infusion rate they could get me through my chemo without the drama of the first encounter. They were right. This session went smoothly, without the near-epileptic activity associated with the first visit.

Three weeks later, I went for my first CT scan since my diagnosis. I did have to choke down two bottles of oral contrast which, despite the flavoring, will never replace Coke or Pepsi. The CT scan would determine my progress on chemotherapy. The staff at South Texas Radiology was polite and encouraging. After my scan, Dr. Todd Tibbetts took the time to review the images with me. The results were obvious even to the average anesthesiologist. The abdominal mass, the lesions in my spleen and the lymph nodes shrank to a fraction of their former size. The chemotherapy was working, and the success was better than anything I could have imagined. For the first time I understood what it felt like to want to weep for joy.

Up next: Complications.

Wednesday, August 27, 2014

TEDMED Live to Unlock Imagination in Austin Sept 10-12

TEDxAustin, in collaboration with the Texas Medical Association (TMA), The University of Texas at Austin (UT), Seton Healthcare Family, and the LIVESTRONG Foundation, will host TEDMEDLive2014 HD simulcasts and live panel interactions at locations throughout Austin on Sept. 10-12.

Each location will simulcast the TEDMED 2014 Unlocking Imagination in Service of Health and Medicine conference taking place in Washington, D.C. and San Francisco. In addition, simulcast hosts have assembled live panels focused on TEDMED’s stage content to spark dialogue about health and medical care in our region. Made possible through the financial support of local partners, all programs are free, and the public is invited to participate at each location.

Best known for its annual three-day gathering, TEDMED invites the world’s most creative minds to discuss health care’s most pressing problems and innovative scientific concepts. TEDMED’s content inspires critical new possibilities for the future of health and medicine, presented in a provocative stage program of brilliant short talks and artistic performances.

The TEDMEDLive2014 experiences in Austin include (Click here for the full schedule):
  • A discussion on risky behaviors and how Travis County compares with Texas and the nation on binge drinking, alcohol-related traffic fatalities, HIV, and sexually transmitted infection rates.
  • A look at innovations that help Austinites become and stay healthier where they live, work, and worship.
  • A deep look at “frequent flyers” — patients who return repeatedly to the emergency department — and factors driving emergency department use at one Austin hospital.
  • Insight into health care’s adoption of technology solutions from other industries to make our community better, smarter, and healthier.
  • Designing with intention to sustain a healthy community.
  • Wrangling volumes of data … and how we understand and use data safely.

You can watch TEDMED at three Austin-area locations (Free registration is required, as space is limited):
  • TMA Building, Thompson Auditorium, first floor, 401 W. 15th St. (parking available in TMA’s on-site garage);
  • Seton-University Medical Center Brackenridge, Clinical Education Center (CEC), Room C1.115, 1400 N. I-35 (parking available in garage near main entrance of CEC); and
  • The University of Texas at Austin, TACC Visualization Lab, ACES Building Room 2.404a, 201 E. 24th St.

TEDxAustin, TMA, UT, the Seton Healthcare Family, and the LIVESTRONG Foundation will host the streams and panel discussions featuring a cross-section of minds with views of health and health care — including health care professionals, architects, legal experts, academics, entrepreneurs, technologists, community leaders, and students.

Tuesday, August 26, 2014

What Is Behind the GMO Label Debate?

By Theresa T. Vo, MD
Austin Family Medicine Resident

Many of us calmly amble through the rows of our local grocery store unaware that the products on the shelves are the subject of tumultuous controversy regarding labeling of GM foods (genetically modified) or GMOs (genetically-modified organisms). Original Cheerios, one of America’s favorite breakfast cereals, is now appearing on shelves with a new label, “GMO-Free.” Whole Foods will be phasing out GMO food that wasn’t labeled.

State legislation is changing as we speak. Connecticut in 2003 followed by Maine this year are the first two states to approve legislation requiring labeling on foods with GMOs. However, both Maine’s and Connecticut’s laws are on hold until several other states enact the same legislation. Pending legislation exists in California, Missouri, Minnesota, and Rhode Island.
This controversy is global as well. The certification of GMOs could be restricted to 10 years from prior unlimited duration, according to a draft law by Russia’s Ministry of Education and Science revealed on April 3, 2014.

So what exactly are we labeling?

The term “GM foods” or “GMOs” refers to crop plants created for human or animal consumption using the latest molecular biology techniques. DNA transformation introduces genes from different organisms, including naturally occurring soil bacterium (Agrobacterium tumefaciens), into the plant while particle bombardment shoots DNA-coated microscopic gold particles into plant cells. The first genetically engineered foods appeared in the food market in the 1990s. Today, GM crops are being grown on about one-fourth of the world’s farmland, including staples such as corn, soy, canola, and potatoes.

Although we may not realize it, genetic engineering of food has been occurring for centuries. Resourceful farmers have bred plants and animals to emphasize certain attributes, gathered and planted seeds of fatter grains, selected meatier and hardier animals for breeding, and cross-fertilized different species of plants.

With advancements in biotechnology, we have improved fruit and vegetable shelf life, protein quality, and crop yield. Biotechnological advances also enable us to strive to manufacture edible vaccines and drugs; reduce the amount of herbicide and land needed for agriculture; and create vehicles for bioremediation, a technique that uses organisms to break down toxic substances. However, there are also major concerns about the impact of GMOs on human allergic reactions, increased resistance to antibiotics, and crossing GMOs with organic crops or species.

Some recent studies are suggesting links to human and animal health problems. For example, research from Dona et al (2007) suggests that GM foods may cause toxic effects in the liver, pancreas, kidneys, and reproductive organs of rats. Yet, other studies indicate that animals fed with feed derived from GM plants do not differ with respect to intake of nutrients, health and performance, hatchability, and milk yield compared with animals fed with conventional comparable feed (EFSA GMO Panel, 2007).

While it remains to be seen if these results are reproducible, it should be noted that GMOs have been studied and scrutinized for years. GM food manufacturers subject their products to more rigorous testing than is required of traditionally bred fruits, vegetables, and animals. The U.S. government also regulates biotechnology via three main agencies: the Food and Drug Administration, the U.S. Department of Agriculture (USDA), and the Environmental Protection Agency (EPA). Currently, major scientific authorities such as the World Health Organization hold that the position that GM foods are not likely to present risks for human health.

For a controversy like GM foods, creating a distinction between non-GMO and GMO foods through mandatory labeling requires some thought. Supporters of labeling argue it will enable consumers who prefer specially engineered GM goods to get them while enabling others to avoid certain foods. Labeling also can promote brand identity. Opponents of labeling believe the act would stigmatize biotech products, scare away shoppers, and unjustifiably mislead consumers into thinking that biotech products truly have different effects. Labeling could also be difficult to implement because the label may have to be maintained throughout the food chain if the GM food is used as an ingredient, food, or feed. With consideration to expense as well, are there enough consumers willing to take on the cost of such an enterprise?

Labeling GMO and non-GMO foods lends itself to different interpretation by individuals based on personal knowledge and bias. However, there is not enough research data at this time to prove or disprove a cause-and-effect relationship between these nicknamed “Frankenfoods” and bad health outcomes. Are we prematurely hyping up the fear by mandating labels? If it is going to be an expensive task to label foods, it may be worthwhile funneling those funds into further studies and dialogue to get more real answers. And while we wait, the GMO-averse can still keep to their personal GMO-free diet by choosing USDA-certified organic foods, looking for “Non-GMO Project Verified” sealed products, and examining barcodes on produce stickers. A four-digit code means the product was “conventionally grown.” A five-digit code that starts with a “9” means that the product was organically grown.

So although it may appear that we are quietly buying our weekly groceries, each of us also is casting our own vote in a movement that is stirring our nation.

Monday, August 25, 2014

Texas Physicians Practice Choosing Wisely: Part Two

A Fort Worth physician is saving his patients from medically-unnecessary colonoscopies.

When Fort Worth gastroenterologist Monte E. Troutman, DO, first heard about Choosing Wisely®, it immediately changed his thinking.

“I’ve been a big advocate of colorectal cancer screening my whole career, and remarkably, over the past 10 years, we’ve seen a dramatic decrease in the incidence of colon cancer because of aggressive screening, most noticeably colonoscopy,” he told Texas Medicine magazine, the Texas Medical Association’s (TMA’s) official publication. “But there’s still about 45 percent of the population who should get screened and do not. And while a lot of people say we are doing a good job, unfortunately, we may be overdoing [screenings] for the people who are already adherent to the guidelines.”

The goal of the physician-driven Choosing Wisely campaign is to enhance quality and reduce waste by getting doctors and patients talking about medical tests and procedures that may be unnecessary ─ it’s about doing the right thing at the right time for the right patient. More than 60 national medical specialty societies have joined to identify more than 300 recommendations for physicians to consider.

For Dr. Troutman, “choosing wisely” means talking with his patients who are low-risk for colon cancer and explaining why they might not need colonoscopy testing as often as previously thought.
“You would be surprised how receptive patients are when you tell them, ‘You don't need to have a colonoscopy done,’ ” said Dr. Troutman. Patients want an explanation, he finds, and “then it doesn't take much convincing.”

Dr. Troutman said it’s in patients’ best interest that physicians take time to talk with patients and attempt the extra steps instead of defaulting to administering another test. “Sometimes the best thing to do — and the hardest thing to do — for the patient is nothing, other than offer advice. Put the pen and prescription pad away,” he said.

The ABIM Foundation awarded the association and its philanthropic arm, the TMA Foundation, a grant to advance Choosing Wisely among Texas physicians. Support for the grant program comes from the Robert Wood Johnson Foundation. 

Friday, August 22, 2014

Texas Physicians Practice Choosing Wisely: Part One

A Keller family physician is starting a conversation with his patients on antibiotic overuse.

In an era of scrutiny over medical costs, tests, prescriptions, and procedures, physicians are sharpening an old diagnostic tool — conversation with patients.

Doctors are taking extra steps to engage and inform patients to “take quality medical care to the next level,” explains Texas Medicine magazine, the Texas Medical Association’s (TMA’s) official publication. “Hopefully future conversation will be the patient asking, ‘Why are you doing this?’ and not, ‘Why AREN’T you doing this?’ ” said TMA Council on Health Care Quality physician Gregory M. Fuller, MD.

Having discussions and redoubling efforts to think through specific problems and solutions unique to each patient is the idea behind the new Choosing Wisely® campaign — it’s about doing the right thing at the right time for the right patient, and avoiding unnecessary care. The physician-driven initiative asked national specialty societies to identify specific tests, procedures, or medications that are common but may not be necessary at that time. More than 60 national medical specialty societies have amassed more than 300 recommendations for physicians to consider.

For Dr. Fuller, “choosing wisely” means engaging patients in discussions over their own care and educating them about why antibiotics or other treatments aren’t always the answer. Patients often visit the doctor with respiratory symptoms and immediately want the physician to prescribe antibiotics. But doctors know antibiotics sometimes are not the correct solution to the problem, particularly if they suspect the culprit is a viral infection. In that situation, Dr. Fuller says he educates the patient about why what he or she wants is not a beneficial solution.

That education starts with what Dr. Fuller describes as a “frank” conversation with his patients about side effects and antibiotic resistance, for example. He also uses the terms “virus” or “viral” frequently in conversation when explaining why prescribing the drug won’t make a difference with a viral infection and will end up wasting money.

“I try to teach my patients what is appropriate use of an antibiotic. Not why aren’t you prescribing an antibiotic, by why are you prescribing an antibiotic?”

The ABIM Foundation awarded the association and its philanthropic arm, the TMA Foundation, a grant to advance Choosing Wisely among Texas physicians. Support for the grant program comes from the Robert Wood Johnson Foundation. 

Thursday, August 21, 2014

100 Things to Know About Texas Health Care

Becker’s Hospital Review created a list of 100 things to know about health care in Texas. As the second-largest state in the nation in size and population, Texas boasts a large health care system, with 83,000 hospital beds and 630 hospitals, 80 of which are in Harris County alone. The state is home to nine medical schools and is the sixth-least expensive state for personal health spending per capita at $5,924. But not all news is good: Texas ranks second behind California in number of health professional shortage area (HPSA) designations with 375 primary care HPSAs, and has the highest percentage of uninsured residents in the nation.

The lengthy list covers many more interesting facts. Check it out.

Tuesday, August 19, 2014

Dying Peace

By Johnson Wu, DO
Austin Family Medicine Resident

A recent CBC News story showcased a research study conducted by Harvard Medical School and Cornell Medical College that examined what happens to patients who received palliative chemotherapy. Palliative chemotherapy is the use of medications for cancer patients to ease symptoms and prolong survival but not to cure their disease. The study showed that 68 percent of patients who received palliative chemotherapy died in the place they wanted; within this group, 47 percent died at home. By contrast, 80 percent of patients who did not receive palliative chemotherapy died in the place they wished, and among these patients, 66 percent died at home. Unfortunately, patients who received palliative chemotherapy were less likely to realize their illness was terminal and less likely to discuss end-of-life care with their families and physicians.

Patients and families face the terribly difficult question of what to do after being diagnosed with a progressive cancer. Based on the numerous slogans and war cries to “win the fight” and “beat cancer,” it's not surprising that many patients and families opt for chemotherapy, radiation, and surgery. Sadly, it’s not uncommon for patients to misunderstand the effectiveness of chemotherapy on some of the most common and deadliest types of cancer. A 2012 publication in the New England Journal of Medicine (NEJM) reported that 69 percent of patients with lung cancer and 81 percent with colorectal cancer did not report understanding that chemotherapy was not at all likely to cure their cancer.

As a newly graduated physician, I have already seen my fair share of patients who received aggressive therapy at the end of life. Most recently, I followed a 92-year-old patient who underwent surgery to remove a stomach tumor. She ultimately spent her last two months of life in the hospital with a tube placed through her nose into what remained of her stomach, suffering from severe abdominal pain and intractable nausea and vomiting until the day she died. She is a prime example of the consequences of aggressive care at the end of life.

My hope is to see every person treated with respect, dignity, and without suffering at the end of life. We can do this only if we as a society are open and willing to accept comfort care and quality of life over aggressive treatment. This is directed not only to patients receiving care but also to the physicians who provide that care. Death is inevitable, but patients should be able to die in peace.

In 2006, the Board of Medical Specialties officially recognized hospice and palliative medicine. Its main goals are the treatment of symptoms, relief of suffering, and end-of-life care. Hospice care specifically applies to those patients who are estimated to have six months left to live, while palliative care encompasses all patients with life-limiting or serious disease. Though the subspecialty was formed less than a decade ago, physicians have always practiced palliative care. Historically, most palliative care has been offered by a patient’s primary care physician.

When a patient decides to refuse treatments aimed at curing disease or extending life, it should not be viewed as “giving up.” Rather, we should look at this in a positive light, a choice to accept quality of life over unneeded pain and suffering. Interestingly, for certain cancers, another article in the NEJM has shown that early palliative care not only provides significant improvement in quality of life and mood, but also can actually help patients live longer when compared with aggressive care.

In the face of an aggressive cancer with low cure rates, it is understandably difficult for patients to decide between treatment and comfort care. The treatments that are toxic to cancer are also toxic to the body and can cause significant side effects such as pain, infection, memory loss, nausea/vomiting, and bleeding.

At the end of life, I urge everyone to consider this for themselves and their loved ones: Do we want to spend our last days tethered to machines and as victims to suffering caused by chemotherapy, radiation, and surgery? Or would we rather be amidst our loved ones, in a comforting place, with medications to ease our pain?

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