I Need Some Viracillin, Cause I’m Illin’.

iStock_000000633147_MediumOne of the purposes of this blog is to educate and inform, and hopefully help you become a better consumer of your health care dollars. Knowledge is power, or something like that.

You’re sitting at work. Your throat is a little scratchy. You feel some drainage down the back of it. As you twist in your chair, you notice an ache in your back that wasn’t there when you woke up this morning. You push on through your day, mostly ignoring the gradual onset of malaise and fatigue. I’m just tired, you convince yourself. I slept wrong. You will yourself to health and wellness.

In bed early, Nyquil your evening nectar, you fall asleep easily. But, at 3:45, you awaken with chills so violent (we call them rigors – rhy-gors) that you’re certain your bone marrow suddenly became infused with liquid nitrogen. Your body shakes and shudders in an attempt to warm itself. You bury yourself beneath the covers. You have a fever. There’s no denying it now: you’re sick!

What’s the first thing we think when this hits us? “I don’t want to be sick. I didn’t ask to be sick. I want to be well. Well. That’s where I want to be. Who can help me to get back to well and away from sick? Who’s that person… went to school for a long time… practiced indentured servanthood for several years learning his craft… A DOCTOR!!! That’s who it is!!! That’s what they do. They get me from sick to well. And, they do so quickly!”

So, you make your way to see your friendly neighborhood medical professional, either at her office, or, if money is no object, you waltz up to the emergency department.

“May I help you?”

“Yes. I am here to be well. I’m sick, but that’s not what I want at all. Make me well.”

Now, here’s where things fall apart. There’s no debating that you’re sick. Clearly, you don’t feel well. Herein lies the rub: can we do anything about it? For the most part, the more ill you are, the more we can help. Like, if you’re really dying, we have some fancy interventions that involve tubes and plastic sheathes placed in various natural and man-made holes in your body. We can drip things into said tubes and paraphernalia and maybe make you better.

The real disconnect between what you want and what we can do comes when you feel horrible but you’re not that ill. This is when you start investing large amount of coin for little or no return. When you come see me in the emergency department, I’m going to do a few things. First, I will try to make certain you don’t have a life-threatening issue. I look at your vital signs, examine you, and, maybe, order some tests. (I don’t always need the tests.) Next, I’m going to try to figure out if this illness is something that can get better with antibiotics. More on this next. Lastly, I’ll try to see if I can at least help ease your suffering.

Viruses are not weakened by your silly little antibiotics. Bacterial illnesses (sometimes) get better with antibiotics. For a long time, we’ve over-prescribed these drugs, now to the point they’re expected for anything and everything. How do I determine if you have a virus or bacterial infection? Well, bacteria mostly cause what I call “focal” infections. Pneumonia, skin infection (cellulitis), urinary tract infections are often caused by bacteria and get better with antibiotics. Bronchitis, being the distant cousin of pneumonia, is an infection that doesn’t get better with antibiotics (the exception being if you’ve got bad lung disease from naughty habits like smoking). Think of bronchitis as a cold with a cough, and a disappointingly normal chest x-ray. Well, disappointing if you were hoping to get some antibiotics from me!

Does a cold get better with antibiotics? Nope. What about the flu? I mean the flu. Even though it can be fatal, it is still a virus. What about vomiting and diarrhea? Surely, you’ve got something to cure that, right? Well… um… no. These things are what we call “self-limited” illnesses. Meaning, your body has the capacity to deal with these on its own, it’s just not on the timeframe you’re looking for, like NOW.

Who needs to go see a doctor when they’re sick? Anyone who feels bad enough that they must be seen. I know that’s a cop out, but this blog really isn’t a substitute for an evaluation. I’m just trying to teach you what we look for. If you’re on chemo so your immune system is shot, you should be seen. If you’re extremely old or extremely young, err on the side of getting seen. If you’re delirious, have a severe headache, stiff neck, or your blood pressure is lower than where you want your IQ to be, by all means, go to the doctor!

On the other hand, if you’re a healthy adult and you want to try treating your symptoms and seeing how you do for a bit, that’s a good plan. Take some Tylenol and ibuprofen, assuming you’ve not been told you can’t have these. If you’re not doing better in a couple of days, or you ever feel you’re rapidly getting worse, make your way to a doctor.

My friend and fellow emergentologist, Dr. Edwin Leap, is a lyrical master in his poem that describes the woes of the dreaded virus sufferer. Please be aware that I’m not talking about the proverbial man cold here. Women are lucky to not be plagued by such catastrophic infirmary!

I always want you to be seen by a physician when you’re sick sick, but Zithromax won’t help if you have a virus. I could write you a script for Suck-It-Up-icillin, but you won’t find it very palatable. Instead, you can probably save yourself a little time and money if you try some remedies at home and reset your expectations of what we can do for you if you do decide to pay us a visit. For most things, we’re not going to be able to have you beckon our doors feeling like poo and leave feeling like a million bucks. We’re just not that good. Unless you’re dying. Then, we just might shine. But, let’s not find out.

 

Witchdoctoring: ups and downs of vertigo

Empty Spinning Merry-go-roundThere is nothing like bouncing along, Bluetooth in your ear, imagining a cool soundtrack setting the backdrop to this scene in your life, a cool swagger in your step, then, suddenly, BAM! Your world is a scene out of Twister with your brain in the center of the storm. You’re not sure if your body is spinning, the room is swirling, which way is up or down, or if the planet is suddenly coming to an end in an epic finale in which the Milky Way is blended by a cosmic food processor.

You have been hit with a sudden case of vertigo. Not only is balance a long-forgotten memory, but your GI track seems to think that emptying the contents of your stomach will relieve your distress. It doesn’t. Your tossed cookies only contribute to the embarrassment, as you become a scene out of Looney Tunes.

For clarity, and to preserve my sanity in explaining this, we’re talking only about vertigo, which is any abnormal sense of movement. We’re not talking about lightheadedness, passing out, or feeling woozy. Emergency physicians cringe at the complaint “weak and dizzy” because that means different symptoms to different patients, and each one can represent a blue-million diseases.

As I care for patients with vertigo in the emergency department, I try to do two things. One, figure out if what my patient has is something really bad, like dangerous or life-threatening, or, two, try to provide some symptom relief for this poor soul. Even to the seasoned physician, sometimes neither of these tasks is very easy. First, we try to establish if this is peripheral (not brain = less bad) or central (brain = bad).

Peripheral vertigo, which is the less severe and more common, originates from a problem in the inner ear. Each inner ear has three fluid-containing “tubes,” called semicircular canals that send signals to the brain to tell it how our heads are positioned in space, relative to gravity. For the math nerds out there, these canals are in the x, y, and z plane. That’s not so important to the story. Little hairs along the canal interpret that movement for the brain. To understand vertigo, just realize that as the head rotates or moves, the fluid in these semicircular canals moves.

When peripheral vertigo occurs, it is because little calcium deposits, called otoliths, have gotten into that fluid where they shouldn’t be. That means the fluid doesn’t move freely, which means that it moves abnormally. The brain gets really jacked up signals from those little hair cells and thinks that the head isn’t moving causally, but that you’re suddenly a stunt pilot doing barrel rolls over the countryside.

There are some drugs, like meclizine and Valium, that can help settle the symptoms. Also, there is a series of movements, called the Epley maneuver, that can reposition those otoliths so that they aren’t impeding the movement of the fluid in the inner ear. I once did this for a patient, and it was so effective she told me I was like a witchdoctor. I took that as a complement. I’ve been called worse.

There are multiple causes of peripheral vertigo not covered here. But, the other major category of vertigo is central. That means that the dizziness is coming from something bad going on in the brain. It’s weird, but usually the central causes of vertigo have symptoms that come on gradually. The peripheral (inner ear) causes usually hit lightning fast as described above. That said, if the balance areas of your brain suffer a stroke, that causes pretty abrupt symptoms.

Central causes of vertigo are worrisome processes like tumors, strokes, and hemorrhages. There are other causes of dizziness, including blood chemistries that are out of whack, medication side effects, and trauma, such as concussions.

So, if you find your brain suddenly transported to some phantom carnie-operated gyroscope, without the benefit of elephant ears and caramel apples, try to find this blog, attempt to click the link to the Epley maneuver (puke away from your laptop), and see if you can settle your symptoms via a little witchdoctory magic. If it helps, call your doctor and arrange follow-up. If not, ask Siri to hail you an ambulance. Please don’t try to drive. Especially in my city.

What vertigo experiences have you had that you lived, or didn’t, to tell about.

Transporters on strike: Understanding strokes.

Brain strokeThere he sits, perched on high. The little control freak, with his pompous attitude, acts like it’s all about him. Barking out orders, he expects, no, he demands, utter and instant obedience. And, what he wants, he gets. Like the CEO of a complex organization, this leader monitors and makes corrections to be certain that his domain and its components function in perfect harmony. In exchange for the minions’ immediate carrying out of his demands, he makes certain they survive the constant barrage of attacks against the unit.

All is well until there is the tiniest of revolts. One of the transporters within the system decides to go on strike. He stops making his deliveries. Then, the vulnerability of the man behind the machine is exposed. Not as pompous as he pretended, he’s actually quite vulnerable.

For all the control the brain exerts over nearly every aspect of our being, it remains dependent on a constant flow of energy and tasty nutrients to do it’s job well. When one of the arteries supplying this ceaseless transport of blood gets blocked, it’s no longer making deliveries. And that, my friends, is when one starts to suffer a stroke. And, when a stroke occurs, nothing seems to work as it was intended.

I see a lot of misconceptions about the symptoms of a stroke as well as and the underlying cause. So, let’s clear that up.

Actually, there are different types of strokes. We’re talking about ischemic strokes. Ischemia is where a part of the body is not getting an adequate supply of blood. If this occurs for too long, that part of the body begins to die. More accurately, the cells in that area not getting blood flow start to die. This can happen not only in the brain, to cause a stroke, but also in the heart (a heart attack), the bowels, the retina, or a limb.

To the brain, blood must be flowing constantly. The supply of oxygen and glucose is vital for even the most mundane of tasks. When a part of the brain does not get that constant flow, we have symptoms of a stroke. These symptoms vary based on which part of the brain is suffering. Sometimes it’s an arm and a leg on one side of the body that stops working normally. Or, there can be a loss of vision, slurred speech, or the inability to talk or to at least find the right word to say. We call that expressive aphasia.  Sometimes a stroke can simply affect our balance, so that we stumble around like we are three sheets to the wind.

Strokes occur when a blood vessel gets blocked by an embolic clot. Embolic means that this clot originated elsewhere and is coursing through arteries which are like pipes that get smaller and smaller until they reach their final destination. The clot is a clump of blood and platelets that wedges itself into a tight little crevice to keep the flowing blood from getting through. It’s like the collection of hair, Legos, and Matchbox cars your plumber had to snake out of your pipes so the toilet would flush. It’s this clot that is the target of the so-called clot-busting drug, tPA.

Now, forever ago, it was commonplace to give this type of medicine to patients having heart attacks, which are also caused by embolic clots. That worked well until the cardiologists figured out how to go in with little catheters and just remove the clot.

While the idea of using tPA on strokes makes sense, it doesn’t work as well as it did for heart attacks. Brain and heart are different. You see, sick brain, like one that isn’t getting enough blood flow, has a tendency to bleed. So your ischemic stroke turns into a hemorrhagic stroke. And, even if there is no bleeding, the brain has a harder time bouncing back from this insult.

In simple terms, if you have a stroke and it’s severe enough, you may be offered this clot-dissolving drug. First, though, you have to get the drug within the first 3 hours of the onset of your symptoms. Sometimes this window of opportunity can be extended to 4.5 hours. If you wake up with stroke-like symptoms, we have to assume those symptoms started all the way back when you fell asleep, because we just don’t know. That excludes a lot of people from getting tPA.

Now, for some numbers. If 100 people get this drug for their stroke, 12 of them will be improve more than if they didn’t get the drug. 6 of the hundred people, though, will have bleeding in their brains. Half of those who bleed will die. Most patients will not do any better or any worse than they would have without the medicine.

Study after study is underway to figure out if the interventional radiologists can go in and just remove the clot. So far, that’s not been perfected. Every day, some new catheter and protocol is being developed to try to make that happen without doing more harm. So far, it’s not ready for prime time.

To increase the confusion, there are things that mimic strokes. Low blood sugar, complex migraines, Bell’s palsy are a few things that come to mind. You see, there has to be some reason you still need us doctors.

Unlike most of my posts, this is not a place to save money. If you notice part of your body revolting against the orders being given by your brain, don’t hold it against the site that’s misbehaving. More than likely, the corpuscles supplying the brain with it’s tasty goodies got log jammed. Don’t wait. Come see us and we’ll figure if a little dynamite is in order to get the pipes flowing again.

Respiratory illness targets 50% of population. Are you at risk?

Sick man wrapped in blanketRecently I wrote about influenza. Influenza is certainly bad news. It’s to be avoided at all cost. For influenza there is not a cure, but at least there is a vaccine.

What doesn’t get a lot of press, until now, is the viral respiratory illness that seeks to decimate half of the planet’s population. With no known cure, and certainly nothing as trendy as a vaccine available, this beast is locked and loaded, targeting any human blessed with a Y chromosome.

Yes, I’m talking about the man cold.

I suppose this plague-like illness is mother nature’s way of evening the score. Men are blessed with larger muscle mass, rational thought, and the ability to get from point A to point B without ever stopping to ask for directions. So, I guess all that awesomeness set us up in the cosmos to be targeted like Jason Bourne in his latest action flick.

Let’s break down the man cold from a medical perspective. Initially, there is the slight sniffle. Maybe a tickle in the throat. We try to ignore that it’s there. Allergies, probably. Then comes the full on runny nose. This sucker is like an upside down geyser, wreaking havoc on the upper lip. There’s nothing you can do for this faucet: it’s immune to over-the-counter medications. All you can do is get the softest, lotion-soaked facial tissue and wipe, wipe, wipe. Eventually this cloud-like cotton feels like sandpaper strapped to a power tool.

As if this assault on all that is masculine is not enough, that scratchy throat sometimes evolves into a cough. Not a cough-up-a-lung cough like pneumonia. More of a post-nasal drip like tiny lemmings leaping to their death down your gullet cough that prohibits you from obtaining any amount of sleep. Couple that with fever and aches that run as deep as your bone marrow, and you’ve got a full-blown man cold. And, once the case progresses to this state, whining is inevitable. We think the whining actually soothes the soul. Maybe it releases some endorphins. The studies are still pending.

YouTube is a great source of education. This video puts into perspective the serious nature of the man cold. Thanks to our friends across the pond.

Women joke about men and their little man colds. Ladies, this is nothing to be scoffed at. There are two reasons women do not often get man colds. First, their congenital Y chromosome deficiency somehow offers protection via immune-modulated pathways, perhaps. Secondly, if a woman happens to get a man cold, it is often fatal and underreported in the lay press. Women reading this: by definition, if you had a cold, and lived to talk about it, it almost certainly was NOT a man cold.

The detriment to society of the man cold is almost incalculable. First, men obviously cannot work while contending with such a devastating illness. At the very minimum, it’s not fair to go into the marketplace and infect other men. Secondly, there is usually the need for someone to mend the man back to health. Women, with their natural inability to become infected with this man-hating virus, function well in the role of caretakers, bringing Tylenol and Advil, warm blankets, chicken noodle soup, and love. Don’t forget the love. That’s key to ensuring a full recovery.

In conclusion, men, I feel your pain. I’ve been there. I’ve been the source of ridicule both at home and in the work place. Persevere. Women, the next time a man you love has a man cold, be thankful you were blessed with two X chromosomes. Show him some sympathy and compassion, with an extra dose of doting, as needed. Doctor’s orders.

 

Prevent getting hit by a Mack truck. Get vaccinated!

“Yeah, I had the flu yesterday. Much better now.”iStock_000000633147_Medium

“My kid had the stomach flu last week.”

“Man, my throat hurts. I think I’m getting the flu.”

Wrong. All wrong. The word “flu” gets thrown around a ton as a substitute for any of a number of respiratory or GI illnesses. They are not in the same game as The Flu. Not even the same sport. No. These other common ailments? They hear the word influenza and they shudder. Influenza is the T. Rex of the viral world.

I want you to take one thing away from this blog. Influenza: avoid it like the plague.

What’s the big deal? Well, first of all, influenza is very contagious. In fact, you can get it from someone even a day before he has symptoms. You’re infectious for a week after your symptoms start. On top of it, you feel horrible. Not like “my nose is running and my throat is scratchy.” No, more like being dragged behind an RV through the desert would be an improvement in my symptoms. Ok, I’ll admit, I just finished watching Breaking Bad.

So, fever, cough, congestion, body aches, chills, headache, fatigue. I’ve had patients tell me that even just moving their fingers were painful. Did I mention body aches? I consider that to be a hallmark bad symptom of influenza. And fatigue to the point you don’t even want to sit up in bed. Of all the people who come to the ED in their pajamas, these are the ones I might give a pass to.

These are just the walking wounded. Some people get really sick from the flu. Like, fatally sick. We’re not great at predicting who is going to get hit really hard.

This year, we’ve seen a lot of H1N1, the nasty influenza A strain that hit us so hard in the 2009-2010 flu season. Back then, H1N1 caught us off guard. By the time it was identified as traveling over from Asia, as the flu does, it was too late to get it in the vaccine. H1N1 was particularly vicious toward young, healthy people. If you were young, especially pregnant, and had a great immune system, H1N1 caused an exaggerated response of that immune system. There was more inflammation going on in the body, particularly the lungs. This year, as in previous years, we’ve seen fatalities from the flu, including some young, otherwise healthy people.

How do we diagnose it? Mostly I ask about your symptoms. We have rapid tests for influenza, but they aren’t sensitive enough to rule out the disease. If your story fits with influenza this time of year, you probably have influenza. It’s not rocket science.

Now, to let you into the mind of how the emergency physician thinks, what do I look for in the patient I think has influenza? Well, I look to see what other illnesses they have. Immune suppression from diseases or drugs, diabetes, obesity, and extremes of ages (the babies and the octogenarians) are all risks for badness. Then, I look at vital signs. The people who have low oxygen level, rapid breathing, and look sicker than just “I feel horrible” make me worry.

Now, there is antiviral medicine that may be helpful if started in the first 48 hours of the illness, but the data on its effectiveness is not great. If it does help, it probably shortens how long you’re sick by about a day. You’re sick 4-6 days without the medicine. You pay dearly for that 1 day improvement.

Want one more kick in the pants? There is some data that taking fever-reducing drugs like Tylenol and Advil may prolong the duration of your symptoms. If I get influenza, I’m taking some ibuprofen to help with my fever and my aches and pains. I’d rather hurt less for a longer period of time than roll over and let influenza do as it pleases. But, I’m a fighter. You do what you want.

Here’s an idea. How about an ounce of prevention? Yeah, even this far into influenza season it’s not too late to get vaccinated. It’s especially not too late to plan to get your shot this fall. Really, why go through this misery? Yes, sometimes you still get the flu because the vaccine isn’t perfect. But, you don’t get the flu from the vaccine. It just so happens you get vaccinated the time of year all the little wimpy respiratory viruses are going around. The influenza vaccine won’t help you with those. Man up, cupcake. Those are just a symptom of living.

Get vaccinated. You’re much better off using those sick days on a nice spring day when you would rather be kayaking. Shhh… I won’t tell. I’ll probably write you a work note.

Wearing The Patient Gown – Part 2

iStock_000016531274_SmallAs patients, we really just want answers. When my hunger pangs vanished (see previous post), I sat in the hospital waiting for follow-up cardiac testing. My mind became liberated to think of the possibilities of what my doctor would find or what would happen to me during the course of my evaluation. This is probably the hardest time to be a physician wearing the patient gown.

Ignorance is bliss, so they say. And they would be correct. As an emergency physician, I’m trained not just to recognize what my patient likely has, I’m also to be an expert concerning the worst possible diagnosis, and the worst possible complication. So, that’s how my brain is wired when encountering the health care profession as a patient. In most of these situations, armed with neurons that assess for every possible bad outcome, then, yes, ignorance would be bliss. However, it’s impossible to unlearn those many years of formal training and the experience that has contributed to the salt-and-pepper gray hairs on the side of my head.

As a patient, I was moved through normal hospital flow. I waited in the ED for more testing to be done. I was given updates about my tests. I was moved to PCU for monitoring overnight. I knew that a heart cath had my name on it the next morning. I was able to hold strong as family members came by. Then, I had time to sit and contemplate. What will my cardiologist find? Will there be a huge complication during the procedure? Surely not, they do these all the time.

At some point that evening, I got to speak to my 11 year-old son by phone. Keeping him in the dark may have sounded like, “well, they’re checking out my heart.” While I downplayed the situation, I did explain that the doctor was going to go in with a catheter to make certain my heart was ok, that my blood flow was good. He seemed to mostly buy my nonchalant description, until his voice cracked, and my voice, maybe, and then only ever so briefly, may have betrayed my confident exterior. Very, very briefly, of course.

The next morning, my cardiologist explains the risks of the procedure. I do this regularly with my patients to obtain informed consent. As a part his full disclosure, I am informed that my risk of dying during the procedure is less that 1 in 2,000 – 3000. That’s great, I think. Unless I’m the unfortunate 1. But, obviously I’ll take my chances and agree to proceed.

As I mentioned above, patients want answers. Doctors are not always equipped to provide those answers, despite the best of efforts. At the end of my evaluation, I was informed that my cardiac cath was normal. Normal? But, I had chest pain! While running! But, my EKG was abnormal! But, my heart enzymes kept rising! Nope. My arteries were normal. That’s wonderful news, but what landed me a night in this inn?

Maybe it was spasm of a small artery. Maybe it was a tiny tiny clot or plaque in a tiny tiny artery that we can never see by cath. Take an aspirin daily, and keep running.

While I’m not at all disappointed in the results, I can understand how a non-physician could be somewhat put off by such a huge ordeal resulting in no definitive answers. Me? I’m glad my arteries are clean. Knowing the piping is wide open, I was able to shave 24 seconds per mile off my personal record during a 4-mile run the following week.

So, when your doctor can’t find an answer, it may be because there isn’t one to be found. We aren’t gods, despite what our egos sometimes tell us. We can’t know every little thing that happened. What we can do is to try to make sense out of the information that is in front of us, and provide the most plausible explanation and treat accordingly.

These days, I run, I haven’t missed one dose of aspirin, and I try to get my patients food as quickly as is reasonable. Personally, I found food a double-edged sword. Once my hunger was gone, I lost enough distraction that I had to sit with my own doctor thoughts and consider the life-altering findings that were waiting for me the next day, or contemplate the endless complications that could leave me comatose or dead. Perhaps I would have been better off fasting.

Wearing The Patient Gown

I wish I could eat. My doctor told me I can’t. Not until all my tests are back. I understand. I do that to patients all the time. Still doesn’t make my stomach feel any better. That should be the least of my worries, but it’s not. I’m still hungry.

So, I sit in my little room in the ER, trying to keep my chest leads on so the annoying monitor doesn’t beep. Let me tell you, I prefer to be on the other side of this experience, not half naked covered by a not adequately buttoned gown. Shot caller. That’s the place I prefer to be in this patient-doctor arena.

Yet, I’m not the shot caller. Today, I’m the patient who was out for a 6-mile run and developed chest pain about 2 miles into that. Not bad pain, maybe 3/10, left sided, kind of an ache. Not a big deal. I’d stop and walk a little and it would go away. Hmm… Probably nothing. Start running again, at an 8:40/mile pace, after a third to a half mile, the same pain. It feels like when I’m running in the cold and my chest is a little tight. The only problem with that is it’s a perfect 75 degrees.

I’m an emergency physician. I’m trained to not overreact. But, I’m also trained to not ignore. I run through all the typical questions I would ask patients, only I’m not a good patient. I’m still running. Does the pain radiate to my arm or my neck? No. Is it getting worse? No. Am I short of breath? No, not any more than I should be on a run. Am I sweaty? Duh.

So, after 7-8 episodes of chest pain with running that goes away with walking, I run (yes, I did) on over to the firehouse, where I ask the fire fighters to do an EKG for me. They did, and it’s not normal. Uh oh. Honestly I’m too young for this. I’m 42, I run 20-25 miles per week. Blood pressure, and cholesterol good. I don’t smoke. I don’t snort cocaine. I don’t really have time for this. I’m supposed to be at work in 3 hours. Doctors don’t get sick. We don’t NEED doctors. We ARE doctors.

Until we’re not. So, I wait hungrily. Maybe I’m not so hungry. Maybe the hunger is a diversion that I’m anxious that something could be wrong. It’s easier to focus on a few pangs from my stomach than to concentrate on the fact that my ticker is in disarray. Sometimes it’s good to be a physician. Other times, ignorance is bliss. Right now I’m somewhere in between.

If you’ve ever wondered what happens when doctors get sick, let me tell you. We try to be good patients. We have an intelligent dialogue with our health care providers to develop the most reasonable plan. We try not to complain. We ask good questions, but we defer to the experts taking care of us. It’s impossible to give yourself good care.

And, like all the other patients, we wait. We wait for tests and consultants. We wait for good news or bad. While our stomachs churn just like all the non-doctor patients around us.