Monday, April 17, 2006

Thyroid Update, Long Overdue

In case anyone was wondering...

The next day, I went to UHS to see the endocrinologist. Dr. G was wonderful--she squeezed me in for an immediate ultrasound, which showed just what the endocrine surgeon predicted: hemorrhage into a cyst. The ultrasound guy stabbed me in the neck with a needle (which was, surprisingly, practically painless) and aspirated a good 10cc of dark blood and debris (ew, gross! but of course I wanted to see it anyhow), which made a huge difference symptomatically, instantly alleviating the pain and slight dysphagia.

He said he would sent off the gunk for analysis, though he assumed it will prove nondiagnostic. The cyst was complex, with some debris and colloid among the blood, and there was only one other little cyst visible, on the other (right) side of the thyroid. And, my thyroid function tests were all quite normal. Best of all, I got a copy of the ultrasounds to show all my friends and put up on my refrigerator to show off my clinical accomplishments as a patient... :)

So I guess that's the end of the story for the time being. The thyroid is still a bit enlarged, but I hope the blood will resorb over time and hopefully not reaccumulate. Both the ultrasound guy and the endocrine surgeon had little in the way of pathophysiology to explain why this happened to me; their best theory was that stress had something to do with it. Stress! I can't believe that after all of my frustration with the lack of mind-body awareness among conventional medicine doctors, and all of my successes in undoing my own stress response, the one medical problem I get is dismissed by multiple clinicians as stemming from stress! Harumph. Personally, I was thinking maybe it had something to do with the contortionist positions I've been getting myself into retracting during surgery over the past few weeks...

Either way, I'm glad it turned out to be nothing serious, and that I was given the opportunity to serve as a teaching tool for medical students all over New Haven. I think more people have now palpated my thyroid than have palpated any other part of my anatomy. Uh, yeah.

Tuesday, April 11, 2006

Takes One To Know One

That's what they say, right? Well, today I began a Freaky Friday-like switcheroo from almost-patient.

It all started with a headache. Not my normal monthly migraine, or the underacknowledged bulging-pocketed-white-coat neck muscle tension headache. Those I know. I wouldn't say we're good buddies--but to me they are familiar, and expected--like two neighbors who exchange the same nod and wave every single Wednesday night while taking out the garbage, but would never think of inviting each other over. Known, albeit unwelcome.

But this was not that kind of headache. This was a new neighbor, who moved in suddenly and started playing a loud, incomprehensible cacophany in my sinuses. I tried caffeine and water, to no avail. Exercise seemed like a good idea, if not because I hadn't done any in a few days, then because it's worked for me in the past as an endorphin-mediated cure for headaches, knee pain, and other minor ailments. The good news is: it worked, and by the end of my elliptical endeavors, my headache was gone. The bad news is: while shoveling legs and arms in furious synchrony on the machine, my throat started burning something awful. It was the burn of an out of shape body sprinting to catch the train--but I'm not *that* out of shape these days, and I wasn't doing any sprinting. So it seemed unusual. But overall I felt better after the workout, so I figured maybe I was just coming down with something, nothing a good night's sleep (ha) couldn't manage.

The next day, which was yesterday, all was going smoothly until after lunch, when I felt a scratchiness in my throat. Being the good medical student that I am, my hands immediately flew up to my neck to where I imagine my lymph nodes to reside. BUMP. Before I could get to the lymph nodes, my fingers had hit a smooth, bulging bump. A lump, to be more precise. Or, I guess to be really precise, a soft, tender mass in the anterior neck. It has to be my thyroid, I thought as the lump figuratively got stuck in the very throat it was literally feeling stuck in. I grabbed a classmate and told her that I thought I had an enlarged thyroid. She gave me a look--the same look that the three doctors I've seen in the past year have all given me (when I came in claiming to have, in chronological order, axillary lympadenopathy that I was sure indicated metastatic disease, migraines that I was sure indicated a space-occupying brain tumor, and symptoms that I was sure indicated severe hypothyroidism--all diagnosed conclusively as normal anatomy and physiology, of course), a look that says, "oh, you poor hypochondriac medical student, you always think you're dying of something awful and rare and there's not a lick of anything wrong with you, you healthy paranoid freak." Then, she (my classmate) put her hand on my neck and popped her eyes open with a gasping "oh!". Yup, she felt it. It wasn't just me.

Then, she grabbed another classmate, said, "hey, feel Rachel's thyroid", and he gave the same look, and the same eye-popping 'oh, wow!' as soon as his hands touched my neck. This was repeated with one of my residents, my chief resident (who gave the most disbelieving look of all pre-'neck touch', then immediately became the most supportive and helpful post-'oh wow'), and several other med students who happened to pass by. I felt like the more legitimate cousin of Chicken Little.

By nightfall, my left thyroid had been manhandled by more medical professionals than a little old lady with a doctor for each body part; and it had become quite tender. I talked to two close yet non-medical friends before bed, and both reassured me with excellent "bedside manner" that it was probably nothing and I would be fine. I slept fitfully.

This morning, I changed into scrubs and waited outside a certain operating scrubroom at just the right time to catch one of the major endocrine surgeons before her next case--which was, ironically, a partial thyroidectomy. Even more ironically, I know particular surgeon largely because of her lecture to us med students on surgery several weeks ago, during which she picked me--yes, me!--to come up in front of everyone else and demonstrate the physical exam of the thyroid on a classmate. I felt nervous waiting for her to come out of the OR, where she was setting up the next patient. When she emerged, all I could muster was a plaintive "feel my thyroid? I think it might be enlarged..." This time, my claim was once again met with a look; but this time, for the first time, the eyebrow raise was one of concern, not doubt. And upon palpation, Dr. R gave a reassuring 'ahh, yes', not the disconcerting 'oh, wow!' of previous palpaters. What a relief. "I guess you could say I take the term experiential learning very seriously," I said, trying to make light of the situation. "Don't panic, you're going to be fine," she said, seeing my underlying anxiety clearly through my veil of humor and intellectualization.

Within minutes, Dr. R scored me an appointment with an endocrinologist tomorrow; within hours, I got blood drawn to check thyroid function. As she and some of my residents helped me use inside connections to navigate speedily through the maze of healthcare acquisition protocol, I realized how lucky I am to be on the inside of the system. How long would I have waited to see someone if it took me days to get around to calling for an appointment, weeks to get the appointment, days to wait for the lab results, and weeks more until the followup? And what if I worked equally crazy hours, but not at the hospital where I'm literally surrounded by doctors? Or what if I didn't know that what I have is most likely a small hemorrhage into a thyroid cyst, a benign and common condition that will resolve without difficulty--what if I thought I might have cancer, and was scared of finding out, so I postponed going to the doctor because I preferred the ignorant bliss of not knowing? I began to think about all of the ways that people don't get timely appropriate healthcare for reasons that have nothing to do with insurance coverage.

Outside of those larger issues, I also felt the anxiety that every patient must feel before a diagnosis has been named. Knowledge is truly power when it comes to diagnosis; the uncertainty of "what's wrong with me?" is almost worst than even the gravest diagnosis. To live in uncertainty is like floating in a sensory deprivation tank: there's nothing to go by, nothing to hold on to, nothing to feel. Which, in a sense, is a denial of what it is to be human--we are by nature and design sensory gluttons. We live for sensual experiences, and they provide motivation and support for much of what we find meaningful in our lives. Without certainty, we are stuck holding our breaths indefinitely, flying in a holding pattern, stagnant as a grimy pond sitting under a thick blanket of late summer heat. In some cases, uncertainty can be a good thing--it can be infinite possibility. That's exciting! But here, uncertainty only breeds ickiness. And I hate ickiness., yeah, I think I have some sort of thyroid disease. More tomorrow.

Tuesday, April 04, 2006

Worth the Weight? Part 3

This evening I attended one of the monthly Bariatric Support Groups organized by my attendings' practice. It's open to all of their post-op patients, whether two weeks out or two years out, as well as prospective patients who are considering the surgery. Ironically, it was held, of all places, in the conference room directly behind the hospital cafeteria, at the very time a Family Feud contestant would likely get the most points for naming as "a time to eat dinner" (6:00pm). Incidentally, I heard the other day that Max Taffel, the conference room's namesake, was a well respected surgeon who inexplicably did not believe in the utility of the bellybutton, and would therefore remove it whenever possible during abdominal surgeries on his patients. I can't quite put my finger on what feels so deeply wrong about bellybutton rejection; but I bet Freud would have a field day with that guy.

All anyone talked about was food. What they can eat, what they can't eat--what foods are tolerable, what makes them vomit or get "dumping syndrome". Listening to them all, there seem to be two types of people who undergo this surgery: first, there are those for whom it is truly a godsend, the very catalyst they need to enable them to stick to and maintain a healthy diet for the first time in their lives. They are the ones that adhere to every requirement, start exercising immediately, and just melt the fat off their body with astonishing speed. Then, there are the ones who will fail--from the very start, they find ways to tolerate the forbidden foods and eat more or quicker than the post-op regimen indicates. More importantly, although they may switch to a dramatically lower calorie diet, they still spend their evenings parked in front of the TV--only now it's with water bottle--not slurpee--in hand. For them, the surgery is, tragically, just another quick fix yo-yo (albeit an incredibly more expensive and higher risk one than, say, the cabbage soup diet).

A few women talked about their favorite moments since surgery. Among them: being able to get out of a car in under five seconds, without fanfare or a sweat-inducing battle with gravity and the steering wheel. Being able to buy a party dress that they actually like, rather than having to settle for whatever comes in a big enough size. Being able to walk 32 blocks in NYC, to go hiking and biking and enjoy the feeling of bodily movement and activity. Sitting in a chair along the wall of the conference room, scanning the several dozen participants, I felt a strange feeling: for possibly the first time in my life, I felt a murky mixture of embarrassment and pleasure at being among--if not the--most slender woman in the room. Aside from the guilty pleasure I took in this rare moment of superficial smuggery, I also had a feeling of guilty shame--and silliness, really--at the years and countless moments I have wasted feeling fat. Listening to one woman recount how she has gleefully returned to several former favorite restaurants, not to eat the food, but to slide triumphantly into a booth that used to be inaccessible to her--I felt a deep sense of patheticness at my sob stories hung like gaudy, disproportionately large earrings on the flimsy earlobes of an extra 10 pounds of flab. As the meeting was ending, I snuck out to the cafeteria, feeling hungry...and ended up buying a little bowl of jello and crystal light, which I guitily downed before heading back into the room to get my things.

Thinking more about the ease of eating healthier and maintaining weight loss following bariatric surgery, I realized something. We all, to some extent, believe that eating well requires some combination of willpower, determination, strength of psych--all characteristics presumably stemming from the brain. And as I mentioned earlier, the stomachs of obese people appears to be identical to those of non-obese people. Yet, in reference to yet another earlier posting, this supposed cure for obesity is not, either literally or figuratively, brain surgery. It is stomach surgery. Brain stays the same, stomach shrinks...and suddenly, weight loss. So maybe...the problem all along has not been that our eyes our bigger than our stomach--but that our stomachs were bigger than our eyes?

Monday, April 03, 2006

The More We Know, The Dumber We Get...

It is with great disappointment that I present to you the "astounding" results of a major study published in the current Annals of Internal Medicine (a highly respected medical journal representing the results of the best and brightest's years of intense scientific inquiry):

Effects of Comprehensive Lifestyle Modification on Diet, Weight, Physical Fitness, and Blood Pressure Control: 18-Month Results of a Randomized Trial

Objective: To compare the 18-month effects of 2 multicomponent behavioral interventions versus advice only on hypertension status, lifestyle changes, and blood pressure.
Conclusion: Motivated adults can sustain several lifestyle changes over 18 months, which might reduce their risk for cardiovascular disease.

In Other Words: We live in an environment that makes it so difficult to live a healthy lifestyle, and doctors are so incompetant at educating and motivating patients to make lifestyle changes to reduce their risk for chronic disease, that we have actually begun to doubt that it is humanly possible for people to stop eating donuts and start exercising, to the point that we had to spend several years and who knows how many thousands of dollars re-convincing ourselves that there is hope for the masses. Seriously? Seriously??