Hit me with your best shot

No vaccine for stupidity

Even before the recent news flurry over anti-vaccine spokesmodel Jenny McCarthy and the status of her son's reported autism, there was a provocative news item in the Sacramento Bee concerning a new medical clinic designed for parents who need assistance in opting out of California's childhood vaccination program, recently made more stringent by long overdue changes in state law. The clinic's founder, Dr. Dean Blumberg, supported the new state law but also describes himself as a firm supporter of parental rights:

“I’m pro-immunization, but I’m also in support of parental rights,” Blumberg said. “That’s why we decided to set up the clinic as a community service, in case there are parents whose health care provider won’t sign the [exemption] form or some parents who don’t have a primary care provider.”

The Bee article generated a laudatory letter to the editor:

Dr. Blumberg helps no-vaccine parents' right to choose

Re “Clinic to aid no-vaccine parents” (Our Region, Dec. 19): Surely, we as doctors and parents can debate the many merits of and concerns with vaccination programs. However, UC Davis Medical Center physician Dean Blumberg has taken a position that is both praiseworthy and responsive to parental rights. As a parent working in emergency medical services, I have decided not to participate in vaccination programs for reasons that are really not at issue. What is at issue is that we are afforded the right and responsibility as parents for our children. I encourage Dr. Blumberg to continue providing information to assist parents in our choices and to continue honoring us as parents as we evaluate this information and make our decisions. The doctor should be recognized for his commitment to the higher standard of self-determination in the practice of pediatric medicine. —CK, Roseville

I was inspired to submit a response that the Bee did not see fit to publish, so I offer it here:

Anti-vaccination parents who leave their children vulnerable to preventable diseases are always so eager to appear rational and reasonable. As one said in Letters, “I have decided not to participate in vaccination programs for reasons that are really not at issue.” Not at issue? How delusional a statement is that? How would people react if a parent said something only slightly different? For example: “I have decided not to use child safety seats in my car with my children for reasons that are really not at issue. In case of a traffic accident, I prefer to hope that my children will be thrown clear.”

The medical merry-go-round

Caught in referral hell

It seemed a good idea at the time. Heck, it still seems like a good idea. People did try to help out and some leads were followed. So they turned into dead ends. Whose fault is that? Everyone who offered suggestions deserves thanks.

I prefer to blame the doctors.

Frankly, it's like they're playing a game of keep-away with a friend of mine. However, instead of swiping some short kid's cap and tossing it back and forth over his head, it's more like they're lobbing his medical file to and fro: “Here! You take it!” “Hell, I don't want it! You take it!”

I get it. They can't figure out what's wrong with him, so they ignore him as much as they can (this part is easy, because they are actually very busy people with easier cases to consider) and then try to make him someone else's problem when he gets to be a nuisance. My buddy wouldn't mind this latter part so much if at least someone in the long-running game of tag-you're-it could actually make sense of his situation.

As previously reported, one of my good friends (we go back all the way to the height of personal computer fun, West Coast Computer Faires, and user groups) is suffering from a combination of symptoms that include ferocious migraines, loss of voice, and a strangling sensation of throat constriction. Doesn't sound like fun, does it? Initially it seemed like his lymph nodes were going crazy, but now it appears the swelling and constriction must be from some other cause. His thyroid levels were messed up, but medication to bring his numbers under control had no impact on his other ills (even though the thyroid tests got back into the normal range). It's as puzzling as ever. Here's his most recent update:

I have seen three different otolaryngologists in three different clinics: One at UC Davis, one at UCSF, and one at the Sacramento ENT clinic. No one could find a cause in my throat. I followed up by seeing an endocrinologist at the UC Davis Elk Grove clinic. He ruled out my thyroid causing the problem and also ruled out Riedel’s thyroiditis as a potential diagnosis. On July 26 I saw an allergist at UC Davis and she ruled out allergies as a cause because allergies come and go. She suggested I go back to the UC Davis ENT clinic because the doctor I saw at that clinic said that I should see them again if the problem persists; the allergist said I should see them for voice and swallowing problems. I told her that would be useless because all the doctors I’ve seen are trying to address the symptoms, not the cause.

The swelling continues to grow in several places that have been swollen for a while, and a new area of swelling appeared on the back of my neck in the last week.  I’m starting to feel more pressure and pain on my throat when I lie down, which makes it even harder to get comfortable when I need to sleep. Twice this week I’ve slept for 8 hours at a time only to wake up exhausted. I still have no appetite and I’ve lost nearly 19 pounds since this started 4.5 months ago – I was at 163.8 pounds when I started and I’m now down to 145.2 pounds. I’ve asked my current primary care physician about next steps including a PET scan and a follow-up ultrasound scan. I’m currently looking for a new PCP.

He doesn't mention it, but his PCP's referral to the UCSF otolaryngologist provoked an irritated response from the latter, whose specialty is oncologic surgery; he was clearly irked at being sent a patient with no indications for cancer. The wasted trip to San Francisco was further evidence that his primary care physician is out of ideas and is randomly sending him around, hence the search for a new primary. And for a new referral that finally produces results.

Anyone out there have any ideas? Are you a retired diagnostician with time on your hands and an itch to solve an intractable problem? Everybody needs a hobby!

The situation gets monotonically worse, with neither diagnosis nor remedy on the horizon. What can we do to get this guy out of purgatory?

And please don't suggest prayer.

It's a headache!

And that's not all

A friend of mine is (figuratively) banging his head against a brick wall. The results are similar to what they would be if his activity were literal.

Interestingly enough, his medical condition began quite misleadingly. Eventually his doctors figured out that his symptoms of disorientation, dizziness, and weakness were the results of “silent” migraines. While migraines are most commonly associated with acute, debilitating headaches, this is not the only case. The headaches might be absent, while the victim nevertheless experiences the distorted vision and weakness that migraines induce.

The diagnosis of silent migraines resulted in my friend's introduction to the extensive pharmacopeia of anti-migraine medications. Problem solved!

Sort of. Temporarily, anyway.

Things began to change. For one thing, my friend's prescriptions worked for only a limited time. As he became inured to the therapeutic effect of one drug and the symptoms ramped back up, the doctors would move him on to another. He was now working his way through the list of drugs, wondering how long this could go on. For another thing, the pain showed up. Classic, stabbing, excruciating headaches. “Silent” no more. Fortunately for my friend, the sharp, stabbing headaches are intermittent—triggered by loud noises (he suffers from hyperacusis). Only the dull pain in his head is constant, day in and day out (and denying him sleep, because there's no longer any such thing as a soft-enough pillow).

Now he was getting passed around in the medical community. The UC San Francisco headache clinic looked into his case and shot him up with drugs to “reset” his pain level. It failed. UCSF was on the verge of confining him to a hospital bed for a days-long infusion of a drug that required 24-hour monitoring when a bad reaction to a milder form of the medication provided a very serious contraindication.

The UC Davis Medical Center subjected him to a series of tests, none of which proved definitive. It was clearly something more than just a migraine condition. My friend was wobbling about with a cane and it took a regimen of physical therapy to help him relearn how to stay upright and walk like a sober person. The migraines had laid waste to his balance system.

The standard migraine drugs were used up and then recycled at higher and more dangerous levels. Relief was still merely temporary and palliative. His doctors began a series of off-label prescriptions (where “off-label” means using medications to treat conditions for which they are not formally approved). It was, in a word, a series of experiments. Each experiment lasted as long as a month or two. Much shorter, of course, in the case of hallucinations or other serious reactions. Recently the doctors started mumbling about using botox, but I'm not sure what that's all about.

But that was merely prelude. This year his condition escalated in a completely unexpected way. Let him tell it in his own words. It's a total mystery:

In early March I started to experience swelling in the front center of my neck. A couple of days later there was a small lump on the back of my neck. The lump in the front of my neck has continued to swell and the swelling has grown into my jaw. This past weekend a new, fairly large lump has appeared at the intersection of my jaw and neck just below my right ear. The swelling in my neck has put enough pressure on my neck to cause difficulty swallowing, occasional difficulty breathing, and the loss of my voice. (I can only talk in a whisper.) I have also had swelling in both underarms and in my groin, but the doctors can’t feel anything in those spots that would warrant more testing.

Blood tests suggested that I have hypothyroidism, and I’ve been taking levothyroxine (50 mcg/day) for over a month to combat that potential cause. The levothyroxine has lowered my thyroid stimulating hormone level to normal, and I’m still taking it per my doctor’s orders, but that drug hasn’t lowered the existing swelling, kept existing swollen areas from growing, or prevented new growths from forming.

I’ve had three ultrasound tests of my neck and though these tests have found a slightly enlarged lymph node that hasn’t grown or shrunk in the subsequent two tests, the node is too small for a biopsy. I’ve also been to the ENT and to a gastroenterologist without any success or insights. My primary doctor is now at a loss about what to do next.

While lymphoma has been suspected because of the swollen lymph nodes, nothing has ruled it definitively in or definitively out. The constellation of symptoms is totally confusing.

And Hugh Laurie is busy wrapping up his final season of House and isn't taking new patients.

Any ideas, anyone? Know anyone who might? Perhaps you have a better clue than any of my friend's doctors. They keep passing him back and forth like a hot potato, cheerfully suggesting to him that his life isn't really at risk because they can always resort to intubation if his throat becomes too constricted to permit adequate breathing. It's a comfort, isn't it?

Please feel free to pass this post along, link to it, or otherwise bring it to the attention of medically savvy professionals who can solve this puzzle. It's a headache—and then some.

California going to pot?

They have a proposition for us

I know that the proponents of Proposition 19 aren't really talking to me when they cry “Just Say Now!” and try to appeal to my generation's long and intimate acquaintance with marijuana. It's not my thing. And I am not at all representative of “my” generation. Nevertheless, I am almost certain to vote in favor of Proposition 19 on California's general election ballot next month. If it passes, the state's various legal proscriptions of pot will be expunged and a new era of good feelings will be ushered in.

Not bloody likely.

Passage of Proposition 19 is a fair bet to set off an overreaction by the federal government, whose laws misclassifying marijuana as a narcotic would remain on the books and whose zealotry in the unending war on drugs appears to be unabated under the Obama administration. The main reason to vote for Proposition 19 is to poke one's thumb in the eye of the people who scream constantly about our always having been at war with Eurasia. (Or is it Eastasia? I forget.) Criminalization of pot has merely lumped the moral equivalent of beer with the physiological equivalent of eye-blinding bathtub gin. Does anyone except the misinformed and the professional narcs really believe that marijuana deserves to be classified with heroin?

They must be on drugs.

The San Francisco Chronicle, the newspaper of record for the geographical region centered on the Haight-Ashbury, offered a carefully reasoned and detailed editorial explaining why Proposition 19 is a flawed measure that deserves a No vote. As an exponent of reason myself, you'd think I'd be more susceptible to the Chronicle's laundry list of potential problems:

• The proposition's ban on pre-employment drug testing would conflict with federal law.
• A citizen's new right to grow pot in the backyard would be exempt from local control, reasonable or not.
• Drivers would still be prohibited from driving under the influence, but passengers enjoy the right to have a nice traffic toke. Oops?
• Proposition 19's free-for-all approach to county-by-county taxation and regulation of marijuana cultivation would induce chaos.

I think these are all valid concerns, yet I care about them about as much as a chronic pothead. “Yeah, wha—?”

Let the lawyers and the courts sort it out. They'll be happy to.

Drug policy is already chaotic and already stupid and Proposition 19 would merely underscore that. I fear, of course, that teenagers will begin to reject pot once it becomes just another garden plant in grandpa and grandma's backyard or window box. Serious uncoolness is about to set in.