Let's trade, I fix your dizziness and you'll teach me...

We all know that it's called the "practice of medicine" and everyone has heard that a doctor is always learning. In fact, I bet that you have heard at least once in your life that your doctor learned from you. Usually we think of this in a different way, for example, a unique disease teaches us, or maybe a patient responds in a special way to a treatment and we learn and log that experience in our memories. But, today I have a very different story to tell.

First, I want to tell you how I helped my patient. A gentleman in his sixties presented with a month of significant dizziness. He would have severe rotational vertigo when rolling over in bed lasting several seconds and leaving him with a feeling of imbalance. He could pinpoint the exact time andplace when his symptoms developed and ever since he had been uncomfortable and actually fearful of motion.

On physical exam he was completely normal except for one abnormality. When I did a Dix-Hallpike maneuver he became rapidly vertiginous on his right side. The Dix-Hallpike maneuver is done by rotating someones face to either their left or right side while sitting up and rapidly laying them down flat. When one experiences intense vertigo that starts after a brief delay and lasts for about twenty seconds they are diagnosed with a disorder called benign paroxysmal positional vertigo, or BPPV.

BPPV occurs when very tiny crystals in the inner ear in the balance portion fall off and become lodged in one of the three semicircular canals. Those semicircular canals are oriented in the X, Y, and Z axis. When crystals become lodged in there when ever you move your head the crystals slide around and cause vertigo. The disorder is very common yet very strange. Whenever I show a patient a diagram of the inner ear and explain how this occurs everyone is amazed how the problem occurs.

Before 30 years ago people suffered until the brain learned to ignore the problem. They would be given exercises to practise. If they didn't improve surgery would be done to plug or destroy the balance portion of the ear to stop the problem. But then a ENT doctor in Washington ,Dr. John Epley, was doing doing surgery on someone with the problem and he could see the little crystals floating around in the semicircular canal. He took a model of the inner ear and figured out that if you placed someone in just the right position and rotated them 360 degrees you might be able to cure the problem.

His idea was slow to catch on because everyone thought it was kind of hokey. I attended one of his lectures and I was impressed by the idea. I was in residency then and my professors thought the idea was silly and wouldn't let me try it. But when I was in practice a few years later I did the maneuver on a nurse who had been dizzy for over a year and cured her.

So, with this gentleman I identified the likely offending ear and took him through my modification of the "Epley maneuver". As I was taking him through it I discussed with the patient that he might be skeptical but that I had a 90% chance of helping him. He promised me that the next time I saw him he would teach me something as well.

Two weeks later, a few days ago, he showed up and said his dizziness was cured. He hadn't had a problem again since he saw me that day. So now he was ready to teach me his trick. When he was young he was frequently afflicted with hiccoughs. Nothing would help. One day he saw an elderly woman that he described as gypsy like. She put her finger on each side of his face just in front of his ears and held them there for a few moments. And, his hiccoughs were instantly cured. Amazed, he asked her exactly how to do this and she taught him. Ever since then he would cure people who were afflicted. He said it was a great barroom trick and earned him more than one free beer. He explained to me exactly how to do the trick.

Just my luck an opportunity presented itself a couple of days later. My three year old daughter Ellie, developed hiccoughs. I did the maneuver and Voila! She was immediately cured. Granted this was just one time and it may have been coincidence so time will tell if it really works. But, either way, this is a patient who really did teach me something new and unique.

Virestorm Chapter 8

Chapter 8

Ann Arbor

Alex awoke with a start. She could hear a knocking on her door. At first she was disoriented. She started to raise up and realized she was unable to. As the fog in her mind began to clear she could hear Stephanie in the background calling to her over the music playing. She reached up and remembered she was still in the tanning  booth. “Oh shit” she thought to herself, how long had she been there? She raised the clamshell top and pulled out the earbuds.

“Stephanie I’m fine, I fell asleep. Sorry”

“That’s ok Alex, it happens all the time.” Stephanie rolled her eyes and backed away from her door and returned to her desk.

Alex grabbed her watch. Uh oh, it was already nine o’clock. How could she have slept for an hour on that bed? She could feel the sticky sweat in the small of her back. She grabbed a towel, wiped the bed down and a with a fresh towel wiped her back arms and legs. She must look like a disaster. She pulled on her panties and bra and went over to the mirror. She brushed her hair, applied make up and then put the rest of her clothes on. Paula was going to kill her. If she decided to stand up and do her routine she would have been first up like all of the newbie first time performers. Alex headed out the door and into the main room. Stephanie looked up at her.

“Alex, you owe for an hour and you only paid for 30 minutes.”

Alex rolled her eyes, reached into her purse and pulled out the punch card. “Fine, just punch it I’ve gotta go!”

“Fine, not like it’s my fault you passed out in there you know. Maybe you should be getting your sleep at home.”

Alex was perturbed by this latest comment, partly because it was rude but partly because she really wasn’t sleeping well at night and Stephanie’s comment hit a chord. Alex headed down the narrow wooden staircase and bounded out onto South University Street. She speed walked down the side walk toward State Street. She passed the undergraduate library, better known as the “Ugly” from the old days before they replaced the 1950’s boring brick structure with the new modern glass and brick structure. She saw the undergraduates heading in and out with their back packs full starting their Spring term studies. She made it to Main Street and headed up the steps to the Union building.

The Union building is a red brick structure with peaking roofs and a traditional old school East Coast appearance. Built in the early 1900’s for men only the building is now used for all sorts of University student functions and is very popular for its lounge with frequent band performances and on nights like tonight amateur comedy hour.

Alex entered the heavy wooden doors and went up the hallway to the lounge. She could hear the tail end of laughter followed by applause. She headed through the crowd and could see a table just in front of the stage where Paula’s boyfriend Malcolm was sitting and next to him two empty chairs. She walked up and looked up at the stage. Paula was bowing to the audience and waved and said thank you. She caught Alex’s eye and raised her eyebrows quizically. Alex sat down next to Malcolm. He looked over at her. His ice blue eyes cut straight through her.

“I can’t believe you Alex, you’re her best friend and you missed her entire act.”

“I know Malcolm, look I feel like a total shit ok? I didn’t plan on missing her debut. Today was crazy, I raced over here and I know I blew it, but I didn’t mean to. I wanted to see her too you know.”

“Well, she did great, and you better make her feel like you were here even if you weren’t. She’s been behind you through all of your issues and you owe her more than this. Oh, here she is.” Paula ambled up, she was smiling although her lips were a little tight. When she leaned over to give Malcolm a kiss Alex could see that she was shaking.

“I hope I didn’t make a complete ass of myself.”

“No babe, you were great. We were all laughing. You totally had us. Great job. Didn’t you think she did great Alex?” He gave her a kick under the table.

“Oh yeah, great job. I missed some of it but you totally had everyone eating out of the palm of your hand.”

“Really?” Paula was starting to relax, her tremor in her voice began to settle down. “I wasn’t sure if the joke about Bush nuking the “liberal country of Hawaii” carried well. You know how everyone’s so sensitive.”

Alex didn’t know what to say but Malcolm stepped in and saved her, “You nailed it right on. Maybe the junior national guard didn’t quite get it but everyone else was totally with you. You did great. Do you want to stick around for the other acts or go out for a beer?”

“I could really use something a bit stronger. Let’s head to the Full Moon and get some chili fries and drinks. I’m starving, I never ate, I was way too anxious.” She reached over and gave Alex a hug. “I’m so glad you caught part of the act. I was so pissed I thought you missed the whole thing but you must have been out of my sight. Those bright lights distort, like, everything. Come on guys, let’s get out of here.”

They headed out of the club and turned onto State Street and again on South University.  Students were heading out of their dormitories, apartments and houses and heading in loosely amalgamated groups toward the various bars in town. A few were heading out with stuffed backpacks to pull all night study sessions at one of the several libraries but since the term had just started most students remained in party mode. As they navigated the streets Alex struggled to keep up with Paula and Malcolm. She could over hear the two of them dissecting the monologue to refine and improve it. Even though Alex could practically recite the routine herself she didn’t feel she was invited to contribute.

Eventually the streets became quieter and they reached Main Street. This area was more of a graduate level group of students who tended to be more serious. Evening festivities tended to be less noisy and more intellectual. Branching off Main Street were a number of establishments catering to this crowd for several decades. Most of the bars and restaurants maintained their early twentieth century architectural style with tin ceiling tiles, old wooden floors, and brass railings.

They turned into the Full Moon restaurant. At the entrance outside was an iron gate enclosure and behind it were several tables. Sitting at one of the tables was a thin guy with thin light blonde hair. He was surrounded by a couple of other guys and girls who looked to be graduate students and at least ten years younger. They were watching the thin blonde guy closely and he was gesturing with his left hand which was holding a partially burned cigarette, the right was holding a pint of a dark beer. He looked over to Alex, Paula and Malcolm as they entered.

“Hi Alex, how are ya doing tonight?” He opened his arms and Alex leaned in to give him a kiss on the cheek. One of the woman who was sitting across the table looked Alex up and down and not with a look of approval.

“I’m doing pretty good Vince. They totally bombed me in the lab today. Nine specimens to process from Pakistan, well really only eight arrived. Tomorrow will be marathon part two so I hope you don’t have too many plans for tomorrow.”

“No problem, we’ve been light lately. Hey, you want me to get you a beer?” Now the girl sitting with Vince was really glaring.

“No, it’s okay, I’m going to help Paula and Malcolm celebrate her debut at the Union, but I’ll catch you up tomorrow.” She headed in after Malcolm and Paula who had already navigated past the narrow bar area to an available table. As they walked through more than one of the men at the bar turned to look at Alex. Her near hip length blonde hair was always a potent visual stimulus and was a source of both good and bad fortune depending upon your perspective. Paula caught several of the visual shakedowns in mid view and projected one of her “concerned friend” looks to Alex who was happily sashaying in the midst of the attention.

“Oh, don’t worry, I haven’t anytime for games tonight. With the work load I have tomorrow I only have just enough time for a basket of chili cheese fries and a beer. I still don’t get why you guys just blow past Vince every time we see him.”

Paula rolled her large brown eyes to the ceiling, shrugged, and shook her head a little. She probably understood Alex’s need for masculine attention better than Alex did and she wasn’t convinced that Vince was a “good friend” like Alex was always saying. Paula didn’t really think it took a Ph.D. in psychology to recognize that Alex was eventually going to have to discover a better method of dealing with her father’s absence in her life. Because of this she gave Alex a lot of free space and support. She knew deep down Alex would eventually confront these demons, a few weeks ago after a night of copious alcohol consumption Alex began to discuss her dad. But, the discussion was just the tip of a very deep iceberg.

“Look Alex, he plays this Mayor thing every night. He closes the place down, surrounded by his disciples and the rest of his “city council”. You’d think he’d grow up by now. These girls he dates are like at least fifteen years younger than him. Anyway, I’m not so sure his intentions are true with you.”

“Oh Paula come on, we work together sometimes but besides that he’s totally harmless.  It’s not like I’m going to sleep with him or something.” Just as Alex said this Malcolm walked up.

“Hey ladies I got a pitcher of the draft  weissbeer.” After Malcolm poured three tall glasses he raised his to Paula, “To your triumph at the Union, may we all laugh until our buttons pop and our trousers rip,” with that they all crashed their glasses together in unison.

Moments later Malcolm and Paula were dream talking about her great future career of physician by day and comedienne by night. Alex’s mind slowly wandered to the day’s work and the inconsistencies in the lab specimens. Paula reached over and punched Alex in the shoulder busting her out of her thoughts.

“Oww, what was that for?”

“Well, for like ten minute Alex we’ve been asking you what’s going on in your head and you haven’t responded. Malcolm was ready to call the paramedics.”

“Ha ha. Today was just very strange. There was another flu outbreak, this time in Pakistan. Looks like nine people died but they only sent eight specimens. Anyways, tomorrow I have to process everything. Looks like the weekend might even be burned. We’ll just have to wait and see.”

“Bummer, I was hoping we could take a canoe out on the Huron River together. This will be one of my last weekends for a while since clinical rotations have us doing Saturday Grand Rounds and Sundays we have to work. Let me know if you end up getting any free time.”

Just then the food arrived. Alex hadn’t even thought about eating today, with the frantic work pace she just realized the last thing she ate was that cinnamon raisin French toast at breakfast. She voraciously dug into the fries and half of Paula’s blue cheese bacon burger.

“Wow Alex, I’m glad you didn’t mistake any of my digits for a fry or I would be ruling out surgery as a specialty. I think your enthusiasm for the meal scared away half the single guys at the bar who’ve been eyeing you all night. Of course the other half are wondering if you could do that to a burger, hmmm.”

Alex made a limp chuckle. Her eating habits were a common topic of humor to Paula and admittedly there had been some pretty funny times but she didn’t always like being the butt end of some of Paula’s humor. Anyways, right now it didn’t really matter, she was tired and she knew she better head home and catch up on her sleep, tomorrow was going to be a very long day. Alex broadened her lips into a smile leaned over and gave Paula a hug and a peck on the cheek for Malcolm.

“With that, I must go. Those of us who work for a living get few chances for rest. Ciao guys.” Alex quickly headed for the door, no sashay this time, only one brief eye contact with an attractive twenty-something long light haired guy in a tie-dyed shirt, and out into the Spring night.

Can a talk show change how I treat my patients?

Every day is an oportunity to learn something new and medicine is full of a
 tremendous amount of complexity where the information changes on what seems a daily if not hourly rate. I'm always trying to keep up with what's new and there are many sources of information. Of course there are journal articles, meeting updates, and even the newspaper can be a source of knowledge. The trick is to integrate that information in a way that has a meaningful impact on patient care.

One of my more surprising sources of information is from a colleague of mine, Dr. Dawn Motyka. Dawn has a radio call in show on public radio in my community. She starts off with information about journal articles or publications she thinks may be of interest and then she takes calls from patients. People call her about a wide variety of issues and interestingly some call from quite a distance. I recall one person calling from Florida. Dawn is a Family Practice physician so she often times introduces topics of interest that without her talk show I would be unlikely to have any exposure to.

One phenomenon that has been increasingly recognized in medicine is the increasing number of patiets diagnosed with elevated calcium levels associated with an elevation of a hormone called Parathyroid hormone. Parathyroid hormone is secreted by four small glands that surround the thyroid. When they sense a low calcium level they secrete parathyroid hormone which tells your bones to breakdown a little and secrete calcium into the blood stream.

Sometimes the system goes haywire and the hormone is secreted when it isn't supposed to be and one ends up with elevated levels of calcium in the blood stream with demineralized and weakened bones and elevated levels of the hormone. For an unknown reason we have been finding more patients with this condition in the past several years. This has been attributed to the fact that doctors are more frequently ordering routine blood panels that include calcium levels now than they did in the past and therefore have uncovered more people with the condition.

So, a couple of years ago I was referred a patient with this exact same issue. Since she had elevated calcium levels and had a high parathyroid hormone level the concern was that she needed surgery to remove the glands that were over secreting the hormone. When I see patients with these findings I think of three possible sources of the problem. First is that this is seen in people with renal failure, but that was not the case here. Second, is that there is a single gland that has developed into a benign tumor called an adenoma that is the source and the third possibility is that the glands have just become defective.

To further evaluate I did some imaging studies to see if one of the glands had a tumor but the result was negative. I was considering surgery for the patient but I was uncomfortable because her calcium level wasn't terrible elevated and she wasn't having problems such as evidence of bone loss or kidney stones from the high calcium level. The surgery involves removing three and a half of the glands, thereby leaving just enough tissue to kick the body into a normal level. But if one removes too much the opposite occurs and the patient is stuck with low calcium which can be even more dangerous. So just to be sure I repeated the blood testing for her third time and surprisingly, everything was normal. The situation was strange, I advised her to have monitoring and I placed the experience in my library of unsolved mysteries.

Now, back to the present. Last week I was listening to Dawn and she was discussing another problem we are well aware of in medicine which is that we are prescribing large quantities of very powerful antacids called proton pump inhibitors which are more familiar to most of us as Prilosec and Prevacid among others. In fact currently those two are available without a prescription. The usage of these medications has gone up probably in direct correlation with the increase in obesity in our population. Unfortunately, these medication are not used without risk. They have been shown to be asssociated with poor calcium and vitamin B12 absorption as well as increased levels of osteoporosis.

But, interestingly Dawn found an article with some new information. Apparently these medications are also associated with an elevation in the secretion of parathyroid hormone. This recently published study immediately caught my attention because it may explain why my patient had the combination of elevated calcium and parathyroid hormone and then spontaneously returned to normal. Of course, now that three years have gone by I have no recollection of the name of the patient so I can't review her records to see if she was on this medication at that time.

But, I wonder if this mini epidemic of patients being found with high calcium levels might be a result of these now very common medications. Ironically, a couple of days after Dawn's radio show I bumped into her and shared my thoughts with her. She certainly was intrigued and we both agreed it was something we were going to share with our colleagues and monitor for among our patients.

So, in answer to the title of today's blog. Yes, a talk show can change how I treat my patients and I view every source of information as valuable as long as it comes from a legitimate background.