It is finally here. The Van Iwaarden clan always (except for an interruption for surgery 2 years ago) takes a ski trip to Copper Mountain, renting a condo somewhere close to the resort. We generally ski up until Thanksgiving day, enjoying the lack of crowds in the early week and then get a wonderful dinner cooked by my personal chef, Stephanie Van Iwaarden. Stephanie is usually limited by the mystery kitchen, appliances, and cookware but always pulls together a meal that is awesome.
I have been particularly worried about this ski season. Our last day skiing in the 13/14 season was our traditional closing day at Copper Mountain on Easter. The mountain had just gotten a bunch of new snow the night before but the afternoon temperatures were in the upper 40s and lower 50s which turns snow into slop. Skiing these conditions an be tricky because the skis will grab and release almost without warning and the mounds of melting slush are hard to get through.
This was also the Sunday after my last I-131 treatment. I did not have much of an issue with the previous treatment and expected this to be similar. The day was horrible. I had to make 4-5 stops on one of our favorite runs (Copperfields) where we normally finish it in a single stretch or with just one quick break. My legs were dying and my heart felt like it was exploding.
You may remember that, at this time, I knew I had stage 4 kidney disease in addition to the cancer but that was the end of it. What we did not know at the time was that my hemoglobin production was faltering and I had dropped to a hemoglobin level of about 9.5 (17 was normal for me 3 years ago). I also did not know that the mass on my lung had continued to grow collapsing part of my right lung and now was causing an accumulation of pleural effusion, significantly reducing my lung capacity. The combination of all these issues is probably what was leading to my bad day skiing.
So, you can imagine my concern at the start of the 2014/15 season. I did not know if my lungs were going to give out or my legs were going to collapse. I have also been dealing with edema lately which has caused my legs, feet, and ankles to swell considerably. We have treated this with some diuretics (lost 10+ pounds in the first week) but I did not know if my ski boots would even fit.
The ski season has had a slow start but, in the last two weeks, it has dumped almost 5 feet of snow at Copper Mountain and they have now opened a remarkable amount of terrain for Thanksgiving week. We started off with a ride up American Flier and then dropped down into some of our favorite blue runs under Timberline Express.
Our first run was on The Moz which had just been opened today although many had been cutting the lines the previous couple of days. The snow was deep and soft and the old muscle memory kicked in and I glided down the run. There was the familiar feeling of floating on powder with no sounds around but the light whistle of the wind as the skis carve, dive, and surface in the deep snow.
Skiing is on for this year. I am certainly nowhere where I was last year at this time and I know I never will be again but I still can love the feeling of my skis sailing through blankets of snow. We skied Copperfields again with just one stop and I even took the side cut through Tempo which has not grown any real moguls yet.
We flew down Little Burn which was also opened today and enjoyed the smallest bumps that run will have all season. We broke for lunch, relaxed and warmed up and then headed out for a few more runs. Jaques Pique was just opened and we got to enjoy some untracked snow on that trail. Unfortunately, that was also the run that ended my day. I fell in some deep powder and the struggle to get back on my feet finished my legs and my lungs.
The day was wonderful. Seeing my kids bounce and play in the snow and watching my wife float down the runs is something I have never stopped enjoying. My kids are all better than me now and are certainly faster. It is rewarding to see them advance and enjoy the skiing that we have done as a family. I hope it is something that continues with them as they leave home and start their own lives and whatever families or friends they make.
I am back. I am not the skier I once was (Warren Miller said that "If you claim to be a better skier at 40 than you were at 20, you were a pretty bad skier at age 20) but I can still enjoy it. Find your snow this year now matter what form it takes or where you find it!
Monday, November 24, 2014
Saturday, November 1, 2014
Z is for Zebra
This was one of the easiest letters to pick. The Zebra is the mascot for carcinoid cancer because physicians are taught that 'When you hear hoofbeats, think horses, not zebras." This is excellent advice and is an example of Occam's Razor. Essentially, the answer that has the fewest assumptions should be selected.
Carcinoid mimics many other more normal diseases like irritable bowel syndrome, Crohn's disease, stress, gluten intolerance, or any one of number of other diseases. In spite of my misdiagnosis, this is exactly what a doctor should do. You should choose the most likely situation but (and here is where my doctors originally fell short), you also need to keep the zebra in mind when the horses don't materialize.
The misdiagnosis in my first years were not outside of the horse arena as my symptoms were quite minor. In the final months, that is where the zebra should have started making an appearance in my doctor's diagnostic sequences. On the other hand, it is certain that the few months of misdiagnosis would not have lead to any difference in my current situation. However, if it had been caught several years earlier, that diagnosis could have lead to a potential full cure.
But at what cost? The blood test is pricy, nuclear medicine scans are extremely pricy, and neither may have been definitive. This sort of shotgun testing is a significant part of our healthcare cost explosion in the last few years. Doctors order batteries of tests because it is easier to just administer a test and it is safer from a malpractice point of view as well. These tests are often not cheap (CT Scans and MRIs for minor head injuries) but they are a quick and easy way to rule out certain diagnosis and to CYA. Doctors are also not the only ones at fault here as patients demand or expect this tests to be done in order to ease their mind about the possibilities.
We need to get these costs under control. Zebras need to be considered but they need to be addressed further down in the diagnosis tree rather than pushed up to the top. Without getting these costs under control, healthcare is going to continue explode. Whether you like it or not, the Affordable Care Act is attempting to implement some controls that will use the carrot of higher payments for doctors and hospitals to implement more efficient care. This already has proven effective in some areas such as reducing hospital recidivism through follow up care and doctors visits.
Are you a zebra too? Perhaps. Follow the diagnostic tree through the most likely illnesses. If you have a fever, almost certainly,it is flu or a head cold and you don't have ebola. Even malaria or typhus would be a more likely diagnosis than the albino zebra of ebola. Attack the most likely situation first and save the expensive or invasive tests until later. I had this exact situation about 4 months ago when I had persistent low grade fevers (100-101) every evening. We checked the easy, cheap, and higher probability causes and then waited to see if my scheduled stent swap would solve a possible UTI. It did and no more tests were needed.
Doctors need to be given the time to go through proper sequences and then also need to not be punished (sued) for missing the 1 in a million case. Be patient as they try to diagnose you because medical science is not as precise as we would like due to the amazing complexity of our bodies.
Carcinoid mimics many other more normal diseases like irritable bowel syndrome, Crohn's disease, stress, gluten intolerance, or any one of number of other diseases. In spite of my misdiagnosis, this is exactly what a doctor should do. You should choose the most likely situation but (and here is where my doctors originally fell short), you also need to keep the zebra in mind when the horses don't materialize.
The misdiagnosis in my first years were not outside of the horse arena as my symptoms were quite minor. In the final months, that is where the zebra should have started making an appearance in my doctor's diagnostic sequences. On the other hand, it is certain that the few months of misdiagnosis would not have lead to any difference in my current situation. However, if it had been caught several years earlier, that diagnosis could have lead to a potential full cure.
But at what cost? The blood test is pricy, nuclear medicine scans are extremely pricy, and neither may have been definitive. This sort of shotgun testing is a significant part of our healthcare cost explosion in the last few years. Doctors order batteries of tests because it is easier to just administer a test and it is safer from a malpractice point of view as well. These tests are often not cheap (CT Scans and MRIs for minor head injuries) but they are a quick and easy way to rule out certain diagnosis and to CYA. Doctors are also not the only ones at fault here as patients demand or expect this tests to be done in order to ease their mind about the possibilities.
We need to get these costs under control. Zebras need to be considered but they need to be addressed further down in the diagnosis tree rather than pushed up to the top. Without getting these costs under control, healthcare is going to continue explode. Whether you like it or not, the Affordable Care Act is attempting to implement some controls that will use the carrot of higher payments for doctors and hospitals to implement more efficient care. This already has proven effective in some areas such as reducing hospital recidivism through follow up care and doctors visits.
Are you a zebra too? Perhaps. Follow the diagnostic tree through the most likely illnesses. If you have a fever, almost certainly,it is flu or a head cold and you don't have ebola. Even malaria or typhus would be a more likely diagnosis than the albino zebra of ebola. Attack the most likely situation first and save the expensive or invasive tests until later. I had this exact situation about 4 months ago when I had persistent low grade fevers (100-101) every evening. We checked the easy, cheap, and higher probability causes and then waited to see if my scheduled stent swap would solve a possible UTI. It did and no more tests were needed.
Doctors need to be given the time to go through proper sequences and then also need to not be punished (sued) for missing the 1 in a million case. Be patient as they try to diagnose you because medical science is not as precise as we would like due to the amazing complexity of our bodies.
Subscribe to:
Posts (Atom)