I had an appendectomy in 2018. I tell a few parallel stories about healthcare providers providing care to themselves and end with a discussion in pharmaceutical treatments for general pain.
Doctor confirms a self-diagnosis of cancer
I came across an article a few years back where a Radiologist -someone who professionally reviews and translates MRI scans - underwent a routine checkup with oversight from his general practice physician. What made this article interesting was the fact that the Radiologist was the first to receive the imaging set and interpret what he had. It was a shock to discover pancreatic cancer. If you did not know this, pancreatic cancer is usually viewed as a death sentence. While there are people who do come ahead, it is a very difficult condition to treat. In the normal business cycle, the ordering physician would have received the results from the Radiologist but in this case, the chain of communication was not needed. The radiologist explains the shock and disbelief in viewing the images; part of the quick conclusion was the shortened life expectancy. I often reflect on this story as a healthcare professional and health issues I personally go through.
It is a weird feeling to know how the body works, what treatments are used and the outcomes expected when you are diagnosed with a condition or disease. Imagine knowing how fucked you are and someone not having to tell you.
The annoying kid in class
In my graduate studies, I seldom attended lecture. I never understood the point of attending unless there was a well versed speaker or lecturer. Most of the time, I found the lecturers to be regurgitating word for word their PowerPoint slides or passages from textbooks. Boring. I spent most of my time traveling while being referred as the Jetsetter Crew by other classmates. The two weeks prior to midterms and finals, you would locate me in the cubicle of the library in complete isolation. Unlike most students, I sat in the front row of class, nearest the lecture stand with a few of my colleagues. Absorbing material like a sponge.
The classmate I sat next to began to unburden himself. He complained of a stomachache that did not seem to go away. He had taken stool softeners and laxatives in the previous days and complained of bloody stool. To be fair, he ate a lot of garbage food so I dismissed a lot of the conversation and attributed it to poor dieting. A few days later, he was hospitalized and intubated. His appendix had inflamed and swelled to the point of no return. It ruptured. The bacteria we find in the lining of our intestines found itself in the interstitial fluids of the abdomen, leading to sepsis. I visited my classmate who laid on a gurney of a shared hospital bed. It reeked of strong yet fowl body odors from the neighboring patient. I gave my condolences and thought to myself how strange and odd for someone to have appendicitis.
The appendix can be described as a tube/tail that is located on at the beginning part of your large intestine. It is notably long and averages roughly 3.5 to 4 inches in length. There isn't a whole lot of use for the appendix but its theorized to be play a role with the immune system. It is believed to be an evolutionary holdover. The practice of removing ones appendix is called an appendectomy.
Trust me i'm a doctor lol.
Pre-Op
I had just finished dinner with my father. The sushi was bland, to say the least. No amount of soy sauce and wasabi would have improved the rolls we ordered. We made it a point to try different Japanese restaurants on the days we had left work earlier than usual - before going home. Like any other night, I nodded off while watching television at home. I woke up with a dull pain on the right side of my lower abdomen. I turned off the television and figured the spicy wasabi was catching up to me. This pain, felt different from any other stomachache I have had in the past. It felt dull and annoying, not sharp and excruciating like the occasional the Dehli Belly from Indian food. I sat in silence on the king's throne contemplating if it was serious enough to go to the hospital. It was two in the morning and the grogginess of sleep was setting in. I decided to not wake my parents and drove myself to the nearest Kaiser hospital. I had to stop for gas first.
The drive seemed uneventful for the most part. I parked my car in the parking garage, walked down a few flights of stairs and waltzed into the Emergency Room and began discussing my concerns with the on-call Physician in a semi private room. I glanced at the attending physician and noticed "First Year Resident" on the identification badge. "I woke up and took a shit. My stomach still hurts", I said out loud.
The Resident looked exhausted, tired and somewhat unenthusiastic to help. It was difficult to not notice the bags under the eyes. He quickly dismissed my concern and insisted that I eat more fiber in the future to not have future stomach pains; probably believing that it was a nothing burger case. I thought to myself, it's time to bust out the doctor-speak. This resident is not taking me seriously. I countered, "Look, I am having pain in my lower right quadrant pain. It presents as dull and consistent. I believe I have appendicitis which will may require an appendectomy. Can you please order a CT scan with IV contrast so I can rule this out?" The Resident's mouth slacked open and the conversation quickly changed.
In the ER, there is an acronym used called GOMERs which stands for GET OUT of MY EMERGENCY ROOM. The logic is quickly applied to those frequently med-seeking but carries on to most visitors of the hospital unfortunately. Unfortunately decision fatigue occurs and pain is often so subjectively described that is difficult to know who to triage (rank in importance) first, second or third.
The CT confirmed my thoughts. The resident insisted on starting an IV line for antibiotics. He believed Cipro to be a great choice. To his credit, it was. I asked for Zosyn instead since cipro gives me huge vertigo. You can actually get away without antibiotics for a procedure like this. In theory, if the appendectomy is performed correctly, there should be zero bacteria reaching the insterstial fluid of our organs. This resident did not want to take the chance. I shrugged and politely asked who the Surgeon would be. I felt relief when the Attending Physician arrived to announce the quarterbacking.
Post-Op
A few hours later, I received a call from my mom, "Where are you?" I responded "I am about to enter the operating room, about to have my appendix removed." The nurse hurried my conversation and urged that we needed to operate urgently. I don't remember much about the procedure other than counting down from ten to one. I woke up with my mom next to me who look frantically concerned. My eyes felt heavy from the anesthesia.
I had difficulty urinating after the procedure. They handed me a bedpan. It felt foreign but I didn't argue. There was no way I could physically stand up and walk to the bathroom. I struggled and would find out that anesthesia can cause difficulty in relieving ones self. Unfortunately I was the small subset that
Appendicitis is quite common and can happen to anyone although it presents itself to a younger age demographic. The risk of having it burst is most troubling however it is entirely possible for it to resolve on its own.
The nurse checked my fluid intake and stated, we need to cath you. My eyes widened. "WHAT?!" "We need to cath you." The shock of what needed to be done quickly burned off whatever grogginess I had from the anesthesia. A male nurse entered the semi private room. "I can't" my mind blurted. I would ask for a different individual to cath me but I guess the moral of the story here is to ask to be cathed during the procedure because it hurts. A lot.
I would stay overnight be leave the next day. Little did I know, the post-procedure pain would be the worst experience in the world. As I was about to be discharged, I mentioned to the attending physician that I parked my car on-site and would be driving home. He could not believe that I took myself to the hospital and refused to release me unless someone would pick me up. I would pick up my car the following week.
Reflecting on this experience, it was a little bit crazy to think what I knew I had based on experience and teachings. I often wonder if I had not been so assertive, would things have turned out differently. It can be a curse and blessing in disguise to have absorbed so much medical information. At times, I wish I could be a tad more ignorant. As the saying goes, ignorance is bliss.
give me another painkiller already.
Pain is incredibly subjective. If you recall going to your doctors office, there is probably a poster with varying facial expressions with a score of one to ten, with one being the most miserable. What one person may consider painful, another person may be more tolerant.
Depending on the root cause of the pain, there are a handful of treatment options. In this write-up, I describe over-the-counter pain treatments to the most likely used prescriptions for general pain. I will do a write up someday on neurological pain. That is a little bit more complicated and nuanced for the most part.
Typically, the headache you'll get after having an argument or migraine from your ex partner will be paired with Acetaminophen (Tylenol). This is a widely used medication and is safe to use in the pregnancy population. It can be paired with codeine or a derivative of it. (Think Percocet, Vicodin, etc) You will typically find codeine and codeine derivatives mixed with acetaminophen. Codeine by itself has been shown to reduce pain however codeine with acetaminophen (Tylenol) is significantly much better. For the most part, it is generally safe but your liver will only be able to tolerate so much of it in a 24 hour period. The strength of liquid is standardized across the board in America. IV Tylenol does exist however it is expensive in America. It is cheaper to give IV Morphine of IV Fentanyl compared to IV tylenol. I recall a resident getting chewed out by the CEO for ordering IV Tylenol for everyone on the floor. It was her first time practicing in-patient in America. Yikes!
Codeine itself is great as an anti-tussive. This means its great for suppressing coughs. I had a patient that frequented our Pharmacy. In an era where promethazine and codeine, known as 'Lean', are heavily advertised by rappers - codeine gets a bad wrap. I originally believed my patient to have faked her cough to get me to agree to fill her prescription. She would go outside and wait while I did my medical due diligence. To my surprise, I would learn that she had a neurological condition that caused her to cough violently. I could sometimes hear her walking to the Pharmacy based on that specific sound. Crazy! For the most part, Pharmacies hate carrying 'Lean' because of the high risk exposure to med-seekers.
We typically look at NSAIDS (Non Steroidal Anti Inflammatory Drugs) as a comparable first line treatment to pain. Most people will look towards ibuprofen (Advil) or naproxen (Aleve) as choices. Most of these are hard on the stomach if taken regularly and should be taken with a snack or meal. It is important to note, that reaching the anti-inflammatory effect for NSAIDS requires a higher dose than what is publicly available. For Ibuprofen, you will need a minimum of 600mg (which is usually three 200mg tablets) for a dose to achieve the anti-inflammatory effect. This is great for a swollen ankle that you may have sprained.
We can break down opiates into three easy categories. These are typically used for post-op pain, acute trauma and should seldom be used long term.
​ | natural | semi synthetic | synthetics |
source | naturally occuring(think organic) | derived from natural | synthesized independently |
structure | typical | similar | completely different from natural and semis |
examples | morphine, codeine | heroin, hydromprhone, oxymorphone, hydrocodone, oxycodone | methadone, fentanyl, meperidine, tramadol |
Through CYP metabolism, morphine will breakdown and convert to codeine in the body. It is important to take into consideration dosing. Someone who is long term usage of opiates, will have a higher tolerance. They may take what seems like a ridiculously godly dose compared to someone who is "opiate-naive" or someone who does not take opiates regularly.
Fentanyl is probably the most dangerous of all the opiates because of its potency. It is measured in MICROgrams. Most medications are measured in MILLIgrams. 1000MICROgrams is equivalent to 1 MILLIgram. A kilogram which is roughly 2.2 pounds of Fentanyl can wipe out an entire city if leaked into the water supply.
We may look to anticonvulsants, antidepressants, antispastics and sedatives as also other avenues of treatment towards pain.
Surgeon does an appendectomy on himself
In 1962, a Russian surgeon took an expedition to Antarctica - Leonid Rogozov. Without the presence of medical help or civilization, Rogozov operated on himself after self-diagnosing he had appendicitis. You can read more about his story here.
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