Tuesday, April 06, 2010

Waiting for the Electrician or Someone Like Him

I'm betraying my hippie roots tonight, but there is a point, although it will probably take too long to get to it for most of you who didn't stay up way too late to listen to these guys in your misspent youth.

Ah well. On to the past...

I had an ultrasound of my upper right chest and shoulder and right arm Monday afternoon. No blood clots were found, for which I am grateful. I have changed my sleeping arrangements, which is relatively easy to do when your bed companions are two miniature dachshunds, so that now I am perched on the side of the bed (those dachshunds may be small but they like to crowd right up next to you) where it's easiest to sleep on my left side. This seems to have alleviated the pain symptoms on my upper right side from last week. I am hopeful that this is auspicious news for my port.

I went to Group Health this afternoon to pick up my new glasses. My current pair is 4 years old and while fairly serviceable, the lenses are scratched and in need of polishing. Or so I thought. When I picked up my new glasses, I mentioned to the optician that I wanted to leave my old glasses so the lenses could be polished. "You could do that," he responded, "but we use a very caustic agent to strip the lenses and they could end up all white." And why would that be? I inquired. He explained that the anti reflective coating on my glasses was responsible for my inability to clean the scuffing off the lenses by myself, and that's why it would have to be done in a chemical vat--to remove the coating. With not a very good chance that the lenses would actually be clean in the end. Ah. Right. That would be the same reflective coating that I agreed to apply to my new lenses when I purchased them last week for an additional $70 and nothing was disclosed to me at that time about this, right? Right. Figures.

This evening I went to a panel discussion at the University of Washington in Kane Hall. The topic was: New Discoveries in Medicine: Implications for the Cost and Quality of American Healthcare Panel Discussion. On the panel were 4 eminent physicians: a doctor from Group Health, one from Harvard Medical School, a doctor from Amgen and the dean of the UW medical school. The discussion was very interesting, even if they did not answer the two questions I wrote down and submitted to the group. But one of the topics that was touched on as sort of a pathway for the future was standardization of protocols. It was mentioned in connection with treatment of low back pain, which is of interest to me professionally as I do worker's compensation cases for a living and low back pain is a major cause of the cases that are heard by the Board of Industrial Insurance Appeals. Standardizing care for low back pain would definitely make my work, and the work of the Board easier. However, I'll believe it when I see it.

My scepticism is further reinforced by my own experience with respect to the multiple doctors who have read ct scans that I have had since I was diagnosed with lung cancer. I have had ct scans on Sept. 16, 2009, December 9, 2009, and February 19, 2010. Each time scans were taken of the neck and of the chest. Each time one doctor read the neck scan and one doctor the chest scan. Of the six scans, there were five different doctors doing the reads. Is it any wonder that if you took all six of those scans and read them together you might be a bit confused? Just so you can get a better idea of the confusion, I am posting the letter I sent to my oncologist on February 20, 2010, outlining my problems in understanding:

Dear Dr. N***,

Tonight I reviewed all of the ct scans done on my neck and lungs--that would be 3 for each--and I have a number of questions based upon them. To begin with, I summarized each of the ct scans and then after each nodule, the radiologist identified as cancerous, I put my question in parenthesis. There are additional questions at the end as well. I hope we can discuss these at some length next week.

September 16, 2009, CT scan:

A. Neck (reader: Dr A**** N**, MD)
1. right thyroid lobe, 5mm nodule (is this cancer?)
2. left thyroid lobe, 2mm (is this cancer?)
3. Pretracheal node, 13mm (is this cancer?)
4.Heterogenous mass seen in aortopulmonic window, 24 mm (what’s the difference between this and the aorticopulmonary window?)

B. Lung (reader: J*** B***, DO)
1. Left lower lobe lung mass, 2.6 x 2.1 cm
2. Smaller left lower lobe posterior subpulmonary nodule,1.3 x 1.0 cm
3. Left upper lobe pulmonary nodule, 4mm
4. Aorticopulmonary window, 2.3 x 1.4 cm
5. Precarinal lymph node, 1.2 x .8cm

December 9, 2009, CT scan:
A. Neck (reader: A**** N**, MD)
1. Interval enlargement of a lymph node; currently 11mm, as compared to 7 mm previously (where? I don’t find this on the 9/16/09 neck ct scan)
2. Anterior supraclavicular region node, 13mm—previously measured at 11.3mm (again, where is this found on the 9/16/09 ct scan?)

B. Lung (reader: J******** K****, MD)
1. AP window, centrally necrotic mass, 1.8 cm unchanged (really? It shows as 2.3 x 1.4 according to the ct scan above)
2. Dominant mass inferior medial left lower lobe decreased in size to 2.3 x 1.8 x 1.7 cm—previously 2.8 x 2.2 x 2.2 cm (Is this no. 1 in the 9/16/09 lung ct scan above? Numbers don’t match)
3. More cranial left lower lobe mass unchanged, 1.1 cm (which one is this? I don’t see it above)
4. Left apical noncalcified nodule unchanged, 4 mm (is this no. 3 from the 9/16/09 ct scan above?)
5. Noncalcified nodule in left lung base unchanged, 5 x 2mm (where is this on the 9/16/09 ct scan?)
6. Densely calcified granuloma in right lower lobe, 4mm (is in the right lobe of the lung as opposed to the left lobe and is this cancer?)

February 19, 2010 CT scan:

A. Neck (reader: C********* K*******, MD)
1. 3 nodes in a vertical row anterior to scalene musculature, overall size unchanged compared to 12/09/09 ct scan (12/09/09 scan describes only 2 nodes—so what gives here? And is this a problem that they are not shrinking?)

B. Lung (reader: M******** O*, MD)
1. Paraspinous location of left lower lobe, 22 x 16 mm previously 30 x 22 mm at same location (there’s no nodule that matches this measurement in the 12/09/09 lung ct scan—which one is she talking about?)
2. Right lower lobe posterior nodule, 4mm, down from 5mm (which one is she referring to here?)
3. Left upper lobe anterior lesion appears slightly smaller and less plump as well (is this the apical nodule, B.4 from the 12/09/09 lung ct scan? If not, which is it?)
4. Subplueral posterior left lower lobe superior segment, 9mm-- previously 15 mm (which one is this?)
5. Adenopathy in the AP window decreased, 32 x 14 mm (is this B.1 in the 12/09/09 lung ct scan? If not, which is it?)

Additional questions:

1. Why are there 6 identified node sites with cancer in the 12/09/09 lung ct scan and only 5 in the other two lung ct scans?

2. Do you think that having different radiologists read the exams can create inconsistencies? Would it be too much to ask that one very good radiologist sit down with all three of my ct scans, and read them, to give a more uniform interpretation of the development/shrinkage of my tumors?

3. What is going on with the neck scans? I really don’t know what the reading on the last one means.

I sent this to my oncologist and he had one of the radiologists read the scans and although I would love to post the consolidated report, the Group Health site is down tonight, so that will have to wait for tomorrow. However, to tie this back into the panel discussion on standardization from tonight, it was suggested that rather than just one doctor doing the reading for these six ct scans, it would be far better to put all five of the radiologists together and they could jointly come up with the correct reading. Rather like what a jury does with a civil or criminal trial. I like it. Sounds good to me. Except for the price tag. Which is always the 800 lb purple cow in the middle of the room.

So I guess I will continue to wait for the electrician. Or someone like him.

No comments: