Archive for the ‘Chronic Pain’ Category

Ovarian Cancer – five tips to make sure you get the medical care you need

Wednesday, May 11th, 2011

Did you know that more than 21,000 women are diagnosed with ovarian cancer in the U.S. each year? An astonishing 15,000 women die from ovarian cancer each year. Despite numerous advances in healthcare, the mortality rate for ovarian cancer has not improved in the last 30 years. Simply put, ovarian cancer is the deadliest of all gynecologic cancers. If the cancer is diagnosed in its early stages (i.e. before it spreads to other organs), the five-year survival rate is about 93.8%. However, if it the cancer is diagnosed in its later stages, the five-year survival rate is about 28.2%.

There is no question that ovarian cancer is quite deadly and that early diagnosis and treatment is key for survival. There is an abundance of information about ovarian cancer online and in other written sources. Simply put, take the time to familiarize yourself with the symptoms of this terrible disease. Let’s share with you some information, which I believe can make a difference. Call it a male lawyer’s perspective, if you will. I’ve seen what happens when early detection should have happened, but tragically did not.

1. Examine Your Medical History

Whenever the possibility for ovarian cancer exists, consider your medical history as you discuss your symptoms with your physician. If you are having symptoms consistent with ovarian cancer, take the initiative and discuss your symptoms and history with a gynecologist as opposed to your primary care physician. Make sure to tell your physician if you have any cancer history. Don’t forget to include information about any family history of cancer (parents, siblings, etc.). Of particular importance is any history of breast or ovarian cancer, although any cancer history is relevant. Unfortunately, women with a personal or family history of ovarian cancer or breast cancer are at a higher risk.

2. Understand and Appreciate Your Symptoms

Although your physician is likely to talk to you about ovarian cancer, it is always a good idea to familiarizer yourself with the signs and symptoms of ovarian cancer before your doctor’s appointment. Many of the symptoms of ovarian cancer overlap with the symptoms of cervical cancer. Therefore, if you are experiencing symptoms of cervical cancer, you and your physician should also discuss the possibility of ovarian cancer. We have seen cases were a physician will consider one or the other but not the possibility of both cancers. Here are some of the more common symptoms of ovarian cancer:

-          Irregular uterine bleeding

-          Abdominal  and/or pelvic pain

-          Abdominal fullness or bloating

-          Fatigue

-          Unexpected weight loss

-          Fatigue

-          Headaches

-          Frequent urination

-          Low back pain

Watch this video for more information about symptoms of ovarian cancer:

httpv://www.youtube.com/watch?v=fH9N4auMblE

 

Watch this video for more information about symptoms of cervical cancer:

httpv://www.youtube.com/watch?v=HHA_0HsjeBI&feature=related

3. Is it a solid mass?

If your radiographic studies reveal a mass, make sure that you get a clear answer as to whether the mass is solid or fluid-filled.  A fluid filled mass will typically turn out to be a cyst. It could also be a blocked fallopian tube (i.e., hydrosalpinx, hematosalpinx, pyosalpinx). Generally speaking, a fluid filled mass is less likely to be malignant. However, if your radiographic studies reveal a solid mass, especially one that arises from an ovary, the possibility of ovarian cancer must be seriously considered. If you are found to have a solid mass, talk to your gynecologist or primary care physician about consulting with a surgical oncologist.

4. Should you have a CA 125 blood test?

CA 125 is a protein. It is a tumor marker or biomarker for ovarian cancer because it is more prominent in ovarian cancer cells. The CA 125 test is a test designed to test the levels of CA 125 in a patient’s blood. Elevated CA 125 levels can be indicative of ovarian cancer. If your CA 125 levels are elevated, you and your physician should seriously consider the possibility of ovarian cancer. An elevated CA125 should prompt your physician to order additional radiographic studies, including a CT of the abdomen and pelvis, an ultrasound of abdomen and pelvis, a PET scan or even a CT pyelogram. You should also consider consulting an oncologist or a surgical oncologist. If you are found to have a solid mass and your CA 125 level is elevated, time is of the essence for further investigation and surgical intervention.  Ask your doctor about other tumor markers that can be tested.

5. Who is reading your ultrasound?

Many patients who present to their gynecologist with symptoms of ovarian cancer will initially undergo an ultrasound. A great number of gynecologists will themselves perform and interpret the ultrasound. Here is the problem. With all due respect to gynecologists, they are not trained ultrasonographers or even radiologists! Ultrasounds can be particularly difficult to read. This can be due to the patient’s position and, more frequently, the size of the patient. In heavier patients, a pelvic ultrasound can be quite limited if one is trying to visualize the ovaries, discern the presence of mass, or determine whether the mass is solid or fluid-filled. So, if your gynecologist is the only person to read your ultrasound, the result is potentially quite devastating. The mass could remain undiagnosed, and you may be told to come back if your symptoms get worse. The ultrasound may be interpreted as limited, and, for whatever reason, your gynecologist may simply neglect to order a more sensitive study (i.e. a CT scan). Instead, he or she may choose to monitor you for any further deterioration of symptoms.

In yet another instance, if the ultrasound is limited, a solid mass may be confused for a fluid-filled mass. Under these circumstances, you may be asked to follow-up in six months. The problem with all of these permutations is delay, and you cannot afford delay with ovarian cancer. Make sure that your radiographic studies, whatever they may be, are read by a skilled specialist in the interpretation of whatever study you undergo.

As we always say, be your own patient advocate and be an informed patient. Be an active participant in your medical care by being informed and by demanding the care you require. Having an understating of the types of mistakes that can be made during medical treatment is simply prudent.

Please share your familiarity or experience with ovarian cancer treatment. What do you think women should watch out for should they find themselves afflicted by this terrible disease?

For more information, see our other blogs:

Ovarian Cancer – Early Intervention is Key, What You Must Know…

New study links gene to ovarian cancer and may assist in early detection 

Ovarian Cancer – The Smear Test Won’t Tell You Much

 

Image from cancersyptomspage.com

Neck & Back Pain: When is it something more serious?

Wednesday, December 22nd, 2010

Statistically, 4 out of every 5 adults under the age of 50 have experienced at least one episode of neck or back pain.  For most people, the symptoms resolve in a reasonable period of time with or without intervention.  For others, the symptoms become chronic, often leading to surgical procedures and even disability.  Sometimes, there is a specific identifiable incident that incited the pain while in other cases, no particular injury or overuse syndrome could be identified.  Neck and back pain are one of the most common complaints leading to medical evaluations in the emergency room, urgent care center or primary care physician’s office; they are also a significant cause of lost time from work, lost wages and productivity, and high expenditure from a healthcare perspective.

Neck and back pain are symptoms of an underlying problem.  The majority of the causes (~97%) are purely mechanical, that is related to the mechanics of movement of the neck or back, involving the bones, muscles, ligaments, discs and joint spaces.  They include such diagnoses as lumbar strain/sprain, degenerative disc disease, herniated discs, spinal stenosis, spondylolisthesis, osteoporotic compression fracture and traumatic fractures.  Some of these, obviously, are more serious with potential neurologic sequellae than others.  Any condition that results in compression of the spinal cord can cause permanent neurologic injury, including paralysis; these include fractures, stenosis and significant spondylolisthesis. Causes include acute traumatic injuries (car accidents, falls, direct blows), overuse syndromes, poor lifting techniques, poor posture, chronic degenerative arthritis leading to spinal stenosis and spondylolisthesis, and osteoporosis.

The remaining 3% of causes of neck and back pain are considered non-mechanical, but they can be further divided into non-mechanical spinal conditions (1%) and visceral (internal organ-related) conditions (2%).  Of the non-mechanical spinal conditions, neoplasias/malignancies comprise 0.7% while infections and inflammatory arthritides (inflammation of joints due to infectious, metabolic, or constitutional causes) comprise the remaining 0.3%.  Of the 2% visceral complications, etiologies are potentially due to vascular problems (aortic aneurysms, retroperitoneal hemorrhage, coronary syndromes, etc.), prostatitis, endometriosis, pelvic inflammatory disease, kidney stones/infections, pancreatitis, cholecystitis or ulcer perforation.  Thus, the sub-categories of non-mechanical neck and back pain have very small incidences in the global sense, but they are potentially more serious with more ominous consequences, including paralysis and death, making them diagnoses not to be missed or ignored.

So, how can one tell the difference between mechanical versus non-mechanical neck or back pain?

As a general rule, mechanical neck/back pain, since it is related to movement, is typically worse with movement or specific body positions and better with rest or lying supine without the burden of one’s weight causing an axial load on the vertebral column.  Non-mechanical neck/back pain is relatively constant and not related to body position or movement.  Pain in either case can be sharp or dull/aching, and each can have instances in which there is neurologic involvement causing pain to radiate along the nerves that exit the spinal column.  In the neck, nerve pain typically radiates to the arms causing pain, numbness and sometimes weakness.  In the upper to mid-back, nerve pain typically radiates to the anterior chest and abdomen.  In the lower back, nerve pain typically radiates into the pelvis, genital area, and especially the legs.  Radicular pain can be either one-sided or bilateral, the latter of which is more ominous and indicative of spinal cord compression as opposed to a single peripheral nerve root.

What are the “red flags” that raise concern for more serious problems?

There are specific risk factors that, when present, raise concerns for more systemic disease processes.  A history of cancer, for instance, increases the likelihood of the pain being related to a metastatic lesion or tumor.  Presence of a fever increases the likelihood of the pain being related to an infectious etiology.  Unexplained weight loss increases the likelihood of the pain being related to either a primary malignancy or metastatic cancer.  A history of intravenous drug use or even diabetes increases the risk for an acute or chronic infectious cause.  Blood in the urine can indicate a malignancy or other kidney-related problem.  Swollen glands can be indicative of a malignancy or infectious problem.  Anemia can be indicative of an underlying malignancy or vascular problem.  Rashes are often associated with rheumatologic or auto-immune problems that often involve the joints.  Chronic steroid use or other immunosuppression can increase the risk of infectious causes or osteoporosis with compression fracture.  Obviously, a history of trauma increases the risk of fracture, disc rupture/herniation and ligamentous injury leading to spinal instability, but it can also be a cause of intra-abdominal injuries or retroperitoneal injuries that present as back pain.  Any time there are neurologic deficits (numbness, tingling, weakness, muscle atrophy, etc.) beyond sciatica, the risk of nerve compression or spinal cord compression becomes higher.  Abdominal pain associated with back pain can be related to an intra-abdominal process (infection, abscess, aneurysm, ulcer perforation, etc.).  Neck pain that is associated with headache, fever and neck rigidity is often indicative of menigitis.

Overall, there are a plethora of potentially serious causes of neck and back pain.  One can see that the diagnosis of more serious conditions can be a little more complicated, especially since they are much rarer than the  common, everyday, garden-variety mechanical back pain without complications.  There are, however, a variety of clues that can lead one to an accurate and relatively rapid diagnosis.  The intention of this blog has been to introduce the topic and the dilemma faced by a provider when diagnosing these conditions.  Since the topic is broad and more complicated, a series of blogs dedicated to some of the more devastating etiologies of neck and back pain will follow.  The key to diagnosing any condition is an accurate and in-depth history and physical examination with keen attention to specific clues that are typically present.

Confusion with Advanced Directives: Palliative Care, End-of-Life & Hospice Care

Tuesday, December 21st, 2010

In a previous blog, I raised the issue of “Advanced Directives” and how, according to a Medscape physician survey, physicians do not always honor these legal documents.  One of the “excuses” cited the definition of futility in treating a terminal medical condition, arguing for palliative care as opposed to withdrawal of care.  Obviously, confusion exists amongst these providers as to what constitutes comfort care versus unnecessary prolongation of life and/or exposure to unnecessary procedures in a patient with a terminal condition.

Palliative, End-of-Life and Hospice Care

Palliative care is essentially comfort care.  To “palliate” means to “ease” or “make less severe” – therefore, medical care that is designed to palliate symptoms of a particular disease is care designed to ease or lessen the severity of symptoms associated with that disease.  It can be in an acute condition, a chronic condition or even a terminal condition depending on the stage of the illness.  Some of the symptoms often palliated are nausea and vomiting (chemotherapy, cirrhosis), anorexia (cancers, AIDS), pain (rheumatoid arthritis, cancers), shortness of breath (COPD/emphysema, interstitial lung disease), dizziness (Meniere’s disease, multiple sclerosis), incontinence (spinal cord injuries, stroke), constipation (inflammatory bowel disease, chronic pain syndromes), and many others.  There are various treatments available for the treatment and/or management of these symptoms, but they are not necessarily curative of the underlying condition.  Some chronic conditions, like Rheumatoid Arthritis, are manageable but not necessarily curable, so the treatment rendered is to palliate/lessen the symptoms and hopefully put the auto-immune disorder into remission for a period of time.  Rheumatoid Arthritis, however, is NOT a terminal condition; patients usually die of complications or other co-morbidities.  Palliative care can also incorporate a variety of specialties with overall coordination of care that involves communication with the family, spirituality and emotional support.  Palliative care is a critical component of end-of-life and Hospice care.

End-of-Life care is a well-coordinated approach to end-of-life issues when a condition is deemed terminal, such as incurable metastatic cancer, end-stage multiple sclerosis or even liver cirrhosis when organ transplant is not an option.  Life expectancy can vary widely, with physician guestimates being greater than 6 months (as much as one year or more).  End-of-life care typically incorporates palliative care to ease the symptoms of the disease process as well as counseling services, emotional support and even spiritual support.

Hospice care is end-of-life care, incorporating palliative care, reserved for the last 6 months of life or less.  Care is shifted from curative therapies to pain management and ease of other symptoms of illness.  There are many Hospice programs that offer services in a variety of locations, all of which is dependent on the patient’s and the patients’ family’s wishes. They can be rendered at home, in a nursing home, in the hospital or in a dedicated Hospice facility.  Services provided by these organizations can even include basic housekeeping, personal hygiene care, grocery shopping, and even companionship in addition to the palliative medical therapies.

Where do advanced directives come into play?

Advanced directives can affect every one of these aspects of care.  They reflect the patient’s or the patient’s medical power of attorney’s wishes regarding palliative care modalities, end-of-life care and Hospice care.

About.com’s website on palliative care offers a great example of palliative care that transitions to end-of-life and at-home Hospice care for “Aunt Tilly”.

A patriarch of the family has essentially been healthy his entire life, shoveling  snow and cutting grass into his 85th year of life.  Things shift during the 86th year, and he develops congestive heart failure which has triggered multiple falls and syncopal episodes, presumably from hypoxemia.  There are several hospitalizations to evaluate his condition with institution of multiple medical therapies/drugs to stabilize his condition.  Unfortunately, his heart is weak, and ultimately his kidneys begin to fail.  No advanced directives had ever been discussed, as with many people of his generation; fortunately, he remained of sound mind.  At first, everything was a whirlwind……medication infusions to prevent irregular heart rhythms, blood transfusions to address his anemia since the kidneys were no longer working properly to stimulate the bone marrow to make more red blood cells, and finally, dialysis???  Well, if the kidneys are not working very well, not filtering the blood to produce urine and not stimulating the bone marrow to produce RBCs, we have to fix this, right?  What was not mentioned was that blood transfusions have to be given with intravenous fluids, which then worsen the fluid overload and congestive heart failure making it even more difficult for the poor man to breathe.  Higher and higher amounts of oxygen are needed to keep him comfortable, while his body is swelling up with fluids.  So, STOP THE MADNESS!  This family patriarch, after being informed of the complicated nature of his essentially end-stage condition, opted to forego hemodialysis; he did not want to be hooked-up to a machine for 3 hours a day, 3 days a week, just to filter his blood in an attempt to garner perhaps 6 more months of life; that kind of life had no quality to it in his mind.  In addition, since the blood transfusions would only worsen his breathing, he refused any more blood.  He wanted to be kept comfortable with pain medications and oxygen which was done in the hospital; he did not want to be shocked (defibrillated) or resuscitated in any way.  Comfort measures were provided in the hospital where he was given a large, private room, and he passed away peacefully within 3 days; there were no restrictions on family visitation, and he was surrounded by those dearest to him.  A chaplain was available within minutes of his death to comfort the family and offer prayer to ease everyone else’s suffering and loss; this patriarch was already at peace and without pain.

In this particular example, it was beneficial that my family member was of sound mind to make his own decisions at the end of life with regard to blood transfusions and hemodialysis.  It would have otherwise been very difficult for the family to come to some kind of consensus.  It was also better, in this case, that he remain in the hospital since his wife was still living and would have to return to their home alone following his death; having her live in the house in which her husband of 67 years had died would have been too much for her to bear.  This emphasizes the importance decision-making while one is of sound mind.  Cancers can spread to the brain; toxic metabolites that accumulate when vital organs fail can render a patient confused or even comatose; acute strokes can also affect one’s cognitive capabilities, not to mention other organ systems (breathing, toileting, swallowing, etc.).

Advanced directives can be as precise or as vague as one desires.  It seems to me that the more detailed the directive, the less chance one encounters of a physician or care provider ignoring the directive or “interpreting” the directive in a way that confuses loved ones, exposing the patient to unnecessary procedures and/or life-extending treatments.

Have you ever had to deal with any of these issues – advanced directives, palliative care, end-of-life care or hospice care? What has your experience been? Do you have any suggestions that might be helpful to others, who may be faced with similar issues?

More on this topic soon: What constitutes a terminal condition?

Related Posts:

Advanced Directives: The Right to Die With Dignity. Does the Medical Profession Honor Them?

Making Your Wishes Known at the End of Life (NY Times article by Dr. Pauline W. Chen )

Image from mylocalhealthguide.com


Chronic Pain

Thursday, December 2nd, 2010
We are very pleased to introduce a new guest blogger to our readers – Kaye Miller, R.N. Kaye has had a long, illustrious career in various fields of nursing (OB/GYN, Labor and Delivery, Nursery, Neonatal Intensive Care – to name a few). She is currently working as a nurse in a cardiac catheterization lab in Kentucky. In addition to her clinical work, Kaye Miller is a member of the National Alliance of Certified Legal Nurse Consultants and the principal owner of North Star Legal Nurse Consulting.

Kaye brings a fresh new approach to Eye Opener. While our firm’s members have been practicing in the field of medical negligence litigation for decades, it is exciting for us to have someone, who actually gives care to patients in the real world of medicine, periodically provide insights and knowledge to you, our readers,  on matters that may affect your daily lives or the life of someone you know and love.

With that said, we present Kaye’s initial blog for Eye Opener - a topic that affects many people every day of their lives – chronic pain.

Chronic Pain
by Kaye Miller, RN, CN-III, CAPA, CLNC

Intractable or chronic pain was once a condition an individual simply had to learn to live with. The economic, psychosocial, and physiological effects of chronic pain are far-reaching. Medical advances in pain control management can now afford patients complete or partial relief of their pain in lieu of invasive surgical procedures. When given an informed choice, many people prefer this more conservative route of therapy.

Epidural steroid injections, facet and medial branch blocks, and stellate ganglion blocks are a few of the options that can be life savers for patients suffering the consequences of chronic pain (lasting more than 3 months). The procedure may be done under local anesthetic or with the assistance of IV sedation. When aided by fluoroscopy (specialized x-ray), the medication can be directed at the site with reduced risks/complications. Undesirable side effects can include:

  • Increased pain
  • Elevated blood glucose
  • Loss of function in the extremity or extremities
  • Temporary weakness/numbness from the neck down
  • Loss of bowel or bladder control
  • Infection
  • Nerve injury
  • Reaction to medications
  • Hematoma (bleeding)
  • Pneumothorax (collapsed lung)

The procedure is usually performed by an anesthesiologist or radiologist. Anesthesiology is a highly skilled, and many times overlooked, discipline in the medical field; a topic I will address at a later time. Injections are usually done in a series of three in order to achieve optimal outcome. Positive effects may start to present immediately after the first treatment or may not appear until the series is completed.

As with any medical procedure, it is imperative the patient is forthcoming regarding medical history. This includes a list of present medications as well as use of other drugs, legal and illicit. One should not discount the effects of herbs and over-the-counter medications as harmless and not worthy of mentioning to the health care provider. Make sure you do so.

One anesthesiologist estimated that 50-60% of his patients were in his clinic for less than honorable aspirations. For this type of patient, the pain goes much deeper…deeper than any pill or injection the health care facility can provide.

If you are truly suffering from chronic pain, consider discussing treatment alternatives with your physician. Be aware of the risks, benefits and alternatives and make a wise, informed choice.