My Recent Trip To The ER

Three days ago I critically reflected on the idea of preventative medicine in a post where I talked about a troublesome health condition that I had developed and my experience of having it examined at a local doctor’s office. Today, I went to the ER for that same condition.

What happened?

Between Tuesday, when I first noticed discomfort in my leg, and Wednesday, when I decided to go get a doctor’s opinion before spending some family time out of town, the swelling and redness increased, but I did not develop any other symptoms. On Thursday, the swelling and redness had encircled my entire lower leg, down to my ankle (but strangely not affecting my foot) and up to my knee joint, but not beyond. On Friday, no one who had a look (and there were many prying family eyes beside mine) could tell a difference between Friday’s swelling and Thursday’s– it didn’t seem better, but it also wasn’t clear it was worse. On Saturday morning (today) we packed up and made for home, and the swelling seemed unchanged.

Some family members tried to look up bug bite sites to help guess at what caused my reaction. Others just expressed shock and concern that I wasn’t doing something, anything, to address the obvious symptoms. Suggestions were made that I visit the ER in town at our vacation spot, or at least do it when I got back.

Here is how I was thinking about this decision: the fact that the swelling wasn’t getting obviously worse seemed like a good sign, the way the body fights its fight against invaders and injuries is going on below the surface, and without some kind of evidence (increased pain, swelling, etc.) that it is slowly losing the fight, I assume it is winning it. The discoloration was more extreme and enveloping, but no increase in pain with it seemed less than frightening. I did not develop any other symptoms which suggested a spread of the condition to other vital organs– no dizziness, nausea, vomiting, confusion, etc. And as ever, I am an otherwise healthy individual who rarely experiences illnesses and generally makes speedy, fully recoveries on my own. I felt like I had a lot on my side in terms of weighing the wait.

When we got to town, I had lunch with a friend from high school who was in the area visiting relatives. His father is a doctor, and he mentioned my leg to him, to which his response was the predictable “He should get it checked out.” His dad is a good doctor and a thoughtful person in general, so I asked if he’d take a look at it to see if it was at all obvious from a visual inspection what was going on. He agreed and was surprised that I did not have tenderness or problems moving my toes up toward my shins, indicators for possible blood clot. Still, my leg looked “nasty” in his very medical opinion and he suggested I go to the ER and have them take a look. It could be a blood clot or cellulitis, an under the skin infection, both of which generally require medical intervention to treat.

The blood clot thing did concern me. I was exhibiting some of the symptoms (swelling, redness, soreness) but not all of them, and based upon my diet and exercise I assumed it’d have to be freak luck or a weird immunological response (say, to a bite?) to develop a blood clot in my leg. It seemed a really low probability, but the way to diagnose it is an ultrasound, which I’d rather not do if I don’t have to, but I don’t see as a health disaster for me for attempting.

A trip to the ER brings with it some risks– contracting an infection you didn’t come in with, incompetence in conducting routine medical exam techniques (blood draw, IV), “intervention spiral” where the medical professionals push you to treatments for diseases you don’t even have that just make your health worse, false positives. So I don’t want to go to the ER if I can avoid it. And I still think I could’ve avoided it. Aside from the swelling and redness, nothing else about my condition seemed to be getting worse and I wasn’t exhibiting any other symptoms, it seemed like it was worth taking a punt.

I decided to go to the ER based on the following:

  • second opinion of a non-specialist MD was that my reaction/condition was not “normal” and may be symptomatic of conditions that are potentially tissue-damaging or fatal
  • family was getting worried and doesn’t have the same mental and emotional framework for thinking about this as I do, so they’re going to increasingly see my approach as needlessly risky and stubbornly defiant over what could admittedly be a long self-recovery period
  • so far, no one including myself is able to diagnose what’s likely going on with any certainty
  • because I believe I am an otherwise healthy individual with a strong immune system, I think the specific risks of being exposed to an ER are pretty low for me, so I am willing to trade the potential cost of exposure to risks for gaining more certainty about my condition; my suspicion is that my condition is nothing to be worried about, but I am not prepared to take a gamble on it as we near the delivery date for our first child (best part about this, my wife was pretty skeptical and kept sending sarcastic texts to me as I explained what was going on along the lines of “What did you expect at an ER?”)

Getting admitted was even easier than going to the GP’s office on Wednesday! I filled out a half sheet of paper with my name, birth date, phone number and reason for coming to the ER. It was raining today and there were all of 2 people in the waiting room when I arrived, I got pre-screened in about 3 minutes and then walked to my private room in another 2 minutes and was seen by a nurse attendant in another couple of minutes. The doctor came in and talked to me while a scribe annotated the conversation about 5 minutes later. In total, I was at the ER from about 3pm to 6:30pm.

Before I go further, I want to make something clear: I don’t see myself as anti-Western medicine or anti-medicine in a general sense, and my observations are not supposed to be read as some unbridled skepticism or lowbrow guffawing at the “scam” of the system. I felt I was treated with concern and respect by everyone who I interacted with at the ER, and whoever is the equivalent of the General Manager of that operation is doing a great job because it runs smoothly and its clear customer service is something they’re trying to deliver. This ER is in the hospital I was born in, and which we may have to turn to in the event of a complication with our home birth plans in the coming weeks. I don’t think it’s necessary or reasonable to try to scandalize the people or the process. I simply want to illustrate my thinking about the interventionist mindset and how I experienced it at the ER.

And I knew exactly what kind of a jungle I was walking into. I made the decision when I went to the ER to also go along with (but question first) any routine intervention they’d attempt to administer unless I could get them to talk themselves out of it, or I seriously feared it posed an undue risk to my health. I’ll provide more explanation about this in a bit, but for example, they put me on an antibiotic IV– that wipes out my carefully cultivated gut bacteria and potentially exposes me to direct bacterial infection through intravenous contact, but I believe my full immunity and health profile make it statistically unlikely I will be unduly harmed by this specific intervention.

With that out of the way, I will say this: life is an uncertain enterprise.

Perfect knowledge and omniscience is not something any individual can obtain, nor need they try. We are always grasping at a little bit more illumination in our lives, more clarity when there was less focus, more understanding when before there was ignorance, and this goes for the practice of medicine as well. The contributions to the improvement of human life on this planet by innovations in medicine and physics over the last 200 years are truly astounding, so astounding that some people have concluded that we know most of what we can know about these subjects or that, at least, we need not question their conclusions. I just don’t share this conviction. I look at all actions in life as being about tradeoffs, and I see these tradeoffs being motivated by perception of uncertainty and a desire to gain more certainty. So I look at medicine as offering many answers, but not everything, and certainly not any answers that shouldn’t be questioned. Everything should be questioned, if you’ve stopped asking questions you’ve probably started to experience the knowledge dishonestly.

I went to the ER to try to relieve some uncertainty.

The nurse informed me that they planned to run a blood panel on me, which meant they needed to draw some blood. The reason for the blood panel was to see if there was any distress markers in my blood, particularly an indication of acute infection. The two theories that the doctor who saw me had were that I either had a blood clot, or an infection. Because they were going to put an IV into me to draw the blood, they decided they’d just hit me with an antibiotic drip right away as well. This was puzzling to me, because they planned to do this before confirming the results of the blood panel. The response I got from the doctor was (summarized) as follows:

MD: It’s better to be safe than sorry, don’t you think?
ME: Let’s say I have an infection, what are the chances my body could fight this on its own?
MD: (pauses for a few seconds) …mmm, 50/50. But if your wrong, and your body loses, you could lose your leg. I don’t want to scare you, but I’ve seen these things go fast, like if that’s what it is, you could be fine and then an hour later you’ve lost and it’s too late.
ME: I generally try to avoid antibiotics.
MD: Me too! I never give my kids antibiotics. Like, I won’t give them antibiotics unless they’re dying. Trust me, I wouldn’t suggest this unless I thought it was absolutely necessary, okay?

Of course, if I don’t have an infection, but a blood clot, then what good were the antibiotics? And if I have neither, what good are the antibiotics?

The nurse also informed me I’d get an ultrasound of my leg done to check for the possibility of blood clots. The doctor and the nurse worked together with a doppler to check my pulse in my legs and feet, which they were able to confirm, but their concerns about the heat emanating from my swollen leg led them to the “safe vs. sorry” compromise of ordering another test.

As the nurse walked me through the test regime I was about to run, I asked, “Any idea what this will cost me?” Of course he didn’t know, and up to this point, no one bothered checking with me about the cost of services. It ended up being $250 for the co-pay and I don’t know yet what it was for the tests. I also don’t know if the IV antibiotics costs more than an oral treatment. I asked the nurse about this and he went into a rationalization about not taking chances, etc.

The nurse was very good at drawing my blood. The injection was almost undetectable. The ultrasound technician was also efficient. We talked about her automobile purchase history and she had me all checked out in about 15 minutes. An orderly wheeled me around from room to room in my gurney bed, which enhanced my feeling that something was really wrong with me and at any moment I could crater. I noticed passing through the hall that the other patients at the ER were all males, either very elderly males probably near the end of the road who had had a fall, or gotten sick, or very young males who had just made a very poor judgment call and were now paying the price.

I couldn’t help but thinking, “What is wrong with this picture?” as my seemingly-healthy, 30-year-old trim frame was being shuttled from room to room. Two ideas came to mind: either nothing was wrong with me, and that’s why I shouldn’t be in the ER with these people, or something was REALLY wrong with me, and that is why I was suddenly in the ER with these people.

I waited another 45 minutes by myself on my bed gurney before learning of the test results. A financial admin came in and out to run my insurance and have me initial some boilerplate. I started initialing without reading it and got halfway down the list and saw something saying I agreed to have my medical history inserted in a state database. “Do I need to do this?” “No. I know, next thing you know you’re going to be getting called by a telemarketer…” (not really what I was worried about on that one). So I didn’t initial it, went back over the ones I did, finished the others and wondered what law or series of events had conspired to have a financial admin highlight for initialing the sharing of private medical data in a public database without comment or concern?

Ultrasound: no blood clot found.
Blood panel: no acute infection indicated, blood work looked very good including liver and kidney function (I made sure to ask my nurse for a copy of my blood panel so I could interpret it more fully later, since a blood panel costs $$$ and I planned to do one eventually anyway, this helped me recoup some of the cost on this unnecessary intervention visit)

So, what was wrong with me? The doctor admitted she really didn’t know. Her suspicion was that I was bit by something and it either had some bacteria on its fangs, or it triggered a strange reaction. She told me she wanted me on an antibiotic regimen “just to be sure”, and to come back immediately if my leg felt tingly or numb. She said I could take some Benadryl to try to treat the inflammation as well.

I asked the nurse to help me interpret my blood panel. How did it look? “It looks great, really good panel, no indication of acute infection…” “So then why am I being administered an oral regimen of antibiotics if there is no infection indicated?” “Well, the body is funny, it COULD be infected and it just hasn’t shown yet in the panel, but anyway, we’ve seen a lot of crazy stuff, better safe than sorry right? I mean it can’t do any harm to get the antibiotics, it can only make it better.”

He grabbed my checkout paperwork and had me look over it and sign. The paperwork says that I acknowledge the diagnosis and the treatment being recommended. The nurse says, “We don’t know what you have, but we’re calling it ‘cellulitis’.”

I gained some additional certainty that I don’t have a life-threatening blood clot and that I am not at risk, as of this very moment, of losing my leg to a bad infection as one doesn’t seem to exist. My experience led me to conclude that allergy and immunology medicine are perhaps younger, frontier sciences within the practice of medicine with higher levels of uncertainty than the practice itself. Everyone’s still uncertain about what actually happened to my leg!

Secret Secrets Are No Fun

Why are media people, including owners, allowed to have (and acknowledge) non-public conversations? Whose interests are served by that practice?

SULZBERGER: If I could interject, we had a good conversation there, you and I, and it was off the record, but there was nothing secret, just wanted to make sure. The idea of looking forward was one of the themes that you were saying. That we need to now get past the election, right?

I mean what bullshit! If there was nothing secret, why was it off the record?

Why I Try To Avoid Visits To The Doctor’s Office (#health, #medicine, #choice, #selfesteem)

I don’t go to the doctor much. I think that’s a good thing, but people who believe “an ounce of prevention beats a pound of cure” might be horrified to know that I don’t even do my so-called oil changes and other regularly scheduled maintenances with regards to my body– false positives, risk of complications from the cure that are worse than the disease, etc.

Generally, if I’m not in pain, I’m not going to see a doctor. And even sometimes when I am, I think, “This too shall pass” and carry on. I pay attention to my body, I’ve gotten pretty good at knowing when I’m in trouble versus experiencing discomfort that will resolve itself over time. I have a pretty high pain threshold I think, I won’t even mention I have a headache until I’m somewhere around a migraine for someone else.

And I do believe in prevention! That’s why I eat a nutrient rich diet, exercise (weight lifting) weekly and walk my dog daily. That’s why I work hard to keep a reasonable bed time and get as much sleep as I can. That’s why I try to think happy thoughts and help others do the same. And that’s why I listen to my body and take it easy when it tells me “No!”, rather than flailing myself before the altar of No Pain, No Gain and reveling in masochistic torture.

So I do my darnedest to avoid visiting a doctor. That’s why I’m bummed I decided to go in today, and that’s why I think this decision was yet again illustrative of my principles!

You see, where I live, medicine is practiced a bit oddly– legal liability dictates that the doctor does anything he can to avoid taking responsibility for your treatments and it’s consequences, as they don’t want to be sued for malpractice. But their medical school instruction plus their ever closer relationship with the State leads them to an aggravated mindset anytime you insist on thinking for yourself and following your own judgment. Think about that, they don’t want you to make your own choice, but they don’t want to be responsible for the choice you make.

I had some kind of strange reaction to an insect bite on the back of my calf last night. I don’t know how it happened or what bit me, I’ve never seen anything like this on my leg, nor felt this kind of pain, which is severe but within my tolerance levels. Normally, I’d just keep walking around and unless it seemed to worsen or I showed other symptoms, I’d just let time work it’s magic on healing it. Painful, yes, but nothing my body can’t handle.

Unfortunately, my plan was to travel out of town for the holiday this week to spend time with family. If my condition worsened, I might end up in an ER in a strange place. I don’t want to end up in an ER, and certainly not in a strange place. As a result, I decided to visit the GP at the last minute to see if they thought it looked dangerous. If it was going to kill me or save my tissue, I’d want to intervene, but anything short of that I’d just make do.

I should’ve just kept on going and took my chances.

The doctor squeezed me in, which I’m very grateful for. But because I hadn’t seen them in over ten years, they subjected me to a battery of questions about my health, my family’s health, and so on. I spent 20 minutes talking about everything but my bite and about one minute actually discussing the course of action about the bite.

I got lectured about the need to do regular check ups. I got lectured about treatments available for some historical conditions, as if I was unaware, hadn’t tried them and was suffering needlessly (because the assumption is I don’t take care of my health). I witnessed the doctor exhibit some unhealthy conditions of her own and then was told not to worry, wasn’t contagious, etc.

The worst mistake I made was mentioning that my wife is pregnant and nearing her due date.

“When did you last get your tetanus shot?”

This is a terrifying question. Something innocuous like this, ostensibly asked our of concern for my health and the health of my family, could lead to a spiral where either the baby snatchers come for my kid, or I submit to vaccinations and other invasive treatments I don’t have any interest in.

She continued, “I don’t mean to alarm you, but EIGHT babies in the whole state died last year because of whooping cough connected to tetanus, likely contracted from a parent or relative who didn’t get their shots. I wouldn’t want you to be one of them!”

When she said 8 in the whole state, I wanted to laugh. Are you kidding? I probably have more risk driving my baby around in its car seat (don’t worry, she lectured me about that, too). And its probably not PC to say, but I doubt those babies had my socioeconomic background (ie, I’m wealthier and I don’t have relatives traveling back and forth to third world countries or other impoverished areas). It’s simply not reasonable to be worried about this risk, measured against the potential complications.

“It’s really quick and out nurse is great with shots, can I go ahead and get that taken care of for you?”

No, thanks, I’m traveling and don’t want to deal with it right now.

“Okay no problem, I’ll put a note in your file that you’re going to come back in two weeks and take care of it. Due to state mandate, they won’t let you go near your baby if you don’t have an up to date tetanus shot.”

I sure hope I don’t get that call.

What I Learned In Our At Home RIE Session (#RIE, #infancy, #education, #parenting, #philosophy)

Earlier this week we hosted a RIE-sponsored seminar, “Before Baby” at our home. The seminar organizer asked each of us to journal about our time together and what we took away from the lesson. In no particular order, here are some of the reflections I had.

Infancy is an active developmental stage for child and parent alike. Although not capable of verbal communication, the infant is rapidly assimilating to a brand new world and is not only deeply observant but deeply capable of interpreting its environment and sensory input and forming meaningful relationships with the world around it, including the people in it such as its parents. It is a huge mistake for parents and other adults to view the infant in this moment as helpless, unresponsive or otherwise dull or ignorant of these early experiences. The infant is in the process of becoming an interdependent adult and it is doing this difficult work all on its own– it is anything but helpless or ignorant, although it is dependent in various ways.

For the parents, this is a time of habit formation. In what ways will they learn to habituate their behavior toward their child? With what respect will they conduct themselves toward this new member of their family? And as what kind of model will they illustrate their values and beliefs to this watchful eye? It is also a time for meaningful connection to their child through the acts of caregiving and observation. Seemingly mundane tasks such as clothing, feeding, washing and changing the child can be just that, or they can be something more– the fundamental basis of the relationship that is now forming, to be treated with dignity, concern and attention. Will the parents learn to be fully present in their child’s life, even when their child can not share what that presentness means to them personally? Or will they convince themselves they can have a deep connection to another person without actually putting that work in?

Our organizer encouraged us to think about the phrase “Slow down!” Infancy doesn’t last forever, and in the course of the total relationship with one’s child (40, 50, maybe 60 or 70 years if one is lucky) it is a fleeting moment that is soon lost. Take it in, appreciate it, make the most of it. Slowing down also means learning to wait before intervening. Give the infant some credit for finding its own way in a difficult situation– it is learning basic problem-solving skills and techniques in this time which are fundamental to not only its intellectual functioning but also its self-esteem and identity. Don’t take that away from the infant by insisting on doing everything for it.

We watched a couple videos together, produced by the RIE foundation. One was a collection of distilled wisdom by Magda Gerber, the progenitor of the RIE approach. Another was a demonstration of infants at play, showing their interesting physical and intellectual capabilities that are so easily overlooked. The essence of each video was this– if we give infants respect in terms of what they are uniquely capable of at this moment in their lives, we might well be amazed. Balancing, climbing, walking, crawling, socializing, they’re really quite accomplished in their own way and seem to need less of our help (as adults) as we might like to think. It’s important that they have their own world in which they can move at their own pace and explore their own needs.

We briefly explored the RIE practice of “sportscasting”, narrating interactions with the infant. As Magda Gerber put it, people have no problem doing this with their dogs (“Oh, you’re very hungry, I am putting your food together and then I will feed you, please wait.”) but they shy away from this simple communication with their children lest they or others think they’re strange for talking to a being that can’t talk back. But infants are not deaf! They can and do listen and sportscasting not only teaches the parents to see their children as participants in caregiving and family life, but it also gives these little observers an opportunity to connect cause and effect and see predictability in their lives.

We also talked about the place of RIE in a larger parenting framework. Can you take what you want from RIE? Can you follow other parenting philosophies as well or is RIE it? RIE seems to be a valuable set of core ideas about relating to infants and children that is not only useful now and extensible later, but which is potentially valuable in relationships with grown adults and which doesn’t seem to come into direct conflict with other values or beliefs. If RIE is wrong, does that make its opposites right? Can we imagine a world where treating infants with disrespect is good for children and parents? What would the benefit be of that approach?

RIE may or may not be a hard sell when it comes to communicating about it with people who are unfamiliar with the principles. Rather than trying to argue or convince people it is right, it is best for RIE adherents to simply model the RIE behavior and let it speak for itself.

The Greatest Time To Build A Fortune Is Now (#investing, #wealth)

From Is Value Investing Broken? by Geoff Gannon:

There’s a tendency for people – people of any time – to see the time they live in as unique, dangerous, different, unlike any other age. In some ways, they are always right. Some things really are different this time from all other times. But, mostly, they’re wrong. And what they are wrong about is reading a golden age of stability into the past. I was talking with a value investor once and this value investor said that sure Ben Graham’s ideas worked in Ben Graham’s times. But Ben Graham invested in simpler times.

Here are the times Ben Graham invested in: the 1910s through the 1950s. He invested during Two World Wars, the start of the Cold War, the atomic bombings of Nagasaki and Hiroshima by the U.S. and then the testing of nuclear weapons by other countries, The Great Depression, a big explosion (reportedly a terrorist bombing) on Wall Street, and the longest shut down of trading in Wall Street history that I can remember at least (right as World War One started). People talk about political risk today. Political risk in Ben Graham’s time meant Marxists and Fascists. Investors saw hyperinflation in Germany after the war and then they saw deflation after the 1929 crash. These were not simple times. If you go back and read the newspapers from the time – you can see how not simple they were.

Now, yes, they were different from today in some ways. Much of the period investors and economists in the U.S. study were more regulated than today. So, you either had the Gold Standard or Bretton Woods. You had much greater belief in planned and insular economies in a lot of countries. With the benefit of hindsight – and seeing the entire sweep of history – many of these decades seem simple to us. They rarely were. Try to find a decade without too much inflation, too much deflation, too much war, the mania of some bubble, or the bursting of that bubble. At any point in that past, people could have believed value investing was dead. And yet, buy and hold investors – business owners and the like – have been compounding fortunes in the U.S. from the 1800s through today. If there are companies that can make founders and their families billionaires – there are companies that can make shareholders very rich if they buy and hold.

The Unwritten Constitution of the United States (#politics, #government, #USA)

It would be a fascinating exercise to actually write down what the Constitution would say if it actually described the structure of the US government today.

from Why I am not a libertarian.