CCU

The CCU- Coronary Care Unit, or the Cardiac ICU. Call it what you will- this is where you see REAL heart attacks. What I mean is, we get LOTS of admissions for chest pain. Just about anybody who mentions "chest pain" in the ER has to be "ruled out" for an MI (myocardial infarction- aka heart attack). Even though a cast majority of these "chest pains" are NOT from the heart, there are always the rare exceptions which ARE from the heart, and it's a major problem if you miss it. So when you work "the floors" (the regular inpatient part of the hospital) you get lots of chest pain admissions to "rule out MI." What does that mean? In essense, you "cycle the trops" and get a repeat ekg in the morning, sometimes with a stress test, then tell them it's acid reflux and send them home. ("Cycle the trops" means checking a troponin level every 8 hours three times. Troponin is an enzyme found in heart muscle, so if heart cells die, it's released and the amount in the blood increases. As long as the troponin doesn't go up over 24 hrs, there's probably no heart damage- no MI.) Ok, sometimes it's NOT acid reflux. But that's usually our best guess. In either case, these admissions are plentiful and pretty much... boring. Because the REAL heart attacks are usually obvious from the start, and never come to us on the floor. They go directly to... the CCU. Finally, I'm seeing the REAL heart patients. It's pretty overhwelming at first. "They" (I'm not sure who "they" are) never let us get close to these patients on the floor, so it's like entering a whole new world. Here the EKG's are actually abnormal, the troponin levels actually rise, and we don't send patients for stress tests- we send them for "angios" and "caths" (where you stick a wire into the artery in the groin and guide it all the way into the arteries of the heart and if you're lucky, clear the blockage, thus avoiding surgery) and sometimes for open-heart surgery (the infamous "CABG"- or by-pass.) It's a very unique little world, the CCU. The best way to explain it is to demonstrate it with a few typical patients. (ALL patient identifiers have been completely re-worked so that you would never know who I'm talking about...) First is Mr Smith, a 56yo male, probably weighs about 250-300lbs, most of it around his middle. Has a couple of grown kids, and a wife who probably nags him about eating less. He came in with a STEMI (a full-blown heart attack, one severe enough to cause "ST elevation"- a specific pattern on the ekg- hence the name ST-Elevation-MI), and had a successful angio (no open-heart surgery necessary). But he still suffered some real heart damage, and was having some serious trouble keeping his blood pressure up after the procedure. At the time I met him, he was lying flat on his back in bed with COUNTLESS tubes and wires forming a meshwork all around his body. He was intubated and on the vent (a machine was breathing for him, which meant there was a nice tube sticking down his throat). He was on SIX different constantly-running IV meds (requiring 2 IV poles and 5 IV pumps and tons of IV tubing, as well as a couple of needles in his arms for IV access). He had the typical foley in place (can't go to the bathroom on your own when you're knocked out and dependent on a machine to breath for you!) And he was "special"- because of his trouble with blood pressure, he was on an IABP- intra-aortic baloon pump. Basically similar to the idea behind "angios" and caths"- only this time the wire they thread up to the heart is attached to a balloon which inflates and deflates in coordination with the beating of the heart, to help it get enough "oomph" behind each beat. The IABP means another machine, more noise, and even more wires. Oh, and I forgot all the monitors- the tele leads (sort of a continual ekg watching what his heart is doing) and the pulse ox (measuring how much O2 is in his blood) and such. To see him for the first time, you'd have to wonder if he'll ever come out of the CCU alive. I spent some time in his room, watching the monitors, listening to the machines that were helping him breath and assisting his heart... and marveling at the nurse who could so deftly work her away around countless wires and somehow know what each one was for. I wondered about his family, wondered if they'd worried about his health... wondered if HE'D worried about his health. I think most Americans are aware of the risks of heart disease. We all know (at least in general terms) what a heart attack is, and that being overweight and eating fatty fast food diets are risky. But I think it's all just words, until an actualy heart attack lands you or a loved in one a bed like Mr Smith, hooked up to all kinds of tubes, wires, and machines, and everyone around wondering "Is he going to live?" Working in the CCU this last week, I've had to rethink heart disease. An "MI" isn't just a common problem that we talk a lot about in medicine. It's a pretty dramatic often very serious disruption to the lives of unsuspecting vicitims and their families. I'm pretty sure that the average middle-aged American male who is content to be overweight and enjoy his food would consider changing a few things if he had to face a Mr Smith. I don't imagine Mr Smith expected to be in that bed, and I like to think he would've tried to avoid it had he known, at least for his family's sake. Now on to another patient- Mr Jones. (You HAVE to use classic, all-American names like Smith and Jones when talking about a classically AMERICAN disease like heart attacks, right?!?) Mr Jones is a 51yo who has been pretty healthy, basically not taking any meds at home (he had high blood pressure once but it hasn't really been an issue...) He works in construction- doing things like roofing and plumbing, so he feels he's in pretty good shape. He's had a few episodes of chest-type pain but they always went away and he doesn't really like doctors so he's been content to ignore them... until one day the pain started and got worse and worse... he was struggling to breathe, and then his left arm went numb, and even looked pale. Now he began to get worried, and called for the ambulance... While in the ER, they did an ekg, and instead of coming over to talk to him, the doctor huddled over the paper with several other doctors. When they had spent several minutes mulling over his ekg without anyone coming over to him, he said that's when he knew something was wrong. They told him they were concerned about his heart, and that they needed to send him to a bigger, univeristy hospital with more experience in acute heart disease. No one really told him if he was having an MI or what was going on. At the larger hospital, he was taking straight to the cath lab (remember- wire through the groin to the heart, find the blockage, attempt to clean it out...?) They found the blockage alright- 4 different blockages, 2 of them blocking 99% of the area the blood has to flow through. Because of the number and location, this was NOT a "successful cath"- he was going to need surgery- an "emergent CABG." He went from the cath lab to the CCU, and was told he would need a bypass in the morning. (To give you a sense of time, his pain started ~5pm; he was in the OR by 8am the next morning.) In the CCU, he has multiple nurses and doctors connecting him to the inevitable tubes and wires, asking him questions, filling out paperwork... he asks questions, mostly about the upcoming surgery. "Is it the only way? What are my chances- 50/50? Should I be calling a priest or something? I didn't know what was happening. When my arm went numb, it sort of scared me. I guess it was a good thing I called 9-1-1?..." I spent a good deal of time talking with him, explaing what all those doctors had been examining on his ekg, talked about what they found during the cath, and why they decided he needed surgery. I answered as best I could his questions about the surgery itself (how long is the recovery?) I printed some information about MI's and CABG's for him to read and share with his family. He was very candid about his feelings- that morning he'd believed he was a pretty healthy guy, now he was scheduled for open heart surgery in the morning. This sure took him by surprise (as I'm realizing heart disease often does...) He was understandably anxious, appreciated having someone to talk to... The next morning, before surgery, his heart surgeon came to talk to him about the surgery, answer all his questions. I listened, so I'd be better prepared to answer the questions of the next Mr Jones I'd meet. The surgeon assured him the surgery WAS necessary, but his chances were GOOD, and the recovery would be slow (3 months before he'd be doing any more roofing!) but in the end he'd feel better than he had before (the symptoms of heart disease had been there- gradually losing ability to perform physically-demanding work, increased shortness of breath when climbing a hill or lifting something heavy, a general decrease in energy that was slow and subtle, not easily noticed...) The most enlightening part of the discussion came early on. After asking the patient for a brief description of "what happened" to land him in the hospital, the wise surgeon asked "so, did you have a heart attack?" And the patient said "No one's really told me for sure." What? I'd talked all about MI's with him the night before. I'd even printed information for him about MI's. I'd explained how we diagnose them using the ekg and lab tests. But, I suppose I didn't actually say "YOU had a heart attack. That's what this was." But surely the ER doctor at the other hospital had... or the doctor who did the cath, and told him he needed surgery? No, all of us had talked about and around it, but none of us actually wanted to say "sir, you have just had a heart attack." As much as we all squirm on the inside at the thought of giving bad news, this man really needed to know. He's already lost control of his plans for the day and for his forseeable future; he doesn't need to deal with any more uncertainty than necessary. He really needed someone to tell him kindly, but in straight-forward way- yes, this was a heart attack. So I learned something from that surgeon- next time I have a patient with a "bad" diagnosis, instead of assuming someone has told him, I'm going to ask "do you have ?????" So, two patients whose lives (and families' lives) were turned upside-down by unexpected, serious heart conditions, taught me a few things about communicating with patients, and hopefully can teach you something about your health. Heart attacks are real, they can be devastating, and are worth taking seriously- at least, seriously trying to prevent them. Go take a walk! Drive past that McDonalds. Don't open that bag of chips- go dance with your little girl instead, and remind yourself that being there for your family matters ever so much more... By the way, Mr Smith is now sitting up in a chair, visiting with his family. No more tubes, no more wires. Probably leaving the CCU soon. He made it- but you might not be so lucky. And Mr Jones? He's 3 days post-op, still having some pain but feeling better, working with his family to move forward and face the future with a slightly new perspective. I feel I must end with a Point of Grace song- the lyrics capture the message well. "Turn up the music, turn it up loud. Take a few chances, let it all out. You won't regret it, looking back from where you have been... 'cause it's not who you knew, and it's not what you did- it's how you live." This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.

Also 12/18/08...

Ratatouille. Yes, I mean the movie. I picked it up back in July, thought it looked good. I brought it home to watch with my family in August... but never got around to it. So here it is December, I'm home again, and my sister gets the credit for me watching it last night- and I just watched it again with my mom tonight. Why is it worth writing about? Because it has some powerful "allegory moments" that I must share. By far my favorite is towards the end. Remy (the star, adorable, rat) is asked what to cook for the critic who can make or break the restaurant's reputation. He hands them a recipe for ratatouille, and the response is "but that's a peasant dish. Are you sure you want to make that?" Yes, Remy IS sure. As it turns out, this almost impossible-to-please critic tastes the dish and is instantly brought back to his early years, enjoying his mom's cooking as a little boy. He is indeed impressed. How did Remy know? Although it's never stated, it's a beautiful picture of divine guidance and inspiration. It's the idea of allowing the Holy Spirit to guie you in small decisions, things that could seem insignificant to us but can have tremendous impact on others because God has the "inside scoop" on what is meaningful to them, what they need most, etc. The idea of God's guidance can be seen in other settings as well. Throughout the movie, Remy is the one guiding Linguine (a human), thought to be a great chef but in fact helpless without Remy guiding him, telling him how much of what to add when. Remy sits under Linguine's hat, guiding his every move by holding clumps of his hair like a horse's reins... Isn't that how we should function, with the Holy Spirit guiding our every move? At one point Linguine begins to take the credit for the popularity his dishes have found... but left alone only briefly he is quickly reminded that He can do nothing without Remy's help. Indeed, there are many times in my life when I am tempted to take the credit for my achievements and successes- but I dread the thought of being left alone for even a moment as I know I can do nothing without Him enabling me... and we all need (frequent!) reminders of this truth. It is ONLY by God's grace... There's also the lesson of integrity, and listening to the Holy Spirit's conviction. In this case, it is again Remy we identify with, and "God" is represented by the Remy's hero-chef (don't ask me to spell the name!) Throughout the movie Remy imagines this chef talking to him, often encouraging him to be brave and pursue his passion for cooking. But Remy is also grappling with the issue of stealing food. That's how rats are supposed to live! But his hero-chef and his friend Linguine teach him that if he uses his talents (cooking) to help and bless others, his food "will be provided" (by God!) and he doesn't need to steal. But his brothers and friends are pushing him to steal food for them, and he keeps trying to justify it... until he realizes he needs to be true to himself and the friends who have believed in him. No more stealing- it does not have to be what rats do! Finally, the pursuit of your dreams- God-given ones at that. Remy is a rat- he's supposed to see humans as the enemy and steal food because that's what rats do. But Remy wants to make food, to create... he feels inexplicably drawn to humans and to all things cooking-related. His family wants him to be a typical rat, and he feels torn between 2 parts of himself until he realizes they are, both, parts of him. He learns, rather than dreaming of being a chef, to see himself as a chef. This is so similar to my own journey, as I had to learn to no longer "dream of going to medical school" but to see myself as a doctor. Remy is guided by the chef and the unmentioned but clearly present God, Linguine is guided by Remy... in many ways and on many levels, Ratatouille is not just a fun, clean movie, but a wonderful reminder of how much we need- and can appreciate- the Holy Spirit's guidance in our everyday lives. This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.

Originally 12/18/08...

Clearly, I get in trouble when I talk on the phone and work on the computer at the same time. I thought I was deleting old drafts... turns out I was deleting actual, completed posts! At least I've saved copies of all of them in my email, so now I'll re-post them! Here's the most recent... Yes, I'm behind. It's been a few months. I don't even have a good excuse- senior year of med school leaves a lot of free time! Well, except for traveling to interviews... but I think one reason I haven't been on here lately is because I've discovered facebook. If you already know about this little gem, just skip down a few lines where the real meat begins. But if you don't have a facebook (fb) account, hear me out. A friend from Pittsburgh recently moved to Texas, and she told me I should get on fb because it's a great way to stay in touch, and she's been surprised how much she enjoys it. I would never have explored such a thing on my own- I totally relate to all of you who don't want to play with "risky" internet websites or end up connected to someone you don't really know, etc, etc. But for Keeley's sake, I checked it out. You find people you know, and request them as "friends." If they ok it, you become friends and can see each other's information. But anyone who isn't your friend can only see your name, picture, city, school... very limited information. You're totally in control of who sees what. But beyond that- it's incredible! I have reconnected with multiple friends I'd lost touch with over the years! It's been so exciting to reconnect with so many people... and it's a way to sort of know what their doing and know how to contact them when I want to without having to send frequent emails to multiple people. Is it clear what I mean? We all cross paths with people for a time that we'd like to stay in touch with but as we move in different directions, we just don't have enough time to regularly correspond with all the wonderful people we've met over time. Facebook lets you share information about yourself- and see their info- so that you're in touch, feel connected, but it doesn't require a lot of time! It's also been an amazing place to connect with people that are still in my life. I have a lot of "friends" who are current classmates... but as we all do different rotations, we don't see each other that frequently. Fb has given me a great way to talk with them more frequently, to know when they're sick and need prayer, to encourage someone who's stressed about residency interviews... it's both a blessing and a ministry. So check it out, and add me as a friend!!! Ok, now for the real meat of this post. I promised to discuss most-med school training, and as I'm in the midst of interviewing, now's a good time. To start with, residencies basically fall into 4 categories: the non-patient care, the medical, the surgical, and the "surgical subspecialty" which are a mixture of medical and surgical. So as a 4th yr in medical school applying to residency, here are your options (this is not meant to be an inclusive list, only exemplative): If you are headed for non-patient care, that means you're looking at something like radiology or pathology. (You can actually still have patient contact in these fields, but a lot less than in other areas). The medical options are also sometimes considered the "primary care" options: these include internal medicine (adults), pediatrics (yes, that's kids), family medicine, and med-peds (I'll discuss later family med vs med-peds). But there are some other medical options also- neurology and psychiatry are 2 that come to mind. Emergency medicine and dermatology would be others (althoug derm could also be a surgical subspecialty... Then there's your surgical- basically you do a general surgery residency. Surgical subspecialties include urology, neurosurgery, ENT and opthalmology. All of the options listed about are residencies you could choose and begin right after medical school. Now- what about internship? It used to be that the first year after med school was called "internship" and the rest of the years were "residency." As a result, in your first year out of med school you were an "intern" and then you became a "resident." BUT- doctors who specialize in internal medicine (any doctor trained to medically care for adults, who are done with all their training) are called "internists" and clearly patients can easily confuse an "internist" with an "intern." So for the most part, all of the training after med school is called "residency" (althoug we still do use the term intern for 1st yr residents...) NOW- the length of residency varies with the specialty. Medicine, peds and family med are all 3 yrs. I think psych is 3 yrs too. I honestly don't know how long path and radiology are- probably 3 or 4 yrs. Gen surg is at least 4 yrs, I think. Neurosurg is 7 yrs if I'm not mistaken! What have I left out? Oh, ENT and optho and the other surgical subspecialties are mostly 3-4 yrs. Emergency med is 3 yrs too. OH! Ob/gyn is a big surg subspec- it's 4 yrs. Anyway, you get the idea. As I explained previously, after residency you can do fellowship if you want to further specialize. For example, after a pathology residency, you could just do general pathology- a little bit of everything- or do a fellowship- you could focus on neuropathology or renal pathology, or cancer pathology, and so on. Same thing for radiology- you could focus on neuroimaging, or "interventional radiology" (that's when you use radiology to actually perform procedures- it's a way for radiologists to have more patient contact). Emergency medicine basically only has one fellowship, which would be to specialize in peds, but you can also do peds ER by doing a pediatric residency and then the same peds ER fellowship. There might a few other possibilities- disaster medicine is a growing field in EM. After general surgery you could go a LOT of directions- cardiothoracic, vascular, GI, transplant... oh, I think plastic surgery has it's own residency, just like neurosurgery. So after either of those I'm not sure if there are fellowships. Oh, you could do a pediatric neurosurgery fellowship... Basically all fields have a peds fellowship (neuro, derm, psych...) If you do a surgical subspecialty (ENT, optho, etc) peds is probably the only fellowship option- you're pretty much fully specialized from the start. The primary care areas- medicine, peds, and family- are very different. It's after these residencies, by doing a fellowship, that you go into cardiology, rheumatology, pulmonology, GI... but not neuro, uro, derm, as they have their own residency. See? Right! At least you see why it's confusing! To my grandfather, his dermatologist is no different from his cardiologist (who sees him once a year to say "yep, you're still healthy" even though he's 93!!!) But to a medical student, the path to derm is very different from the path to cardio. Ok, so what about family medicine vs med-peds? Well technically, I shouldn't have included med-peds in the list. Or, at least 3 yrs I shouldn't have. Because med-peds is a combined residency- it's like doing internal medicine and pediatrics. Now, if the combined program didn't exist, and you wanted to be an internist and pediatrician, you'd have to do a 3-yr medicine residency and a 3-yr peds residency. But there's overlap in what you need to know for the 2 specialties, and there actually a number of people who want to do both, so combined programs have been developed to let you do both in a total of 4 yrs instead of 6. Other combined programs also exist- lots of them, in fact! Pitt has one called the "triple board" where you do pediatrics, psychiatry, and child psychiatry (which is really like doing 2 residencies and a fellowship)- the equivalent of 8 yrs- in 5. Like I said, lots of them exist- medicine with emergency, family with psychiatry, neuro with radiology... it's a long list. But most of them are not too common- only a few schools in the country will offer any given combination, and only a few people each year choose them. I think part of the reason is because you have to know a lot more specifically what you eventually want to do when you're still only in med school. But med-peds is a bit different. It's by far the most common combination, and is the only one now certified as it's own program. What do I mean? Each residency (surgery, dermatology, etc) is certified by the ACGME (sort of like JCAHO for hospitals or the organizations that regulate universities...) ACGME has requirements for each (each surgery program must ____ and each resident must be able to ____ in order to graduate). Each specialty also has it's own boards. (So aside from the boards that all medical students take, at the end of residency you take boards specific to your specialty to be "board-certified" in that area.) In the past the med-peds programs simply med the requirements for pediatrics and the requirements for medicine... as long the med program was approved by ACGME and the peds program was too, the med-peds residency could exist. And graduates took the medicine boards and the peds boards at the end. It was only 2-3 yrs ago, because med-peds has remained so popular (there are ~80 programs in the country- in comparison, there are ~150 peds, 200 medicine and >300 family med programs) ACGME developed separate guidelines for med-peds and now individually reviews and certified med-ped programs separate from the medicine and peds departments they work with. (We do still take medicine and peds boards at the ends and are thus "certified" in both internal medicine and pediatrics. We can practice any amount of either or both, and can do any fellowship a medicine or peds graduate can do... and there are some med-peds fellowships where you can do, say rheumatology, for adults and kids). Med-peds is the only combined program with it's own ACGME standing- all the others still work like med-peds used to, riding on the certifications of whatever programs they depend on. But WHY med-peds? What's the difference between that and family medicine? Why should you care? Well, because med-peds is relatively new (it's been around since the 60's) and certainly less common than family med, many people are unfamiliar with it. So when I say I'm doing "med-peds", it's amazing how many people hear the "peds" and assume I'm just doing pediatrics. So for all the people who wonder what it is exactly I'm doing- here's the explanation! Family medicine is a 3 yr residency (there are fellowship options afterwards; sports medicine is a very common one.) During that time, they learn medicine, pediatrics, ob/gyn, some minor surgery and some basic emergency medicine. They do much more outpatient than inpatient, and much more adults than kids. Family medicine is a great option for people who want to be able to "do it all"- to be THE doctor for all of a patient's needs, to not have to refer them to another doctor except very rarely. This is especially good for rural areas where it's hard to get to other doctors, for international healthcare (where there often aren't other doctors) and for underserved areas (populations, often immigrants, who don't have much access to healthcare and are unlikely to be willing to trust or able to pay a specialist). The family doctor can do all the basics- heart disease, prenatal care, sports physicals, etc. But they don't do as much inpatient, and don't usually do the more complicated cases (disability medicine, maybe complicated geriatric care...) Med-peds, on the other hand, spends 4 yrs doing just medicine and peds. No ob/gyn, no minor surgery. Our goal isn't so much to work in an area where we're the only MD- we just want to take care of all ages. Family medicine has a heavy focus on the family- a patient's experience of illness is greatly affected by their family, culture, beliefs, etc- and they really enjoying knowing and caring for all members of the family. Med-peds has that option too, but the focus is more on development and life span- seeing an individual through all ages, being able to follow them through childhood, adolescent, adulthood... Med-peds is great for adults who have "childhood" diseases and disabilities, and kids with "adult" diseases. Because of how the time in residency is spent, we also do more in the hospital and in very sick or complicated patients. I've learned to have respect for my classmates who are going into family medicine- but they see themselves practicing in rural or underserved areas, whereas I see myself working closely with a community hospital, relying on having other doctors and services available but being able to care for all ages. The diving lines between "child" and "adult", or "adult" and "geriatric", or so artificial. I love being able to see the patient has having a continuous life, instead of childhood "stopping" and adulthood abruptly beginning.... and for patients with chronic diseases or disabilities, it's so useful for them to be able to stay with the doctor who knows them and their medical history- and for them to know their doctor! One last thought- it's a popular theory in medical school that personalities attract like personalities- you can pretty much predict what specialty a person will go into based on their personality. There are certainly exceptions (it's always fun to see who in the class surprises you!) but for the most part, it seems to be true. Pediatricians are very different from surgeons... and "med-peders" are very different from family docs. Like I said, I have great respect for my classmates going into family med, but I "fit" SO much better with the med-peds people! It has been so much fun to meet the med-peds residents at my school, as well as the residents I meet as I interview, and even my fellow med-peds applicants. We all, with very few exceptions, tend to get along instantly and have fun together- I would have a VERY different experience interviewing for family medicine, based on my experiences with the various programs in Pgh. Funny how that works. But it's great to know I'll not only love what I do, I'll enjoy the people I'm doing it with! This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.

Patient Education

I'm back! No, I can't claim busy-ness, as the 4th year of medical school is unlike any other. There's lots of free time! I think it's just preoccupation- interviews, rank lists, WAITING, the match... now preparing to move! Oh yes- I matched in med-peds!!! Not sure if I've mentioned this, but there was a time when I hesitated to do med-peds, when I debated between peds or medicine, or maybe family med. But when I finally realized my hesitancy was a fear that med-peds was more competitive and I might not "get in", I knew that fear is a bad way to make a decision- and instantly I knew med-peds was exactly what I wanted. So now, a little more than a year later- I'm doing med-peds! Never make a decision based on fear. One of my favorite quotes is from Princess Diaries: "Courage is not the absence of fear but the belief that something else is more important than the fear." Never base your course on fear of failure. Follow your heart- you will always succeed if you love what you do; you can never excell if you don't love what you're doing. But back to matching! I am moving to Buffalo in June to start med-peds residency. It's a pretty cool place for me to train for a couple of reasons: they've had med-peds since 1981, so it's a well-established program, with LOTS of med-peds faculty. They've got an awesome, well-established (meaning large patient base) combined clinic with an incredible curriculum for the full outpatient months. They had multiple, clearly-defined opportunities for me to be involved in QI right from the start. They have awesome disability medicine and transitional care opportunities. And they get snow! And finally, it's less than a 4 hr-drive back to Pittsburgh, so I'll be able to come back and visit all my friends at Life Church (and elsewhere in the 'burgh) and I'll "have somewhere to go" during those breaks that are longer than 12 hrs but too short to fly home to Colorado! So yes, I'm pre-occupied with preparations for moving to Buffalo and becoming a "med-ped'er"!!! But that's not what this post is about! As the title reflects, I want to talk a bit about patient education, more specifically, about how we (so poorly!) educate patients about the medications we so (carelessly) prescribe. Why this topic, this morning? Well, because I'm sitting here having just swallowed effexor, excedrin and zomig, waiting for it all to relieve the headache, dizziness and poor coordination that has plagued me since yesterday. I'll explain all that as we go. But let me start with topamax. If you've had any amount of conversation with me in the last few years, you've almost undoubtedly heard my topamax story. It was the 2nd day of the 2nd year of medical school. I'd been on elavil and atenolol previously for migraine prophylaxis (prevention). Elavil is a TCA anti-depressant, and did help reduce my migraines, but also caused the typical side effects of dizziness, fatigue (the most troubling side effect for me, being in my first year of medical school, as I typically slept through lecture and fell asleep while trying to study at home), nausea and other things I can't remember. So we switched to atenolol, which is actually a medication for high blood pressure but at low doses is used for migraines. It didn't give me any side effects, which was wonderful, but it also did NOTHING for my migraines. So as I was starting 2nd yr, I was having "17 migraines a month"- basically daily pain and almost daily needing a zomig (my "triptan" for treating an actual migraine, as opposed to a daily preventative medication.) Previously, when I started atenolo, my doctor had told me I could try it or topamax, an anti-seizure medicine, which had the risk for more side effects but was more powerful. So we'd agreed to try the atenolo first... but I'd misunderstood what he said to be that atenolol and topamax were the only remaining options for reducing my migraines (I think he meant they were the next 2 he would try- he never meant they were the only 2, as I've sinced learned he has many "tricks up his sleeve" and seems to never run out of options. Have I mentioned that I go to one of the best migraine doctors in the country? He is truly a nationally-known expert in migraine, and I'm very "lucky" to be in Pittsburgh and benefit from his knowledge.) Anyway, when the atenolol didn't work, I believed Topamax was the only option left- otherwise I'd be left to deal with almost daily migraines. When the appointment came, that second day in second year, he wasn't in the office so I saw his PA. (I've seen both of his PA's, and they're both awesome, one of the rare places where I don't mind seeing them instead of the MD.) She did, what I thought, was a great job of educating me on this new medication, topamax. She told me it was known to cause "tingling in the hands and feet, which never seems painful or to really bother anyone" (which, in fact, is true. It did cause an odd tingling, not painful like when your foot falls asleep, almost a pleasant sensation. It usually occured after relieving pressure- so when I finished driving and took my hands off the steering wheel, or when I sat down after a long walk- that's when the palms of my hands or soles of my feet would tingle, and if anything I enjoyed the sensation because it told me the topamax was working.) She told me it could cause weight loss, a side effect few people minded. (Indeed, I DID lose weight, ~5 lbs/month, and it's the one side effect I really miss! In fact, topamax is even sometimes prescribed for patients struggling with obesity for the purpose of helping them lose weight. This seems, in part, to occur because of reduced appetite, but I think the weight loss is greater than the reduction in diet, so it must also alter metabolism. It was surely the only time it was easy to lose weight!) She also told me that in "people prone to anxiety" it could increase that anxiety or tendency to worry. Now, it's important to know that at that point in medical school, I was very much struggling with anxiety but in denial, so I thought (and told her) that it wouldn't be an issue. She gave me the prescription, just as Dr K would have, and had me slowly increase the dose exactly as he does it (more slowly than usual- he always makes medication changes more slowly because "migraneurs" are more sensitive to changes...) The first week or two, I didn't feel anything. Every 7 days, I increased the dose by 15mg. I think it was about the 3rd week the tingling began, which as I mentioned before, I didn't mind. I also began to notice a "nausea" which was associated with the expected decrease in appetite. It wasn't the usual nauseous sensation though- it was more a feeling of "sick" or tired abdominal muscles as I walked down the hill to the bus, and a strong desire to sit and rest my stomach. Odd, but something that eventually went away and wasn't a huge deal. But as I got to the higher doses, the other side effects kicked in. The ones they didn't tell me about. The ones topamax is infamous for. The ones that cause so many of the patients I've met who've tried it to say "topamax is nasty." Within a day or two of increasing my dose, I would feel an angry sort of anxiety- mild stressors would leave me resentful of the situation. I remember grumbling about various duties at school, questioning why I was in medical school and complaining about why I agreed to all this work, etc. It was quite in my nature to worry about things; it was not at all like me to get so angry and resentful and just not want to deal with the situation. Even worse, however, was the "pressure" I began to feel. It felt as though the whole world were closing in on me, as though my world was about to collapse and I had more anxiety than I knew what to do with- but I couldn't name a single reason why. There was not one identifiable thing I was worried about, not one explanation I could find for the sense of impending doom that surrounded me. I just felt horrible. I learned about this time that our emotions are (usually) the result of our thoughts, and if I was able to stop my negative thoughts, I'd feel better. But there weren't any specific negative thoughts on my mind- no situation I was specifically worried about- so I couldn't change my thinking. I just felt awful with no specific focus. I remember going outside between classes, just enjoying the fresh air and telling myself "5 more days, just 5 more days" because I knew by the end of the week I always adjusted to the new, higher dose and this "pressure" would go away. But it was during these times that I first truly understood suicide. I'd always struggled to understand why someone would feel so hopeless that they'd think there was no way life could ever get better. But in those days, I felt so miserable that even though I knew it would get better by the end of the week, I hardly knew how to live through the next 5 minutes. I never actively wanted to kill myself or seriously contemplated how, but I did have the "passive death wish", wishing I could just not wake up in the morning... not because I thought it wouldn't get better, because I knew it would!- but because I couldn't live through 5 minutes let alone the next 5 days until it did. The obvious question would be "why in the world did I keep taking it?!?" And, any doctor hearing such a story would say "why didn't you call your doctor and tell him you were having such side effects?!?" Both questions had the same answer: I was under the impression that this was my last chance at reducing the frequency of my migraines- it just had to work- and I believed the side effects would eventually go away. And eventually they did- some of them. I did develop a chronic sort of fatigue, but I didn't realize how abnormal it was for me to need ~13hrs of sleep/day. I continued to lose weight, but didn't mind! And that horrible "pressure" subsided... but in it's place came THE side effect topamax is best known for, the one no one told me about. The one so eloquently described as "mental dulling." And let me just say now that if you're mentally dull, then you're too mentally dull to realize you're mentally dull. Remember I said I didn't realize it was unusual how much sleep I was getting? That's because I didn't "realize" much of anything. I couldn't process, couldn't compute. I remember sitting in lecture- nephrology and GI pathology (sounds fascinating, doesn't it?!?) The lecturer was one we'd had many times before, one I really liked, one whose teaching was always very effective. But I truly felt she was speaking in a foreign language! I couldn't follow what she was saying AT ALL. I'd sit there thinking "I don't have any idea what she's talking about, I couldn't even give you an overall subject... pay attention Tiffany!" So I'd focus, really concentrate... I'd end up listening to each individual word, slowly processing the meaning of the words, piecing together phrases... and by the time I understood the first half of a sentence she was 3 paragraphs ahead. I just couldn't follow lecture! I remember trying to send emails... I'd spend an hour writing and re-writing a paragraph, and eventually give up because I just couldn't seem to communicate what I was trying to say- I couldn't put my thoughts into words. And I remember moments of disorientation- like pulling into the garage I'd been parking in for 2 years, getting out of the car, and finding ~3 feet of it was sticking out of the garage! I'd stare it, wondering how it happened that I didn't pull in all the eay... but wouldn't think much further about it. I remember other things I said- things that I now know didn't make sense, but at the time made perfect sense. The best example was about studying for Step I for the boards. I remember so clearly telling my mom "my classmates are obsessed with the studying. They worship grades and test scores- I'm so glad I'm not like them!" By this time it was spring of 2nd yr, and while topamax had reduced my migraines somewhat, I was still having ~12/mo, basically every other day instead of every day! So my wonderful (and I'm not being sarcastic here) doctor added Effexor to the mix. Now, as an aside, I must explain how migraines work. No, I'll save that for another post. WAY too much to cover. Anyway, Effexor plus Topamax really made a difference- I was down to only 7 or 8 migraines/month- a huge improvement. BUT. Now, I haven't seen this documented anywhere. It might not occur every often. I have no way to prove it and no explanation for it. But in me, the topamax and effexor interacted- takingf effexor in effect increased the amount of topamax in my system, as if I'd begun taking even more. Of course, I was already mentally dull so when things got worse, I didn't notice. But my mom did. This was when it became really obvious I was losing weight- probably ~35lbs by this time. And she KNEW it wasn't like me to be so blase' about studying for something as important as the boards. It didn't make sense to her for me to complain that my classmates carried they're study books with them and talked about it and wanted to get good scores... that's what I should've been doing too! Instead, it sounded like all I did was complain and then sleep through the time I should've been studying. I also remember during that time we had a class where we were supposed to teach each other, and it was the only time I really remember having difficulty working with my classmates. They always seemed frustrated by my presentations, that I would get lost in details, present irrelevant information, and- true to form- didn't seem at all focused on helping them prepare for the boards. Looking back, I understand why they were frustrated! I'm sure my presentations were as useless as they said... but at the time I didn't know what the problem was. Anyway, my mom knew I wasn't sounding like myself. Knowing I'd lost weight, her concern was anorexia. I knew that wasn't my problem, but denying it did nothing to reassure her as those who struggle with it also deny it. So she booked a flight to come visit me for 2 weeks. She watched my every move. she wanted me to stay home and study instead of go out with friends. She constantly asked what was wrong (I wasn't aware anything was wrong, except for her pestering me!) She would discover I'd run out of things like hand soap and ask why I didn't buy more- I just hadn't thought of it! It didn't occur to me to buy more of something when I ran out. That's how badly my ability to process had been affected. But she couldn't figure out what was wrong and I didn't think there was something wrong, so I proceded to ignorantly condemn my classmates, take Step 1, and start 3rd yr. In those first 2 months I did my scholarly project- research on autism. It's amazing I functioned as well as I did in those months- I had an amazing mentor helping to giude me! It was towards the end of those months that I learned I'd failed the boards. I sincerely never expected it to be possible. (My mom, on the other hand, wasn't really surprised, but still didn't know what was wrong with me! And by the way, I didn't fail by a little bit, etiher. My score was WAY low.) I worked through the shock, went back to "studying" and had a plan to keep moving forward. I concluded the reason I failed was because I'd gone home and been distracted when I should've been studying, and I also hadn't felt well- I'd been sleeping a lot due to what I blamed on reactive hypoglycemia. I'd have a milk shake for lunch and then sleep through 3 good hours of study time. I remember my dad so clearly during that time saying all I did was sleep and play on the computer, wasn't I suppose to study? But he just didn't know what he was talking about (according to my dulled mentality, at least!) So now that I'd failed, I decided he was right, found a new doctor who could "fix my hypoglycemia" and stayed in Pittsburgh while I took a month of to study and re-take the exam. Then I could continue 3rd year, and the "only" consequence was that I'd only have 1 free month in senior year. My mom could tell I didn't study any more in that month off than I had back in spring when I was "studying" in Colorado. But I thought I was doing ok... until of course I failed, AGAIN. Now I panicked. Well, actually, no, not yet. I still didn't get it!!! My score had gone up- this time I only failed by a little bit- and I really don't think I even thought much about why I'd failed twice when most of my class passed the first time... I just went on "studying." This time the school thought I was so close, I could just study while taking some of the easier 3rd year courses; no need to take time off and end up delaying graduation. And for a while, I thought that would work. Now, I mentioned a while back a key point- I found a new doctor. Not a new migraine doctor- I still see and love him- but a new primary care doctor. See, you only see a migraine doctor every 6 months or so, and I hadn't told him I'd had any side effects because I didn't want him to stop my medication and leave me with constant headaches! So he had no way of knowing what was going on.... the PCP I'd had previously really was the perfect example of a horrible physician. He had no patience for me, thought because I was a medical student was "perfectly healthy and just thinking I had the diseases I studied" and would totally dismiss what few complaints I was able to recognize (like being so tired all the time.) So I gave up on being "anonymous" and went to a doctor who was also a faculty member, someone who also knew me as a student, but someone who I KNEW was a good physician. I think from the very first visit, when I hit her with a list of like 13 things I wanted her to fix (doctors hate those kinds of visits!) she told me it was the topamax and I needed to stop. I was SOOOO not going there! Mainly because it not only helped my migraines, but because if she was wrong (and I really thought she was) I'd have to go through that horrible suffering a second time to get back on it. There was no way she was stopping my topamax! But she helped with a lot of other things- helped me get into physical therapy for a lot of my aches and pains, pushed me to get some counseling for anxiety, took my complaints seriously and got blood tests to prove to me I didn't have lupus or hypothyroidism or anemia. And she helped me prioritize, focus on one thing at a time, instead of catastrophizing every little ache and pain. See, she was teaching me the cognition topamax had eliminated. Most importantly, it was during this time I was supposed to take the boards for the 3rd time. As the date drew near, I was finally beginning to realize I had no idea if I would pass and that it maybe mattered! I began to panic... I asked the school if they'd allow me to continue if I failed a 3rd time. I wondered if I could take time off. I watched the calendar, knowing the date I had to cancel by if I was going to postpone the test. I worried constantly. Finally, a few days before the deadline, I had an appointment with my teacher/doctor. I went hoping she could give me some guidance, secretly hoping she'd tell me I had to postpone the test and take time off. I wanted to, but was afraid to say so. I got to her office to learn there was a scheduling glitch and she didn't have an appointment with me; in fact, she was done seeing patients and had a meeting! But my ever so patient doctor told them to let me wait and she'd see me after the meeting. They must've seen how stressed I was and took pity on me. When I did see her, she listened to how stressed I was, and finally suggested I take time off, told me she'd tell the school I needed a medical leave of absence, and that I should postpone the test, that they were setting me up for failure and it wasn't fair. I breathed a sigh of relief and said "that's what I wanted!" I remember her so clearly laughing and saying "why didn't you tell me?! Next time, if you know how I can help you, tell me instead of making me read your mind!" Good idea. Probably never thought of it because of the topamax. Anyway, the test was postponed, med school was put on hold, and a great deal of stress was relieved. this was when I worked on the physical therapy, counseling and the like. But my PCP was also telling me I needed to get off the topamax, and I adamantly refused. All I could think of was having to restart it. I was NEVER going there again. My mom, meanwhile, kept contemplating all she knew, trying to figure out what was going on. She finally realized that things had really gotten bad around the time I started the effexor. Pretty soon we were telling my PCP it was the effexor I needed to stop, not the topamax. She kept saying we were wrong. (She was so patient!) This is why I say they interacted in me- when I added the effexor, the topamax "dulling" got much worse, and all we could do was connect my "downward spiral" with the timing of the effexor... it didn't make sense at the time to blame the topamax. BUT. One day I forgot to take the topamax. And took it late the next day. Certainly not intentionally (any time I did forget, I felt some of the old pressure return when I did remember the following day.) As soon as I remembered the 2nd day I took it, but I also realized I'd felt better during the ~36hrs I'd been off it... I kept thinking about that, and I think I "accidentally on purpose" skipped another dose a few days later... I slowly began to realize I felt better when I didn't take topamax. I talked to my PCP, and she finally convinced me to stop taking the topamax. THAT DECISION SAVED MY FUTURE! Within days I felt WAY better. My mood was improved, my thinking was clearer, I was less troubled by life. I remember thinking "I don't like the person I've become" but I couldn't have told you exactly what it was I didn't like. It just seemed like life wasn't working for me. Stopping topamax changed that feeling. What's more, every week I felt better than the last. After a few weeks I felt dramatically different, and even 3 or 4 months later I was still feeling continued improvement. I very clearly felt I had received a brain transplant, my thinking was so transformed so quickly. I also slowly recovered from my fear of effexor (since the topamax side effects had worsened when I increased effexor, I had insisted on staying at a low dose) and eventually increased the effexor to the point of having my migraines reasonably well-controlled! I also took time off from school- medical leave. It gave me time to straighten out my meds, and also gave me time to study for the boards. There was a brief time of stress when I learned I'd have to work in some way to support myself- time "off" wasn't really time off after all! But God had a plan, as always. I worked in the pediatric neurosurgery office for 4 months. I worked with some great people, had a non-stressful 8-4 type job, and was easily able to study at night and on weekends. Furthermore, it was the perfect complement to my work before med school. At Penrose I'd been a part of inpatient administration; now I got to see outpatient administration... I was involved in CPT and ICD-9 codes, insurance authorization, etc. It was a wonderful experience- beneficial and enjoyable. The ultimate test, however, was in retaking the boards. I felt somewhat confident knowing my score had gone up between the first 2 times, and that I'd been just under passing the 2nd time. I also knew I'd studied more than previously! But I'd lost the level of self-confidence that previously had me "assuming" I'd pass just because I'd "always been a good student" and "hadn't had trouble with tests" previously. (Another example of how topamax twists my thinking- I HAD struggled with tests throughout the first year of medical school, and consequently had a lot of stress over tests during 2nd year, so it made NO sense to suddenly be unconcerned about the boards...) I took step 1 for the 3rd time, knowing I was continually improving and that I'd have the chance to take it yet again if I needed to... I also knew (having gone through it twice before!) which day I was likely to receive my score, even though they don't really tell you when it will be available. SO- on that day I was checking the website "just in case." When I found out I'd passed, I belive my reaction was equivalent to when I learned I'd gotten into medical school. I was so thankful for Karen, one of the ladies I worked with, because she knew I'd been studying and bit of my stress over the test, and she helped me celebrate when I told her I'd passed. It was an overwhelming moment- actually brings tears to my eyes even now to remember all that emotion. I learned a lot about not taking knowledge or the ability to learn for granted, and how to balance a healthy self-confidence with a necessary humility. But this is about what I learned about patient education! When I was prescribed topamax, I was NEVER told it could cause mental dulling- and they knew I was in medical school! Since then I've seen many patients on topamax, and have met many of them who tolerate it well with minimal side effects. As with all medications, everyone responds to them differently. I've met other patients who hate effexor as much as I hate topamax. I've also seen several doctors prescribe topamax for the first time... most of them provide less education than I received! Mostly they mention nausea and fatigue, emphasizing they usually go away with time. Should patients be told more than that? Should everyone be warned about mental dulling? Or should those with highly intellectual jobs- like medical school!- be warned? One of the many aspects of the art of practicing medicine is in deciding how much to disclose when prescribing a medication or getting consent for a procedure. If you say too little, the patient might make an uninformed decision, or not recognize the source of future complications, delaying proper treatment. (If I'd know topamax could cause difficulties thinking, would I have stopped it sooner?) But if you cover too much- to the point of everything known- it would not only take too long, it would confuse many patients and would fully scare others. When getting consent for procedures, the details covered are usually balanced by severity and likelihood. If it's rare but serious (like death after anesthesia for a minor surgery) it'll still be covered- for medicolegal reasons, and so the patient and make an informed decision to continue. If it's not so serious and rare, it usually won't be mentioned. Similarly, if it's not serious but quite common, it'll be mentioned, so the patient knows what to expect. These determinations are more complicated with medications, in part because patient response is so varied. There's no way to predict who will respond to topamax like I did and who will tolerate, so you can't have a sense of "how common" the mental dulling is. Also, the severity of side effects if difficult to measure- fatigue to me might be much more serious than someone who is able to sleep late and take naps during the day. I tend to think more disclosure is better- cover all of the more common side effects even if you think the likelihood is low... but what constitutes "more common"... and how well can doctors know all of the common side effects for all of the medications they prescribe? Not to mention the time it takes to explain them. You don't just tell a patient "this could cause bone less, think skin, poor dental health, mood swings and weight gain." You have to explain those statements! (By the way, that's an example of some of the side effects of prednisone, a common medication for which patients usually DO receive good education because the side effects are SO common...) So my first conclusion about patient education is that it needs to be more of a priority. I think a physician should have a collection of resources- articles, websites, information sheets- for the medications, diseases, procedures, etc- commonly encountered in his (or her!) patients, so they con provide material for any patient interested in reading more. Also, some offices are set up so that the nurse spends time educating the patient on new medications, which can be especially useful for the ones most commonly prescribed. But I have another conclusion, one which is even more important. CLOSE FOLLOW-UP is essential to providing good care!!! Regardless of what I was or wasn't told about topamax, when it was prescribed I was given a follow-up appointment in six months (the usual) and probably told to call if I had any questions or concerns. But have you ever called a doctor's office with questions or concerns? It's rarely that easy!!! It takes a good deal of persistance to actually get an answer to your question. If I had been seen a month later, they would've asked if I was experiencing any side effects. When I answered yes, they could have corrected my misunderstanding right then, that there were other options, stopped the topamax and tried something else. The entire ordeal of taking the boards 3 times, not to mention the rest of the topamax "misery", would've been avoided. Alernatively, if there were a reasonable way to contact my doctor (via email, perhaps), I would've been much more likely to contact him with questions when the side effects first developed. More and more doctors are using email as a way for patients to get questions answered without the hassle of trying to call the office. I think it vastly improves communication, allowing the patient time to think of questions, giving the doctor adequate time to answer (not to mention ensuring the doctor actually gets the message!) and also helps the patient feel that asking questions is more feasible and less of a nuisance to the physician. Interestingly, I think I remember calling the office shortly after starting topamax because it was making me tired, and I'd recently stopped a medicine because of fatigue was particularly concerned about that side effect. They assured me it would go away... so if I called just because I felt tired, why didn't I call when I was feeling so miserable I wished I could die??? I wonder if that was the mental dulling, the inability to process "if ____ then I should _____", just like not replacing soap when I ran out. The only way to avoid that would've been follow-up, someone asking me "are you having any side effects." Better education might've helped me recognize the mental dulling and call (when lecture seemed to be given in a foreign language...) but I HAd been told about the "anxiety" and didn't call because I was in denial. The only thing that could've stopped that was a pre-set follow-up appointment... or someone taking a little bit more time when asking if I had any trouble with anxiety! (At that time, I knew I did, but lacked the courage to volunteer the information and ask for help. I remember various physicians screening for anxiety/depression but never slowing down long enough to notice my hesitation or less-than-convincing answer...) So there are many lessons to be learned from my experience with topamax... but if you can still remember back to the beginning of this (lengthy) post, I mentioned having an extreme amount of pain and dizziness... now it's time to explain why: effexor. When I was started on effexor, I believe they told me it could cause constipation (it does!) They also told me to take it in the morning as it can cause people to be more awake and have trouble falling asleep. I really liked the sound of that! Once I was off the topamax, I experienced very few side effects. I always took it in the morning, and haven't had any trouble with sleep or fatigue. As mentioned, it does cause constipation but that's easily remedied by taking magnesium (side note: magnesium is known to reduce headache as well as muscle and joint pain; it is also a natural treatment for constipation and I belive it is highly under-used.) At higher doses, it also causes "heat intolerance"- for me, that means I get hot flashes! That's sort of hard to explain when you look like you're barely 20, so when I'm all red and fanning myself, I tell people I "overheat" because of my medicine. That's what it feels like! It's annoying, but SO much easier to deal with than the topamax. But this is a side effect I was not told about beforehand. Should I have been? I don't feel particularly strongly about it, but I did go online and research the medication to find out that it was, indeed, a side effect. Many patients would have difficulty finding that information... that's where better access- either email or an easy way to communicate with the doctor between visits, or printed information, readily accessible, provided to every patient for every new medication- would be beneficial. But there's one more detail about effexor that I wasn't told about: withdrawal. Many medications "mess with" our bodies' normal systems. In the case of effexor, it provides an external stimulus to increase serotonin (oh, another great topic for the future would be serotonin and it's role in appetite, mood, pain and more.) As a result, the body becomes somewhat dependent on the medication- if you remove it suddenly, it will take a while for the body to "turn on" and increase serotonin on its own. In the meantime, you experience withdrawal. I recognized early on that if I forgot to take a dose, within a few hours I would begin to feel dizzy. I describe as feeling as though my brain is spinning within my head, as though my eyes are spinning in the sockets... if I turn my head, it feels like my eyes or my brain don't keep up, and if I turn my eyes it feels like my brain spins the other way. Very distracting! I (again) did some research to learn this was typical with effexor and simply learned to 1)remember to take my medicine! and 2)I must've forgotten whenever I begin to feel that way. (Another side effect I was told about was that it causes one's eyes to dilate, so I quickly learned that if I wasn't sure whether or not I'd taken it, I could look in the mirror and my eyes would tell me!) I've always been somewhat grateful for this phenomenon, as it ensures that I don't miss any doses! If I forget, I'll be reminded! Once I forgot and didn't have any extra with me, so I went many hours without it... and learned that as time goes on the withdrawal only gets worse! In addition to feeling increasingly dizzy, I began to get a headache and feel nauseous and overall just "not well." So I've always tried to carry extra with me, so I can take it as soon as the dizziness kicks in, as it takes a few hours for the dose to set in and relieve the wthdrawal symptoms. Anyway, the day before I started this (yes, it is that long that it took several sittings to finish!) I really thought I'd remembered to take it. I went through most of the day feeling fine, though in early afternoon I had a headache threatening and wasn't sure why. I took a nap, and when I woke up I was beginning to feel dizzy. (I get dizzy from BPPV- an ear thing- much more commonly than from forgetting my effexor). I didn't think much about the dizziness- just thought it was my ears. But my head still didn't feel right and I still felt sort of tired or out of it... but it was Thursday, and I was determined to go to small group, so I simply left early. I knew once I was out of the house I wouldn't be tempted to just go back to sleep! As I walked around the bookstore while waiting for small group, I began to feel more and more dizzy, reaching the severity at which it's unusual for it to be due to my ears and I would usually think about effexor withdrawal. I still really believed I'd taken it, but I was so dizzy I was beginning to doubt it. (Unfortunately, I totally forgot about checking to see if my eyes were dilated or not.) So when I went out to my car I was going to take some extra just in case... but I didn't have any with me! I wasn't about to turn around and miss small group now, so I figured I'd just have to last another 2 hours and I'd take it when I got home if I was sitll feeling dizzy. By the time small group was over, I'd totally forgotten about it! The dizziness was totally gone, I felt fine... and concluded I must've taken the effexor that morning like I'd thought. Late that night though the dizziness began to come back... I thought it awful strange for it to come and go, especially because I would've been ~12hours late by that time, and if I'd really missed the effexor I should've been much sicker! So I went to bed, figuring I'd take it in the morning anyway and be back on track whether I missed it or not. Apparently I should've taken some just in case. For most of the night I slept for only ~30min at a time, having dreams about migraines and then waking up in so much pain, all I could was lie there and try to fall asleep again. It hurt too bad to get up and take something, and I wasn't sure what to take anyway. When I finally got up the next morning, I was still trying to figure out what to take, when it finally dawned on me- I MUST have forgotten my effexor, and this pain was the result of being a full 24hrs late. Ouch! (I was, by the way, still quite dizzy and also felt like I was stumbling around instead of walking smoothly...) That was the point at which I took effexor, zomig and excedrin and started this blog while waiting for some relief. (At some point I began to feel better and slept all morning while the effexor went to work...) After all that, it was time to do some more research on effexor withdrawal! Yes, it is commonly reported. Yes, it involved dizziness, lack of coordination (remember I felt like I was stumbling around) and headache(that's an understatement!) Yes, the dizziness is described at "your brain doesn't keep up with your skull when you turn your head." Exactly! But here's what's more interesting. Many doctors have been slow to acknowledge this occurs, claiming that there "shouldn't be" withdrawal. (I hate to tell them, there is.) There are also a lot of patient reports that when they try to stop effexor, just slowly decreasing the dose isn't enough to avoid the withdrawal. Several of them describe opening the capsule and counting the number of "balls" or granules they take every morning to wean down by that small of an increment. Now, you can find all kinds of things on the internet and I don't know how often it's that severe or if it can be fully blamed on just the effexor. But it was clear the withdrawal syndrome is well-documented, consistent across many (all?) patients, and especially common with effexor. Doesn't that sound like something a patient should be told when starting a new med? "If you forget a dose, you can get very sick so try to take it the same time every day and always have extra with you in case you forget..." Back to patient education. There are a few other things I've had to learn for myself about effexor. I had to look up "hypnagogic and hypnopompic" hallucinations... basically as you're just falling asleep or just waking up. For a time, I was experiencing the latter. As I was just waking up, I would feel sure I heard someone walking down the hall (I live alone) and a few times I was sure someone was standing right over me or sat down on the edge of my bed. Not only is that scary, it was all the more eery because I flet frozen, couldn't move, open my eyes or even whisper my landlord's name in the hope it was her (and not an intruder). It would only last 30-60 sec, and then I'd be fully awake, no one around, and wondering if that'd been a dream or what. But way back early in med school, they taught us about hypnagogic and hypnopompic hallucinations, and the words are so unusual, it stuck in my memory, so I quickly figured that was what was happening- I just wasn't sure why! So back to research I went... and learned they are another side effect of effexor! Knowing that helped a lot. (By the way, the stage of sleep right before you wake up includes a sort of paralysis, and when the sleep cycle is disturbed, it is possible for you to be "awake" as far as alert and thinking, but still "paralyzed" as far as voluntary movement, which explains why I felt frozen during these experiences. Sleep is a fascinating subject to study...) And while I was reading about these phenomena I also learned effexor can cause "vivid dreams" which indeed I experience! I dream a LOT, rarey bad dreams, often a bit unusual though, and always very "vivid"... they seem so real I sometimes have to really convince myself I only dreamt ____ happened, and I'll find myself thinking about them and "re-seeing" the scenes over and over throughout the day. (Good thing they're NOT bad dreams!) So to review: I experience withdrawal, vivid dreams, occasional hypopompic (I love those words!) hallucinations, hot flashes, constipation and eye dilation from effexor. I was only told about 2 of those 7 by my doctor; the rest I had to research and discover on my own. Again, fine for me but not feasible for all patients. And this is the perfect example of side effects which I consider mild and can easily deal with- it's not worth changing medications over them- but it's much easier to cope with them if you know the source actually is the medicine. Providing patient education can prevent SO many hassles, complications, fear, confusion, and suffering. And it's a perfect passion to combine with my interest in QI- I imagine working in the outpatient setting to develop systems which allow quality education to be feasibly provided for all patients on medications, test, diagnoses, procedures, etc. That's all for now- I'll resist the temptation to launch into the effect of media on medical knowledge in the general population (for now) in favor of getting to sleep before midnight (that leaves me 5 minutes...) I'm working on another blog about hockey and why I'm a Fleury fan. In the meantime... go Pens!!! vivid dreams This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.