#9 Liver Cancer - The Diagnosis (April 5, 2010)

Wife again...

Hunt received a phone call from Dr. Cohen at Kaiser in Vallejo.  Dr. Cohen was brief on the phone informing the pathology report was back and he wanted to see Hunt in his office to discuss the results as soon as possible.  I was at work when Hunt called me and asked if I could leave early that afternoon to go with him to the appointment.     

For all Hunt’s struggling with Kaiser and the health care system in general to get proper diagnosis, for all the constant pain, the painful colonoscopy procedure and the tests he had been through, I had never been with him physically.  For thousand times I regret that if I were with him or if I paid a little more attention, things could have turned out differently and Hunt would not have suffered the way he did.  I waited until the last minute to accompany Hunt to this appointment just to be told that he had cancerous tumors in the liver.

Dr. Cohen said he would quickly send Hunt to UCSF where Kaiser has a contract for liver transplant patients.  One with a sound mind would wonder why Hunt’s case was still being handled by Dr. Cohen of Gastroenterology Department but not by the Oncology Department by then.  But Hunt couldn’t hold his tear back and we for a moment, let our emotion out of control.  All I could murmur at that time was to ask Dr. Cohen to contact the liver transplant board at Kaiser and keep us informed about the process.  We left Dr. Cohen’s office in a state of confusion.

Hunts Notes:

My wife has nothing to feel guilty about. We all do the best we can, when we can, and she has most certainly been the driving force of my team. And lately I wouldn't have made it this far without her. My undying love went immortal.

#8 Liver Biopsy on March 31, 2010 and Two Passover Seders

This is my wife's posting...

It was around Passover.  I received an email from Roberta, my “older buddy,” as she called herself, at Concord Mental Health, asking “Remember our date?” and inviting Hunt and me to her Seder on March 30^th which was the second day of Passover.  Back to Passover the year before, Roberta and I happened to sit together in the lunch room and I told her about my experience with Passover since I joined the Austin family.  Then we set a date for next year Passover at Roberta’s place.

Hunt’s cousin Nicole and her family flew out from the East coast to visit this part of the family living in San Francisco and around the Bay Area.  Hunt and I were looking forward to seeing Nicole and her family and also joining her Seder.  Family, friends, Passover, the pain and the fact ... a liver biopsy and the possible diagnosis.  Hunt had not had a good night sleep for a long time since the pain started in early February.  He was not in good shape and we didn’t want to socialize or to be in public at all.  Despite of the fact, we decided to go to both Seders.

Roberta’s Seder took place  on Tuesday night, the night before the biopsy.  It was very unique Seder as the table was surround by a group of close friends and family and led by Roberta, an English major grad, and a friend of hers. They read from five different Haggadah's!  Hunt and I asked for a leaving early excuse and we left the Seder with high spirits.  Thanks Roberta for having us that night.

The biopsy went well the next day.  Despite Hunt's snarl. Then Friday came and Hunt felt better as he recovered from the procedure so we went to cousins Craig and Sharon’s house for the second Seder with Nicole’s family.  Hunt’s mother Barbra, sister Alex and sister-in-law Jessie and their son Amir were also there.  The food was great, the play about the story of Passover was fun, and the Seder was remarkable.  We sent our love to Auntie Rhoda and Uncle Stan who live in Massachusetts and couldn’t join the Seder with us but we Skyped them in.   At the end of the Seder we said together, as we had done last year and the year before, as we will do next year and the years to come, “Next year in Jerusalem!”

Next year for a healthier Hunt, for sure.

#7 A Chain of Tests Done Before Liver Biopsy (March 05, 2010)

As I’ve mentioned in post #6, Dr. Streett at Kaiser in Vallejo had ordered an ultrasound of the liver and upper abdomen to better evaluate my abdominal pain. Finally, some real tests, that led to other more real tests, that led to a world of information I never wanted to have in my head, and a carcinoma invasion of my liver. You don't have to be a doctor to get the gist of these reports.

Below are the tests results:

Ultrasound - Echo, Hepatic, B-Scan/RL TM-LTD on 03/05/2010

History: 54y male CAC infection, mildly elevated LFTs and question of varices in the gastric cardia.  None noted in esophagus. Evaluate for portal hypertension, splenic vein thrombosis

Technique: Real time and static gray scale sonography with Doppler

Findings: ... The liver is markedly heterogeneous, with focal echogenic areas as cystic spaces, raising the possibility of metastatic disease, and there may be a small hemangioma in the left lobe. ...

Impression: Thrombosed portal venous system with associated varices and markedly heterogeneous liver suspicious for metastatic disease. Enlarged/prominent spleen measuring 15mm.

Alert Notification: Report called to on-call MD

CT Scan Abdomen on 03/05/2010

History: 54 y o m ultrasound shows suspected cirrhosis with pvt, but also possible mets in the liver. CT liver mass protocol recommended to assess for cancer in the liver.

Technique: Multiphasic contrast-enhanced hepatic Ct (100 mL of Omnipaque 240) with IV and oral contrast.

Findings: The examination is severely limited for the purpose of hepatic mass evaluation due to insufficient amount of contrast visualized in the vessels in all phases (nearly equivalent to noncontrast CT.)....

Impression: Severely limited examination as discussed above.  Recommend repeat multiphasic hepatic CT or MRI if indicated. Hepatomegaly and varices.  Likely cirrhosis. Heterogeneous hepatic parenchyma with multiple areas of subtle hypodensity (more prominent in the left lobe.) Differential diagnosis as discussed above. Portal vein thrombosis. Nonspecific nodular appearance of the gallbladder wall.

CT Scan of The Liver 03/10/2010

History: Liver mets, hepatoma

Comparison: Comparison is made to prior study of 3/5/10

Technique: Serial axial images of the liver were obtained utilizing a liver mass protocol. ...

Impression: Findings consistent with cirrhosis. There is accompanying right, left and main portal vein thrombosis.  There are some mild accompanying varices.

Vague areas of enhancement within the liver. Given the additional findings, areas of malignancy cannot be excluded.  There are numerous scattered hypodensities throughout the liver.

Lymphadenopathy as noted above.

Mild contour irregularity within the wall of the gallbladder. Differential diagnosis given above.

Splenomegaly.

Up to this point, Dr. Cohen requested a liver biopsy for further evaluation.  And the biopsy was scheduled for March 31, 2010. A month away...seems a little long to me, and in retrospect, it begs the question of whether or not he consulted an oncologist with these results? But as you'll find out in the coming posts this guy has a particularly enormous sense of self-inflated worth; an ego you couldn't drown in the Pacific Ocean!

#6 Colonoscopy on February 24, 2010 & GI Complaint Filed

This was not my first Colonoscopy.  I had one three years ago at the VA in Martinez.  It was a breeze, they knocked me out with fentanyl and a muscle relaxer, and I woke up in what seemed like a few minutes feeling good and with a decent buzz. My wife was waiting to drive me home.  Hence this time at Kaiser both Ha and I thought it would be much the same, and I would be home within a couple of hours.  My mom, Barbra, volunteered to take Hunt to the appointment at Kaiser in Vallejo this time. 

Kaiser could learn a few things from the VA. I specifically asked to be knocked out this time again, so they gave me benadryl and a muscle relaxer. I began to worry. Well by the time they were half way through it they had to have three or four people hold me down while Dr. Streett tried to, what felt like, puncture my colon! Screaming, yelling stop to no avail...horrendous. When I finally left, my mom said she heard me yelling from the waiting room, but couldn't get past the front desk. Here's what my wife saw upon her return from work. "When I got home from work that day, I felt something going on since my mother-in-law was still at the house with Hunt.  As soon as Hunt saw me walk in, he broke into tears.  My husband is very sensitive and emotional. He told me he was awake during the procedure and at some point he was hurting.  He asked and then cried for them to stop as it hurt him so much but the doctor  wouldn’t stop.  She kept telling him “It’s almost done!” Hunt later described to me the pain so tremendous that he thought he would die then.  The incident has haunted him for a long period of time that my sister-in-law Alex noticed once she went to an appointment with Hunt.  She told me “his hands started shaking as soon as we [Alex and Hunt] pulled into Kaiser parking lot.”

As a matter of fact, Hunt has filed a complaint with an attempt to prevent the same situation happen to other patients. Below you find Hunt’s six-page letter to Kaiser Member Services.  Not to surprise, the Kaiser team found nothing wrong had happened."

      Discharge Summary:

     This is what I [Dr. Streett] found on your colonoscopy exam today:

The preparation was not ideal, with retained stool.

Your colon appears healthy and normal.

Hemorrhoids were noted.

Your next colon screening test can be considered in five years, because of sub-optimal prep.

Start taking a fiber supplement

     This is what I [Dr. Streett] found on your upper endoscopy exam today:

A prominent vein in the stomach was noted, and an ultrasound of the liver and upper abdomen has been requested to better evaluate this.

Your exam is otherwise normal.

Please do ordered blood tests to recheck your anemia.

A follow up appointment with Dr. Cohen [the Gastroenterologist] will be made.

Dr. Streett  noticed an abnormality in the stomach during the procedure and ordered an ultrasound of the liver. 


Following is my letter of complaint to member services: 

3/01/2010

To: Kaiser Member Services                                                                                                         

Re: Colonoscopy Mistreatment of 2/24/10

From: Hunter R. Austin

Below follows a letter that was dropped off at Member services Kaiser Vallejo. I’m sending it again, to you, because I received a letter from you on the 9^th of March about said grievance. Your stated that if I had anything to add  you would need it by the 12^th of March. Short notice? Sure seems like it. I’ve had to put a number of projects on hold to sit down and get this done. Again, a Kaiser inconvenience. So, to me, this is important enough to drop everything because my life feels like it’s at an impasse and I am clearly exhibiting mental, spiritual and physical changes since the day in question. 

Also, your letter states that I have “concern regarding your (my) dissatisfaction with the quality of care and service you (I) have received from Dr. Paul Rubin of the Kaiser Permanente Vallejo Medical Center Medicine Department.” While this is also true, it is a SEPARATE issue as stated in the Re: Colonoscopy Mistreatment of 2/24/10, at the very beginning of my letter. I want to keep it that way until the matter at hand is resolved. At which time I may file a separate grievance.  So here’s the original (with a few minor changes that I’ve since remembered) and also, below the original, what I’ve added since...

To whom it may concern,

            I had an experience at Kaiser Vallejo GI dept. yesterday(when I started to write this) 2/24/10 that was so painful, degrading, and horrifically unprofessional that, if I could afford it, I would change my health insurance today. As well as look into what my legal options are for this level of improper care. Also, judging by what Dr. Streett wrote in the “after visit summary” which was “The preparation was not ideal, with retained stool.” If that was the case then this procedure should have been postponed until the conditions WERE ideal. After all, since day one with Dr. Rubin (over a month ago, during which I’ve had extra pain on top of my chronic pain) one of my original complaining symptoms has remained, time and time again, including the morning of and before my procedure, “ It feels like there’s still stool stuck in there, or something blocking the stool from coming out.” Why would one of your doctors, after having read my chart before the procedure (unless they actually didn’t) continue with a test that, in order to get the optimum result, the entirety of the intestinal tract, colon, etc… needs to be as clean and clear as is possible? Also nowhere in the “after visit summary” does it mention my screaming, begging, and pleading to stop!

I got there at 8am, in pain, and I left, a few hours later, in worse pain. Then again (this has been recurring, on and off, for the last 3 weeks) the pain in my stomach woke me up at approx. 3:50am the next morning, and was so intense (9-10) I took a Percocet, and then another one twenty-five minutes later, and as I write this, the pain wavers between a 4 and 5…close to where it’s been for the last two-three weeks with little or no relief and my test appt.’s being spread out over that time instead of getting me in there and finding out what the heck is wrong! You can read my records and (hopefully it’s well documented) find out what’s been going on as I’m quite frustrated with the fact of how many times I’ve had to tell it and how many of the EXACT same questions have been asked by different Dr.,’s…sometimes even the same ones asking the same questions! I don’t expect perfection, but a modicum of professionalism would be nice. 

But the long and short of it is, four months ago I had a bad belly ache with nausea and constipation, that lasted overnight, during which there were a few (non-related?) bloody noses,  then went away. Same exact scenario happened around two and a half months ago.  A bit under a month ago, same thing, at which time I made an appt. with Dr. Rubin. During this time, pain and constipation, loss/fear of appetite, feeling bloated after just a few bites, extreme fatigue, and attacks of #9-10 pain occurring regularly and lasting from 45 min. to 3 hours during which time I tried to move my bowels for relief but was unsuccessful.  Dr. Rubin said it was blockage and gas and prescribed Rx’s to no avail. I ended up in the emergency room that following weekend. Monday I spoke with Rubin (after two unanswered emails) and told him I wanted to see a GI, and he said, “Oh, I completely agree with you.” Gee thanks doc. At this juncture I wondered whether My Dr. had been taking me seriously all this time, or was it the all too common and usual ego-laden, off the cuff diagnosis…next patient please, kind of thing.

So I saw Dr. Cohen, he was leaving for vacation, so he set me up with Dr. Streett. My Last Colonoscopy, about five years ago at the VA; I went in (after the fasting and go-lightly treatment) they sedated me and when I awoke I was fine, no discomfort during or after the procedure. When I asked the GI nurse at Kaiser about the sedation she said that most of the patients fall asleep, so I wasn’t that concerned. Although I had asked, clearly, to be completely sedated, instead I was given Benadryl. An allergy medicine that makes one drowsy. That is not sedation. 

My Colonoscopy at Kaiser felt like a real pretty-boys first night in jail with the Aryan brotherhood. I was held down on the bed while they rammed, twisted, pumped, and anything else painful that one can do with a fat tube in your anus was done. Let’s just hope I’m not the one in a hundred that’s had something punctured. Throughout the entire procedure I was told about twenty times “It’s almost over, it’s almost over, and it’s almost over…and stop moving, don’t tighten up, stay this way, don’t move your leg, and on and on.” I was screaming and yelling Stop!, Stop!, the whole time, to which their reply was always. “It’s almost over.” People in the pre-op, and waiting room (one of which was my mom to drive me home) heard everything. My mom was totally freaked out and started crying when we got to the car.

I understand now why the VA sedated me. Smart move. But during these last few days, at home and in pain, I spoke with friends and family, most of which have had these procedures, more than once, and they were flabbergasted with my story. All of their experiences, while not referred to as pleasurable, not one person had any pain during or after, and those who were sedated, upon arising, felt like nothing happened. Two of my friends were awake, and while they watched the procedure on the monitors said they experienced “little if any” discomfort.

I am still in constant pain at about a 2 to 4 level, even driving over bumps in the road is like a punch in the left side of my gut. I’ve had two attacks, one the morning after the procedure and another 45 minute or so attack yesterday, very early morning, and they always start with it feels like I have to move my bowels, but sometimes I do and other times I can’t, but even when I do have a bowel movement, it does not abate the pain. My energy level is so low that if I try to read I just end up falling asleep. It took me three days to finish this letter because I can’t seem to focus on anything except the traumatic experience Kaiser put me through. Even talking, or writing about it totally stresses me out, which as far as having had a heart attack a little over a year ago is certainly not good for me. Isn’t the first thing Doctors promise to do in the Hippocratic oath is “no harm,” what happened to that?

What to do now? I want a diagnosis before the end of the week. At this point I don’t care about protocol, scheduling, vacations, or anything else except my diagnosis. I have been in (more than usual) pain for a month, with about eight to ten horrendously painful lower left/center abdomen attacks. I cannot and will not put up with this any longer. I will make myself available today, and then again from Wednesday the 3^rd forward, for any tests that could result in a diagnosis.

Hunter R. Austin

OK, since then I‘ve been keeping notes on a regular basis-

I realized, after a couple, maybe less, days, what I had been so scared about. Before a colon/sigmoid-oscopy I was informed that there was a very low percentage chance of “something” (I don’t remember exactly what could be punctured, but the chance of death I do remember) being punctured that could result in death! This has been stressing me out ever since. Have you completely forgotten that I have a cardiac history as well, and that my heart attack and subsequent scares have been triggered by stress? Lately, I’ve woken up in the middle of night scared, like I know I had a bad dream, but I can’t remember what it was, and after a little while of being up I start to think about that ordeal y’all put me through, and I can feel my blood pressure going up. It’s like some kind of bad thing is happening to me and I have to take a Zanax to go back to sleep. I feel like you guys (Kaiser) only see one problem, and totally forget about the rest of the person. Like a horse with blinders.

I had my scheduled ultrasound on the 5^th and the tech performing the procedure said that it was imperative I get another CT scan immediately, and sent me to radiology to make an appt. What ensued there was first “take a number and have a seat” but after a few minutes I got up and went back to where they did the ultrasound and said that I thought this needed to be done right away and all I’m doing is waiting out there, at which point the receptionist came back and in hushed tones (I heard my last name mentioned a couple of times but not much else.) I can only imagine what was being said, which in and of itself puts a patient ill at ease. Then the receptionist asked me to follow her, and we went back out front, and (from what I could glean and from the questions I asked) there was over an hour of checking with Dr.’s back and forth, because my primary and my GI were both on vacation. 

I was then scheduled for a CT scan that day at 5pm, it was now 2:30. I asked the woman running the front desk/appts. AOC (whose attitude, by the way, couldn’t have been more laissez-faire) if  that was enough time for the contrast drink to have an effect. She said “I’m sure the doctors know what they’re doing.” Maybe in her experiences they did but not in mine. She also said that she was faxing or emailing (I didn’t quite hear which) my Rx right over to the new pharmacy right now and to hurry and go get it and start to drink it over the next two hours. I went right there, a five minute walk, and they had no idea what I was talking about. Again, mayhem ensued, telephone calls, record checking, repeatedly telling me there was no record of it, etc...after asking for the pharmacist a number of times and being told to “Just hold on a minute” and “Gimme a sec, I’m looking for it.” I ratcheted up my requests on an audible scale until I got the pharmacist involved. Finally at 3:05 the Pharmacist began to explain how this medication should be taken, which involved an overnight process. I told her (why didn’t she know this? Was a note in my records forgotten?) that my test was in two hours, at which point she gave me the Rx and said “Oh OK, is that going to be enough time?” I thought back to the receptionist saying “I’m sure the doctors know what they’re doing.”

After the CT scan I asked the tech how it looked,  was it clear, and readable? He assured me it looked great and that because of the urgency that someone would be contacting me immediately.  Friday, Saturday, and Sunday went by without a word from Kaiser. On Monday Kaiser called to tell me my Rx (an unrelated, online ordered Rx for pain) was ready and to come by and pick it up. 

The woman I spoke on the phone with said that she was from Dr. Rubin’s office, and that he was on vacation but the covering Dr. had approved my refill. I asked her if there was any word about the urgent CT scan I had done on Friday. No idea, we don’t handle that, and basically a go bleep yourself attitude, and I know nothing.  She didn’t say “Let me see if I can find out” but instead she told me that I needed to call that dept. or the advice nurse...not even an offer to connect me with the right person who might be able to help me. I know how I’ve been dealt with, and I make it a point to watch how your other patients are dealt with, I say dealt with for a reason, which is; a good 75% of the time there’s no “care” involved. So when I got my hard copy of the Rx I asked the front desk woman ( who has always been helpful as well as nice) at Dr. Rubin’s office if she could help and she said “let me check it out.” A half a minute later she asked me to have a seat and the covering (Rubin still on vacation) Dr. would like to speak with me. 20 minutes later a nurse, not a doctor, came out and said the CT was unreadable and I had to go down to GI dept. and get another scheduled! I had to go down there! There’s no way this nurse or the Dr. that “supposedly” deemed the CT scan, which the tech said looked great—unreadable, could call and get me another appt.?  I walked away laughing, which was a darned sight better than what I felt like doing, at that point. It feels like I’m in a war with Kaiser, a war to see who will outlast who, a war of wills. A war where it’s me against the bureaucratic behemoth that is Kaiser. 

I’d say a strong 25 to 30% (that I’ve come in contact with) of your staff, top to bottom, seem to be doing well in the criteria with which I use to judge. Unfortunately only 5% of them are doctors. And the two that I’ve had the most interaction with were sadly not part of that meager 5%. In fact Dr. Streett, although probably not a direct cause of any cardiac issues to come, I know has already had some kind of psychological effects with which I have no experience. It would be a presumptuous comparison to rape with a foreign object, but still in all, that’s where my brain takes me when I think about that morning. The way I was held down, how I begged for it to stop, and the pain, my god, that kind of non-medicated pain! In a hospital no less. I couldn’t look anyone in the eye afterward...not even my mom. I  felt so embarrassed, childlike, and emotionally out of control. It was like I was holding on to the edge of a cliff with my fingertips and I just couldn’t do it!

I also seem to be very short-tempered lately, and up-tight in general at home and at work. My wife has had to put up with these unwarranted outbursts, and has been very understanding and supportive, but I still feel like it’s only my problem and I have to deal with it alone. It’s too embarrassing to talk about what happened and how I feel. But I’m trying to put that aside for now because my anger outweighs everything else. And when I think about this possibly happening to someone else, someone not as strong as me, and the discussions my wife and I have about this situation, I KNOW I have to go through with it.

At work it’s like I’m self-sabotaging my business. I can’t help it; I’m not happy-and it shows,  usually I’m quite gregarious, and smiling, quick to make a joke and laugh, connect with people; all the things a good salesperson does. But now I just feel limp and wrung out, I watch the clock, and I find fault with everyone and everything. I don’t like my job anymore because there’s too many people near me. They just keep coming and coming with no end in sight.

3/7/10  This morning I feel nauseous and, at the same time, have to move my bowels. I don’t know which to do first. The pain level in my lower left abdomen is at a 4, and climbs to six when I start/try (very little still coming out and it still feels like something is stuck in there...same original symptoms I came to you with) to move my bowels, not ‘attack’ level, but enough to defocus my world from everything but the symptoms. Also not bad enough to take a Percocet (on top of the methadone) because then I’m looking at 4 or 5 hours of giddy incapacitation. It’s been over a month now with the most minimal amount of relief and maximum amount of stress. I blame this ALL on the colonoscopy ordeal.

Kaiser’s problem, as I keep being exposed to it (like a virus)is an inability to prioritize, and act swiftly on those priorities. Speaking of your priorities-I was called at 8:30 pm Monday night to reschedule yet another CT scan. The woman on the phone asked how next week looked for me. “Huh?” I said. “I thought this was an urgent priority.” “That’s the earliest we can take you sir,” she said.  I felt like crying, this short conversation had me on the verge of an emotional breakdown. My wife whispered “What about another Kaiser somewhere else?” So I asked the lady on the phone, and after a few seconds she asked if I was close to Vacaville. I said yes, and she asked, “How about tomorrow?” I said fine and made the appt. (Do all your patients have to do all the problem solving in every situation?) Well, here it is, Friday, and no word yet! 

And by the way, that tech also said the CT scan looked perfect! I did have to ask him to put gloves on during the execution of what I believe is called administering a “central line”...the number one reason and area for/of systemic infection likelihood. I may be wrong.

So, here it is Friday the 12^th and no word, no call, no nothing. Another depressing weekend of wondering what could be wrong with me.

I finally received a call on Mon March 15^th, from Dr. Cohen when he returned from vacation. He said the CT scan was in and he needed to see me asap. An appt. was set for 8:30am Wed the 17^th. At the appt. he explained that I needed a biopsy because the problems he sees either stem from something to do with Cirrhosis or Cancer. At this time I asked about all the lower to mid abdominal pain and how did that have anything to do with my liver. To the best of my understanding his answer was that they are unrelated and I need to keep taking fiber so there’s no more blockage...Although I haven’t had any severe attacks in a couple of weeks, there is still pain (probably would be a lot worse if weren’t on pain meds already) and other symptoms. But clearly, in Dr. Cohen’s words,  “This takes a back burner to the Liver issue.” Although I agree I don’t understand why both problems can’t be worked on simultaneously while giving priority to the Liver. Speaking of which, when I left the office Dr. Cohen said “someone” would be calling me to schedule an appt. for the biopsy, and if that hasn’t happened by Friday the 19^th, to call him on Monday the 22^nd.

Now this what I don’t understand, with all your modern technology, why can’t an appt. be made right then and there? Why does the ball always seem to land back in my court to follow-up and make sure things get done? It only seems that Kaiser Vallejo (in my limited experience) suffers from this follow through malady. Kaiser Martinez, and Dr. Yallagada, my new primary care location and doctor, said that I needed a Cardiologist appt. asap, and I was called later that day! Something which (the cardiologist appt.) Dr. Rubin neglected to do in the six or seven months that I saw him. Which actually surprised Dr. Yallagada because I had a heart attack Nov 11^th 2008 and should have been assigned a Cardiologist immediately. In fact, it took a month of constant asking, emails and hassling, to get Rubin to schedule my yearly treadmill test! And then he had the cheek to say something like “Well, if it’ll make you feel better, and less stressed than I guess we could do one. But it’s really not called for.” I had spoken with the Cardiologist, Dr. Weiland, the Cardio-Surgeon who did my stent and angioplasty, and he said the treadmill test was imperative! Also Dr. Yallagada couldn’t understand why I was still on Plavix, a medication usually stopped after the first year of the heart attack.

Developments:

I saw a therapist outside of Kaiser because I was getting worried about some issues that started shortly after my colonoscopy trauma.

If you have ANY questions please call-

Hunter Austin

#5 Office Visit with Dr. Cohen, Gastroenterology Department (February 17, 2010)

When I told Rubin I needed to see a GI he totally agreed. "Of course, of course, that would have been my next suggestion." I wondered why he hadn't thought of it before. 


There was nothing remarkable during the office visit with Dr. Cohen other than a colonoscopy test was ordered.  The procedure would be performed by Dr. Streett at Kaiser in Vallejo as Dr. Cohen was going on vacation.

#4 Emergency Room – Severe Abdominal Pain (February 13, 2010)

On the way to the hospital every little bump and pothole was like pinball pain with my abdomen the game board and a searing red-hot metal ball shooting around. I was hoping the ER doctor would be able to get to the bottom of my abdominal pain.

Dr. Nelson at Kaiser emergency room in Vallejo was very thorough.  After he had done all the physical exam and tests needed to rule out that nothing wrong with my heart, Dr. Nelson went ahead and ordered CT scan of the abdomen and X-ray. The CT scan results show no signs of kidney stone or gallbladder. The chest and abdomen X-ray results show no evidence of pneumothorax or any visible masses or abnormal calcifications. Then why so much pain? 

Discharge Summary:

History of Present Illness: Hunter Austin is a 54 y male who presented to this emergency department with CHEST DISCOMFORT and CONSTIPATION.  Patient on Methadone for chronic pain, having trouble with constipation for past five days.  Seen Thursday by PMD, started on Lactulose.  Feels like can’t pass stool, with some pain in LLQ. NO fever. No vomiting.  Tried fleets enema without success. Today in bath had some upper midline sterna fleeting CP after straining on stool.  Nonradiating, lasting only a few seconds.

Medical Decision Making/Diagnoses Considered: constipation, kidney stone, diverticulitis, hernia.

ER Course:

IV placed 1 liter bolus given

EKG: nsr, no acute changes. His chest pain is not his presenting complaint.

Soap suds enema given with po Magnesium Citrate for presumed obstipation.

Labs sent.

UA with trace blood, so sent for CT Renal, pending at this time.

CT Renal: “no radio-opaque urinary stones or obstructive uropathy; no signs of acute inflammation, incl. diverticulitis; borderline overdistended but otherwise normal GB;”

Assessment and Plan:

Abdominal Pain; Constipation; Chest pain, fleeting; History of CAD s/p PCI 2008, stable; Likely disposition: home with following medications: Metamucil; Go-Lytely 4 liters; Push fluids

Return as needed.

I was discharged to follow up with my primary doctor. I needed to see a gastroenterologist, and I knew it.

#3 Second Office Visit – Still GI Related (February 11, 2010)

After the first visit with Dr. Rubin,in January I had an EKG test on 01/06/2009 and blood tests on 01/08/2010.  The tests results show nothing to be worried about an acute cardiac attack.  However the pain did not go way but had escalated so he went to see Dr. Rubin for the second time with the same chief complaint of abdominal pain and constipation. Office visit notes show that I “reported several days of abd pains, constipation, usually effectively treated with fiber and stool softener.

Below is an excerpt from Hunt’s office visit notes:

Assessment & Plan:

ABDOMINAL PAIN (primary encounter diagnosis)

Note: likely constipation which may have been exacerbated by recent increase in methadone to TID dosing. Advised reduce methadone to BID at least temporarily and increase fluids and fiber and trial of lactulose.  Patient was advised to return for re-evaluation if symptoms persist or worsen. Advised re-eval if bleeding or fever or increased pain or increased emesis.

Plan: LACTULOSE 10 GRAM/15 ML ORAL SOLN

Dr. Rubin also advised me that a hot bath would be very helpful to ease the pain. I went home and spent most of the night that night soaking in the tub and fell asleep there for a while. The next day the abdominal pain became severe and unbearable that I asked my wife to take me to the emergency room on the night of February 13, 2010.

#2 Hunt’s First Diagnosis - A GI Related Issue (January 4, 2010)

Getting back from our short vacation, I went to see my primary care physician, who at that time was Dr. Rubin at Kaiser in Vallejo. Rubin thought it may have been a GI issue.He was on the computer most of the time I talked with very little eye contact. He then had me hop up on the table and tapped my abdomen in various places. The right hand upper abdomen hurt (liver) and the left lower felt like it was blocked. While tapping he said " Hear that? Gas." Here's an excerpt from the report.

Review of Systems:

Constitutional: Negative for fever, negative for chills and negative for weight loss

Ears Nose Throat: Negative for headaches and negative for nosebleeds

Cardiovascular: Negative for leg swelling and no palpitations or PND

Respiratory: Negative for cough and negative for shortness of breath

Gastrointestinal: Negative for heart burn, negative for nausea and negative for vomiting.

Genitourinary: Negative

I don’t know why Dr. Rubin would write “negative” for nosebleeds, heartburn, nausea, and vomiting as these were my main complaints. I was under the impression these notes are meant to document your condition and what led you to coming in...

#1 Snug Harbor in Sacramento– Hunt’s First Signs of Symptoms (December 28, 2009)

After a year full of struggling – Hunt was working hard on his way to be fully recovered from a heart attack that happened the year before, and I was coping with changing my job to a better position and closer to my house - we decided to celebrate the holidays by going away to Snug Harbor to spend our quiet moment with nature.  We brought Beastly Baby the cat with us for his first time on the road and to our surprise, he appeared to enjoy the trip and behaved himself as a very pleasant passenger.

We booked into a small cozy cabin at the resort.  Our back windows open to a dock that goes along the resort which is located on a peninsula off Ryer Island on the Sacramento Delta.  It was during the resort’s off season and we were the only guests there at the time we arrived.  Hunt got very excited about the whole situation where he was Robinson Crusoe with his wife - Friday on the island.  He pulled the fishing poles right out and ran out onto the dock.  Beastly did not hesitate for a second; he jumped right up to the couch and poked his nose to the cabin glass window to keep Hunt in sight.  I looked out the window and found him on the dock holding the fishing pole and smiling at the water. After a few minutes he set his pole down and walked back up the dock holding a tissue to his nose. 

 

It started with a nose bleed.  Hunt had been having fairly severe nose bleeds several times earlier during the month. After that cleared up he went back out for more fishing, but it wasn’t more than half an hour or so when he came inside with the pole and bucket complaining of a stomach ache. The sturgeon would have to wait. He was nauseous and threw-up. Then he laid down on the couch for a while. Beastly instantly trotted over to the couch and laid down next to him. Two boys napping.

I sat down to read.  Sometime later Hunt sat up with his head in his hands, and I asked what was wrong. He traced from the bottom of his ribcage, down his intestine to the lower colon pointing out where the pain was, and a strong case of heartburn. We decided to get an appointment with his primary care physician at Kaiser, Dr. Rubin, when we returned home. Hunt took some Tums, and then a half hour later some more, that seemed to work. Besides the occasional pain and nausea the holiday weekend at Snug Harbor went well. No sturgeon or any other fish took our bait, but it was nice to get away and Hunt made some great meatball and spaghetti.

A Christmas Eve Dinner in Houston, Texas

It's Christmas Eve and we're stuck here, in Houston, two thousand miles away from home and celebrating the holiday from our hotel room.  Earlier today, Hunter and I went to H.E.B. to get his prescription filled at the pharmacy as it will be closed tomorrow for Christmas. For those of you who are not familiar with Houston, H.E.B. is a supermarket chain with stores throughout Texas and Mexico.  We compared and found the price of prescription drug we needed was cheaper at H.E.B. than at Walgreen's so we've been going there for what we need.

While waiting for the prescription to be ready, we wandered around the store and found they had lobster tails on sale for just $5.97 each. The lobsters looked pretty good and we decided to get two of those for our Christmas Eve dinner later. Then we got back to the hotel and Hunt prepared dinner for both of us.  The food was very good as usual but Hunt couldn't have more than two bites. Lately he cannot have a full meal and sometimes the food makes him nauseous so he just breaks it up into smaller meals and feels it much better this way.

We may have Chinese food and see a movie tomorrow; Hunt said it's a family tradition that we should follow.  Every year he keeps saying the same thing and ends it up with a story about his grandpa, Zaide Barney who took the whole family out for the "Jewish tradition thing" many years ago in Brooklyn, New York.  For me, I have nothing to oppose since Chinese food is one of my favorite foods.

Outside right now there is a thunderstorm going on here in Houston.  It sounds like a nuclear bomb every ten or so minutes and then the rain comes down so hard.  This will be a Christmas Eve that I would never forget.

Ha -