SideEffects – Barrelhaven

Resurfacing

Please allow me to fill in the blank space between early July and late August. First off, I have to say I thought it had been much longer than that since I had written anything here. This last month was a long year.

Sometime back in June we learned that the mega-pharmacy chain we had been using was going to close and all our prescriptions would be shifted to another mega-pharmacy chain unless we specified somewhere else for them to go. This would have been our third mega-pharmacy chain, and really there isn’t much difference between them, but this one was a bit further away than was convenient so we instead had all our prescriptions transferred to the pharmacy at a mega-grocery chain that is closer to where we live. The kind of choice in the consumer market our government’s economic policies have worked for years to achieve.

I want to take a moment here to talk about the Swiss Cheese Problem. This is a topic of frequent conversation in health care and, I suspect, management circles in other high-risk professions as well. We’re all human and everyone makes mistakes, like the holes in a slice of Swiss cheese. You’re never going to get rid of those holes in the individual slices so what you do is, you build systems that stack slices on top of one another. If something falls through the hole in one slice, it gets caught by the one below it. The difficulty is, every now and then, by sheer chance all the holes in the individual slices line up and something drops clean through. This is the situation I found myself in over the last month.

The pharmacy that was closing was supposed to transfer my prescriptions. They didn’t. The new pharmacy insisted that I had picked up a refill of my medication. I hadn’t. During all this, Dr. Psychiatrist was out of the office and unavailable. The result of all this was that I was out of my heavy-hitter antidepressant for about a month, and out of all my medications for 2-3 weeks. I have been on at least one antidepressant for at least ten years so facing reality without any kind of chemical filter was challenging. Also, in addition to two different medications that help turn down my sympathetic (fight-or-flight) nervous system, I have been taking a combination serotonin–norepinephrine reuptake inhibitor (SNRI) / norepinephrine-dopamine reuptake inhibitor (NDRI). The physical withdrawal symptoms were rough.

The good news is, all the medication issues are resolved and I have a reasonable supply of everything again. The automatic refill service at the mega-grocery chain pharmacy even seems to work, which is nice. The bad news is, I have essentially been starting from zero with all my medications again. I am feeling much better and much more stable than I was but Dr. Psychiatrist estimates I have another couple of weeks before I’m back at a steady state.

Best healthcare system in the world.

Another Clever Title

I never quite know what to do with myself when I’m like this. I know retreating from the world and everything in it is probably not the healthiest option right now but it’s kind of all I want to do.

I believe I mentioned previously, Dr. Psychiatrist is adjusting meds again which always seems to make me a bit unsteady no matter what is being adjusted, or by how much. In this particular instance I switched from just bupropion to a relatively new combo drug approved in 2022 that adds, of all things, dextromethorphan. The theory is the addition of DM will improve my anxiety symptoms. If I don’t have any terrible side effects, I’ll be increasing the dose of DM in a couple weeks.

Whatever the DM is supposed to do I wish it would get on with it. I’m certain I’m not terribly pleasant to be around when I’m this symptomatic and, as I mentioned above, I have increased difficulty doing anything other than sitting and moping.

I hope people will bear with me until I’m tolerable to be around again. Fingers crossed it won’t take too long.

My very own To Err is Human

In 2000 the Institute of Medicine published To Err is Human: Building a Safer Health System, a landmark work that shone the light, really for the first time, on the incidence and severity of medical errors. Why do I mention this? Because I’m pretty sure I had one.

As seen in the previous post, for the last few weeks I’ve still been having panic attacks and was quite symptomatic with depression and anxiety which prompted Dr. Primary Care to start me on sertraline. While I was seeing Dr. Primary Care I also got a refill on my bupropion since I was nearly out. I started the newly refilled prescription yesterday and noticed something kind of odd.

I want to take a moment here to mention I am aware of the difficulties and pitfalls of identifying pills by sight. Pills from different manufacturers will look different even if they are the same drug and the same dose. That said, I’ve seen quite a few pills in my day and I can generally spot things that are different because of manufacturer and things that are genuinely off.

So I started my newly refilled prescription and noticed that the new pills were markedly larger than the ones I had previously been taking, in spite of appearing to be from the same manufacturer. By chance I have access to examples of 150 mg XL tablets in addition to the 300 mg XL tablets that I am supposed to be taking and I am as certain as I can be without any physical evidence that the pharmacy filled my last prescription for 300 mg XL with 150 mg XL.

Two additional pieces of evidence that could add weight to the theory; once I started taking my new 300 mg XL tablets I immediately started feeling better. My mind has not been this calm in weeks and my overall mood has improved a great deal. Also when I started taking my new 300 mg XL tablets, I was struck with a serious case of insomnia which is a common side effect of bupropion. It hasn’t really been a problem for me¹ except for a couple of days after a dose increase.

There are potentially confounding factors to consider however. As mentioned above, I don’t have any physical evidence. All I have is an empty bottle that says 300 mg XL, and a comparison of my mental image of the pills I was taking to known samples of 150mg and 300mg tablets that appear to be, but can’t be said for certain to have, come from the same manufacturer. There is also the addition of sertraline to my regimen. I’ve been on it for a week and, while usually SSRIs take a bit longer to really take full effect, the possibility that I’m just feeling the benefit of the sertraline cannot be ruled out. Finally, the insomnia could very easily have resulted from me working my first full week on night shift after being on a “sleep when you want, wake up when you want” schedule for a couple months.

Pretty sure but not certain.

The thought of the difficulties I’ve been having with my mood over the past few weeks being the result of a medication error is actually reassuring to me. I was feeling distraught because I thought I’d been making all this progress in therapy and introspection and self-analysis and all, but here I was feeling like shit most of the time again. Additionally, if this was a medication error, any doubt about the benefit of being on medication that I may have had is gone. Being on a half-dose was all kinds of no fun so I don’t even want to think what being off it entirely would be like at this point.

¹ I know, I know. But there is my baseline insomnia and then extra insomnia gets piled on top of it. Insomniaception. A couple of days after my last increase in dosage I was back to my baseline insomnia.

Hey… didn’t I have cancer?

Remember how I was going to start a blog to keep everyone up to date on how my cancer treatment was going? What ever happened with that?

I started the second round of BCG yesterday. I had completely forgotten about it until about 5 pm Monday evening so it was a nice surprise. As always the procedure went smoothly. Pretty much as soon as I got home, though, I was right back to the frequency and urgency with urination. It was like the treatment never stopped. I’m feeling a little fatigued today but there are plenty of non-cancer treatment related reasons for that as well.

The plan was for three more doses but that is going to get really complicated. After my second dose, I am going to be changing insurance and my current urologist won’t take my new insurance. Just out of morbid curiosity I asked the billing people at the clinic how much getting a dose would cost and the answer was somewhere on the order of $10,000. For one dose.

Yeah. I’m just going to finish this post later. Or not.

Apparently, mental health is a real thing

There is a possibility that I’m overgeneralizing somewhat with this, and I may also be doing some post-hoc revisions of my internal dialogue. That said, what follows feels true to me and has allowed me to resolve some very perplexing things that my brain has been doing.

For some time now I have been having a harder time than usual with work. I’ve been finding it increasingly difficult to go to work in the first place and once I’m there I have a really hard time staying. This is not an entirely new phenomenon, and is also not unique to me. Who looks forward to going to work and who is happy to be there once they arrive? Almost no one, that’s who. That said, this has felt very different than the usual vague malaise of dissatisfaction that comes from having to put down Animal Crossing and leave the house.

“Well of course you’re having problems,” you might say, “you’ve been in cancer treatment and dealing with fatigue from that. No one expects you to be at the top of your form!”

This is true. I have a very real physical medical condition and I have unquestionably been experiencing some physical side effects from my treatment. However, at this point there really isn’t any reason that these side effects should be as limiting as they appear to be and, if I’m completely honest, they probably aren’t as limiting as I have been allowing them to be.

As I have discussed here previously, my brain constantly tells me that I am malingering or exploiting the system somehow because, in terms of physical health, I likely could be working without any restrictions right now. The slow realization that there might not be an actual physical problem sapping my willpower and energy has kicked the “you’re just a lazy bastard” message from my brain into overdrive in the last few weeks

Again, though, I genuinely have been feeling like I’m incapable of working, and the worst scolding from my brain hasn’t made it any easier to keep pushing and just do the work, so WTF?

At this juncture it is important for the narrative that I mention my longstanding prejudice when it comes to mental health. My poor opinion results from long years of dealing with the healthcare consuming public, which certainly has no shortage of people with genuine, serious issues, but also no shortage of people just trying to game the system. The way my mind works, it comes down to Sick or Not-Sick. You can’t objectively measure depression, anxiety, and trauma so they probably aren’t real. Intellectually I know this is nonsense and when it comes to patients I try hard to stay aware of this bias and to not let it affect the care I provide.

When it comes to myself, though, it is something of a blind spot. Deep down, I don’t completely accept the notion that my mental health is a real thing that can actually affect how I approach the world. Again, intellectually I know this is nonsense but that seems to be how my brain wants to see things.

Keeping all that in mind, my thought process has been something like the following;

Stage 1

The only valid reasons for me being unable to work are physical ones.
I’ve been feeling very limited in my ability to work.
Therefore, something must be physically wrong with me.

Stage 2

The only valid reasons for me being unable to work are physical ones.
I don’t physically feel all that bad, really.
I still appear to be limited in my ability to work.
Therefore, I must be faking it.

Stage 3

The only valid reasons for me being unable to work are physical ones.
I still don’t physically feel all that bad, really
I still appear to be limited in my ability to work.
This doesn’t feel at all like I’m faking it.
???

The explanation, of course, is that my first assumption is faulty. I really am limited in my ability to work but at this point it’s for mostly psychological and emotional reasons, not physical.

In February of 2020, an emergency room doctor at Evergreen Medical Center in Kirkland was infected with Covid. His condition deteriorated quickly and he was transferred out of the ICU at Evergreen to Swedish Cherry Hill so he could be put on ECMO. He was the first Covid patient on the west coast, probably in the whole United States, to be put on ECMO. That was my unit and I was one of the lead ECMO specialists.

I lost count of how many more Covid patients we put on before I left Cherry Hill. They all were insanely sick¹, insanely complex to care for and most of them died, as did most of the Covid patients we had that weren’t on ECMO.

This went on non-stop.

For months.

And it still hasn’t exactly stopped yet.

There was a lot of non-Covid unrest at Swedish at the time as well, of course, so I had plenty of reason to be discontent before I left. Given that mental health isn’t real, I attributed my angst to the external situation and didn’t think about it past that.

Since then I have changed jobs two more times for a total of three job changes in the last 18 months or so. Each of the jobs ended up feeling unsatisfactory for one reason or another and, like I had at Swedish, I felt compelled to leave. True, the working conditions weren’t (and aren’t) ideal but I’m also starting to think that there is an underlying current of mental disfunction that is making it nearly impossible to get comfortable and settle in.

The point is that it has been a difficult couple of years and perhaps there could be some lingering trauma that I’ll probably need to deal with at some point.

For all my airs of professionally detached objectivity, I may be merely human after all.

Looking after my mental health has never been one of my strong suits but entertaining the idea that I could be mentally fatigued enough to impact my job performance has been something of an eye-opener. It explains a great deal of what I’ve been experiencing and it has already helped me to get the asshole part of my brain to shut up every now and then. Beyond that, I’m not sure if this shift in thinking will make any difference or not.

This post was very long and has an unsatisfying conclusion. It also may not matter because, hopefully, I will be changing jobs again in the near future.

But that is a story for another day.

————

¹I’ve talked about this before too, although I can’t remember if it was here. I don’t think it’s possible to convey the actual reality of how sick these patients were/are to normal (non-medical) people. Even most medical people, I think, fail to grasp how sick they are. The best analogy I’ve come up with is that caring for these patients is like trying to keep someone who is on fire alive but you have to do it without being able to extinguish them. I love doing that kind of work but it is exhausting under the best of circumstances.

Well at least I found out

It turns out that I may not be as ready to go back to regular work as I thought I was. Tuesday night was fine, I felt a bit more tired than usual but it was also my first full night shift in several weeks. Wednesday I felt like I’d been put through a wringer and I most certainly didn’t feel like I could go back and do it again. My new proposal is going to be working on the unit, say, Tuesday and Thursday, and in employee health on Wednesday and Friday. I think that might work. Once again, though, the only real way to find out is to try it and see what happens.

To be perfectly honest, part of the reason I felt so drained on Wednesday was that I spent a couple hours of it fighting with Verizon about phones. Our phones are old enough that ~~Apple has started throttling their data speed and battery function~~ their performance has really started to suffer, so we decided it was time to get new ones. Verizon, as I’m sure most carriers do, has a deal to turn in your old phone and get an upgrade (with an extra two year contract to stay with Verizon of course) so we did. Ordered two phones, one for Shannon’s number and one for mine. This was maybe the first week of October. For a couple weeks everything looked fine, then I got an email from Verizon saying that one of the phone orders was cancelled because it had been “confirmed as fraudulent”. This was news to me. I don’t recall anyone actually asking me if the order was fraudulent and the other order had gone through without a hitch.

I called Verizon’s customer service line and, after slightly more than the usual frustration navigating through their automated system, and after spending 75 minutes on the phone with three different people, the “fraudulent” order was cancelled and a new order put in. Good. This was late Wednesday morning.

That afternoon I got another email from Verizon saying that a recent order had been flagged as fraudulent and that I needed to contact the fraud prevention department.

So after considerably more than the usual frustration navigating through their automated system, and after spending 45 minutes on the phone with two different people, the “fraudulent” order was cancelled and a new order was put in.

I did give serious consideration to cancelling everything and switching carriers but after making some inquiries it seems like all the carriers are approximately equally awful.

First world problems…

Updates

Updates are called for;

House:
- The basement floor project is still in a holding pattern. Last word was that everything should be in place to have it done by the end of the month
- The new plumbing leak is also in a holding pattern. There is slightly better news than I expected here. Not good news, but not as bad as it could be. The leak was from the seal on the toilet in the bathroom upstairs. It was fast and (relatively) inexpensive to fix. We are waiting on hearing back from the people who are going to come and fix the floor and/or ceiling to find out exactly what is required there.
Work:
- I’m going back to work on the unit starting next week. With the most recent covid surge settling down, Employee Health isn’t as busy as they have been and don’t need as much help. There are certainly other things I could do for light duty but the fact is I’m probably recovered enough to just go back to work. I’m never going to feel ready and the only way to find out if I can do it is to do it.
Health
- Health is also in a holding pattern. No news has been good news.
- Mental health is honestly as good as it can be under the circumstances. The previous post announcing the bathroom leak is typical of how I’ve been reacting to new difficulties recently. I’ve been feeling very brittle; when something hits I kind of break into a thousand little pieces and can’t see anything but crisis and my brain does everything it can to persuade me that things are as bad as they can possibly be and they will never be fixed. This is a known issue. I haven’t had much luck moderating my initial, disproportionately negative, response but I have been getting better at pulling myself together again.

The fact is, in spite of everything I, right now, today, I feel pretty good both physically and mentally. There is still a lot on my plate and I’ve been ready for all this shit to be done for about 6 months or so, but the struggle can continue.

Two days until round 2

Time for some brief updates on everything.

I had previously decided that I was going to take a short break from school during the month of October and that has gone through, been approved and is all taken care of. I’ll be back to working on my degree in November. I’m not terribly excited about the delay, but I think it will allow me to get enough other fires put out that when I do go back I will have a much easier time focusing on schoolwork, so I think this will be a good thing.

The basement is frustratingly close to being done. We have been wrestling with the people who are going to replace the bits of the floor that are missing since the second week of August with almost nothing to show for it. Supposedly they’ll have all the flooring tiles, adhesive, baseboards, etc. this week and the installers are tentatively scheduled for Thursday. If everything goes well. Maybe. It’s not certain.

I’m trying to remain optimistic that the floor will be done by the second week of October and then The Great Unpacking will commence. The Great Unpacking should only take a few days, a week at most, and then the basement will be done.

Side effects; the fatigue is way better. I’m still not 100%, maybe more like 75-80%. Just in time to get scoped in two days and start round two of treatment. Round two will not necessarily kick off right away, but this is what is going to set the schedule. I am hoping that with only three treatments instead of six, maybe I’ll only be half as fatigued afterwards. Time will tell.

Work; I will confess to being somewhat anxious about work, likely for no good reason at all. As previously mentioned, My doctor wrote me a note authorizing essentially indefinite light duty and I plan to take advantage of that. I don’t think there is anything that my employer can legally do to pressure me to return to my usual job but I also have to wonder what kind of reception I’m going to get after slacking off for 2-3 months. Time will tell.

Events may be aligning such that I will only have to deal with work and treatment during the month of October which will almost be like a vacation compared to the last six months. Of course the last time I said something like that we ended up having a global pandemic, the country elected one of the top three worst presidents in the history of the United States, the basement flooded (again) and I changed jobs three times.

I’m keeping my mouth shut this time.

In the spirit of transparency

Too much information alert!

Proceed at your own risk

This is another one of those things that I would ordinarily keep to myself, both because I didn’t want people around me to worry, and because I genuinely don’t know how much it should be worried about at all.

Since Friday I have been having symptoms very much like a urinary tract infection. This was kind of curious. While I have more reason than some to have a uti, it’s pretty much been life as usual for me for the last month or so and I would think that any infection issues related to the BCG treatments would have popped up before now.

So I went in to urgent care (my primary care doctor was scheduled out for the next month or so), dropped off a urine specimen, picked up a prescription for nitrofurantoin and went on my way. A couple of days later I got a call reporting that my urine culture was negative. Which would almost certainly mean I didn’t have a uti.

And yet I continued (and continue) to have symptoms very much like a urinary tract infection, only thing missing is fevers. So what is causing the symptoms?

The answer is, of course, “I don’t know, but probably not anything I’m going to be happy to find out about”. I already have an appointment with the urologist in three days and I don’t think three days is going to make any difference with anything one way or the other.

We shall see.

Okay, fine…

If you run into an asshole in the morning, you ran into an asshole. If you run into assholes all day, you’re the asshole.
Raylan Givens; Justified

Not saying I’m the asshole (not meaning to imply that I’m not the asshole either) but when different people are all independently telling you the same thing, you may want to pay attention to what they’re saying.

As mentioned in the previous post, nearly every person of significance in my life that I talked to about the question of whether or not to come off light duty said the same thing with surprisingly little variation. The common theme seemed to be a general concern that I was going to scramble my brain if I didn’t ease up on things a little.

I will certainly admit to having felt overwhelmed and overcommitted for most of the last three years or so, but I always assumed that was because my life was a disorganized mess and I couldn’t get my shit together. It is possible that I have been feeling overwhelmed and overcommitted because I actually have been overwhelmed and overcommitted. And then I got cancer.

The point to all this is that my primary care doctor gave me a note that appears to authorize light duty for me indefinitely and I may take advantage of that to stay on light duty until I actually feel better. As one particularly insightful person pointed out to me, I have obligations to my family that should carry at least as much weight as my obligation to work. It has been altogether too easy for me to forget that and I needed the reminder.

I’m still not sure what needs to happen before I feel like I’m ready to go back to work but I’m going to make an effort to find out rather than just going back whenever.