Maybe I’ve got this all wrong. Maybe I need to look at things from the doctor’s perspective and channel Stephen Colbert so I can upchuck thoughts as they occur uncensored while adopting the persona of a mainstream medical doctor.
After all, what do patients expect from a doctor within the typical eight-minute office visit? Miracles? Do they expect the doctor to change water into wine, exorcise demons or reverse years of accumulated oxidation from eating all those Big Macs and KFC fried chicken sandwiches – all by prescribing a magic pill???
To tell us more about the doctor’s perspective, I visited hyperbaric medicine specialist, Cosmetic Surgeon Eric Desman, M.D., as an outpatient in the Wound Healing Center at Inova Mount Vernon Hospital in Alexandria, Virginia on August 26, 2010.
I went there because Medicare pays for hyperbaric oxygen therapy for patients with persistent actinomycosis.
Dr. Desman is a handsome, burly type with the kind of intimidating arm muscles that come with a tire gauge much like those of ex-Marine and Daily Show correspondent/comedian Rob Riggle. (Google their photos. You’ll know what I’m talking about.) They’re the kind of arms that make you feel protected, and docs have to protect the weaker minds of their patients from worry.
Docs can’t show any signs of indecision or wavering when treating patients — even if they don’t have the faintest idea of what’s wrong with the patient. (The ubiquitous idiopathic ailment.) Docs have to be absolutely sure that the prescribed medicines or therapy will not “harm” the patient. (The Hippocratic Oath or Lawyer’s Treatise.)
House, M.D. fans may have noticed that TV Dr. Gregory House prescribes treatment based on an educated guesstimate of what’s troubling his patient. The practice is based on the assumption that medicine that cures the patient proves the diagnosis. But we all know Princeton-Plainsboro is no typical hospital. It’s the enchanted forest in never-never land. Prescribing treatment without a positive biopsy or culture never occurs in real life medical care. (Ahem.) Much too risky.
In real life medical care, doctors surgically remove a large enough sample of the patient’s tissue so the pathologist can definitively proclaim what the patient has prior to any treatment. As Dr. Desman said, it’s for the patient’s safety. Of course. And although performing such biopsies (cutting tissue) in patients with anaerobic bacterial infections causes the infection to rapidly spread, this cutting and removing of otherwise needed tissue ensures that the patient with an anaerobic infection will get worse and will therefore definitely need treatment. (Win-Win. No if, ands or buts here.)
I knew this. So I was not fazed when Dr. Desman told me that before I could receive treatment for my infection(s), I would have to have another doctor somewhere else perform such a biopsy. The positive test results I had, he said, expired after three months. It’s water under the bridge that I was not properly diagnosed nor treated previously. (No crying over spilled milk!) Docs have to make sure the patient is still sick now. (Miracles do happen.) And docs hate looking at other doctors’ homework. (Too much reading and deciphering.)
What’s the treatment? Oxygen. More specifically, hyperbaric oxygen therapy or HBOT, for short. In HBOT, the patient spends multiple two-hour sessions breathing in 100 percent oxygen in a chamber in which the oxygen pressure is higher than in the atmosphere. It’s used to treat a variety of ailments such as carbon monoxide poisoning, the bends (from scuba diving improperly), non-healing wounds and anaerobic bacterial infections, such as actinomycosis.
Inova Mount Vernon Hospital’s website calls HBOT “a highly effective and safe treatment.” In fact, in The Oxygen Revolution authors Paul Harch, M.D. and Virginia McCullough point out that the only side effect of HBOT that isn’t reversible is due to tank operator error – giving the patient too much oxygen under too much pressure. This happens when the patient’s reactions to treatment aren’t properly monitored. (Hospital liability is a side effect?!)
Dr. Desman did clarify that my lungs could collapse during HBOT if I had any lung conditions like emphysema, but that the risk of this side effect occurring was minimized by requiring all HBOT candidates to have a chest X-ray prior to treatment. (Whew! Had me there for a minute.)
Now getting a decent biopsy of an aerobic bacterial infection — one that lies on the skin – is one thing. Performing a biopsy on a patient with an anaerobic bacterial infection – one you can’t see – is far more challenging. Trying to even convince a doctor you have an anaerobic infection is akin to a new car salesman trying to convince his customer to pay for the clear coat on his new car. You can’t see it. The dealership won’t let you in the back to see if it’s actually applied…
Anaerobic infections nestle deep within tissue to avoid exposure to oxygen because oxygen kills anaerobic organisms. For anaerobic infections, docs have to get a tissue sample large enough to encapsulate and shield any anaerobic germs from coming into contact with the air so as not to compromise the specimen.
My first biopsy was from a tonsillectomy. The tonsils have tonsillar crypts that safeguard the actinomycotic granules from the atmosphere so they can be seen under the pathologist’s microscope.
Finding another biopsy site in the head and neck region proved a bit more challenging because there’s nothing there I really care to part with.
(Sidebar: Mrs. Christine Wicks, who was diagnosed with actinomycosis in England at age 67, had to have a biopsy prior to being approved for HBOT by England’s National Health System to show that the months of intravenous penicillin therapy failed to eradicate her infection. She had a large chunk of her neck removed, which was not only unsightly – leaving what she called “a visible hole in her neck” – but also caused the infection to spread to her lungs so she no longer qualified for the treatment for which she got the biopsy. How ironic.)
Dr. Desman instructed me to see Dr. Michael Abidin, an otolaryngologist I’d seen years earlier, for my updated anaerobic bacterial biopsy. “He trained at Johns Hopkins,” Desman said trying to reassure or convince me that although neither surgeon admittedly knew anything about actinomycosis, that I would be in good hands with Abidin because of his affiliation with Johns Hopkins.
This was the same surgeon who, on the last of a half dozen office visits, handed me another patient’s file to take to check out. It was the file he’d been referring to during our brief visit. Abidin never addressed me by my name, nor identified the disease-causing pathogen(s).
Apparently, Dr. Desman is good buddies with both of my former otolaryngologists, “Mike and Larry” (Dr. Laurence O’Halloran).
Dr. Desman never mentioned the letter recommending HBOT from my primary care physician, Dr. Norman Levin. Instead, he called one of my former infectious diseases physicians, Dr. Richard Sall, who had prescribed a few months of penicillin VK 500 mg oral tabs the year prior for actinomycosis. And he called Dr. Abidin. Desman was hoping they would remember me and fill him in on the details of my ailment so he wouldn’t have to read any of my paperwork.
He said he’d caught them both between patients and neither recalled who I was, but that Dr. Abidin had agreed to do the biopsy anyway.
Do you really think Dr. Desman knew he was asking Dr. Abidin to take a chunk out of my neck? And did Dr. Abidin really understand that he’d agreed to do that? Of course not. Doctors like to think of themselves as omniscient, but they rarely are. They’re oriented toward what they typically do on a daily basis, which is geared to dealing with aerobic bacterial infections.
Dr. Desman told me that in the 25 year history of the Mount Vernon Hospital Wound Healing Center, there were two or three patients with actinomycosis who received HBOT as an adjunct to conventional therapy. These were patients of Dr. John Symington, an infectious diseases doctor who specializes in treating patients with Methicillin-resistant Staphylococcus aureus (MRSA), a bacterial infection highly resistant to some antibiotics.
It appeared most of the patients undergoing HBOT here were treating open wounds and (MRSA) infection. This was news to me since I understood oxygen only killed anaerobic bacteria — not aerobic MRSA infection. I began rethinking whether this environment was such a good venue for me in my autoimmune-compromised (petri-dish) state.
I later stumbled upon some articles about the turf wars between microbiologists and practicing wound care physicians over biopsies. Apparently, microbiologists have known for some time that not only do anaerobic infections have aerobic co-infections, but aerobic infections have anaerobic co-infections. The microbiologists argued that for proper patient wound care, practicing physicians needed to do two biopsies – one surface biopsy for aerobic pathogens and a deeper biopsy for anaerobic infection.
The community of practicing physicians felt this was unnecessary. One article gave the distinct impression that the reticence on the part of the practicing physicians to do anaerobic biopsies was based more on resistance to what was being viewed as territorial trespassing than on good science — turf wars.
Makes me wonder how many of the MRSA infected patients receiving HBOT had anaerobic bacterial biopsies before being treated. My money’s on “not many, if any.” A bit of a disparity in treatment protocol, don’t you think?
Totally agree with the author , treating patients is not easy even patients have lot of expectations on doctors