219. Pancakes

At 34 weeks Rosie was hospitalized with “intrauterine growth retardation” and poorly controlled diabetes. Are the two complications related? One causing the other? Both caused by an unknown factor? Coincidental?  

Anyway, I walk in for morning rounds and find her eating pancakes.  I go ballistic!  Who allowed that? Then I found out that pancakes are indeed on the hospital’s diabetic diet because the venerable American Diabetes Association wants to make sure that diabetic patients get enough carbs so that they don’t crash from hypoglycemia (low sugar).  That’s fine and good for type 1 diabetics whose blood glucose levels vary widely.

But for type 2 diabetes, carbs are the problem, not the solution.  Many type 2 diabetes will resolve with low carb diets.  So no white bread, no white rice, no potatoes, no pasta, NEVER; and rarely whole grain breads and pasta, brown rice.  As for pancakes?  Give me a break.

218. Heroin part two

A month later, with negative urine screens for any opioids--not even the narcotics (Percocet) that I thought she took regularly, Carolyn returns to preop.  With no unexpected confessions, and a more flexible anesthesiologist, her hysterectomy proceeds without complications. At the eyesight level, the uterus, fallopian tubes, and ovaries appear normal, including no evidence of endometriosis (I wouldn't expect to see adenomyosis).

The pathology report not only confirms the presence of adenomyosis but also notes the presence of small fibroids, which can also cause pain. 

Carolyn went home the morning after as planned.  She did not need more than the usual postop pain medications.  I provided a prescription for 40 Percocet instead of my usual 30 since her history suggests narcotic tolerance--more will be needed for the same pain control.  

It's now been almost a week--I expected a call requesting a refill (at 2 Percocet three times a day, she would have run out by now), but have heard anything.  No news is good news.

217. Heroin part one

Hardly a day goes by without a news headline about the nation's opioid epidemic.  So no surprise when a patient's history reveals a history of substance abuse, including heroin. 

47 year old Carolyn was referred to me by a partner who didn't have time on her schedule for a hysterectomy.  Carolyn experiences chronic pain, especially with menses, which some providers attribute to endometriosis, others to adenomyosis. 

Adenomyosis occurs when the active cells of the inner uterine lining expand into the more sedate muscle fibers that comprise the uterine wall (which they are not supposed to do), Hysterectomy is the only effective treatment.  Remove the uterus--remove the adenomyosis.

Hysterectomy for pain can create more problems than it solves, but I reviewed the chart and said okay. 

The morning of surgery, Carolyn tells the admitting nurse that she used heroin the day before (just a little bit she said; "I didn't really feel anything").  The anesthesiologist promptly cancelled the surgery, saying he wouldn't do it unless he could confirm that she had been off heroin for six months.

But taken at face value, she does have a reason for pain; she takes narcotics for pain; trying to take her off of all narcotics and similar drugs for six months, is not realistic.

So we're going to try again, monitor her urine for a couple of weeks and try again after labor day.