Tuesday, October 21, 2003


I love telling this story. That I love telling it probably bespeaks a terrible character flaw. The story has two titles. One is "How To Diagnose Adult Rickets Colonoscopically." The other is, "Lose Hope, Patients. Doctors Don't Even Listen To Patients Who Are Doctors." The other, less savage title, could be the first word from St Benedict's Rule: "Audite." Listen.

So, as we all know, one ingests a "prep" prior to the unmentionable colon intubation one earns as a rite of passage upon turning 50. To clean out the aforementioned organ. So that it may be scrutinized. Our HMO uses the nasty little prep with a gazillion millimoles of sodium phosphate. Fleet's Phosphosoda, citrus flavored. Like four ounces of bad lime kool aid laced with eighteen heaping tablespoons of table salt. So, good patient that I am, I choked it down.

Next morning I'm lying there in the GI suite of Upscale Suburb Community Hospital waiting (and waiting and waiting and waiting) for the procedure to begin, parched as hell, my teeth are vibrating (really !), there's a bizzarro twitch at the base of my right thumb, but I figured, what the hell, maybe I'm a little dehydrated.

Turns out the doc who was supposed to do my scope, some guy I'd never even met (since colonsocopies occur in a wierd never-neverland annex to the doctor-patient relationship, an impersonal assembly line of specialists and orifices) was off somewhere in New Hampshire giving a lecture. (OOPS ! SNAFU ! FUBAR !) But, fear not, announced the harried nurse who finally delivered this message, the "awesome" (her word) "chief of GI" had consented to do all the mis-scheduled procedures if that was OK with me.

Needless to say it was fine w/ me. Did not relish another quaff of the old Phospho Soda. No blushful hippocrene, that.

So the nurse slapped on a tourniquet to start an IV and my hand promptly curled up into a crampy, spastic little ball. This, as any medical student knows, is the classic, tourniquet-induced "carpal spasm," AKA Trousseau's sign, indicating either low blood calcium or blood rendered overly alkaline by hyperventilation.

Now I do not DO hyperventilation. EVER. I am a model of perfect GRAVITAS. The upper lip ? She is stiff.

Plus, as any medical student knows, PHOSPHATE (as in Fleet's PHOSPHO soda) BINDS IONIC CALCIUM, causing it to precipitate OUT of the bloodstream.

So I announced to the nurse, gingerly, trying not to do the arrogant I-know-best-I'm-a-physician schtick, that I'm an internist and explained all of the above to her and I was concerned my serum calcium might be low. She looked confused, mumbled something and scuttled off. In addition to Trousseau's sign, a very low calcium can cause seizures, arrhythmias and cause one's larynx to spazz up as well. Preventing air from entering one's body. So I was a bit, oh, worried. Silly me.

Then Nurse #2 came in and took my blood pressure in the other arm. Again, tourniquet; again Trousseau's sign in the other hand. Again, I pointed this out, offered physiologic explanation, complete with my credentials as an INTERNIST. "Awww," she said, hooking me up to the cardiac monitor, "you just need a nice HAND MASSAGE." And proceeded to knead my spastic palm. (It did feel rather good.)

Finally, in swanned the "awesome" chief of GI, introducing himself, and offering his credentials as the AWOL GI guy's "boss." I figured I'd go for broke. YET AGAIN, I proffered MY medical credentials. YET AGAIN, I reiterated the Trousseau's sign, phosphate prep, possible low calcium speech, acknowledging that hyperventilation can cause carpal spasm, but noting I was not hyperventilating, and this time I even threw in the twitching -- fasciculating, as we docs like to say -- thumb.

He peered down at me. "Ah yes, fasciculations," he intoned, gravely. "Well, you should certainly discuss those with your doctor. I get them too, sometimes." (I caught his subtext. Fasciculations are the first sign of ALS, Lou Gehrig's disease, but everyone gets benign twitches from time to time.) "And," he continued,"Your potassium is probably a little low. But the cardiac monitor looks fine." (Yes, asshole, I'm not flatlining yet, and low potassium doesn't cause Trousseau's sign !) He continued to peer down his awesome nose at me, and concluded, " You're probably just blowing off a little carbon dioxide."

Blowing off a little carbon dioxide ? Blowing off ? A Little carbon dioxide ?


(Do you think that if I had been a MALE internist he might have ordered a stat serum calcium level ?)

By the time I truly woke from my demerol and benzodiazepine induced stupor (I don't even remember getting home) at about six that evening, my whole body was doing the carpal spasm thing even without the tourniquets.

So I called my HMO.

I explained everything to a nurse. She connected me to some physician's assistant doing urgent care. I went through the whole thing AGAIN, this time venturing that maybe the standard dose of the prep was too much phosphate for a 105 pound woman. "No, no," she interrupted, peevishly, "we give the same dose to everyone," and continued to explain that they were really extremely busy, there was nothing they could do for me tonight, if I REALLY wanted to (as if it were a frivolous option only the most flagrant of hypochondriacs would choose) I could go to an ER. And if I chose that option I had to go to Grossly Inconvenient Community Hospital On The Outskirts Of Nowhere, which I shall henceforth call, acronymically, GICHOTOON. Would she call them and apprise them of my arrival ? Couldn't possibly. Too busy.

So off we schlepped to the GICHOTOON ER. By the time we got there it was 7 pm and I could barely hold and/or let go of the pen they gave me to sign in with. I told the story yet again to an uninterested, suspicious and harried looking triage nurse, she drew a few tubes of blood to send off to the lab, and consigned -- condemned -- me to the (Hell That Is Known As The GICHOTOON) ER waiting room. Where there are TWO TELEVISIONS on full blast, set to two different stations. Where, apparantly, one sits and awaits the arrival of the grim reaper and his tumbril, while being driven clinically insane by sit com laugh tracks, loud potato chip advertisements, and bad Tom Hanks movie sound tracks.

Soon, in addition to the muscle spasms, I began to feel like long wisps of hair were flagellating my cheeks. They weren't. And that I was wearing a pair of electric gloves. I wasn't.

At 11 PM I announced I would rather die than wait another moment in that hell, and a dubious but cowed DK, after the receptionist informed him she could not possibly even consider trying to obtain even an estimate of how much longer it would take before I could be seen, drove me home. It was not one of my better moments. I "eloped," as we docs like to say, from the ER. Thus placing me for eternity in the category "nutjob patient."

Once home we found, on the answering machine, an alarmed message from an ER doc, Dr X, "who'd just come on shift" and been handed my lab reports. He said I'd better get my butt back to the ER because my blood was, well, FUBAR.

Well, duh.

Of COURSE my calcium was low. I'd only been telling them that ALL FUCKING DAY ! (My potassium was in the basement, too, but my calcium was in the sub sub basement.)

So DK ferried (as in Styx) me back to the ER where young (extremely handsome and very patient) Dr X brought my lab tests and body back into the not-quite-right-but-almost-compatible-with-life range. They'd apparantly been having a night from Hell. I felt sorry for them. I felt sorry for me.

And took a taxi home at dawn. Later phoned up my internist who was horrified and made it a point to phone up Awesome GI Chief to give him the rest of the story, as it were. She ordered repeat labs. I had 'em. Calcium improving. But LOW phosphate. Huh ? Low ? I looked in Harrison's Principles of Internal Medicine and had an OMiGod moment. What causes low calcium and a low phosphate ? Of course.

Vitamin D deficiency.

(Am 2 year vegan, 10 year non-milk drinking vegetarian who gets little or no sunshine. Your basic troglodyte.)

Phoned up internist again. Asked her to add on a vit D level. It came back, well, zero. Compensatory hormone, PTH, which basically chews up bones, valiantly attempting to restore blood calcium to normal, was through the roof. Bones ? Translucent. Endocrinologist ? Deeply impressed.

Long dark winter of odd and semi-crippling hip, foot and rib pains ? Resolved with return of the sun and massive doses of D and Calcium.

Results of colonoscopy ? Hemorrhoid.

Apology from Chief Awesome ? None.

Mention of any of my Three Calcium Speeches in Upscale Suburb Community Hospital Medical Record ? None.

Bill For Co-Pay From The Hell That's Known As GITCHOTOON ER ? You bethcha.

Audite. It's good to remember that exhortation.

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