Monday, January 28, 2019

A rare but serious complication of… exercise

Sore throats happen all the time in childhood — and most of the time, it’s nothing to worry about. Most of the time, they are simply part of a common cold, don’t cause any problems, and get better without any treatment.

Sometimes, though, a sore throat can be a sign of a problem that might need medical treatment. Here are four examples:

Strep throat. This infection, caused by a particular kind of streptococcus bacteria, is quite common. Along with a sore throat, children may have a fever, headache, stomachache (sometimes with vomiting), and a fine, pink rash that almost looks like sandpaper. All of these symptoms can also be seen with a viral infection, so the only way to truly know if it’s strep throat is to swab for rapid testing and/or a culture. Strep throat actually can get better without antibiotics, but we give antibiotics to prevent complications, which, while rare, can include heart problems, kidney problems, and arthritis.

Peritonsillar or retropharyngeal abscess. This is a collection of pus either behind the tonsils (peritonsillar) or at the back of the throat (retropharyngeal) and can be dangerous. Redness and swelling on one side of the throat, or a bad sore throat with fever and neck stiffness, can be signs.

Stomatitis. This is caused by viruses, and leads to sores in the mouth and throat. It gets better by itself, but it can make eating and drinking very uncomfortable, which is why some children with stomatitis (especially very young children) end up with dehydration. There are medications that can help coat the sores and make drinking easier, to help prevent dehydration.

Ingestion. Little children are curious and don’t have the best self-preservation skills. If they drink something that is a strong acid or alkali, it can burn the mouth and throat as it goes down. Household products such as bleach, drain cleaners, toilet bowl cleaners, some detergents, and even some beauty products such as hair straighteners, can do terrible damage. If an adult didn’t witness the ingestion, all they might know is that the child is suddenly complaining of mouth and throat pain.
There are few subjects that can stir up stronger emotions among doctors, scientists, researchers, policy makers, and the public than medical marijuana. Is it safe? Should it be legal? Decriminalized? Has its effectiveness been proven? What conditions is it useful for? Is it addictive? How do we keep it out of the hands of teenagers? Is it really the “wonder drug” that people claim it is? Is medical marijuana just a ploy to legalize marijuana in general?

These are just a few of the excellent questions around this subject, questions that I am going to studiously avoid so we can focus on two specific areas: why do patients find it useful, and how can they discuss it with their doctor?

Marijuana is currently legal, on the state level, in 29 states, and in Washington, DC. It is still illegal from the federal government’s perspective. The Obama administration did not make prosecuting medical marijuana even a minor priority. President Donald Trump promised not to interfere with people who use medical marijuana, though his administration is currently threatening to reverse this policy. About 85% of Americans support legalizing medical marijuana, and it is estimated that at least several million Americans currently use it.
Marijuana without the high

Least controversial is the extract from the hemp plant known as CBD (which stands for cannabidiol) because this component of marijuana has little, if any, intoxicating properties. Marijuana itself has more than 100 active components. THC (which stands for tetrahydrocannabinol) is the chemical that causes the “high” that goes along with marijuana consumption. CBD-dominant strains have little or no THC, so patients report very little if any alteration in consciousness.

Patients do, however, report many benefits of CBD, from relieving insomnia, anxiety, spasticity, and pain to treating potentially life-threatening conditions such as epilepsy. One particular form of childhood epilepsy called Dravet syndrome is almost impossible to control, but responds dramatically to a CBD-dominant strain of marijuana called Charlotte’s Web. The videos of this are dramatic.
Uses of medical marijuana

The most common use for medical marijuana in the United States is for pain control. While marijuana isn’t strong enough for severe pain (for example, post-surgical pain or a broken bone), it is quite effective for the chronic pain that plagues millions of Americans, especially as they age. Part of its allure is that it is clearly safer than opiates (it is impossible to overdose on and far less addictive) and it can take the place of NSAIDs such as Advil or Aleve, if people can’t take them due to problems with their kidneys or ulcers or GERD.

In particular, marijuana appears to ease the pain of multiple sclerosis, and nerve pain in general. This is an area where few other options exist, and those that do, such as Neurontin, Lyrica, or opiates are highly sedating. Patients claim that marijuana allows them to resume their previous activities without feeling completely out of it and disengaged.

Along these lines, marijuana is said to be a fantastic muscle relaxant, and people swear by its ability to lessen tremors in Parkinson’s disease. I have also heard of its use quite successfully for fibromyalgia, endometriosis, interstitial cystitis, and most other conditions where the final common pathway is chronic pain.

Marijuana is also used to manage nausea and weight loss, and can be used to treat glaucoma. A highly promising area of research is its use for PTSD in veterans who are returning from combat zones. Many veterans and their therapists report drastic improvement and clamor for more studies, and for a loosening of governmental restrictions on its study. Medical marijuana is also reported to help patients suffering from pain and wasting syndrome associated with HIV, as well as irritable bowel syndrome and Crohn’s disease.

This is not intended to be an inclusive list, but rather to give a brief survey of the types of conditions for which medical marijuana can provide relief. As with all remedies, claims of effectiveness should be critically evaluated and treated with caution.
Talking with your doctor

Many patients find themselves in the situation of wanting to learn more about medical marijuana, but feel embarrassed to bring this up with their doctor. This is in part because the medical community has been, as a whole, overly dismissive of this issue. Doctors are now playing catch-up, and trying to keep ahead of their patients’ knowledge on this issue. Other patients are already using medical marijuana, but don’t know how to tell their doctors about this for fear of being chided or criticized.

My advice for patients is to be entirely open and honest with your physicians and to have high expectations of them. Tell them that you consider this to be part of your care and that you expect them to be educated about it, and to be able to at least point you in the direction of the information you need.

My advice for doctors is that whether you are pro, neutral, or against medical marijuana, patients are embracing it, and although we don’t have rigorous studies and “gold standard” proof of the benefits and risks of medical marijuana, we need to learn about it, be open-minded, and above all, be non-judgmental. Otherwise, our patients will seek out other, less reliable sources of information; they will continue to use it, they just won’t tell us, and there will be that much less trust and strength in our doctor-patient relationship. I often hear complaints from other doctors that there isn’t adequate evidence to recommend medical marijuana, but there is even less scientific evidence for sticking our heads in the sand. We are fortunate to have a country home in the Catskills where we can escape city life. An eight-year-old neighbor often crosses our meadow or bikes over to stop by for a visit. While I’d like to think I’m the featured attraction, his visits are not just to see me; of much greater interest is our basement with its shelves of toys and games. Particularly appealing to this lad is the sports equipment: hockey sticks, goalie pads, a goal to shoot on, baseball mitts, a batting helmet, a catcher’s mask, soccer balls, and more. Name the sport and it is most likely we have equipment for it, even in different sizes.

I’ve given my young friend a few items: retaping a hockey stick that’s the right size for him, a pair of batting gloves, a cracked bat from a Bat Day at Yankee Stadium. He knows these were things that belonged to my son. Visits have been frequent, offering a chance to go to the basement so we could play some more floor hockey, or perhaps do a review of our inventory again, maybe hoping to catch me in a generous frame of mind. Downstairs amongst the gloves and balls and pads, waiting to be discovered, was The Question. “Where is your son, where is William?”

Knowing that sooner or later The Question that would come up, I had a conversation with his parents. Who explains William’s permanent absence to the young fellow? What is age-appropriate detail? Is there a better time for the discussion?

The Answer is, sadly, that William died from an accidental heroin overdose. At the time my wife and I became aware that William was using heroin, he was 22. He was already seeing a psychotherapist. Over the next two years we added an addiction psychiatrist, outpatient treatment, treatment with Suboxone, inpatient detox, inpatient treatment, outpatient treatment, outpatient detox, treatment with Vivitrol, more outpatient treatment, another inpatient treatment, more outpatient treatment, a revolving door of well over a dozen trips to and from the emergency rooms of at least four different hospitals, an attempt to work with another addiction psychiatrist, Alcoholics Anonymous, Narcotics Anonymous, and a home life fraught with tension, despair, sometimes hope during intermittent periods of sobriety, and always filled with the apprehension of misfortune.

That apprehension became fact when William accidentally overdosed shortly before his 24th birthday. Just four days prior he had gone to a hospital to ask to be admitted to inpatient detox. His insurance company denied the request as “not medically necessary.” Six weeks of comatose and/or heavily medicated hospitalization followed before the ultimate realization that William was consigned to a persistent vegetative state.

When we decided to permanently remove him from a respirator we attempted organ donation. Organ donation in William’s condition required an expedient demise within a tight one-hour time frame once removed from the respirator. William continued on and survived for another 21 hours before breathing his last in our arms. Ultimately, we made an anatomical donation of his body to Columbia University’s College of Physicians and Surgeons.

Once, William was young, curious, engaging, and adventuresome, much like our eight-year-old neighbor. I continue to question, puzzle, and agonize over the path that takes a boy from building with Legos, playing catch, bocce on our lawn, snow forts, an entertaining sense of humor, late night talks, fierce and courageous loyalty to friends, right-on-the-money analysis of people, situations, and numbers, a flash of the pads for a save, and the sweetness, strength, inspiration, and love that was William… to a death certificate that reads death due to “complications of acute heroin intoxication.”

One thing I do know. When my young neighbor asks about William, I have to answer him openly and honestly. There’s more of William to share than some old hockey sticks and baseball bats. William’s story, like that of so many others, has to come out of the basement so that it can be the cautionary tale every growing boy should hear.

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