Last Monday, 6/18, I herniated the L4/L5 disk while working out. Made it upstairs where the wife was feeding the baby, told her to call the chiropractor, and laid down on the floor. I stayed there until 2 p.m. when I started making my way to the minivan to go to my 3 p.m. appointment at the office a five-minute drive away. Made it to the front desk at about 2:55.

The doc took my history, poked and prodded a bit, and put me on the decompression table. (Sort of like traction.) It provided some relief while I was on it -- though Jenn said I turned white while I was trying to get onto the table. As soon as they unhooked me I was right back where I started. Doc wrote an order for an MRI and told me to go get it done ASAP.

We went to the local ER where, after several hours of waiting, I finally got the MRI. An hour later, the doc reviewed the scan and came in with the good news. In addition to the herniated disk, I've got congenital spinal stenosis -- narrowing of the channel the spinal nerves are supposed to run in -- plus some arthritis.

The stenosis is familial, which makes sense because my father had nearly this exact same experience at nearly the same age. Jenn was of course thinking that the weightlifting was what caused it. The doc, who said that he also lifts and has squatted over 500 lb personally, said that with the stenosis I could have done this bending to tie my shoes. Dad did it trying to get out of bed, so yeah, I believe it.

At 3 a.m. they transferred me to a different hospital that has a neurosurgeon on staff. I told them I hadn't had anything to drink all day and asked for some water. They said they couldn't give me anything until I saw the surgeon and got orders from him. At 9 I saw the neurosurgeon. Since the disk is not fragmented I'm not a candidate for immediate surgery. I asked the nurse for water and she said the doc hadn't given any orders one way or the other. Took until nearly 11 before they got approval for me to have some water.

Neurologist came in and said yes, we'll do more conservative treatment, starting with a spinal steroid injection. Then physical therapy came in and I told them about the pending injection. They said, "Well then we shouldn't be here yet," and left. Then pain management came in and said, "We don't do the injections here," and left.

Wait, what?

Yes, I'm supposed to go home with pain meds and schedule an outpatient procedure later in the week. Dude, I can't sit up, nor stand, and you want me to go home for three days before I finally get something done?

Okay, fine, discharge me. What's that? There's no discharge order? Fuckin' fabulous.

Wednesday morning comes. The resident comes in and says yup, we'll discharge you with pain meds and, when you can't bear it any more, you can schedule the injection. Ummm ... fuck you.

Neurologist comes back to see how it's going. I told her what pain management said. She looks disgusted and shakes her head. About a half-hour later someone from pain management is back saying, "Okay, we'll get you discharged and you can go across the street to the pain clinic where we do the injection as an outpatient procedure." Well shit, the guy last night just said, "We don't do that here," and walked out. This sounds a little stupid, but okay. (By the way, my mother-in-law is a retired nurse. She saw the neurologist's name after this and said she used to work with her. Someone most-likely got their ass handed to them.)

So now I'm expecting to get wheeled down to the parking lot where I'll crawl into the van for a trip across the street for an injection which -- with any luck -- will get me vertical again. Then 15 minutes later the same person comes back, this time with a doc saying, "I'll be doing your injection. And we'll be doing it here. The pain clinic is on fire."

...

Okay, what-the-fuck-ever. Just stick me with something that makes this stop hurting.

Oh yes, the hurting. You know how your calf feels when you get a really nasty charley horse? Imagine that in your hips, glutes, and groin muscles, and the spasm lasts for two days. Yeah, that blows.

So they wheeled me down to where they used to do the injections, and spent 20 minutes trying to find all the equipment they needed. Finally got stuck and went back to my room. I could feel the numbness from the novacaine, but frankly didn't notice much relief from the cortisone. By this time, though, the spasms were coming and going every hour or so instead of constant.

Wednesday night another new doc -- in three days the neurologist was the only doc I saw more than once -- said they were ready to discharge me. I could lie down and take pain meds at home just as easily as I could lie down and take pain meds at the hospital, and they weren't going to do anything else for several days after the injection anyway. Which was great, except that Jenn had just gone home a half-hour ago.

I called and she was grocery shopping about 10 minutes from the hospital. Cool, she could come back and, by the time she got there, I should have someone ready to bring me down.

No, that's not foreshadowing, why do you ask?

Jenn gets there and I call the nurse to get my IV removed. She says the doc didn't enter the discharge order into the computer. He had left for the day, but they would page him. [big sigh]

Milk, eggs and meat sitting in a dark-blue minivan on a 90-degree day. Great. She knew she'd have some time before I was ready, so went across the street and bought a cooler and some ice for the perishables.

I've been home since Wednesday night, and just had a followup this morning with the doc who did the injection. This is the first day I've been able to sit up long enough to bother getting online. I'll be trying to work remotely starting tomorrow, which mostly means the rest of the week just getting caught up on where everything is that I've missed.

I've got another followup scheduled for next week, rehab starts the week after, then another follup the next week to see if I need another injection.

Oh, and another consult next week with the surgeon to discuss options for surgical treatment of the stenosis and arthritis. Basically they'd scrape off the calcifications, remove-and-reshape some of the bone to provide a better channel, and shave off the protrusion from the disk. It's fairly routine, but complex. If I'm feeling okay without it it's totally optional, but if it's not done then there's the risk for the rest of my life of repeating the same injury.

Fuckin' great.

#1
Studies show most in-hospital medical complications -- including nearly all infections -- are entirely preventable through standard procedures. One doc instituted a checklist (set of lists, actually, one each for various situations/procedures) that he's been advocating for over a decade.

http://www.newyorker...e?currentPage=all

Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

Every hospital that implements the checklist cuts complications by two thirds and infections by more than that. Doctors hate the lists. They don't want to be told what to do.

Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence.

...

Tom Piskorowski, one of the I.C.U. physicians, told me his reaction: “Forget the paperwork. Take care of the patient.”

Here's the funny thing:

In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.

They'd save more money if they did it. But they won't.

#2
Someone built a diagnosis app, based on the same type of algorithms Amazon and Netflix use for recommendations. You put in some symptoms, it starts asking questions. At the end of the process it suggests several possible diagnoses, along with prevalence, accuracy of match to symptoms, and the correct tests to confirm or rule out each option.

Hospitals won't use it because "no machine can replace years of experience" though figures show it clearly can. But the method they use to keep them out is to accuse the creator of the system of practicing medicine without a license.


Doctors hate being told what to do, and they're currently very well funded and well connected. It ain't changing just because it ain't working.

When the open MRI came out and all the top hospitals started converting, there was a glut of old-style closed ones. (And speaking of claustrophobia, I don't have it but good God would that thing test it. Kept my eyes closed for the whole test.)

Clinics started popping up that bought the older systems and offered a full-body exploratory MRI, and of course offering followup on whatever they found. Even leaving aside the financial incentive to find and treat something, it turned out if you scan anyone over the age of 30 you'll find a half-dozen things that would be concerning if there were associated symptoms.

After some analysis, it turned out the risk of complications from exploring and/or treating asymptomatic anomalies was higher than the risk of one of those anomalies being meaningful. But of course every clinic tells the story of the one-in-a-million case where someone identified cancer early.

All that being said ... the condition I have is congenital and familial. My father's near-identical experience convinces me this isn't just what they found to explain what I did, it's the underlying problem. In theory, removing some bone to create a wider channel sounds eminently reasonable. But my lizard brain thinks, "Open up my back and chisel around my spinal cord?" and I get the willies.

If I decide in a few years I need it, it will be a pre-existing condition.