Life Lesson #1: Believe the Labels

A quick update (as usual) regarding my upcoming tumor extraction.  My surgery has been delayed until Tuesday early morning March 3) due to a slow insurance approval.  I’ve been assured that everything is now is now a go.  The fun starts Monday with a double scope (endoscopy/colonoscopy, hopefully not at the same time) at 5 pm to be followed by an overnight in the hospital and surgery bright and early (7 am) on Tuesday.  Light is now slightly visible at the end of the long tunnel.  Now for the life lesson.

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Who reads this?

When my son, Chanon was around 8 years old, I wanted to expose him to winter sports.  I skied from a very young age, and I wanted the same for Chanon.  He decided that snowboarding was more fashionable.  OK, I said, then I will snowboard too.  How hard can it be?  I am an expert skier, and sliding on snow with one board or two can’t be that much different, can it?  So we travelled up to Mammoth Mountain, California for a weekend of snowboarding.  Saturday morning I marched into the rental center and rented a snowboard and boots, while Chanon had a snowboard lesson.  I waited while his lesson finished, then we both headed for the lift.  I confidently strapped on the board like I’d been doing it my whole life, and managed to get on the lift without incident, but I kept reaching for my non-existent ski poles.  Getting off the lift at the top (of the bunny slope) was another issue.  I immediately face planted and had to be quickly dragged out of the way by the lift attendants.  I then proceded to wipe out at least 10 times in the 30 m between the top of the lift and the start of the downhill.  By the time I was 100 m down the slope, I had fallen so hard on my ass that I was pretty certain I had broken by coccyx.  Chanon enjoyed this very much.

That “run” ended after 100 m, when I unceremoniously unstrapped my snowboard and post-holed my way to the bottom of the run and marched straight into the snowboard school.  One lesson and I was good to go, although I still fell a few times smack on that broken tail bone.  Unlike skis, it seems with snowboarding, you either fall on your ass, or you face plant, no other choices. However, snowboarding is actually easy once you get the non-intuitive hang of it.  But the damage to my bum was done.  From that day on, for the next several years, I lived with a sore ass.  It felt ok most of the time, until I sat for more than 10 minutes.   X-rays showed  that it was deeply bruised, but intact.  Apparently your coccyx has a limited blood supply and heals slowly.  For me, that was about 5 years.

I could deal with the pain by sitting on the edge of my seat, or getting up out of my chair every few minutes.  The hardest thing though was enduring the 20 hour flight back and forth from the USA  to Thailand, which in those days was a 2-3 times per year ordeal for me.   I bought one of those neck pillows, and sat on it with my coccyx in the hole, but that only slightly delayed the agony.  Vicodin to the rescue!  I was given a prescription of this opioid following a root canal, and dutifully filled it, but never needed it.   I quickly found out that a dose of Vicodin about an hour into the flight would easy my pain and allow me to sleep for several hours.  Mostly, I avoided any alcohol prior to taking the Vicodin….until one fateful trip.

I justified the pre-dinner scotch and soda by telling myself that I would wait a couple of hours before swallowing the Vicodin.  Yea, I know the label on Vicodin says “no alcohol”  but who reads those?  Everything felt fine, and I sat reading a novel waiting for the medication to kick in.  Suddenly, I felt something I’d never felt before, and it is very hard to describe.  It felt like my blood was quickly heating up and turning to steam.  The word began to swirl.  I thought to myself – is this what it feels like to have a stroke?  Or was this a heart attack?  Or was I about to explode because of an alien fired energy beam?  Somewhere in the inner, reptilian part of my brain, I decided that I was dying, and that since I was dying it would be a whole lot better to die in the toilet rather than in my seat.  I was seriously afraid that no one would notice for several hours if I died in my seat.  I’d probably stink by then. So I undid my seat belt, rose, and took 3 steps down the narrow aisle toward the aft of the plane. Boom!  Out cold in the aisle, at 40,000 feet, somewhere over the north Pacific Ocean.

I awoke a few seconds/minutes/hours later.  I was on my back looking up at three lovely Thai Airways flight attendants, their gorgeous faces swathed in ethereal auras, staring down on me.  I was certain that I was dead and this was heaven.  That notion was soon dispelled in a wave a nausea and dizziness.  The young women managed to haul me up to my feet and back into my seat, but I told them that I was about to pass-out again, or throw up, or both at once.  They quickly moved me up to one of the lay-flat business class seats, and I was comatose within seconds. Some unknown time later one of the male flight attendants rudely shook me awake and ordered back to my economy class seat. I guess my allotted time to be ill was finished.

I slept quite good the rest of the flight, and my ass didn’t hurt.  I survived, albeit a bit shaken.  Life lesson:  Vicodin or alcohol.  Not both.  Read and believe the labels.  Since that time, I have chosen alcohol, and left the Vicodin at home.  And several years later, my coccyx finally healed.

Coming Out of the Closet

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Before I come out, just a quick update on my pending NET removal.  I’ve met with the surgeon, had my MRI, and had my pre-op testing completed.  Forward all engines!  My surgeon, Dr. Kosari at Cedars-Sinai Medical Center in LA was very upbeat.  He said the surgery should be buying me many years.  I may get my gall bladder out as a bonus; this is a preventative measure since the octreotide injections that will likely be a long-term part of my life tend to gum up your gall bladder.  Why do we have a gall bladder anyway since we can apparently survive quite nicely without one?  Maybe they should just remove it at birth along with your appendix. My surgery is scheduled for 7 am February 28.  Stay tuned.

At the risk of TMI, now for the closet.  Not the closet you’re all thinking of (sorry to disappoint).  It is an embarrassing medical closet.  It tuns out I am afflicted with another hard-to-treat disease. If you are at all squeamish about the details of men’s anatomy, now’s the time to close your browser………

I have Peyronie’s disease.  You can read all about it here.  I’ll give you the one sentence definition:  It is a condition whereby scar tissue builds up within your penis causing it to bend at a rather inconveniently acute angle (mine is about 70 degrees) that makes any kind of traditional bedroom fun geometrically impossible (not to mention extremely embarrassing).  The cause is thought to be either an acute injury or (as in my case) accumulated unnoticeable minor injuries during intercourse.  Woman-on-top is a big risk factor.  As my urologist at Cedars-Sinai said, it is perhaps just abnormal wear and tear.  Here’s what blows my mind:  According to my urologist, 9% of older men have this condition (and 3% of younger men)!! How could nearly 10% of men have this condition and I never heard of it until Dr. Google revealed it to me?  More likely than not, one or more readers of this blog also suffers this disease.   It’s time to bring this disease out of the closet. Sure, this is an embarrassing ailment, but really is it more embarrassing than hemorrhoids?  Worse than jock rot?  Worse than ED?  Worse than incontinence? We see all of these on tv ads everyday.  Hopefully more awareness will lead to more research and more treatments.  Hence my coming-out party.

I do understand why this malady is in the closet.  It takes a very heavy psychological toll.  Some men have been known to become suicidal.  To be sure, as ailments go, there are many worse diagnoses.  No one has died from Peyronie’s (not counting suicides).  For me, the realization that I had a condition that was not immediately treatable (at least in Thailand), and that would prevent sexual activity, was devastating.  Being otherwise healthy, but realizing sex was not going to be part of my life, hit hard.  With the help of a very understanding partner, I focused on other aspects of life.  In the end, I have to come to the realization that overall I’ve been pretty damn lucky, and there was still plenty to live for.  But not being able to be intimate with my partner is still quite painful.

It started about 18 month’s ago, so I have known about it for awhile.  Unfortunately, in Thailand, the only treatment they know about is radical surgery that sounded to me like partial castration.  I even travelled to a so called “specialist” at a top end hospital in Bangkok.  Surgical straightening, resulting in drastic shortening, was the only option he offered. Maybe I only imagined the sneer on his face.  

This week I found out the good news that there is minimally invasive treatment for Peyronie’s available in the USA. The treatment involves expensive injections of FDA approved, scar dissolving Xiaflex, and physical therapy (kinda sounds like rehabbing a shoulder injury).  My urologist said I am an ideal candidate – my condition has reached a “chronic” phase with no pain and no progression and my scar tissue is in the best location for this treatment.  So there is hope!  The treatment will necessitate anywhere from 1-4 sets of injections (each set done over a 5 day period) with each set of injections spaced 6 weeks apart.  This would necessitate returning to LA from 1-4 times this year (I can’t have an injection while rehabbing my cancer surgery).  Pending insurance approval, my first injection would be in August.  

The question now will be, is it worth it?  If I was 35 years old there would be no question, but at my age?  The cost of 4 trips to the USA will be substantial.  According to the doctor, the success rate is better than 50%, but I still risk spending money for nothing.  This is a decision that I will need to make over the next few months.  For now, I will concentrate on my upcoming surgery and the aftermath.  I will revisit this once I am fully recovered.  Who knows, by the end of the year I just might be once again an upstanding man (groan).

Thank you for allowing me to share this story.  Just getting it out here is a cathartic.  It will be nice not to have hide in the closet, and I’m ready for the inevitable banana jokes!

Medical Care in Thailand: Observations from a Reluctant Patient.

imagesI am now 7 months into my battle with Nueroenocrine cancer.   I have had way more contact with the medical community here in Chiang Mai than I ever wished for.  I always figured that most people died in a hospital bed, so better to stay away.  However, I now feel somewhat qualified to make some observations about health care in Thailand that might prove useful to anyone thinking about retiring or traveling here for medical care.

An Update

But first, a very brief update of my current status.  I have now been on monthly injections of Sandostatin LAR for 5 months.  These injections are not a cure, but intended to stop or slow the tumor growth, and stop or limit the proliferation of tumors.  They do come with some unpleasant, but mostly bearable, digestive side-effects. Suffice it to say that if I had one of the more common side effects then, I would have been a cult hero in my fifth grade class.  Last month, I traveled to Bangkok for another Gallium 68 PET scan.  The scan showed no growth of my one known tumor, but continued to “light up” my prostate, suggesting something might be there too.  Last week, I had a biopsy done on my prostate where my urologist turned it into a pin cushion by removing 24 small cores.  Fortunately, I was in Lala Land at the time.  Early this week I got the results: nothing at all going on there (except BPH which I have known about for years).  Good news!

I will be meeting with my oncologists next week to discuss our next move (surgery or more Sandostatin injections are the two most likely).  Unfortunately, the one known tumor is in my mesentery, and is very unlikely to be the primary.  Where the hell is my primary?  Most likely it is 1. too small to see, 2. gone already due to immune response, or 3.  hidden away somewhere, most likely in the curlicues of my small intestine.  Neuroendocrine tumors (NETs in the lingo) are sneaky nefarious bastards.  Once they have metastasized they are nearly impossible to 100% expunge from your system via surgery or medicine.  This will make the decision to cut or not to cut a difficult one….So that’s where I stand at the moment.  In the meantime, digestive issues not-with-standing, I feel great and life goes on mostly as normal.

Medicine in Thailand

According to the World Health Organization, Thailand ranks #47 amongst 190 countries in terms of the quality of their healthcare system.  For perspective, the U.S. ranks #37.  Thailand, except for the tiny states of Brunei and Singapore, ranks number one in south-east Asia.  Thailand ranks 65 spots above India that magnet for medical tourism.  So by WHO standards, health care is pretty good here.  My own experience corroborates this conclusion.  But it is only good if you have money (or good insurance).

I receive most of my healthcare at Bangkok Hospital, Chiang Mai (BHCM).  Bangkok hospital is a country-wide system of hospitals that was started by a Thai doctor in 1972 as the first private hospital in Thailand. Prasert Prasarttong-Osoth parlayed his medical degree into a $3.2 billion fortune that includes Bangkok Airways and 3 regional airports.  BHCM is in my view the best hospital in Chiang Mai.  From its welcoming lobby that exudes the ambiance of a 5 star hotel, replete with live music from grand piano, to its immaculately attired english speaking staff,  to its state-of-the art equipment and spotlessly clean ORs and examining rooms, anyone will feel confidence in the care they are about to receive.  But the quality of that care comes with some significant caveats.

Caveats

In the course of my diagnosis and treatment, I have seen more than a dozen doctors.  They all impressed me with their caring attitudes, and general intelligence.  However they collectively are the product of an insular system of in-breading.  Virtually every doctor in Chiang Mai obtained their medical degree from Chiang Mai University Medical School.  Many are listed as faculty members there in addition to their hospital posts.  Thai culture’s pronounced stratification, makes questioning one’s supervisors/seniors/elders difficulty at best.  This just has to stifle innovation and the adaptation of new or alternative treatments.

I normally meet with two oncologists, one is an elderly woman listed as a professor emeritus at Chiang Mai medical school, the other is a youngish male with an MD degree from there.  When I meet with them, she does 95% of the talking, while he mostly stares at his computer.  She will suggest something, and he will do his best imitation of a MLB bobblehead doll.  On the rare occasion when I meet with him alone, he becomes talkative, and full of ideas and intelligence.  I would consider asking to be seen by just him, but I am afraid that it would make an irreparable rent in their cultural universe.

Another caveat is the lack of accountability.  Malpractice lawsuits are nearly unheard of in Thailand outside of a few high-profile nose-jobs-gone-wrong that splash across the headlines.  When a doctor makes even an egregious mistake, about the strongest reaction is “oops”.  Doctor’s are looked up to in Thailand to a much greater extent than are western doctors.  Thai patients seldom question their care, and confidently swallow unmarked pills given to them in completely unlabelled baggies with instructions of when and how many to take.   There is a clear advantage for patients if doctors have a paranoid fear of being sued.  I cannot say how much this accountability issue effects health care, but it will weigh heavily on me if I have to decide on invasive surgery.

The bottom line for now is that my health care has, in my view, been very good.  My doctors’ decisions have been verified to the extent possible by Dr. Google and his myriad colleagues.  I also received a “virtual” second opinion from an oncologist at the Cleveland Clinic, who, after reviewing all my records, scans, and even my original tissue biopsy samples, concluded that the care I have been receiving is spot on.  But my disease is uncommon, complicated, and varies from case to case.  Experience here is lacking so I may have to consider returning at some point in the future for evaluation at one of the handful of “NET Centers” in the USA.