Testing for Lung Cancer

Someone asked me about testing for lung cancer, so I thought I would address that quickly. First and foremost, when talking about medical stuff, I have to say that I am not a licensed respiratory therapist in Kentucky at this time (but will be within a couple of months), and am currently licensed in the state of Ohio, as that is the last place I worked. Regardless of where I am, or am not, licensed, I have to say that I have to act under my profession's standards, one of which is that I am not allowed to practice medicine without a physician over me. So with that in mind, I have to say, your physician is the best person to talk to if you have medical concerns. I can tell you what I know of certain things, but for a proper diagnosis and treatment, you need to speak with a physician.

With that in mind, I know a little about lung cancer because it is how my father died. Believe me, between my experience as a respiratory therapist, my education, and taking care of my father, I could easily write a book about it. Very basically, though, cancers are cells that have, for one reason or another, grown out of control. There are many different types, but they are generally classified as small cell or non-small cell cancers. This covers cancers that affect the alveolar sac, the bronchials and the tissue. 

One of the insidious things about lung cancer is that there are no nerve endings in the lung tissue itself, so that you can have a tumor there the size of a grapefruit, and it won't hurt. Common symptoms prior to diagnosis of cancer are shoulder pain, a sensation of something pulling,  deviation in your trachea (your trachea moving to the right or left instead of running down the center), increased shortness of breath (due to decreased lung capacity), and coughing, either productive (including blood) or non-productive. The symptom that my father initially presented with was shoulder pain, which was misdiagnosed as "Uncle Arthur" (arthritis). 

Lung cancer, at least, causes you to lose a lot of weight, really fast.

Here we get into the practice of medicine vs. the reimbursement machine. Health insurance, medicare, medicaid, etc., wants a diagnosis before they will reimburse for a procedure. It's better to go to your doctor looking for a specific procedure and the reason for it instead of with just a bunch of vague symptoms. So if you were concerned about lung cancer, the very first thing I would tell my doctor is, I have this particular symptom, and I'm concerned about lung cancer because (history of smoking, family history or whatever), and I would like a chest x-ray, (which may or may not pick it up, but still, it's the first step). Hopefully you have a good doctor that you can be truthful with and say this.  And he, or she, will do a few procedural things in the office and then let you get an x-ray. If you don't have a good doctor, you can always go to an urgent treatment center, and complain of coughing or something to do with your lungs. They will almost always do a chest x-ray for you. 

Here is the kicker, though. The doctors will look at the x-ray, but there are professional radiologists who also do a reading, and this reading is a lot more involved than the cursory reading you would get at a doctor's office, or the UTC. It is your right, as a patient, to get a copy of that x-ray, and to get a copy of the radiologist's reading, and I would definitely do that. 

I will probably write more about being a smart patient at a later time, but that is the point I would like to make now. So, to answer the question, I would first get a chest x-ray, then get the radiologist's reading, and based on that talk with your doctor. If you don't have a good one, get one. If there is anything to be seen on the x-ray, then you would do the next step, which would be to get a cat scan or MRI. Then if there is something, a biopsy. 

Try to find a doctor who expects you to be a savvy patient. This is so important. Doctors are not gods, even though they are treated like they are. Just because they are a doctor, and maybe even an excellent doctor, if you can't be up front, honest and direct with them, then maybe they are not the doctor for you. It's your job to be critical of them, because it's your life you're putting in their hands. When I was going through respiratory school, someone once asked me, what do you call a med student who has graduated with low C grades? The answer, of course, was "Doctor." So be a critical consumer when dealing with medical issues. Access to your medical information is your right, and it would be better for you if you dealt with people who understood and respected that. 

At Home With The Blues

I read an interesting story in the news the other day -- it was classified as news of the weird, or something to that effect. It was a short little article, concise and to the point (unlike my essays), and it basically said that some people who take prozac stop taking it after a while because it makes them feel too good. Seems that feeling good is so alien to these people, that it made them horribly uncomfortable, and they couldn't take it anymore (feeling good or the prozac).

I can actually understand that. Clinical depression and I have been bedfellows for years and years now, and it's a relationship I have long given up hope of ever being divorced from. I have also taken prozac, although I don't now. It did make me feel pretty good. Actually a little too good. I wound up doing some things I pretty much wish I hadn't done now, which we won't get into here. Oh well...

I have tried to explain this malady to friends and acquaintances and very rarely see the light of understanding in their eyes. They listen to me politely but I'm pretty sure they're probably saying something like "God, Lyn, get over yourself," or "Get a grip," or "Such a Diva!!" in their minds. I'm sure they think that all I really have to do is pull myself up by own bootstraps, but if that was true, I'd be the first in line to buy a pair of boots (not owning any). It's not bootstraps that does it -- it's more like that bonk on the side of the head you get when you don't drink your V8.

Clinical depression is not about feeling sad. Unless I've just lost a parent or loved one, or pet, I rarely feel sad. It's more about really not feeling anything. It's worse than apathy. It's more like a lack of a needed spark. If you listen to the clinicians explain it, it makes perfect sense. There are synapses in your brain that your nerve impulses run through, and they need to be bathed in certain chemicals, such as serotonin, for those impulses to make the leap from one synapse to the other. In clinical depression, the person might have the serotonin bath, but it doesn't stay long enough for the impulse to get through. Thus serotonin re-uptake inhibitors, or anti-depressants such as prozac. When the bath is there, there is no signal. Or the bath leaves and here comes the signal. Everything is mismatched and delayed. Reactions, if they happen, are delayed and sluggish. Feelings, if you have them, are delayed. And the sensation of being out of body and space and time happens a lot.

Another thing that happens a lot is lack of activity. Given a quiet day with little or no outside stimuli, I have been known to sit for hours, and even as the sun goes down, never turning on a light -- just sitting there in the dark. My mind is flying through vistas of thoughts, memories, songs or other odd bits of things, and my body is catatonic, hypnotized, almost totally unable to move on it's own. My mind can beg, plead with my body to move, but it remains as still as the big rocks we keep digging up on the farm. I'm not sad. I'm not blue. I'm just "not." It takes a strong stimulus to click me out of it -- something like the dogs barking, someone at the door, or an emergent need to go to the bathroom.

Music, thank God, can break through. I've often told my close friends, if I'm lying in the hospital, and they're trying to decide whether or not to let me die, hook me up to an EEG and play music. If there's no brain activity, let me go, cause if I can't respond to music, I'm gone. Music, somehow, provides a link, maybe through stimulating endorphans, I don't know. That would be interesting to check out. Of course, another rather awkward thing happens to me when I listen to music. I become more and more incapable of maintaining conversation. Once the music is turned on, my mind tunes to it, and it becomes totally intent on following every musical riff of every instrument that is playing. My body subconsciously moves in total and complete time to the different beat of every different instrument. I begin to twitch like a live wire. It's not something I can control very easily, and at this age, I don't really want to control it anymore. I love the feeling of being taken away that it brings. Something melodic like John Mayer's Stop This Train will take me so far away from where I am that when the music stops, for a moment I don't know where I am. So it's not particularly a good thing for me at work. Especially when you work in a hospital.

There is one other strange thing that happens in these states. I find if my laptop is in the area, open and ready to go, I may actually begin writing something -- something that at first may be weird, fragmented, and make no sense whatsoever. But eventually something will come from it -- a song, a poem, an article, an idea. It's because I'm so old and learned to type when I was 12. Typing is a totally automatic thing for me, something I rarely have to think about.

So what do I do with all of this? A brain that doesn't work right? I know my process. Everybody should know their process. It is very important in everything you do. I put music on pretty quickly in the day. My laptop is always ready, and I've given myself permission to write whatever I want whenever I want to. And of course, I keep several dogs. Even if they can't find something to bark at (one of their favorite pass times), they will, from time to time, come into my office to check on me and visit, Jack slipping his long, sleek nose under my hand to force me to pet him. Time to wake up, Mom.

Smoking

I once worked at a large rehab center in Cincinnati, and there had a conversation with a nurse who confided she had recently had a heart attack and had died nine times on the table. She was trying to quit smoking because of it. (No, she said, she had never 'seen the light').
“I guess you never had to worry about quitting,” she said to me, alluding to the fact that I am a respiratory therapist.
“On the contrary,” I said. “I love to smoke.”
She raised her eyebrows.
“I had to quit,” I said. I looked down at the newly waxed floor. It wasn’t a great memory.
“Well, how did you do it?,” she asked, pulling at the neck of her scrubs a little and exposing her nicotine patch. “I got this and it works some, but I still smoke a little.”
“With the patch on?” I asked. “No, no, no, not a good idea. Very, very bad, triples your chance of another heart attack.”
Up went the eyebrows again. Hadn’t they bothered to tell her?
“Well, I still get the cravings,” she said. “I don’t know what to do with them.” She paused. “How long have you been quit?”
“You know, I don’t really know,” I replied. “It’s been a while. It wasn’t like all the other times. I didn’t mark the date or anything. I just quit cold turkey.” I gave her a sad smile and added, "I still get the cravings, and still don't know what to do with them."
We chatted a few minutes more. I gave her some tips for quitting, warned her again about the danger of smoking with a patch on, and went on with my busy job – a large part of which was taking care of end stage COPD (Chronic Obstructive Pulmonary Disease) patients. I could tell she wasn’t impressed by my story, and I had not given her some magical trick that would make all of her angst and cravings go away.
But the conversation stayed with me, and there were several things it brought to mind. I remembered when a fellow RT kept emailing me about upcoming and pending legislation to ban tobacco, and I finally wrote him and told him to please stop, that I wasn’t going to join him in his fight to get tobacco banned. Yes, me, the respiratory therapist. I don’t want the government involved in my personal rights, and I don’t think it’s an issue that should be settled in the courts or through legislation.
I think legislation to ban any moral issue, with the exception of mountain top removal and child exploitation, which I believe to be criminal acts, is a waste of time. As with Prohibition, the black market will undoubtedly step in and take up the slack. In the case of tobacco, they will market cigarettes not made in the United States where the production of tobacco and the chemicals used on it are under extremely strict control, where all farmers handling those chemicals must pass certification to be able to buy and use them. There is no control of any kind over the growing practices used on tobacco that is imported. Herbicides and pesticides like DDT and Paraquat, that are no longer allowed in the US, are routinely used in other countries. It is why, as a respiratory therapist, I tell my patients, friends and family, quit if you can, but if you’re going to smoke, smoke American (or Native American).
Which brings up an interesting side point. According to traditional Native American lore, tobacco is a spirit, and probably, like most spirits, doesn’t appreciate being taken for granted and used without ceremony. Tobacco should never be mindlessly chain smoked, hanging out of somebody’s lips like drying spittle. It is strong medicine. As a native born Kentuckian I will tell you burley should be “sipped,” like fine whiskey or fine wine. If you can't enjoy it that way, then you shouldn't be smoking it. Period. But big tobacco makes sure there will be no "sipping" on cigarettes.
Why? Big tobacco is in the business of making money for big tobacco. They want to sell lots of cigarettes. They don't want you to sip it, they want you to chain smoke it, so they lace it with extra nicotine. Nicotine is about 200 times more addictive than cocaine, and it makes your brain feel so, so good. They learned a long time ago that smoking non-filter cigarettes was killing off their 40 to 50 year old customers, so they filtered their cigarettes so people would live into their 60’s and 70’s – an extra 20 years worth of cigarettes! A lot of our tried and true businesses are in the same category, e.g., most of your fast food places. News flash, they don’t care about your nutrition.
I have been a respiratory therapist (among other things), for about 14 years now, and this is my take home message. You get COPD from smoking the way most people smoke. It is an insidious condition that is comprised of three different pulmonary conditions: chronic bronchitis, emphysema and asthma. It is incurable.
Dying from COPD, from one who works with COPD patients, and has had to watch, is one of the most horrible and brutal deaths you can possibly imagine. By the end, you’ve gone into renal failure and you’re on dialysis. Medications you’ve been given to try to stop the onslaught have made you diabetic. The financial cost is staggering, especially if you don't have insurance. You and your family can lose everything you’ve ever worked for. The suffering you go through, and the suffering you cause your family and friends is horrible. It is an unimaginably slow and torturous drowning in your own secretions, trying to breathe through airways that have collapsed and to get air to places where it can’t go anymore, never being able to fully exhale. You mouth to us to let you die, because you have a breathing tube stuck down your vocal cords. You lie there in bed, unable to do anything for yourself, with tubes in all your orifices, yes, all of them. Your muscle and fat and tissue waste away so that you get horrible decubitus ulcers on your back and butt and hips that you can literally fit a fist into comfortably. Your hospital room reeks like a rotting, living corpse. You can lie this way for months, even years. Your body colonizes the foulest of bacterial infections.
Try this. Take a great, big, deep breath and hold it. Hold it until you cannot possibly hold it anymore and relish that unbelievable rush you get when you are able to exhale and empty your lungs. You can't do that with emphysema. You can't effectively exhale because carbon dioxide filled air stays trapped in the air sacs of your lungs, leaving you to feel like crap most of the time.
I have been a smoker, off and on for a very long time. I still break over. I relish the ceremony of smoking, the act of smoking. I enjoy it immensely. But I hardly ever do it anymore. Why? Because I placed my stethoscope over my own heart one day and just listened to it. Constant and steady, it was doing its job. And then I felt bad. And then I began to feel sorry for it and angry at myself. All the stupid stuff I did to myself and through it all my poor heart kept working so hard, so strong, so steady. I have a heart, a poor, hard-working, fist-sized beating heart! And if nobody else in the whole world cares, I do.
Smoking is an issue that has a little to do with genetics – there is a gene that codes for addictive behaviors – but it is largely an issue that has to do with your own sense of self, your self esteem, or lack of it, how you were raised, and how you are raising yourself. The tobacco is incredibly addictive, with all the crap they put in it, but the smoking is incredibly personal, and all about what it means to you. I can't tell you how to quit because I don't know what your smoking is about. That's something you're going to have to figure out yourself.

My smoking was about several things. It was about anger. It was about my space. I discovered I was extremely pissed off because I could never seem to find a quiet place for myself to be -- a place where I was truly me, and not someone's something. It was about carving out a tiny little fraction of space and time for myself, and when people wouldn't let me, instead of confronting them, I started to hide behind a smoke screen. That tiny little space became so very important. It was the ultimate game, my whole life, my little make believe world. I was trying so hard to be someone that I wasn’t, to please other people. Why was I doing that? Could it be that I didn't have the guts to do what I really wanted to do, that I was afraid of failing at it, and that rather than face that unpleasant thought, I just did what everybody else wanted, and then if I failed I could blame them? Well, it was an unpleasant thought, and I tried to ignore and forget it. I smoked, because when I smoked I bathed my brain in feel good endorphans and I put up an effective little smoke screen that I could hide behind.
I quit because I gave up on that. I quit because that lonely little organ that sits in my chest continues to beat faithfully, regardless of what I do to it. It beats regardless of who I am being. It beats because that is its job. It is my true friend, and I’m giving it a break. Whoever or whatever I am, how ever long it takes me to deal with this problem, I'm not going to screw my heart over. Bottom line. Don't look a gift horse in the mouth.

It's been a hard road, but I choose to look you in the face and be myself with you now rather than to try to be who or what you may expect me to be. I come with issues. Everybody does. It might have been someone else’s fault while I was young. But I grew up; it became my responsibility, and my fault because I didn’t take responsibility for my own actions.
With that comes a huge lesson, and that lesson is, I am no good to anybody if I am not good to myself. If I don’t eat good foods, exercise, sleep well, surround myself with good, positive people with the capacity to love, if I don’t express myself with my music and writing, cherish my boyfriend and my excellent friends and animals and my surroundings, I do a lousy job when I go to work. I’m not able to put my patients before me. I don’t do anyone any good. I come home sore, exhausted and depressed, instead of sore, exhausted and feeling like I did something. It’s a huge difference.
It is about smoking, the nicotine addiction, the habit, big tobacco and it’s not. If it isn’t tobacco, it will be something else. If you’re struggling with tobacco, be aware of the disease process and own that you’re going to pay a huge price for a little momentary pleasure. It's important to remember Big Tobacco does not give a holy rat's ass about you. They are not your friends. Be aware that it might be more about something else than simple smoking. Show some courage and just look and see. You don't have to change it if you don't want. You're the one in control. And you're not going to be anybody in the world but exactly who you are whether or not you smoke. But just once you might try to reach out and take your space. Keep going outside to take a smoke break -- just don’t smoke. For Pete’s sake, don’t tell anyone that you’ve quit. Don't tell a living soul. Make everybody think you've got to go out and smoke. Just don't smoke when you get there. Breathe instead. Breathe. Big deep breaths. If you need a screen to hide behind, go find one. But breathe. Breathe and feel the beat of your own heart.
We are all smokers, with our own weird little cigarettes. Legislation is not going to change tobacco use or any other kind of neurotic behavior. It’s like trying to legislate the sun because it causes skin cancer. If you’re truly concerned about someone else’s smoking, just be a friend. Talk about the uncomfortable things. And use that money we’d spend on legislation for our children and our teachers. They need all the help they can get.