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Sunday, August 13, 2017

dx from Hell update: ICD-10 I26.92

On March 29th, my younger daughter got a crushing diagnosis of Stage IV metastatic pancreatic cancer (ICD-10 code C25.9). Our lives have been on constant high anxiety ever since.

After seven subsequent rounds of chemo (every other Wed - Fri), she had follow-up CT and MRI scans Thursday afternoon.

We'd not been back home from Kaiser long when her oncologist called.

The good news: no new mets evident, substantial size reduction in both her primary pancreatic tumor and her numerous liver mets.

The bad news: a large "Saddle PE." An aortic pulmonary embolism (blood clot).


Above, that Wikipedia image looks like it could have been one of the PACS images the hospitalist showed us in her chart in the ER, where her Onco Doc had advised us to go straight away. We got to the ER at 6 pm. Heparin IV immediately, more bloodwork, and vitals monitoring.

Another long night. They told her she'd have to be admitted for Obs, too dangerous for her to go home prior to subsequent eval monitoring.

She got to a room on the 4th floor MedSurg unit at midnight. I told my wife to go home (she had a 6:30 a.m. work conference call upcoming). I "slept" on the couch (Kaiser, to their credit, doesn't have "visiting hours." Family can stay around the clock). I'm feeling better today, but I was totally wiped on Friday.

Danielle was discharged mid-day Friday. Her BP, pulse, other vitals, and labs indicated it to be safe enough. Henceforth she adds self-administered 2x/day Lovenox subcutaneous abdominal injections to her meds regimen (it's a heparin cousin, a blood thinner). She's handling all of this with substantial grace and fortitude.
Danielle was on a (no doubt Zoloft-assisted) roll in the ER, crackin' wise with the nurses and the docs. Her standup-worthy gallows-humor snarkiness perplexed the young on-call female hospitalist who came into the pod and walked her through the dx and prognostic particulars. We were "like, yeah, we get it. We have deep shit. What're we gonna do? Be all morose all the time?"
Dodged a big bullet. The three primary adverse outcomes of a Saddle PE: [1] total aortic blood flow blockage, and you die, [2] clot stuff breaks loose, jams up your aortic heart valve, and you die, or [3] clot stuff breaks loose, makes it through to your brain, and you have a stroke. Those who've read my "One in Three" essay about Danielle's late older sister might recall that Sissy suffered a stroke mid-way through her cancer illness. Post-stroke reality is no fun, for the patient and caregivers alike.

Meanwhile, The Crazy is on Tilt all week. Will Mr. Locked & Loaded, Fire & Fury Donald Trump attack North Korea? Venezuela too, just for Grins? Will the #GoogleManifesto snowflake bro'grammer successfully sue his now former employer? What's next for the knuckle-dragging "Alt-Right" (whom Tone-deaf Trump refuses to specifically and unequivocally disavow) after the obscene lethal racist carnage in Charlottesville?

I really need all this idiotic background noise in my life right now.

HEALTH IT ERRATUM

As I've noted before, my world is "all Epic, all the time" anymore. I again closely watched the Epic EHR UX of all the clinicians while Danielle was in the ER and on the floor. Paper is not "better," not even close. See, e.g., my prior post "From EMRs to EMTALA: Dorothy J. McNoble, MD, JD."
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More to come...

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