The Moral Conundrum of Max the Cat

We gave him a comfortable home, improved health, food, toys, and love–but we took away what he valued most.

“Let’s see this prodigy!” I said to our handyman as he pulled the cat carrier out of his truck. He opened the cage and lifted out a tiny creature with round eyes and exquisite tiger and white markings. So we brought the kitten to our house and let him out to explore the back porch. Almost immediately there were piercing meows whose meaning was perfectly clear. “Where’s the farm? Where’s my family? I don’t like this!” Later it turned out that there were compensations: unlimited lactose-free milk, toys, soft pillows to sleep on, and lots of attention. It seemed OK for a while.

In an earlier post I recounted our first weeks with Max and Bella, the slightly older female kitten we adopted at about the same time. They got along well with each other and with our older cat Rowan. They played, learned new skills, and grew stronger. Years ago, we would have started letting them out at about this age. Our neighborhood was quieter then and our cats enjoyed exploring the yard and basking in the sun on the back porch. These days, it is simply too dangerous. There are more people and more cars. We even have birds of prey, possibly driven into town by the development of surrounding rural areas – owls, hawks and turkey vultures – that carry off small animals.

Like Rowan, Bella was content to be indoors, but for Max there was always something missing. In the morning about breakfast time, he would run around the house meowing, trying all the doors and windows. This would go on for about an hour. In the evening, the same routine for a slightly shorter time. He showed his contempt for our restrictions in other ways, like pulling a dish towel down on the floor and peeing on it.

Some people have suggested that Max might like a little fenced-in area outside, but I know better. What he wants is to be completely free. He comes from a long line of working cats and he wants to be doing the job he was destined for, killing stuff outdoors. As a barn cat, Max would have been exceptional. He is very smart; he recently taught himself to open the drawer under my bed. He loves challenges and risk-taking and isn’t afraid of anything. He gets up on top of the refrigerator and walks along the upstairs railing with ease. He is frustrated because his talents are being wasted; he has wound up in what is basically a spa for cats!

For a long time I tried to think of other options for Max – giving him to someone with a better yard for cats, even sending him back to the farm – but in some ways he is not well suited to be an outdoor cat. Though mighty in spirit, Max is not a large cat, only about ten pounds, and could be injured by a bigger animal. Max is also friendly and loves the company of other friendly cats and people. Outdoors, he would probably be lonely. He might even befriend a human passerby and get picked up as a stray. Max is also very fastidious and keeps himself clean at all times. When we first brought him home we got a damp paper towel and wiped off his tiny feet, which were dirty from being in the cat carrier. Once he understood what we were doing, he started purring.

As cats get older, they seem to develop a deeper attachment to the people and other cats they love. Max and Rowan take naps together. He and Bella chase each other around the house. Max is two-and-a-half now and the demands to go out are fewer and less intense. Nobody gets everything they want in life, not even cats.

An Alternative to Mohs Surgery for Basal Cell Carcinoma

Last summer I started to notice a spot on my nose. It looked a bit like a pimple but it didn’t go away. After a few weeks I went to a dermatologist and had a biopsy. Bad news: basal cell carcinoma, not the worst kind of skin cancer but not to be ignored. Doctors call BSC “the rat cancer” because it burrows under the skin, out of sight; there is no way to tell how much (or even where) it has spread.

The dermatologist told me that I should have Mohs surgery to remove the cancer. The procedure is for the surgeon to shave off skin a layer at a time, testing each layer as she goes, until a cancer-free layer is reached. There is no way to know ahead of time whether the surgeon will remove one layer or seven. In an area as delicate and contoured as the nose, a seven- layer procedure would leave a large wound that would take weeks or months to heal completely and might require plastic surgery. For me, that would mean canceling the annual scuba diving trip and possibly ending up with a permanent, unsightly mess at the end of my nose. Surely, I thought, there must be a better way.

And there is. It’s called superficial radiation therapy and it has become available within the last ten years. It is distinct from an earlier form of radiation therapy that was commonly used before the introduction of Mohs surgery, which became the standard treatment for BSC in the 1970s. SRT is not available everywhere and has advantages and disadvantages compared with Mohs. The experience of having an SRT treatment is similar to having a dental x-ray and takes about as long.

-  SRT is non-invasive, painless, and non-scarring. Like any surgery, Mohs causes bleeding, pain, and an unpredictable amount of scarring.

-  SRT requires 12-15 very short visits for treatment. Mohs surgery requires 2 visits, one of which may last all day. If there are unforeseen complications, further visits may be needed and, possibly, treatment by a plastic surgeon.

-  The cost of both types of treatment is about the same and both are covered by insurance.

-  The cure rate of Mohs is slightly higher, but both are above 90%.

-  SRT may increase the likelihood of getting cancer again, decades in the future. (If I’m around then, I expect that there will be much better forms of treatment available.)

For me, the good news was that SRT is available in Indiana. The bad news is that the best qualified facility is in Muncie, more than 2 hours from my house (more like 2.5, with road construction at both ends). But I did it anyway – 14 round trips between late September and early November of last year. The facility had an oncologist to determine the dosage but the actual treatments were done by a technician. At the time of the last few sessions I had some mild bleeding from my nose but that was the only discomfort. I’m so glad I did this!

 

More Reasons for the Eroding Trust between Patients and Physicians

I’ve just been reading an article by James F. Sweeney, “The Eroding Trust Between Patients and Physicians”, that appeared in the 4/10/2018 issue of Medical Economics. First, I appreciate the fact that Mr. (Dr.?) Sweeney is addressing this issue, which is a serious detriment to effective medical care. Lack of time and of any substantial relationship with the patient are the causes emphasized by Sweeney, but there are a number of others that deserve attention.

Standard of Care imposes constraints that encourage doctors to play it safe and avoid creative thinking. Especially in the field of oncology, the threat of liability intimidates many doctors and may cause them to see each new patient as a potential lawsuit. The treatments endorsed by Standard of Care sometimes reflect out-of-date science rather than the latest and best thinking in the field.

Reliance on randomized controlled trials (in addition to lack of time) means that patients tend to be treated by category. RCTs are useful as an overall indicator, but they don’t tell the physician anything at all about a particular patient.

Medical offices frequently don’t have accurate, long-term medical records for patients. With the advent of electronic records, decades of precious data on individual patients were discarded and lost. Unless the patient herself has kept hard copies, the doctor must make recommendations based on a couple of years of test results. Adding to this problem is the lack of compatibility among EMR systems.

The connection between medical practice and science is becoming more tenuous. Protocols for some tests are not followed correctly. (My favorite example is the taking of blood pressure, when medical offices don’t have you sit quietly for a few minutes beforehand, the correct protocol. Then they tell you that you have high blood pressure.) We hear confident statements that calcium supplements promote heart disease, when the evidence for this is shaky at best. Medical practice tends to cherry pick scientific studies and highlight those that support what it is already doing.

In spite of substantial scientific evidence supporting the role of diet and exercise to good health, many medical practitioners discount their importance. Ads for medical practices and hospitals featuring photos of overweight doctors and nurses are clear evidence of this attitude.

Current medical practice tends to reject, even scorn, any therapy that isn’t part of the conventional canon. After developing painful scar tissue in my shoulder and arms, I was successfully treated by a chiropractor with myofascial therapy (MRT) and active release technique (ART). Conventional medicine’s recommendation? Pain meds or surgery.

These are all features of medical practice today that are causing physicians to lose credibility in the eyes of their patients.

Foot Surgery the Easy Way

I was born with curly little toes on both feet. That never bothered me until the past year, when the left one decided to curl out a bit more and started rubbing against the insides of formerly comfortable shoes and boots. For a while, I babied it along with band aids and pads but finally it was time for a visit to my wonderful podiatrist Dr. Hoffman (introduced in Respect the Feet).

“What have you done this time?” he asked. I explained that I thought I was getting a bunion. Instead, he identified it as a type of hammer toe, a condition that is often treated by breaking the toe and inserting a wire; big incision, lots of pain, weeks of recovery time. Instead, Dr. H proposed a minimally invasive 10 minute procedure in which a tiny incision is made, the tendon is nicked, and the patient goes back to normal life immediately.

So I did that. The worst part of it was the shots to numb the foot. After that, I really felt no pain at all, either during the procedure or later. Dr. H offered an antibiotic and suggested an over the counter pain med, but I said “No, thanks” to both of those. The only real hassle was keeping the dressing dry for a few days, which meant showering with a towel and a plastic bag around my foot. Now I’m back to wearing my regular shoes and boots. Dr. Hoffman scores again!

Got IBS D? This Probiotic Yeast Could Be Your NBF.

In 2014 my doctor at the time ordered tests in an attempt to find the cause of my longtime gut problems (discussed in Trouble Down Below). The tests came back negative except for the observation that a few Blastocystis hominis (BH) organisms were seen. At some point later on, I mentioned this to a GI specialist and he said, “Oh, that’s nothing!”

In general, this seems to be true. In 2000, approximately 23% of the US population was infected with this protozoan, most with no symptoms at all. (In less developed countries, the percentage is much higher.) BH tends to run with IBS and with colorectal cancer but the relationship is not clear. For a few unlucky people, it can cause major digestive upsets lasting weeks or months.

During a trip last month I started to have diarrhea, acid reflux, and intermittent queasiness. Since I do sometimes have digestive upsets when I travel, I didn’t think much about it. When I got home, the other symptoms went away; the diarrhea got worse­­—many, many trips to the bathroom, often in the middle of the night. Before calling my nurse practitioner to see about ordering tests, I did some online research to see what treatments were likely to be. One word: antibiotics.

I’m not totally against these medications; if I have a life-threatening bacterial infection, an antibiotic is certainly what I want to be taking. In my present situation, though, I had reservations. Antibiotics don’t always work for bowel problems. They can also do long-term damage to the immune system by killing off good bacteria in the gut and they may have unpleasant side effects, like diarrhea and yeast infections.

I started looking around for other options and came upon a yeast called Saccharomyces boulardii (SB). This probiotic is a veritable Swiss Army knife of beneficial functions and has been studied for decades. It has repeatedly been shown to work well against diarrhea, sometimes as well as or better than antibiotics. SB is believed to be a strain of baker’s yeast (S. cerevisiae) and is completely safe and without side effects, except for people who are allergic to yeasts. SB can be combined with antibiotic treatment to help support bowel function; since it’s not a bacterium, antibiotics won’t kill it. SB has been shown in some studies to be effective against Candida albicans, ironic because they are both yeasts. There are also researchers who are looking at various uses of SB for cancer patients.

I started taking SB 250 mg. three times a day. The tests came back showing—you guessed it—Blatocysitis hominis! After a few days with not much change, I went online again and discovered a French study from 1996 about diarrhea in 30 people with AIDS (under Clinical Studies in PWAs). The subjects took 3000 mg of SB per day, six times the normal daily dose. After two days, they saw significant improvement, at eight days their bowel function was normal.

I started taking 3000 mg per day of SB and also saw significant improvement after two days. For me, it took about three weeks to get back to normal. I plan to continue at the same dose for another couple of weeks, then gradually reduce it. Given the possibility of an allergic reaction, I think it was just as well that I tried the lower dose first.

SB is sold under the brand name Florastor, $20 for 20 250 mg capsules, cheaper on Amazon and Ebay. CVS has a generic version that is sometimes on sale. Swanson, the online supplement store, sells its own version, $5.99 for a bottle of 30. Are they as good as the brand name, or better? I don’t know but I plan to experiment later on. Given my gut situation, I expect to be taking SB indefinitely, and happily too!

Layers of Pain

I picture them as cobwebs­ — layer upon layer of cobwebs — binding my muscles, tying them to my bones, pinching sensitive nerves, but unlike cobwebs they are not diaphanous and fragile. These are bands of scar tissue, solid and persistent flesh, and I have them all over my body, palpable reminders of all the times I have misused my muscles over the years: the too-heavy load of books or groceries I just had to carry, the meetings that caused my neck and shoulders to tense up for an hour or more, the overly ambitious stretch in yoga class. 

Up until last year I wasn’t particularly aware of scar tissue as a problem. About a year ago, I started getting pains in my upper arms while doing weight-lifting routines. For a while, I backed off on intensity, thinking that these were injuries that would heal by themselves. I tried heat and ice. Finally, after about six months of no improvement, my personal trainer suggested that I go to a chiropractor, a new experience for me.

The chiropractor turned out to be a man in his early thirties, a serious athlete, who has had more than his share of serious injuries. When he asked me to raise my straight arms from my sides to the highest point possible over my head, he was horrified at the condition of my shoulders. I couldn’t get to the top position and I couldn’t straighten my arms. (Years ago I had had a bad injury to my left shoulder, described in this post, and later to my right, the most overworked side because I am right-handed.) Over a number sessions, this movement improved until he was fairly satisfied with it. But I still had the pain in my arms and rotating my arms forward in a circular motion hurt my shoulders. By now the pain was bad enough that it was waking me up at night.

To treat the scar tissue in my shoulders, arms and legs, the chiropractor used two approaches: myofascial release therapy (MFR), where he presses firmly into tight areas, and active release technique (ART), where he presses into a tight area while I move my arm across a prescribed path. This process ranges from mildly uncomfortable to quite painful, but the benefits have been substantial. I can now sleep at night without pain, though my shoulders and arms are sometimes stiff when I first get up. I am starting to lift weights again. My range of motion is much better but still needs work, especially the right shoulder and arm.

All complex human relationships, especially marriages and doctor-patient interactions, require a constant readjusting of expectations. The chiropractor and I had both anticipated that my situation would be resolved in a matter of weeks, months at the most. It has now been over a year. During that time, symptoms have come and gone. For a while, I had trigger thumb in my right thumb; it lasted for a couple of months, then went away. At one point I mysteriously injured a nerve in my left leg and was hobbling around for a while. We worked on the left leg and that got better too.

Why is all of this happening to me right now? Age is probably a factor; I am 71 now. Another possibility is that in 2016 I stopped taking Premarin, an estrogen supplement I had been happily using for 36 years. Changes in hormones can affect muscles and nerves so this transition may have turned a tolerable situation into one requiring treatment. In any case, I am grateful that these therapies are available to me. Ironically, insurance won’t pay for interventions that are actually restoring me but it would pay for pain medication, which I certainly want to avoid!

How To Keep The Weight Off As You Get Older

One of the sad truths about aging is that you inevitably burn fewer calories than you did as a young person, even if you’re physically active, even if you eat a healthy diet. When you retire you may eat out more often and take more trips to foreign countries with delicious food, making the situation even worse.

At our house we have instituted a system of alternating big meals and small meals. A big meal is protein (often chicken or fish), vegetables, and maybe a starch plus a little fruit for dessert. A small meal is soup with a small piece of bread or a quarter of a frittata or a tuna melt, always accompanied by vegetable juice (bottled or homemade). We do three big and three small each week. On the remaining night we eat at a restaurant.

Lately we’ve been wanting to lose a few pounds so we’ve started a low food day every week or so, somewhat like the part-fasting diets that are popular now. Instead of fasting, we have the Mango Lassi with Anti-Cancer Spices for breakfast (plus coffee), the Pretty Good Almond BerryGreen Smoothie for lunch, and the usual kind of small meal for supper. After a few weeks we’ve lost a couple of pounds without too much pain.

The advantage of our system is that it is sustainable. With diets, you eventually go off the diet and the weight often comes right back. Our program incorporates enough foods we enjoy, including an occasional sweet dessert at a restaurant, so that we don’t feel deprived.