“Take These Pills Or You’ll Die!”

Six months ago, while visiting my 90-year-old Fox News/Don Imus devotee aunt in Florida, I was working out at the local health club and got into a conversation with a lean, muscular older guy who’d just finished his bench presses. I bemoaned the fact that there was so little to do in that part of Florida except visit doctors, eat dinner at restaurants as the afternoon sun poured through the windows, watch TV commercials for bladder catheters, and vote Republican. 

Steve said, “Not at all. In fact, there’s a decent nightclub life. You just have to know where to go.” And sure enough, that very night, as I accompanied Steve to a variety of venues, I discovered that he went clubbing several nights a week with (or without) one of his girlfriends. When he went alone, he was a veritable chick magnet–though hen magnet is probably more accurate–and an excellent dancer. Steve was also fond of going up to the bandstand and leading the crowd in 1940s tunes.

In short, he was vigorous, lively, and unabashed. “Don’t ask my age,” he said firmly. I guessed 75 and later learned he was 85.

Back in July, Steve was having some problems with sciatica, back pain radiating down his leg to his foot. Yes, it slowed him down. Yes, the diagnosis had been confirmed on an MRI. He was taking steroids, which helped with the pain, and was being considered for surgery. No, he told me, no one had suggested a chiropractor.

I located a good chiro for him in Vero Beach, wished him luck, and said I’d see him in six months. When I returned recently and saw him, my first thought was that Steve was in the final weeks of some devastating illness. He looked 40 pounds thinner and moved slowly, his voice hoarse and subdued. Steve had almost overnight become very old. He was clearly depressed, even though he was being well cared for at home by one of his mother hens.

“I had it pretty bad just a few weeks after you left, doc” he said. “Everything just went downhill…”

Let me stop here and say I’ve never cared much for medical care in Florida. From the moment you step off the plane you’re bombarded with physicians advertising themselves as the best this, the best that. You go to a movie and the previews include ads for orthopedists, urologists, ophthalmologists. Combine this with an aged population that has nearly unlimited medical insurance (Medicare and supplemental coverage) and a state reimbursement system that rewards doctors who perform the most surgical procedures and you end up with lots and lots of unnecessary surgery.

Maybe worst of all you’ve got a geriatric generation that maintains perfect faith in the medical profession. “I do whatever my doctor tells me” is the watchword in Florida.

Let’s be conservative

And while the phrase “Let’s be conservative about this” might apply to their politics, it definitely does not apply to slowing the income stream from surgical procedures.

If your doctor doesn’t do the surgery he’s recommending now, in his heart he knows someone else will beat him to it. Get those cataracts out now or you’ll be blind, those hammertoes fixed now or you’ll trip, break your hip, and die. Fix that hernia you’ve been dragging around for decades now or it will strangulate and you’ll die!

In relating Steve’s decline from suave foxtrot dancer to decrepit old man with one foot in the grave, I’m going to pause to comment on the conservative medical options that were never once mentioned to him. Keep in mind that Steve is 85 and except for his annoying sciatica is in perfect health. Believe me, I know. I heard more about his sex life that evening six months ago when we toured the nightclubs than I ever wanted to know: Cialis, Viagra, Barbara, Melanie, Astroglide. We doctors are used to this.

Here’s what happened to Steve

After just four treatments with the chiropractor I’d sent him to, Steve became impatient and decided that since he had back pain, maybe this was a kidney stone. After all, he’d had kidney stones in the past, and while this particular pain was completely different he decided to see the urologist whose billboard he drove past every day.

The ultrasound of his kidney did show a stone, but not in a location that would be causing his current pain. The stone probably had been there for years. Nevertheless, the new urologist suggested immediate removal using lithotripsy (sound waves to break up the stone) because it “might cause trouble in the future.”

Pause: most stones in locations like these cause no symptoms and people are unaware of their existence. You might have one or two yourself. If everyone in America had a kidney ultrasound, there’d be a pyramid of removed stones. In other words, this procedure would have been unnecessary.

But Steve never made it to the lithotripsy because at the urologist’s office his EKG showed he had atrial fibrillation. This is a common heart rhythm abnormality, generally treated with medications to keep the heart beating in a coordinated way. Doctors also recommend adding a blood thinner to prevent a stroke.

Sometimes when people are in atrial fibrillation, the heart rate speeds up to potentially dangerous speeds–over 120 beats per minute, for example. But Steve was told that his heart rate was completely normal, which means his was somewhere between 65 and 95 beats per minute. No treatment is needed for this. My Aunt Hildy has been in atrial fibrillation for decades, blaming it, strangely but insistently, on moving to Florida. “I never had any fibrillation in Chicago when I lived on Kedvale Avenue.”

Discovering this relatively benign heart rhythm abnormality, Steve’s urologist actually called an ambulance and had him whisked to the hospital, where he remained for a week having lots of tests that are usually done on an outpatient basis. Ultimately, Steve was told he had “a serious problem” with one of his heart valves and they recommended surgery as soon as possible.

Remember, not only did Steve feel fine, but, ironically, one morning in the hospital his back pain went away by itself, never to return. “I guess I was wrong about the kidney stone,” Steve told me. (Likely a slipped disc shifted back into place, a common occurrence.) Steve was convinced to undergo surgical repair of his mitral valve because of “what might happen in the future,” even though he had absolutely no symptoms. Keep in mind this is a man approaching his 86th birthday.

Pause: standard treatment for mild mitral valve leakage (called mitral regurgitation) is taking medicine rather than having surgery, especially for essentially healthy patients like Steve. At this point, with the non-life-threatening atrial fibrillation and no evidence of anything actually wrong with his circulation, the only medication he’d really need would be a blood thinner.

However, one week later Steve was in the operating room. The valve surgery did not go well. During the procedure, his heart stopped twice and as a result his surgeon inserted a permanent electrical defibrillator in his chest. After the operation Steve still had his once-non-threatening atrial fibrillation, but now his heart rate was lurching badly out of control and fluid started backing up into his lungs (called congestive heart failure).

The next day, Steve found himself swollen up like a balloon. In an attempt to get his heart rhythm under control, he was sent back to the OR for “the paddles,” electrical cardioversion like you see on TV to jolt the patient’s heart rhythm back to normal. Steve’s was precisely the situation this wouldn’t be effective in (longstanding atrial fibrillation, congestive heart failure) and it wasn’t, lucky for him as sudden conversion from atrial fibrillation to normal rhythm could potentially dislodge a clot and he might have awakened half paralyzed with a stroke.

Finally, bloodied but unbowed, Steve staggered out of the hospital, still shaped like a balloon and into the care of one of his mother hens. After taking water pills for a week and “peeing like a racehorse,” he’d lost a total of 40 pounds and barely had the energy to climb the stairs. Steve doesn’t think he’ll be dancing for a while and his sex life is a memory. Recently, his cardiologist said that Steve still had congestive heart failure along with the atrial fibrillation, so he’s returning regularly to the doctor’s office to get his meds adjusted. Last week he saw his urologist, who said, “We still need to get that stone out” and scheduled him for lithotripsy next month.

Today Steve takes a handful of prescription drugs every morning. “I hate them. They make me sick, I’m dizzy all the time, and I sometimes pee blood because of the blood thinner. I begged my cardiologist to stop at least a few of them. You know what he said? ‘Take these pills or you’ll die!’”

Life lessons from Steve’s tsuris for you, Health Tip reader

• Don’t let Steve’s age lead you to think you’re invulnerable. I’ve seen plenty of unnecessary surgery in patients of all ages, pediatric through geriatric. If a surgeon seems too eager to schedule you for an elective procedure, get a second or even third opinion. Your insurance company is more than happy to pay for multiple opinions. If a second cardiologist had said, “Let’s hold off on the valve operation–after all you have no symptoms and you’re 85,” it would have saved Medicare (according to Steve) about $300,000.
• Always ask the question Steve didn’t even consider: “Doc, since I’m feeling fine, why can’t we just wait until I notice some symptoms, maybe try medications first, and consider surgery as a last resort rather than a first option?”
• Or you could ask, “Is this situation really life-threatening? If it’s not going to kill me, I can live with my imperfection. What are we really talking about here?” (My guess is if Steve had stuck with his chiro a bit longer and eased his back pain, this medical cascade would never have occurred.)
• If your doctor rigidly insists you take all prescriptions recommended for you, consider finding a doctor who’s willing to trim the list a bit. Glancing at Steve’s pharmaceutical smorgasbord, my estimate was that half could be discontinued with no danger to his health. Sadly, the remaining meds were treating the damage he’d sustained in the operating room.
• What Steve experienced is exactly what Karl Marx said was wrong with capitalism—that the profit motive overwhelms clear, rational thinking. Recently, an orthopedic surgeon was arrested for faking hundreds of unnecessary surgeries. My guess was he couldn’t stop himself. The money overwhelmed him.
• If Steve’s heart surgeon simply earned a generous annual salary, which he’d receive regardless of how many (or few) procedures he performed, cases like Steve’s would vanish overnight.

Remember, if you keep yourself healthy you really won’t need the likes of my profession except in a pinch.

Be well,
David Edelberg, MD