Ah, yes. A gun forum (!) on which I am a frequent participant had a thread titled "DNR Orders". Reading the comments by "civilians", I was reminded that there is a huge and poorly understood gap between patients' expectations of what a "DNR order" is, and the expectations and legal responsibilities of a professional, whether intensivist or cardiologist. The "civilian" thinks that a DNR order will save them and their families from a prolonged and futile hospital stay and perhaps subsequent nursing home care as a "vegetable". But it could much more likely save them from many more years of an active life. This is particularly an issue when, as required by law in California, every patient admitted is asked whether they want a DNR order. The patient may blithely sign, with the expectation as above. But what if, during an otherwise simple procedure, the patient has ventricular tachycardia--an arrhythmia readily treated, but. left untreated usually deteriorates to ventricular fibrillation and death. The physician is legally bound to obey the patient's wishes, even though a quick, simple shock would end the arrhythmia. In cardiology, this can happen frequently in the setting of an invasive procedure.
The better answer is an informed discussion, preferably with a physician who knows you well, resulting in a durable power of attorney for health care (DPAHC), which lays out different options for different scenarios. This should be the goal if patients want to be spared futile end-of-life treatment, but avoid a calamity of not receiving life-sparing treatment for a treatable condition.
After a 5 day febrile illness, and presumably no previous symptoms of ischemic disease, one would suspect that chest pain and enzyme elevation would likely be from myocarditis or pericraditis/myocarditis. I'm interested in the comment about EKG- "it read Acute MI". Also interested in the cardiologist thought process when saying "it showed in only one lead so I'm ordering an echo". Showing us the EKG would be instructional. The discussion of facing death is interesting but this case could be a useful one in teaching fellows when not to do a cath.
Some of the people responding sound like they were reading an entirely different thread. I dont they got it. I know you didnt intend to write a book about it but I think a bit more about what it really did to you. How it caused you to possibly rethink anything? How it possibly changed you or caused you to do any preparation? How, if, you will react differently with patients? Im not afraid to die, oddly. Im 71. Im sad about my life nearing its end. It hasnt been the life I thought Id have when I was younger but nothing I can to about that. Ive been near death many times from a misdiagnosis by a university teaching hospital. It was such a bad mistake that I lost my thriving business, almost my home, spent 15 years on medications that changed my life style including warfarin. I was told I had about 5 years left to live. Their continued misdiagnosis sent me back over and over near death from bleeding out internally due to blown varices in my esophagus. I had 14 transfusions. They operated on me at one point for 18 hours doing a (im not sure of the name) renal/splenal?? and cut my belly up so much that I lost all muscles in my left stomach area. They didnt cloe me properly so my huge incisions leaked for two weeks in the hospital and they repeatedly re stitched just the exterior--I heard one doc say to my main doc--I dont know what to tell him, hes going to die anyway. AFter one of my month long stays, I woke up after surgery to find two large square burned areas of skin on my back. I complained and asked what they were. I was told they didnt know and finally someone put some ointment on. I found out months later they were from the paddles used to restart my heart when it stopped during surgery. From the very first being told I had 5 years left, through each operation where we were told I might not make it, I had to face Mr Death. So I had my life and my families lives mostly destroyed forever by this state teaching hospital which was immune form tort law. I went from a big, strong man to a wheelchair bound almost helpless one the last almost 20 years. I wasted all that space to show how and why I faced death so many times. AGain--I was never afraid to die--I was distraught over not having my family in a position financially so that I could be at least somewhat comfortable about leaving them . Now at 71 with a heart problem, I think about death a lot. My experience each time it seemed close was that you are alone. All that matters ---all youre are worried about---fades away and you feel stunned. No one can help you. No one can make you feel better. So I asked above how it changed you. It made great changes in me. It made me more aware of little things. Of beauty I had not recognized. Of bad things we do to our planet. It caused me to wonder if my being born was a positive or negative affect on out planet. Had I contributed or just used resources up? As I see this written out, the subject causes me to be uneasy and as soon as Im through Ill go do something to draw my attention away, like I was never here. Final note: The best thing a doctor ever did for me was to tell me one thing. I was worried about having cancer. She said "Marv, you stop worrying. I do the worrying for you. Ill let you know if and when you should worry---in the mean time be the happiest you can for each moment you have to do it" I gave my worry to her. (Turns out it had been a missed blocked portal vein which was , after all those years, fixed with stents in a two hour operation at a different hospital, and they were horrified and shocked by what the state hospital had done to me all those years)
In 1991 I had an elective epidural for childbirth that left me paralyzed from L4 down for a period of one year. I lived my life in a wheelchair, then a walker, then double canes, a single cane, and eventually I was back on my feet. It was a time in my life when everything slowed down, and I could focus on what was important to me. It humbled me and broadened my compassion for others with mobility challenges. I was unable to return to my work as an ICU nurse, but my skill set transferred nicely to psychiatry, where I could finally focus on the patient and not the technology. While it was a difficult time, I believe it was essential in completing my education as a nurse - nothing replaces the insight you develop from being a patient yourself.
Dear Dr. Heshman, I do not intend to undermine the tremendous work of the ICUs and their invaluable staff during times of crisis, which, disagreeing somewhat with your concept, do not “help overcome severe diseases.” I would say that they are truly a lifeline, offering a second opportunity to reflect on the causality that led to such a critical condition, which needs to be addressed moving forward.
In your narrative, you describe a clinical picture of viral infectious origin that leads to an acute “terminal” autolimited episode like primary viral myocarditis. Since you did not mention any gastrointestinal symptoms, it is unlikely that it was caused by Latin-Asian fusion food (I say this in defense of the latter, given my background). Your clinical picture suggests that the potential causative germs, not foodborne, could include Coxsackie B, Adenovirus, Parvovirus B19, Cytomegalovirus, Influenza virus, etc. It could also be Coronavirus, but your event occurred in 2018.
Now, infections are not diseases in and of themselves. They become diseases if and only if our immune system fails in its evolutionary competence, perfected throughout life (despite vaccinations). In other words, it becomes acutely or chronically insufficient. In our repeatedly confirmed research—especially in COVID-19—while sadness, anxiety, or emotional stress can be pathogenic mechanisms of such immunodeficiency, this is a phenomenon observed in both patients (elderly with Charlson >3) and healthcare personnel “locked away in ICU wards.” The metabolic syndrome, which affects 9 out of 10 American adults, the lack of sun exposure, and low levels (<25 ng/dl) of vitamin D hormone, in conjunction with our hereditary deficiency to synthesize vitamin C, explain 80% of the variance in the disease burden and mortality outcomes in ICUs, not just during pandemics.
So, Dr. Heshman, if this concept makes sense to you, would your perspective on disease, critical care, and your myocarditis event bring a different reflection to your valuable narrative?
In this essay, in the link below, which provides a critical review of the literature, I present the magnitude and mechanism of disease burden related to the acquired and counter-evolutionary metabolic syndrome, and I propose a unified causal theory for your consideration.
I faced death or close enough when my (former) young dr. (PCP) prescribed propranolol as a temporary sleep agent instead of using a PERFECTLY SAFE dose of a benzodiazepine. The precipitous decline in my low normal blood pressure led to an emergency Er visit plus hospitalization. Worse, in a way, I don’t yet understand (nor do 4 cardiologists I consulted) it precipitated a “vasovagal” response that ultimately ended up in 3 more hospitalizations over the course of 7 months.
After monitoring my own blood pressure in the am and pm (per cardiologist’s orders) a pattern of dangerously low am BP plus dangerously high hs BP was elucidated. This was normalized by adding Valsartan 40 mg. at hs. My BP is now at its usual low normal range (110/65 range).
This occurred over the course of 2023-2024. Now, in 2025, things seem to be back to normal but no satisfactory (to me) explanation for WHY this happened in the first place has been forthcoming. I’ll keep you posted if one does.
As it is, I’m now on a statin and Valsartin plus other non-cardiac meds. No cardiac damage was sustained, though due to the precipitous drop in BP , I did sustain a “small” pontine stroke which has left me with a “minor” speech deficit.
I’m still VERY angry.
A word to the wise: NEVER use propranolol for anything other than for what it was intended—i.e. a beta blocker. NEVER use it as an “anti-anxiety” agent or as a “sleeper” for an anxious pt. I WASN’T anxious—tho’ I am now.
And for GOD’S SAKE (and mine) can we stop the crazy paranoia over appropriate use of benzodiazepines for anxiety (gosh!) or sleep disturbances?
Oh, and yes, I feel just fine now, thanks. I am exploring the richness of a happy retirement. We just got back from a trip to Spain. We plan further travels, perhaps to visit the grandchildren.
I use my time writing fiction and non-fiction as well as volunteering at a local museum. I rarely tell people that I am a psychiatrist, unless pressed, as it contributes to their undue anxiety because they believe that I am “psychoanalyzing” them.
If the conversation gets that far, I hastily assure them that I’m not psychoanalyzing them b/c I’m not a psychoanalyst, nor are they paying me. That, humorously, restores the equilibrium.
Also, why do you think I would be interested in your test scores? I find them to be a false measurement of knowledge and competence as the tests are usually T/F which some can excel at without having cracked the true meaning of their subject. The expertise thus implied is superficial.
I am Board Certified, FYI, b/c you are the type who would doubt it placing all together too much importance on that nonsense exam that terrifies those in practice who are now mandated to take that obscenity every 10 years-as if that proved anything except the ability to take a test.
What makes a good physician? Knowledge, and the capacity to selectively and effectively apply that knowledge to the betterment of patients. Humility and self-awareness are also extremely important. Real life personal experience with pain builds compassion for self and others which is never bad.
Yes, I agree. Clinical knowledge, or "knowing the theory" of something, it's useless without all those skills you mentioned. Someone who has the knowledge or is good at tests, won't get to far if they lack humanistic skills such as empathy, open-minded personality, humility, self-awareness of limitations, and being always willing to work on oneself. 💯
This platform is so good for a lot of learning from others 🥂🙌
You sound like the completely unempathic, prig, scientist type who I grew thoroughly sick of prior to my retirement (which was early, due to sexual harassment, not for the first time, by fellow doctor colleagues).
Another internist thought the stroke was due to hypotension. Does it matter? Not to me. I still have the speech deficit.
And yes, I have committed the cardinal sin of using (prescribed by others) benzos (usually Ativan) for intermittent sleep disturbances for greater than 35 years sometimes associated w/ major depressive episodes, that were brought on by the numerous episodes of sexual harassment throughout my career, brain biology aside. Ativan NEVER caused a stroke.
Regardless of your ideas about the horrible effects of benzos, they were highly effective in treating the anxiety disorders and depressions cum anxiety that I treated in pts. over my 30 year psychiatric career.
They were also effective for me in dealing w/ my own issues.
I did not experience “worsening panic attacks” or intense dream states that presumably would result from altered REM. They caused NO problems. I experienced RELIEF.
Your out of touch POV merely illustrates that you don’t connect well with patients, if you see them. You don’t hear their distress. You certainly can’t comprehend the idea of my distress, especially when I had a stroke AFTER following the “no benzo” party line, that you seem to mandate.
What has actually helped my life the most was a kind, caring and empathic psychoanalyst with whom I was in treatment for quite a few years. It was his empathic understanding of my distress and the rotten childhood that had led to it that helped me more than any medication. It enabled me to forge a successful, happy life both personally and professionally. You should try looking at the human dilemma (as manifested in psychiatric disturbances) through that lens instead of your biological hokum exclusively.
That would undoubtedly mean that you would have to own up to your own vulnerabilities and problems (and yes, you have them), and submit to a personal psychotherapy or psychoanalysis by which you could come to understand yourself better, and judge others less.
And if you haven’t guessed, I do feel judged by your pomposity. I await your apology, but I won’t hold my breath.
I am also well aware of the other treatments for insomnia, but frankly the SSRIs and the SNRIs don’t often completely do the job. Trazodone can be helpful—but there is the overdose risk for some.
FYI: The hands down best treatment for treatment resistant major depression with or without anxiety is a 5-10 day treatment of SAINT (Stanford Accelerated Intelligent Neuromodulated Therapy) a TMS variant treatment now available nationwide in larger cities AND covered by Medicare and thus, many insurances.
There is a place for intelligent, insightful, use of benzos with or without antidepressants , but meds are the most helpful with the appropriate psychotherapy. Benzo dependencies (note—NOT addictions, which implies tolerance plus increased dose) are easily handled with a 5-7 day taper.
Meditation and “sleep hygiene” (whatever that is) are helpful until the anxiety and depression gets bad. How bad? Ask your patients. If you have them.
I apologize for how cold my objective comments came across, I certainly did not display much empathy in my wording. I can see now how I came across as very judgemental. It is true that not all cases are the same, and I do prescribe Benzos, Opioids, etc., to patients of mine on a case-by-case basis.
It is hard to sound empathic when just writing on a blog a different point of view that contrasts with others but, it can be done so I have no excuse. I do see patients, take good care of them, and I love it. I love to educate whenever they ask questions. Their gratitude is the fuel that keeps me going through hard times.
Thank you for your feedback. I do go to therapy. I do like to seek self improvement, work on my vulnerabilities, and get better. I suffer from OCD and significant chronic pain. I take Duloxetine, Amitriptyline, Flexeril, NSAIDs, and Gabapentin. Many of my patients have found very helpful moderate-high dose of Effexor along w Buspar, particularly for bad anxiety +/- depression. I will read more about SAINTS, sounds quite interesting. I am passionate about mental health. My sister has Bipolar 1. My wife has severe anxiety, panic attacks, IBS, Interstitial cystitis, and pelvic floor dysfunction.
Again, sorry about how my writing came across. I should have thought of that while wording my comment and give more benefit of doubt. It sounds like you have gone through a lot. I hope you are doing well. Thank you! 🙏
I consider myself a competent hospitalist (Internal Medicine; 92th percentile in national examinations). I understand your frustration. Although, I think there are caveats regarding your disappointments.
Pontine strokes are much more common for high blood pressure (BP) than for low BP. Hypotension causing ischemia in the brain has a different pattern ("watershed"). Propranolol is approved and clinically indicated for some disorders related to anxiety (I.e. performance anxiety, social anxiety, etc).
When it comes to benzodiazepines, I have seen the worst of the worst. They disrupt the natural REM cycle just like alcohol (both act on GABA receptors). They create dependency which can lead to withdrawal syndrome later on. They cause rebound anxiety and worsening panic attacks, especially when anxiety is not adequately treated with SSRIs, SNRIs, etc. Insomnia is better treated with sleep hygiene training, Trazodone, Seroquel, high Melatonin doses every other night, etc.
When it comes to seeking the "Ultimate explanation", many disorders in medicine are "diagnosis of exclusion". Many of them don't have "an ultimate explanation" of why certain things happen to the body. Autonomic dysregulation is relatively common when it comes to BP, syncopal disorders, etc. Providing the "exact" explanation of certain conditions would require biopsy, molecular testing, gene testing, and other "experimental workup" that insurance would not cover and it is only done in basic science research.
I wrote all this because it makes me sad every time I see misinterpreted situations or misunderstanding between patients and physicians, even when some physicians really try to explain and listen to their patients. I hope you feel better. 🙏
I’m curious how that close encounter changed you as of today! I love how “typical” you are as a caregiver…from a walk to the ER as an inconvenience in your mind to ICU. Glad you made it thru!!!
Good question. In fact. it is the first one I ask when people I meet over the past few years tell me they have been diagnosed with pericarditis or myocarditis. I don't trust "public health" statistics but these are disorders I encountered very infrequently in 40 years of practice in cardiology.
I am a retired hospice nurse. I have been with patients when they die many times. If we are doing our jobs right, they slip away easily - without pain, without stress, and possibly able to say goodbye before they go. To help them not struggle, we often use medications that are not common - opioids. For this, we have been called angels, and on the other side have been called the bringers of death. Death is a natural process - we all die. I retired because my Alzheimer's made it impossible to do my job anymore - otherwise I would still be doing hospice work. And, I know that the ALZ will cause my death, unless something else doesn't. I don't care - I look forward to finding out if there is anything on the other side of death - or not. And if they want to carve open my head to see if I actually have amyloids in my noggin to further research, great! Let's keep science moving forward. Maybe some day in the future they will be able to stop this dread disease.
Wait a minute. Your myocarditis was misdiagnosed as a heart attack and you’re non-plussed? My pericarditis was misdiagnosed as gall stones 10 years ago and I’m still pissed about it. Thank god they didn’t do the planned cholecystectomy or I would have died.
My wife had a worthwhile life from 60 to 78, though quadriplegic, on a ventilator, fed with a gastric tube with round-the-clock nursing at home (multiple sclerosis). Predicting what will be best is hard. Before, during, and after, you may have different evaluations!
..."Ideally, I want to die in my sleep, without the pain and suffering of a prolonged critical illness torturing me to death. Most definitely, I do not want to live my last days on a machine"...sounds like you are making the case for dying outside of the clutches of the medical mafia. A very good choice.
Ah, yes. A gun forum (!) on which I am a frequent participant had a thread titled "DNR Orders". Reading the comments by "civilians", I was reminded that there is a huge and poorly understood gap between patients' expectations of what a "DNR order" is, and the expectations and legal responsibilities of a professional, whether intensivist or cardiologist. The "civilian" thinks that a DNR order will save them and their families from a prolonged and futile hospital stay and perhaps subsequent nursing home care as a "vegetable". But it could much more likely save them from many more years of an active life. This is particularly an issue when, as required by law in California, every patient admitted is asked whether they want a DNR order. The patient may blithely sign, with the expectation as above. But what if, during an otherwise simple procedure, the patient has ventricular tachycardia--an arrhythmia readily treated, but. left untreated usually deteriorates to ventricular fibrillation and death. The physician is legally bound to obey the patient's wishes, even though a quick, simple shock would end the arrhythmia. In cardiology, this can happen frequently in the setting of an invasive procedure.
The better answer is an informed discussion, preferably with a physician who knows you well, resulting in a durable power of attorney for health care (DPAHC), which lays out different options for different scenarios. This should be the goal if patients want to be spared futile end-of-life treatment, but avoid a calamity of not receiving life-sparing treatment for a treatable condition.
A physician who knows a patient well? In 2025? Do they still exist??
After a 5 day febrile illness, and presumably no previous symptoms of ischemic disease, one would suspect that chest pain and enzyme elevation would likely be from myocarditis or pericraditis/myocarditis. I'm interested in the comment about EKG- "it read Acute MI". Also interested in the cardiologist thought process when saying "it showed in only one lead so I'm ordering an echo". Showing us the EKG would be instructional. The discussion of facing death is interesting but this case could be a useful one in teaching fellows when not to do a cath.
Got it. When the ED Doc said “we’re doing a CT angio to look at your aorta” and barked “STAT” to the nurse.
When the base of the skull surgeon said “the tumor is…”. As soon as I heard the word “tumor” I heard nothing else for 10 minutes.
As a Medical Intensivist and ID/AIDS specialist beginning in 1981 I gave a lot of bad news. There’s nothing like hearing it yourself.
"Just" myocarditis?
Normal ECHO but, yeah.
Some of the people responding sound like they were reading an entirely different thread. I dont they got it. I know you didnt intend to write a book about it but I think a bit more about what it really did to you. How it caused you to possibly rethink anything? How it possibly changed you or caused you to do any preparation? How, if, you will react differently with patients? Im not afraid to die, oddly. Im 71. Im sad about my life nearing its end. It hasnt been the life I thought Id have when I was younger but nothing I can to about that. Ive been near death many times from a misdiagnosis by a university teaching hospital. It was such a bad mistake that I lost my thriving business, almost my home, spent 15 years on medications that changed my life style including warfarin. I was told I had about 5 years left to live. Their continued misdiagnosis sent me back over and over near death from bleeding out internally due to blown varices in my esophagus. I had 14 transfusions. They operated on me at one point for 18 hours doing a (im not sure of the name) renal/splenal?? and cut my belly up so much that I lost all muscles in my left stomach area. They didnt cloe me properly so my huge incisions leaked for two weeks in the hospital and they repeatedly re stitched just the exterior--I heard one doc say to my main doc--I dont know what to tell him, hes going to die anyway. AFter one of my month long stays, I woke up after surgery to find two large square burned areas of skin on my back. I complained and asked what they were. I was told they didnt know and finally someone put some ointment on. I found out months later they were from the paddles used to restart my heart when it stopped during surgery. From the very first being told I had 5 years left, through each operation where we were told I might not make it, I had to face Mr Death. So I had my life and my families lives mostly destroyed forever by this state teaching hospital which was immune form tort law. I went from a big, strong man to a wheelchair bound almost helpless one the last almost 20 years. I wasted all that space to show how and why I faced death so many times. AGain--I was never afraid to die--I was distraught over not having my family in a position financially so that I could be at least somewhat comfortable about leaving them . Now at 71 with a heart problem, I think about death a lot. My experience each time it seemed close was that you are alone. All that matters ---all youre are worried about---fades away and you feel stunned. No one can help you. No one can make you feel better. So I asked above how it changed you. It made great changes in me. It made me more aware of little things. Of beauty I had not recognized. Of bad things we do to our planet. It caused me to wonder if my being born was a positive or negative affect on out planet. Had I contributed or just used resources up? As I see this written out, the subject causes me to be uneasy and as soon as Im through Ill go do something to draw my attention away, like I was never here. Final note: The best thing a doctor ever did for me was to tell me one thing. I was worried about having cancer. She said "Marv, you stop worrying. I do the worrying for you. Ill let you know if and when you should worry---in the mean time be the happiest you can for each moment you have to do it" I gave my worry to her. (Turns out it had been a missed blocked portal vein which was , after all those years, fixed with stents in a two hour operation at a different hospital, and they were horrified and shocked by what the state hospital had done to me all those years)
Am not scared of death but the moments I wouldnt be here
In 1991 I had an elective epidural for childbirth that left me paralyzed from L4 down for a period of one year. I lived my life in a wheelchair, then a walker, then double canes, a single cane, and eventually I was back on my feet. It was a time in my life when everything slowed down, and I could focus on what was important to me. It humbled me and broadened my compassion for others with mobility challenges. I was unable to return to my work as an ICU nurse, but my skill set transferred nicely to psychiatry, where I could finally focus on the patient and not the technology. While it was a difficult time, I believe it was essential in completing my education as a nurse - nothing replaces the insight you develop from being a patient yourself.
Dear Dr. Heshman, I do not intend to undermine the tremendous work of the ICUs and their invaluable staff during times of crisis, which, disagreeing somewhat with your concept, do not “help overcome severe diseases.” I would say that they are truly a lifeline, offering a second opportunity to reflect on the causality that led to such a critical condition, which needs to be addressed moving forward.
In your narrative, you describe a clinical picture of viral infectious origin that leads to an acute “terminal” autolimited episode like primary viral myocarditis. Since you did not mention any gastrointestinal symptoms, it is unlikely that it was caused by Latin-Asian fusion food (I say this in defense of the latter, given my background). Your clinical picture suggests that the potential causative germs, not foodborne, could include Coxsackie B, Adenovirus, Parvovirus B19, Cytomegalovirus, Influenza virus, etc. It could also be Coronavirus, but your event occurred in 2018.
Now, infections are not diseases in and of themselves. They become diseases if and only if our immune system fails in its evolutionary competence, perfected throughout life (despite vaccinations). In other words, it becomes acutely or chronically insufficient. In our repeatedly confirmed research—especially in COVID-19—while sadness, anxiety, or emotional stress can be pathogenic mechanisms of such immunodeficiency, this is a phenomenon observed in both patients (elderly with Charlson >3) and healthcare personnel “locked away in ICU wards.” The metabolic syndrome, which affects 9 out of 10 American adults, the lack of sun exposure, and low levels (<25 ng/dl) of vitamin D hormone, in conjunction with our hereditary deficiency to synthesize vitamin C, explain 80% of the variance in the disease burden and mortality outcomes in ICUs, not just during pandemics.
So, Dr. Heshman, if this concept makes sense to you, would your perspective on disease, critical care, and your myocarditis event bring a different reflection to your valuable narrative?
In this essay, in the link below, which provides a critical review of the literature, I present the magnitude and mechanism of disease burden related to the acquired and counter-evolutionary metabolic syndrome, and I propose a unified causal theory for your consideration.
https://bit.ly/EcheverryJ_2024_Falsehod_origin_diabesity_pandemic
Regards
Jairo
I faced death or close enough when my (former) young dr. (PCP) prescribed propranolol as a temporary sleep agent instead of using a PERFECTLY SAFE dose of a benzodiazepine. The precipitous decline in my low normal blood pressure led to an emergency Er visit plus hospitalization. Worse, in a way, I don’t yet understand (nor do 4 cardiologists I consulted) it precipitated a “vasovagal” response that ultimately ended up in 3 more hospitalizations over the course of 7 months.
After monitoring my own blood pressure in the am and pm (per cardiologist’s orders) a pattern of dangerously low am BP plus dangerously high hs BP was elucidated. This was normalized by adding Valsartan 40 mg. at hs. My BP is now at its usual low normal range (110/65 range).
This occurred over the course of 2023-2024. Now, in 2025, things seem to be back to normal but no satisfactory (to me) explanation for WHY this happened in the first place has been forthcoming. I’ll keep you posted if one does.
As it is, I’m now on a statin and Valsartin plus other non-cardiac meds. No cardiac damage was sustained, though due to the precipitous drop in BP , I did sustain a “small” pontine stroke which has left me with a “minor” speech deficit.
I’m still VERY angry.
A word to the wise: NEVER use propranolol for anything other than for what it was intended—i.e. a beta blocker. NEVER use it as an “anti-anxiety” agent or as a “sleeper” for an anxious pt. I WASN’T anxious—tho’ I am now.
And for GOD’S SAKE (and mine) can we stop the crazy paranoia over appropriate use of benzodiazepines for anxiety (gosh!) or sleep disturbances?
Oh, and yes, I feel just fine now, thanks. I am exploring the richness of a happy retirement. We just got back from a trip to Spain. We plan further travels, perhaps to visit the grandchildren.
I use my time writing fiction and non-fiction as well as volunteering at a local museum. I rarely tell people that I am a psychiatrist, unless pressed, as it contributes to their undue anxiety because they believe that I am “psychoanalyzing” them.
If the conversation gets that far, I hastily assure them that I’m not psychoanalyzing them b/c I’m not a psychoanalyst, nor are they paying me. That, humorously, restores the equilibrium.
Also, why do you think I would be interested in your test scores? I find them to be a false measurement of knowledge and competence as the tests are usually T/F which some can excel at without having cracked the true meaning of their subject. The expertise thus implied is superficial.
I am Board Certified, FYI, b/c you are the type who would doubt it placing all together too much importance on that nonsense exam that terrifies those in practice who are now mandated to take that obscenity every 10 years-as if that proved anything except the ability to take a test.
What makes a good physician? Knowledge, and the capacity to selectively and effectively apply that knowledge to the betterment of patients. Humility and self-awareness are also extremely important. Real life personal experience with pain builds compassion for self and others which is never bad.
Now I feel judged... I'm kidding 🙃
Yes, I agree. Clinical knowledge, or "knowing the theory" of something, it's useless without all those skills you mentioned. Someone who has the knowledge or is good at tests, won't get to far if they lack humanistic skills such as empathy, open-minded personality, humility, self-awareness of limitations, and being always willing to work on oneself. 💯
This platform is so good for a lot of learning from others 🥂🙌
OK. I now feel that I was overly “judgey” of you.
You sound like the completely unempathic, prig, scientist type who I grew thoroughly sick of prior to my retirement (which was early, due to sexual harassment, not for the first time, by fellow doctor colleagues).
Another internist thought the stroke was due to hypotension. Does it matter? Not to me. I still have the speech deficit.
And yes, I have committed the cardinal sin of using (prescribed by others) benzos (usually Ativan) for intermittent sleep disturbances for greater than 35 years sometimes associated w/ major depressive episodes, that were brought on by the numerous episodes of sexual harassment throughout my career, brain biology aside. Ativan NEVER caused a stroke.
Regardless of your ideas about the horrible effects of benzos, they were highly effective in treating the anxiety disorders and depressions cum anxiety that I treated in pts. over my 30 year psychiatric career.
They were also effective for me in dealing w/ my own issues.
I did not experience “worsening panic attacks” or intense dream states that presumably would result from altered REM. They caused NO problems. I experienced RELIEF.
Your out of touch POV merely illustrates that you don’t connect well with patients, if you see them. You don’t hear their distress. You certainly can’t comprehend the idea of my distress, especially when I had a stroke AFTER following the “no benzo” party line, that you seem to mandate.
What has actually helped my life the most was a kind, caring and empathic psychoanalyst with whom I was in treatment for quite a few years. It was his empathic understanding of my distress and the rotten childhood that had led to it that helped me more than any medication. It enabled me to forge a successful, happy life both personally and professionally. You should try looking at the human dilemma (as manifested in psychiatric disturbances) through that lens instead of your biological hokum exclusively.
That would undoubtedly mean that you would have to own up to your own vulnerabilities and problems (and yes, you have them), and submit to a personal psychotherapy or psychoanalysis by which you could come to understand yourself better, and judge others less.
And if you haven’t guessed, I do feel judged by your pomposity. I await your apology, but I won’t hold my breath.
I am also well aware of the other treatments for insomnia, but frankly the SSRIs and the SNRIs don’t often completely do the job. Trazodone can be helpful—but there is the overdose risk for some.
FYI: The hands down best treatment for treatment resistant major depression with or without anxiety is a 5-10 day treatment of SAINT (Stanford Accelerated Intelligent Neuromodulated Therapy) a TMS variant treatment now available nationwide in larger cities AND covered by Medicare and thus, many insurances.
There is a place for intelligent, insightful, use of benzos with or without antidepressants , but meds are the most helpful with the appropriate psychotherapy. Benzo dependencies (note—NOT addictions, which implies tolerance plus increased dose) are easily handled with a 5-7 day taper.
Meditation and “sleep hygiene” (whatever that is) are helpful until the anxiety and depression gets bad. How bad? Ask your patients. If you have them.
I apologize for how cold my objective comments came across, I certainly did not display much empathy in my wording. I can see now how I came across as very judgemental. It is true that not all cases are the same, and I do prescribe Benzos, Opioids, etc., to patients of mine on a case-by-case basis.
It is hard to sound empathic when just writing on a blog a different point of view that contrasts with others but, it can be done so I have no excuse. I do see patients, take good care of them, and I love it. I love to educate whenever they ask questions. Their gratitude is the fuel that keeps me going through hard times.
Thank you for your feedback. I do go to therapy. I do like to seek self improvement, work on my vulnerabilities, and get better. I suffer from OCD and significant chronic pain. I take Duloxetine, Amitriptyline, Flexeril, NSAIDs, and Gabapentin. Many of my patients have found very helpful moderate-high dose of Effexor along w Buspar, particularly for bad anxiety +/- depression. I will read more about SAINTS, sounds quite interesting. I am passionate about mental health. My sister has Bipolar 1. My wife has severe anxiety, panic attacks, IBS, Interstitial cystitis, and pelvic floor dysfunction.
Again, sorry about how my writing came across. I should have thought of that while wording my comment and give more benefit of doubt. It sounds like you have gone through a lot. I hope you are doing well. Thank you! 🙏
You are forgiven. Thank you for your apology.
I wish you and yours health and success in your journeys. Life can be so very hard.
In peace.
Sheila.
I consider myself a competent hospitalist (Internal Medicine; 92th percentile in national examinations). I understand your frustration. Although, I think there are caveats regarding your disappointments.
Pontine strokes are much more common for high blood pressure (BP) than for low BP. Hypotension causing ischemia in the brain has a different pattern ("watershed"). Propranolol is approved and clinically indicated for some disorders related to anxiety (I.e. performance anxiety, social anxiety, etc).
When it comes to benzodiazepines, I have seen the worst of the worst. They disrupt the natural REM cycle just like alcohol (both act on GABA receptors). They create dependency which can lead to withdrawal syndrome later on. They cause rebound anxiety and worsening panic attacks, especially when anxiety is not adequately treated with SSRIs, SNRIs, etc. Insomnia is better treated with sleep hygiene training, Trazodone, Seroquel, high Melatonin doses every other night, etc.
When it comes to seeking the "Ultimate explanation", many disorders in medicine are "diagnosis of exclusion". Many of them don't have "an ultimate explanation" of why certain things happen to the body. Autonomic dysregulation is relatively common when it comes to BP, syncopal disorders, etc. Providing the "exact" explanation of certain conditions would require biopsy, molecular testing, gene testing, and other "experimental workup" that insurance would not cover and it is only done in basic science research.
I wrote all this because it makes me sad every time I see misinterpreted situations or misunderstanding between patients and physicians, even when some physicians really try to explain and listen to their patients. I hope you feel better. 🙏
I’m curious how that close encounter changed you as of today! I love how “typical” you are as a caregiver…from a walk to the ER as an inconvenience in your mind to ICU. Glad you made it thru!!!
Vaccinated?🤔
Again, it happened in 2018. Can’t pin this one on Covid.
Good question. In fact. it is the first one I ask when people I meet over the past few years tell me they have been diagnosed with pericarditis or myocarditis. I don't trust "public health" statistics but these are disorders I encountered very infrequently in 40 years of practice in cardiology.
Plain old fashioned bad luck?
I am a retired hospice nurse. I have been with patients when they die many times. If we are doing our jobs right, they slip away easily - without pain, without stress, and possibly able to say goodbye before they go. To help them not struggle, we often use medications that are not common - opioids. For this, we have been called angels, and on the other side have been called the bringers of death. Death is a natural process - we all die. I retired because my Alzheimer's made it impossible to do my job anymore - otherwise I would still be doing hospice work. And, I know that the ALZ will cause my death, unless something else doesn't. I don't care - I look forward to finding out if there is anything on the other side of death - or not. And if they want to carve open my head to see if I actually have amyloids in my noggin to further research, great! Let's keep science moving forward. Maybe some day in the future they will be able to stop this dread disease.
My sincere condolences. Both of my parents died of ALZ. Morphine was helpful to my mother and us at the end.
Wait a minute. Your myocarditis was misdiagnosed as a heart attack and you’re non-plussed? My pericarditis was misdiagnosed as gall stones 10 years ago and I’m still pissed about it. Thank god they didn’t do the planned cholecystectomy or I would have died.
Well, I had ST elevation and an elevated troponin so I don’t fault people for thinking that
Don't mean to be snarky but seems there are a lot more cases of myocarditis and pericarditis in the last few years. Wonder why?
Sure we'll be told its just being publicized more, right?
My wife had a worthwhile life from 60 to 78, though quadriplegic, on a ventilator, fed with a gastric tube with round-the-clock nursing at home (multiple sclerosis). Predicting what will be best is hard. Before, during, and after, you may have different evaluations!
..."Ideally, I want to die in my sleep, without the pain and suffering of a prolonged critical illness torturing me to death. Most definitely, I do not want to live my last days on a machine"...sounds like you are making the case for dying outside of the clutches of the medical mafia. A very good choice.
There was a “joke” that I never found funny that I heard in training: “You’ll never die in a university hospital. You just wish you would.” So true.