Partial diagnostic credit…

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After a morning road trip through some of Pennsylvania’s finest horse country and 30 minutes of abdominal scanning, it turns out that my regular vet had the diagnosis right, but gets only partial credit on the underlying cause. Still, I count that as exemplary work for a condition that presents as a shitload of things that don’t feel like they should really be logically related.

It turns out that Cushing’s is the correct diagnosis, but rather than a tumor of the adrenal glands, the glands themselves were “significantly” enlarge. In fact they’re currently 5 times bigger than they’re supposed to be and hammering out cortisol like its their full time job. Since we’ve ruled out an adrenal tumor, that basically leaves a growth on the pituitary glad as the last culprit standing.

In many ways, the adrenal tumor would have been easier to treat – open the abdomen, remove the tumor (and the accompanying gland), and the symptoms go away. It’s an invasive operation with good success if the dog survives surgery and the first week of recovery. The problem is that 30% of dogs that have this treatment don’t get past that first week. I’m a betting man, but when you’re looking at odds of one in three chambers having a live round, I’d have an awfully hard time pulling the trigger.

I’m waiting now for my regular vet to get the report and work up the treatment plan. My best estimate is that it will be to treat with daily medication to reduce the amount of cortisol being made rather than something surgical. My reading shows that surgery for pituitary-involved Cushing’s is possible, though exceedingly rare for dogs. What this really means for Maggie is she’s likely going to have to take some fairly high powered pills twice a day for the rest of her life. There’s going to be more home monitoring and increased testing at the vet to confirm that everything is working normally. Basically it’s nothing that life with a bulldog didn’t prepare me to deal with already.

There’s a catch, of course. Without dragging her back to the specialists and ordering up an MRI of her brain, there’s no absolute way to know if this tumor is benign or malignant. Research says the large majority of pituitary tumors in dogs are benign. With an average canine MRI running into several thousands of dollars, I’m inclined to let the odds dictate our response on this one. If it turns out to be something more aggressive, the options I’m willing to pursue decrease fairly dramatically anyway.

The prognosis for all of us is the same in the long run, so there’s very little advantage to be found in trying to plan against it. With all that said, I’m cautiously optimistic that we can strike on a way ahead that maintains or improves the brown dog’s quality of life in the short and may even mid-term.

A year and then some…

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Back on the 21st of February, I published my usual Thursday edition of What Annoys Jeff this Week. It took me a few weeks to noice that the link for that post ended with /what-annoys-jeff-this-week-365.

It took me even longer than that to recognize the implication of what I was seeing. Somehow, I’ve managed to post a full years worth of weekly annoyances as part of the “blogging to keep myself sane” program instituted here long, long ago. Just let that sit there and sink in (or fester) for a moment.

Saved here in the never-really-goes-away electronic universe are 365+ weekly posts dedicated to telling the world what trifling ridiculousness has earned my ire that week. I mean you could read one a day starting tonight and not read the last one of the batch until some time in late March 2020.

Friends, that’s a lot of being annoyed, I can promise you that. Even so, what’s recorded here is just the stuff that made the cut on any given week. I shudder to imagine what the totals would look like if I bothered to write down everything that was ever in the running. Is it possible to clog the the internet with the sheer volume of bitching and complaining you’re trying to cram through its tubes?

Based on the comment section of most major news sites, I doubt it somehow.

Anyway, I’m currently taking an inordinate amount of pride in the amount of annoyed I’ve managed to rack up. I’m not quite sure it’s a badge of honor, but it’s something.

Specialists…

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I’m old enough to remember taking the family dog to a vet who ran his practice out of a converted shed in his back yard. Treatment for most any ailment was a shot of antibiotics and a bland diet – his weapon of choice was boiled hamburger and rice. It was the middle 1980s and the very notion, at least in the mountains of western Maryland, that there should be anything remotely like a “specialty” vet didn’t cross any of our minds. Dogs got their rabies shot every 3rd year, ate table scraps mixed with their dry food, and all lasted for somewhere between 8 and 10 years.

Flash forward 30 years…

My bulldog, being typical of his breed, assembled an impressive roster of medical professionals on his “healthcare team.” Cardiologists, allergists, orthopedic surgeons, and anesthesiologists over the course of treating his many various conditions. My labrador, now into old age herself, has already acquired a opthmologist. In the coming weeks it’s likely we’ll add a radiologist, an oncologist, and a general surgeon to her list.

Veterinary medicine as it exists today – with the ability to diagnose and treat the family dog in a remarkably similar way to how how I’d be treated if I walked through the doors at Hopkins with the same symptoms – is a marvel. It’s also a money making juggernaught, but that’s a separate discussion. The practice I’m taking Maggie to this week in hopes of working up a final diagnosis and beginning outline of a treatment plan includes easily a thousand or more years of combined experience in emergency medicine, cardiology, dentistry, dermatology, radiology, neurology, oncology, and ophthalmology, in addition to maintaining six surgeons on staff. Their posted resumes are suitably impressive (yes, I’ve read them all). I’m cautiously optimistic that all this will translate into identifying what the best options look like for the road ahead.

I’m walking into this week with just enough knowledge based on internet deep diving and journal article reading to hopefully ask reasonably informed questions. I’ll be counting on this bunch to know the line between what science can do and what science should do. Don’t get me wrong here, I’m thankful that the state of the art has grown beyond crate rest along with boiled hamburger and rice, but there’s more than a little bit of me that misses simple, country diagnostics and treatment – and its inherent acceptance that the power of medical science to extend life has, and should have, logical limitations.


Diagnosis…

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After several rounds of testing, we have a preliminary diagnosis for Maggie of adrenal-based Cushing’s disease. Not being a vet, but being one hell of a good researcher, I won’t attempt to explain exactly what Cushing’s is beyond the fact that it’s a disorder likely being caused by a small tumor located on the adrenal gland that’s making her cortisol levels to go wonky and producing a host of potential symptoms.

In Maggie’s case, the symptoms include excessive thirst / drinking and the accompanying excessive urination, hair loss, and general weakness. At this stage, the disease doesn’t make her feel bad or cause any pain. Based on my observation she’s giving absolutely no indication that she even knows she’s sick. The primary treatment, should it prove to be adrenal-based, seems to be surgical removal, although there are some non-invasive options based on my cursory reading.

I won’t dwell on details at this point, frankly because I don’t have many real details to dwell on yet regarding Maggie’s particular diagnosis. Next week, we’ll be taking a bit of a road trip to a specialty vet who will do an ultrasound to visualize the suspect area and, hopefully, confirm a diagnosis so we can identify the appropriate course of treatment.

I’m already racking up a list of research I need to do between now and then – the success rates of the surgery in question, post surgical life expectancy, impacts on quality of life, and so on. I’ll also have to take a long hard look at my personal ethics with regard to invasive surgery for a dog that by any standard definition has already reached into the “old age” range. Believe me when I tell you it’s times like this when I hate being an analyst by professional and disposition. It’s one of the rare moments when being dumb and happy would appear to be a blessing.

The research and worry is all for a bit later though. Right now it’s Friday evening and I have a happy and contented, if not exactly healthy, dog sitting next to me wanting undivided attention. Tending to that feels like it’ll probably be the most productive and cathartic thing I’ve done all day.

My lane…

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One of the best parts of having been around for a while is that “my lane,” those areas of the workflow for which I exert some measure of control or influence, are reasonably well defined. Put another way, I know my boundaries within the organization or of the specific projects I’m assigned. I know what I can and can’t do – or rather what I’m supposed to do and those areas on which I am not supposed to tread. It helps me not dive into the deep end and fire off my opinion without first having that opinion grounded in fact.

It’s important to remember that your lane can change over time. It can narrow or grow wider based on the needs of the organization you serve or on the whims of those who lead it. Because of this, remembering who is empowered to change the size of your lane, also helps you avoid careening through the guardrail and finding yourself upside down in a ditch. 

It’s critical to remember this when someone who isn’t in legitimate position to shift the width of your lane tries to give you a nudge. The fact is, I don’t care if you are a butcher, baker, candlestick maker, doctor, lawyer, or indian chief, if you’re not one of the handful of people who are authorized to change the width of my lane. Despite all their efforts to the contrary, I’ll smile politely, give them and understanding look, and then carry on as if we’ve never had a conversation. 

I am an American bureaucrat. I have honed my craft over years. Who’d have thought that innate intransigence and a prickly sense of how things ought to be done would ever serve me so well.

Vetting or: The tale of a sick labrador…

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Over the years I’d grown so accustomed to having one sick dog and one well that last month I even noted my budget had gone wonky from the unusual lack of vet bills. You’d think by now I’d know better than to open my electronic mouth and temp drawing the wrath of whatever from high atop the thing. If you thought that, of course, you would be wrong. My mouth has been, is, and seems likely to continue to be my worst enemy.

After a few incidents and observations over the last week or two, what I seem to have now is just one sick dog. Not falling over, edge of the mortal coil sick, but sufficiently sick that we’ve already run two diagnostic panels in as many days and scheduled the next – which promises to be an all day affair for my sweet brown dog later this week.

It’s one of those times when I’m ill served by having a professional and personal bent towards research and analysis – particularly as there’s absolutely nothing I can do about the situation until we strike on a test that does something more than confirm some of the possibilities. Just now we’re tracking it as potentially a kidney issue or a liver issue or the wildcard diagnosis of Cushings disease.

I’m told by those in a position to know such things that all of these are treatable – at least in the sense that it’s often possible to slow down the degenerative processes involved. Time, however, is a remorseless bitch and treatable does not mean “curative.” That at some point everything that’s alive will eventually be not alive is pretty much just one of the rules of nature. Even the best care simply prolongs the inevitable for all of us.

Maggie isn’t in pain. She’s her normal, happy labrador self. That’s something. Personally I’ll feel better when we have an enemy I can fight on her behalf, but for now I’m trying to be calm and contented in giving her endless chin rubs and maximum attention.

Personally…

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I think it’s adorable when someone calls me sounding apologetic and forlorn because they need to make a major change to one of the events managed by Tharp Parties and Events Ltd. (A division of Big Bureaucracy Productions).

Look, chief, we all work for someone. You answer to your bosses. I answer to mine. If yours and mine provide conflicting guidance and we can’t sort it out together, I have absolutely no problem pushing it up the chain for resolution somewhere at echelons higher than reality. Your bosses and mine are allegedly professional adults who should be more than capable of decision making when their staff can’t come to agreement.

Believe me when I tell you that if you come to me saying “I know this is going to blow a hole in the schedule, but my bosses don’t want to do A, B, or C,” I’m just going to shrug, pass the word to the next level up, and move on with the day. The chance of my taking it personally is precisely zero-point-zero.

You see, there are a limited number of hours in the day and I’ve only got so much energy to apply to whatever batshit crazy things happen during any given 24-hour period. I do my level best to wast as little of that time and energy on anything that is absolutely beyond my ability to control or even to exert influence upon.

So, you see, if you ever find yourself in a position of delivering me “bad news,” and I take it with what might generously be called ambivalence, know that it’s not exactly because I don’t care, but rather because even as you were speaking, I assessed the situation as being something well outside my scope and I’ve already made the decision to refer it to higher for further evaluation and action.

I’m nothing if not a man who recognizes his own professional limitations.

What Annoys Jeff this Week?

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1. I left the house a little later than usual. Where the street I live on dumps out into the local county road parents and their SUVs were stacked up like cord wood. There they sat, engines running, more or less blocking the road, and making sure their little princelings had enough heat while they waited for the school bus. It was just below freezing, not exactly polar explorer weather. Basically a decent coat and a good pair of socks would have been enough to make it tolerable for a few minutes. I can’t help but remember my own childhood where if you didn’t walk to school you at least walked to the bus stop – and that’s back at a time and place where temperatures below freezing weren’t cause for any particular alarm, being part and parcel as they are of the winter weather season. These kids have never been allowed to run through the woods throwing rocks at each other and it shows.

2. ISIS brides. The last few weeks have been thick with reports of women and girls who ran off from western civilization for the fun and adventure of becoming ISIS brides. Now, with the dream of an Islamic caliphate collapsing around their ears, they come out of the woodwork claiming to have learned the error of their ways. Here they come crawling “home” after years of providing aid and comfort to the enemy. I’m not a scholar of international law nor does my heart bleed for their reaping the results of traitorous decisions. They wanted the wonder of life in the belly of the beast, the best thing that we can do now is let them have it.

3. Fentanyl. I keep seeing news stories wherein a drug ring has been busted in possession of enough  Fentanyl to kill 375,000,000 people. Look, I know we can’t really aerosolize the stuff and indiscriminately launch it from a mortar tube, but maybe we hold back on making these arrests for a hot second. I mean, look, people are basically awful so with enough of this floating around in the underground economy it seems to me the problem with those who habitually associate with a culture of heavy drug use could significantly reduce the demand side of the market by simply dropping dead. If a subset of the population is committed to continuing  to inject a substance they know full well may kill them more or less instantly, I don’t feel any moral force compelling me to intervene between them and and their apparent desired end state. I’d rather spend a much reduced budget on saving the small minority whose exposure to fentanyl or other high powered narcotics is accidental or that happens in the line of duty. Don’t tell me I never see the bright side, damnit.

A day of staring blankly…

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Today was mostly a day of blank stares, of getting questions loosely related to one another heaved towards me, of trying to clarify, and of creating the illusion of progress. 

It was, for all outward appearances, a very busy day. There was much heat and motion, but if you  found yourself seeking forward progress, you’d have been gravely disappointed… unless you count sending a shit ton of emails as a gainfully productive use of time. Believe me when I say you shouldn’t.

The simple fact is my gears are stripped from shifting focus from one thing to the next from minute to minute today. There’s a pretty good chance that at least some of what I churned through today could have benefited from a bit of thoughtful analysis, but today wasn’t the day for that. I don’t expect many of the next 60 or so days are going to be the kind of days when thoughtful analysis happens. It’s more about input, response, new input, new response, ad infinitum.

If anyone needs me I’ll be over here with the television making background noise, staring off into the middle distance, with my brain kicked into idle.

Mandatory…

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I’m about to be dropped into the 4th “performance appraisal” system I’ll have worked under during the last 16 years. Based on the 8-hour mandatory training there isn’t much new under the sun. I’m going to tell my boss what I think I did. He’s going to tell me how well I did it. And someone above him is going to agree or disagree with the story we’ve crafted.

I’m sure rolling out a new system is quite a feather in someone’s cap… although just because it’s taken years and tens of millions of dollars to accomplish doesn’t really mean there will be much to show for the effort beyond the implementation team getting “top boxed” on their own next appraisal.

I’m not sure I learned anything new today beyond the fact that we’re, at long last, moving from pen and ink to an online system that captures almost the exact same information. How much I trust such a system to be up and running when I might actually need to use it is another issue entirely. Of course even the best performance appraisal system is only effective at all if anyone bothers to make management decisions based on the results. You can put me firmly in the, “we’ll see” category on that one.

Experience tells me the more likely outcome is that over time evaluations across the board will migrate from the middle of the bell curve, where most belong if only by definition, to a place where everyone’s score is inflated back to the top box, which makes objective evaluation effectively meaningless.

That’s not my egg to suck, though. My egg was purely concerned with meeting the objective of attending the mandatory training and not in any way involved with designing a more perfect system. Color me mission accomplished.