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Sunday, December 06, 2009

GOT IT!!!!!

What seems to be driving his blood pressure and heart rate are blood glucose levels which are occasionally swinging wildly although inconsistently.

He doesn't have clear Type II, because I fed him a spaghetti dinner last night and made him go lie down, and two hours later his blood sugar was 96. All through the night his glucose readings were steady and his BP and heart rate calmed down into very normal ranges. But earlier in the day (mid-afternoon) his BS was 157, and dropped to 78 two hours later without eating - and BP and heart rate were way up. Naturally enough, because with blood sugar that high his body was starved for energy.

Late this morning his blood sugar was 168, and his heart rate was up and his BP had taken that sudden jump to 136/77 that presaged disaster earlier. But now at 1:10 his blood sugar is 91 and his BP is 115/65, pulse 56.

So now it's check liver/gall bladder/pancreas. With any luck it is inflammation/partial blockage of that common duct and antibiotics will clear it, although if his gall bladder is really bad he may need to have it out. The other possibilities are liver problems, etc but I doubt it. The occasional sharp pangs the Chief was feeling may well have been clearing of the blockage, so by the time he got to the hospital the high blood sugar had cleared.

I have had very little sleep for the last two days, but I am profoundly relieved. He is moving around a lot more, because I think it might help clear things.

It's probably going to be all right, although until this is resolved this guy has to be watched very carefully. My dear, dear Chief.

In defense of all the doctors who have seen this guy, it is pure hell to catch an intermittent like this in electronics, and probably five times harder to catch it in medicine. You could run test after test on the Chief and not catch the glucose problem, because most of the time it is normal and when it goes really high, it tends to clear itself after a couple of hours. But by then the Chief's system is effed up, and it takes hours more for things to settle down. In fact the Chief's blood sugar readings have been generally normal during the hospital visits. The only way to really figure this out was to take days of readings like this to catch those sudden spikes.

One time we had an extended series of system crashes at a bank. We were back and forth, back and forth, and the bank was getting furious with us. The owner of the firm went out there, checked every thing out backwards and forwards, and sent a tech to sit out there with a voltmeter for days. And on the second day, there it was. Major voltage fluctuations. The solution was power conditioning on the line coming into the building. After that, they never again had any problems.

And lest any of you think I am some sort of really smart person, what caused me to check this was that the Light popped in quite suddenly when we were sitting in SuperDoc's office on Saturday. I found myself saying to SuperDoc without any conscious intention or any thought at all that I would check the Chief's blood sugar readings over the weekend. SuperDoc looked surprised but said that it couldn't hurt, although he would expect them to be a bit off because of all the meds the Chief had been on. I really think the prayers helped; my mind has been blank from sheer terror through a lot of this. I have not been thinking well at all.

Thank you all for the information and support. It has really helped.

Good to hear. Hopefully the Chief can be back to full health shortly.
MOM, I'm glad to hear you got things sorted out. I have little first-hand data on whether you're super-smart ;), but clearly your problem-solving method saved the day!

I'm just asking this for my future information, because I have family with both blood sugar and blood pressure problems:

Am I understanding correctly that, following the initial perturbations caused by high blood sugar, the interventions just made the swings in BP and BS larger? Like a feedback control system with the gains set too high? Or, alternately, like pilot-induced oscillations in an aircraft?

And the gall bladder is really not that serious...ultrasound now is used to blast the little rocks out of existence, although not ll cases are susceptible to this treatment.
But gall bladder removal is the second most common operation: if you need it, there is very little strain on the body, especially the heart.
I know I sound hopelessly optimistic, but between prayer, SuperDoc, and (especially) you, The Chief will look back on this with a sense of satisfaction.
It's strange that you get a dog with wild swings in blood sugar, and right after you get a human with the same. Maybe some common infection? Or was the dog's problems well known?
First Anon - I hope so. I guess I am just focused on making sure that this gets treated before the swings in blood sugar do too much damage. I did not write the worst of this week in the blog because I was too scared; several times the Chief seemed to go into shock.
Second Anon - the dog's condition was obvious from a puppy, but as he got older he got worse. Eventually he developed a form of diabetes from the damage.

I always suspected that the dog had something like Cushing's disease, but his condition could change so rapidly that it was hard to track down. I am guessing that the real underlying cause was a CNS infection that caused transient swelling, because the only thing that would straighten him out as a pup and a young dog were high doses of antibiotics over a prolonged period, but I found early that I had to introduce them in staged doses. Several times he seemed to remit totally, but as he got older and older it became more difficult to manage.

I was just thinking that it turned out to be a very lucky thing that I had that dog; his last year was extremely difficult for me, but it gave me a lot of practical background that has been useful this weekend.
Neil - I think those are doc questions. I just plan to give him the complete data and let SuperDoc do whatever he has to do.

All I can tell you is that the Chief appeared to be going in and out of shock. His blood sugar is at times completely stable and at times it is rising extremely high and then crashing. For example, he moved from 157 to the 70s in well under one hour.

As far as I could tell from Thursday through this week, the nitro did not clear him in the hospital. However in the wee hours of the morning, his feet became suddenly cold and then numb. The cardio nurse came in, found his blood pressure very low and ripped the nitro patch off. After looking at the pattern this weekend, I'd guess the same precipitous drop in blood sugar occurred.

The high blood pressure wasn't controlled by aspirin, lisinopril or nitro on Thursday.

I can promise you that this wasn't my problem-solving strategy. By now I am a mush brain.
I am not sure if my long comments helped.

Are you suggesting you think elevated glucose is the cause of chest pain?

Or are you suggesting it is the cause of labile blood pressure?

Neither would not make sense without more information.

As for biliary colic causing his symptoms, I do not know enough to be helpful as I am a little unclear what the actual symptoms are that he is having at this point. Labile HTN from biliar colic is a little odd however- not impossible, but odd. If it were bad enough from infection to cause wild BOP swings, he should be on antibiotics now. The fact he is not, and his doctor has seen him and not done this but considered the diagnosis suggest this unlikely.

I do wish you luck as I know how tough this can be.

Be well

Well done MoM. Hopefully, progress will be swift and smooth herein.
Your description of intermittent voltage instability is telling. I'm not a doctor, but have friends and family who are diabetics prompting me to question myself whether these blood sugar peaks are a result of a disruption in the feedback impulses to the pancreas, or some, intermittent, disturbance in the insulin sensitivity of cells at the other end. I'm hoping the Doctors can profit from your quickness of thought and care in observation.
Best wishes again.
AnonMD - I last saw the doc Saturday morning. At that time we did not know that the blood sugars were spiking and that this was associated with the swings in BP. In October (the previous major incident) the Chief had just started Zithromax, so that may have addressed it for some time. Like I wrote earlier, there has been very rapid degeneration in the last ten days (now the last 14). I am guessing it really is partial block of the duct, because today whenever the Chief's readings looked stressy I made him get up and walk around, and each time it seemed to settle him down. Dropping BP readings on activity kind of rules out the heart. Of course it could be something REALLY evil, but I am hoping it is not.

Last Tuesday SuperDoc told me that we would probably have to test gall bladder and esophagus, and on Saturday he was talking about testing gall bladder this next week, so he suspects it. But he wanted to see if the Chief could remain stable this weekend before running any more tests. SuperDoc was also considering endocarditis as a possible alternative earlier in the week. I think SuperDoc might not want the Chief on antibiotics because if there is a bacterial infection in the stented aorta, starting him on antibiotics might cause local inflammation and a total disaster. SuperDoc is known for not killing his patients. The stented aorta was reported as somewhat distended in the last angiogram.

I have not called SuperDoc because I was taking up an awful lot of his time last week, and as long as the Chief is not in severe stress I did not want to bother SuperDoc, who is not a young man. I am going to drive the Chief to his office at 7:30 AM tomorrow.

I do not know what SuperDoc is looking for, but he seems to be able to tell a lot from physical examinations. I was guessing that if I called SuperDoc today he would have opened up his office and had the Chief come in, and I did not want him to do that. It is great to take your duty to your patients seriously, but I do not want SuperDoc to kill himself in doing so.

Right now the Chief's blood sugar is in the stable 90s and his heart rate is 62 and his BP is 116/64, so he isn't dying. I was looking for liver signs (the only one I really know are those small spots of blood and to look for signs in the eyes), but the Chief appears to be okay.

As for the help, believe me, people's comments have helped a lot. My mind was racing and I have not been able to sort things out; I am too emotionally involved here to be able to think well, and at times I have been pretty much blanked out.

The chest pain is probably a result of gall bladder pangs. The transient high blood sugars followed by rapid drops appear to be causing the elevated blood pressure. Whenever the blood sugar is stable for a few hours the heart rate and blood pressure readings look very normal.

Great to hear that things seemed to be figured out. The Chief is really lucky to have someone like you looking out for him.

MOM, the problem-solving method I refer to is "push all the buttons and turn all the knobs, then correlate all the data you can get". Which is what got done, between you and the doctors.

It's the only good problem-solving method I know, when confronted with a poorly understood, complex system. It works fairly well, as long as everyone understands they don't know what they're doing.
Dear MoM - what I learned from all of this is that you are a woman who really loves her husband. He is a very fortunate man, indeed. God bless and keep you both!

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Thai - thanks. Don't get me wrong, but the blessed thing about having SuperDoc is that I don't have to think like a physician. Because, let's face it, I ain't one. And even if I were one, I doubt I would be effective in the Chief's case due to emotional involvement. Fooling with the extraordinary complexity of the human body requires a vast reservoir of clinical and medical knowledge plus good reasoning. I'm zip on all three in this situation.

Today it's ultrasound of just about everything left except the brain.

SuperDoc looked a lot more cheerful this morning after he checked the Chief, so maybe whatever he was fearing is getting less likely.

I don't think SuperDoc has ruled ANYTHING out yet. He still doesn't want antibiotics, but he stressed again that the Chief has odd reactions to medicines. Also he said we would probably have to do esophagus but that under no circumstances could the Chief be anesthetized.

Then SuperDoc started bouncing around and cheerfully threatening to throttle the Vice-Chair of the cardiology department at this specialty hospital for trying to use Imdur on the Chief outside of a hospital. SuperDoc is truly irked.
I've been so sorry to hear about the chief's troubles. I had a gall bladder infection earlier this year and had it out in Sept. It did cause pain, and the pain in my case was associated with high bp (which i thought was due to the pain).

They do not use US to get rid of gall stones, btw. They do it for kidney stones but apparently it's not much use for gall stones. I don't know why.

It is possible for medication to do odd things to blood sugar. Has this been explored?
Oops, forgot to hit the anon button.

Of course I understand you do not want that role. My bad and Good Luck.

... And the way to solve the imdur issue it to just say he is allergic to it. You will of course end up with the reverse problem of getting it corrected on his medical record if you ever need to, but at least the pharmacy will stop other physicians from giving it to him if another doctor/mid-level ever orders while he is an inpatient.

PS- for obvious reasons I would like to go back to being anon if you don't mind.
We're praying for you and the Chief
Lithotripsy and gallstones: Kidney stones are very brittle and it's possible to focus waves through soft tissue and liquid to create shock waves that will pulverize them. Gallstones are not so brittle, perhaps not brittle at all, because they are somewhat fatty.
Mama, I've just come late to the comments section here. As I read your description of the Chief's problems, it occurred to me that perhaps he has an insulinoma - an insulin-secreting tumor that can cause wild and unpredictable swings in blood glucose. I'm not a medical doctor, just a veterinarian, so I don't know much about human medicine. Just a thought.

Anniebird. Thanks. I'll keep it in mind if nothing else turns up.
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