The Life Insurance Questionnaire

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So tonight I had to answer some medical questions over the phone to some poor sap probably not making much more than minimum wage. From the way she read the questions, I could tell she was relatively knew at this. The questionnaire was for a new life insurance policy my wife and I are applying for. I had to answer questions about doctors, medical history and diagnoses.  I knew this was going to get interesting when the first question was about medication.

Luckily, this is coming now and not at the time a few months ago when my pill intake was over 40 pills a day.

So I rattled off my list:  Imuran, 100 mg.  Prednisone, 10 mg.  Flagyl, 250 mg three times a day.  Prevacid, 30 mg.

She then asked me the diagnosis that the medicine is treating.

"Crohn's," I replied.

"When were you diagnosed with Crohn's disease?"

"In 2000."

"What symptoms did you have to prompt that diagnosis?"

"I had some pain," I replied.

"Just pain?  Anything else?"

I paused.  I wasn't sure just how much information I was to give.  How detailed should I be?  Did I need to tell her about mucous poops?  Or the times the toilet bowel looked like something from one of those Saw movies?  I decided to go easy on her.  "And frequent elimination," I added.

"Frequent elimination?"  She was quiet for a moment, as if looking for something on a computer screen.  "Did you say elimination?"

"Yeah."  It was silent on the other end.  I could hear the keys tapping.  She was trying to find the box to check off on the form, undoubtedly.

I decided to help her out.  "I shit a lot," I explained.

"Oh," she said with surprise.  I heard some keys tapping and imagined with a slight chuckle a box on a computer screen somewhere in a dark room with the phrase "shits a lot" suddenly checked off.

Then she asked about diagnostic tests.  Oh, boy.  Where to start?  I listed off colonoscopies.  One in 2010.  2008.  And every two years before that.  Sigmoidoscopy in 2012.  Endoscopy in 2012. Exploratory surgery in 2012.  A CT scan in 2012 for a suspected fistula.  That was negative, I quickly added.  Three CT scans in 2010.  Stress test in 2010.  Another one in 2012.

"What were the stress tests for?" she asked.

"Costochondritis," I replied.

She paused, looking for a list on her screen.  "Can you spell that?"

I did and then explained that it is inflammation of the cartilage in the rib cage.  Back in May of 2010, I experienced severe chest pain and was brought to the hospital in an ambulance (I didn't mention that part.)   The CT scans revealed nothing abnormal.  And it was decided that the inflammation was probably related to the general inflammation I had as a result of Crohn's.  Nothing wrong with my heart, I assured her.

"What was the stress test for in 2012 then?" she asked.

"Oh, that.  I was experiencing pain and palpitations."

"Costo...whatever it was?"

"No.  It was the result of the large dose of prednisone that I was on at the time.  And the stress, most likely, during a particularly bad flare up."

"How often do you experience flare-ups?"  she asked.

I paused and thought about it. And the truth was, I really wasn't sure. The worst flare up I had was a year ago. I missed a couple of weeks of work as the Crohn's moved to my lower colon. That was when they had to go in and look at the inflammation and ulceration in the lower colon. I haven't had a severe flare since, but I have been on numerous medications since then, including a whole regimen Chinese herbs and ointments that I have since stopped.

I rarely get flares in the summer.  Probably because I am off from school.

I flare up in the Fall, usually. The Spring. The severity varies. Sometimes food can be a trigger, of course, but I didn't want to go into that whole history.

"About once a year," I said.

After answering some more questions about doctors and family history, the interview ended.  Now some stranger who I will never, ever meet knows a hell of a lot about me.  More than most people, actually.  And all of that data about tests, doctors, medicine and symptoms are now part of another large database.  My personal experience will soon be categorized and quantified; my weight, height and medication transformed into numbers that will be added to spreadsheets and risk assessments.  Everything I am will be reduced to a formula and that formula will determine how much I will have to spend on life insurance so that my family can be secure in case something happens to me in the near future.  Or if medical bills need to be paid.

How much risk is a Crohn's patient worth?  That is what someone, somewhere sitting in a cubicle staring at those numbers will determine.

Generally, I am pretty healthy.  Except for the Crohn's, of course.  But that doesn't matter to a number cruncher.  Life insurance companies are in the business to make money, plain and simple.  My experience---rattled off through a phone interview and a physical examination next week---will be reduced to a single number that represents my worth to someone who really has never met me.

But they have met Crohn's.

And to them, that is all that matters.

Fistula, In-Grown Hair or Staph?

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This is the sore a couple of days after draining;
it is about the size of a dime.

As I mentioned earlier, I took Imuran for two weeks and then stopped due to some pain that had returned in my right side. Blood tests turned out okay, yet the pain was still there.

And then the sore appeared.  It was relatively small, located just underneath my navel.  I hadn't seen it before due to two things:  1) it was located right at my waistline and covered most of the time under the band of my undies and 2) the flab of my gut covered it.

I didn't think anything of it.  Probably an ingrown hair or something, I told myself.  By the time I noticed it, the pain was rather high, however, and it resembled a volcano that was about to blow.  So I did what any person would do in such a situation:  I drained it and cleaned it with alcohol and went on with my life.

When talking with my I doctor, I mentioned the sore and she became concerned.  Although I assured her that it was nothing but a topical skin infection, she said that it could also be a fistula.  These noxious ailments are often mistaken for ingrown hairs or boils.  They are small, but painful infections that tunnel through the walls of the colon, through soft tissue until they reach the outside.  Fistulas can happen anywhere and for someone like me, any such external infection located on the abdomen is cause for worry.

So she ordered a CT scan^* and I was convinced that I now had a fistula.  I looked up fistulas on the internet. I compared pictures of fistulas to the sore on my abdomen.  Self-diagnosis is something we crohnies always do--and almost always assume the worst.  It's not that we are negative about our ailment, just realistic and prone to being prepared for the worst.

I had my CT scan on Friday evening and by Sunday I had the results.  My doctor phoned me to explain that it was not a fistula, but that I did have moderate swelling in my lower colon. Other than that, everything looked okay.  Nothing on the CT scan could explain the sore.

The sore was troubling to her, however.  Imuran is an immunosuppressant and could leave the body open to various infections.  This is the reason why I had to go through additional tuberculosis testing before starting the drug.  Among other things, immunosuppressants have the tendency to awaken latent tuberculosis in the body.

This is the sore today.

I saw my general practitioner today in order to get a look at the sore.  It's still there, but very much smaller.  He too was concerned that, after draining and applying alcohol, it was still red and swollen.  So, he gave me an antibiotic particular to skin infections.  And he told me that if it comes to a head, not to drain it.  I need to come back in so that he can take a culture and determine what type of infection it is.  Staph, he said, is something that has been coming back with a vengeance.

My GI wants to continue with the Imuran.  I am up for that, but have to wait until this sore is gone.  I have a week on this new antibiotic and then we will go from there.  What is strange, however, and most likely the reason for such caution, is that I have been on Flagyl for the last 9 months.

Flagyl is an antibiotic.

So, whatever it was that gave me that little, yet painful pustule, was strong enough to evade the Flagyl.

This new antibiotic is called Keflex.  Amazingly, it is not one that I have every had before.

Let's see if it works.

--------------

^* You know you're a crohnie when a skin infection requires a CT scan

BSI: Bowel Scene Investigation

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The subject was a 43-year old male with Crohn's disease.  A "Crohnie," they call him.  After a particularly good week, he entered a favorite Mexican establishment by the name of Chipotle.  He ordered a burrito bowl:  rice, beans, chicken, a little salsa and guacamole, but no cheese or sour cream.  Nothing big.  He had eaten that the week before with no reactions.  However, this time the meal had a decidedly stronger kick.  And, instead of merely drinking water as was his usual, the Crohnie decided to wash the meal down with a diet Coke.  Coke Zero, actually.  Usually, he tolerates such an extravagance.  However, before he left, he refilled the cup and downed another 16 ounces or so of the carbonated, caffeinated beverage.  About five hours later he was found on the toilet.  His stools were loose.  Real loose.  Telltale signs of undigested food filled the bowl.  The Crohnie had pushed too far.   And now he was paying the price.  But what was the cause?  It was time for a BSI.



Bowel Scene Investigation.  Before coming down with Crohn's, I rarely thought about or paid any attention to my daily (or sometimes, every other day) trip to the throne room.  I can't remember a time before Crohn's when I actually took a close look into the bowl to examine what recently came out of my body.  In-out was my philosophy. I was never one of those guys to sit for a long time on the toilet.  Unlike some people I know, it was not my preferred reading spot.  There was this guy in college who lived in my apartment complex junior year.  He would sit for an hour or so on the toilet, reading a magazine.  He liked to not only keep the door to the bathroom open, but also the door to the apartment open so that he could see what was going on in the courtyard.  Consequently, everyone could see him as well.  He liked to smile and wave at people when they made eye-contact.  That was never me.

Bowel examination is a very important component of the lifestyle of a Crohn's patient.  In fact, doctors say that it should be something that everyone does as the stool can give one clues about general health. But, again, this is not something that most people do.  There is a taboo-like stigma we place on the process of moving our bowels.   In fact, just saying "bowel movement" sanitizes the whole process.  It's not like we are actually moving our bowels.  Let's face it: we're excreting feces.  It's an excretion process that occurs after your body has absorbed the nutrients from the food.  But it is a process that's essential to our well-being.  It is essential to our survival.  The process itself is very complex and when things aren't going right you know it.  All you have to do is look in the bowl.

The day I ate Chipotle, I had a feeling something was going to happen.  I started having loose stools and more gas by the afternoon.  The previous day, I had only made one trip to the bathroom.  Not that day; I had already gone three times as much.  In the bowl, I saw chunks of tomato.  This would suggest the salsa I had on my burrito bowl.  However, I also had spaghetti the night before and there were chunks of tomato in that meal as well.  The question: was the tomato from lunch or the dinner from the previous night? 

According to the Mayo Clinic, the process of digestion can take several days.  The food moves through the stomach after a couple of hours, then into the small intestine.  That takes a total of six hours or so to complete.  Then the journey through the large intestine usually concludes after a twenty-four hour period.

In Crohn's patients, this process is faster.  The food moves, sometimes in its undigested state, from the body to the bowl in a matter of hours.  This can be due to a flare-up or some other reaction to the food in question.  Caffeine can also contribute to the quick bowel and the loose stools as well.

The only way to determine the cause is to examine the stool.  Sometimes you have to get down on all fours and look directly into that bowel.  Don't think of it as a toilet but a window to you body.  The closest most people come to this is probably when they are about to vomit.  Not for a Crohn's patient.

Bowl examination becomes an art form for a Crohn's patient.  We've learned how to take toilet paper and swirl it in the water to move the particles around.  If needed, we can even pick pieces out of the water with the toilet paper in order to get a closer look.  And not once get our hands dirty.
 
What I was seeing was definitely tomato. But it was difficult to tell if it was from the salsa or the spaghetti sauce.   I swirled the water a bit and thought for a moment what my family would think if they barged in at that time.  I could just hear my son, "Dad, are you playing with your poo?"

And then I saw it:  a small green leaf.  It was cilantro.  What I was looking at was the meal that I had just five hours earlier. 

But what was it that was causing this reaction?  After all, I had had this same meal last week with no problems whatsoever.  Except this time around I had the Coke Zero.  And the salsa seemed to be a bit on the "hot" side this time around.

It was probably one of those things or a combination of both; spice and caffeine.  The bane of a Crohnie. 

Caffeine has always been a trigger for me, but I can usually have a little bit before it affects my digestive system.  Over the last several weeks, I have almost completely given up caffeine, except for the occasional half-decaf coffee I treat myself to on weekends.  At Chipotle, I think I pushed the caffeine too far.  One soda probably would have been fine.  But two pushed me over the line.

Stool examination can be an important diagnostic tool for anyone, not just Crohnies.  Even Dr. Oz recommends it.  "At the end of the day," he says, "you can analyze your body really effectively by looking at what comes out of your body."  In 1997, doctors at the University of Bristol developed a scale to help diagnosis problems in the colon by looking at the stool.  It is called the "Bristol Stool Scale."  There are even apps available to track your movements.  Ah, technology.

Next time I go to Chipotle, I will drink only water and see if I have the same reaction to the food.  I doubt I will.

If there is a reaction, I know just what to do.

Mistress Coffee

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It's Saturday and it's a day I have allowed myself to cheat.

As a Crohn's patient, we know there are certain things that we shouldn't eat.  We become very in-tune with our system and know basically how much of a trigger food is needed before it causes a flare-up.

I have two never-fail trigger foods:  fries and coffee.

I can do without the fries.  I like them, of course.  Who doesn't?  But I don't need fries.  If I never have another fry in my life, I would be okay with that. 

Unfortunatley, I cannot say the same thing about coffee.

I don't know what it is about coffee and crohn's, but I assume its the caffeine.  I used to drink a lot of coffee.  Before Crohn's, there was a time in my early teaching career when I would drink basically a pot of coffee, ten cups of so, in a morning.  Then I started suffering from palpitations.  Then I cut down the coffee.

Lately, before the most recent flare-up last Fall, I was drinking about four cups a morning every day.  That was my limit.  Anything over that and I would find myself spending more time in the bathroom.  Then I started seeing my Traditional Chinese Medicine doctor and was told that coffee "adds heat" to the colon and should be avoided.  It's not only the caffeine, I was told.  Coffee in general is not good for the colon, according to the Chinese.  Drink tea instead, he told me.

But tea is not the same thing.  I don't mind tea but it doesn't have the aroma or the bite of coffee.  It doesn't open my eyes in the morning and remove the fog.

In fact, I have come to realize that coffee may be the greatest thing discovered by man.

Over the last couple of months, I have given up coffee, beer and wine---among other things.  If you would have asked me a couple of months ago which of those three I would miss the most, I would have said wine.  I like a nice glass of wine for dinner.  When my wife and I play scrabble like an old married couple, I like a glass of wine.  I like to sip wine by the fire out on the deck.

But now, I would say coffee.  I miss it in the morning.  I have tried coffee substitutes, but frankly they don't come close to coffee.  I can tolerate Teechino.  The "Mocha" blend is quite good, actually.  But it is not coffee.  It looks like coffee, it tastes vaguely like coffee.  But it does not smell like coffee.  At work, in the morning, everyone is walking around with coffee cups and the aroma is in every office you walk into. When I see a colleague walking down the hall with a Dunkin' Donuts cup, I want to knock him down and snatch it. 

So, instead of becoming someone who assaults others for what they have, I have decided to cheat.

I am feeling better, that is for sure.  How much can coffee hurt?  I know if I drink a lot of coffee, I will be feeling it.  Before the flare-up, if I had more than 4 cups I would notice the difference.  Now, I limit myself to two cups, just on the weekends.

Right now, as I type these words, my boys are in the other room watching Phineas and Ferb and I have the morning paper spread out in front of me.  The aroma of coffee is wafting through the kitchen.

Life is good.

The blend is 1/2 decaf.  So, I cut out a good portion of the caffeine, the main culprit.  And it works for me.  No difference in my system.  I don't dare go over this amount, however.  As I mentioned, we crohnies sure know our bodies.

So, I have become a cheater.  And my mistress is coffee.

Just please don't tell Dr. X.