The Dangers of Codeine in Children

In recent years, there have been more and more instances of codeine related issues in children. Recently, the FDA provided an official warning on the dangers of pediatric use. The basic problem is that 1-7% of people have an enzyme in the liver that converts codeine to morphine at an unusually fast rate. High levels of morphine can suppress the body's drive to breathe and serious injury or even death can occur. Because of these risks, and the unpredictable response to codeine, I do not prescribe this drug. Click here for the FDA cosumer warning and suggestions on how to monitor for this unusual, but dangerous occurence

A Surgeon's View of Thyroid Cancer

Recently, Michelle Baker, a writer for the Huffington Post published this article entitled "Thyroid Cancer? Sign Me Up!" While I'm sure she meant well, this brings up a topic that has bothered me for a long time. The bottom line is this:

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  • thyroid cancer is a cancer
  • there is no such thing as "good cancer"
  • take the possibility of thyroid cancer very seriously
  • you don't want thyroid cancer
  • pray for anyone who has thyroid cancer or is facing this diagnosis

Now, if you accept these points  - then, you can stop reading now. You get it. Nothing more to be learned here! But, if you've heard statements to the contrary... read on!

As a surgeon I would like to share my biased opinion. This bias comes from several factors: 

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  • I have spent many years treating thyroid cancer 
  • I have spent many years studying, reading, and going to conferences on thyroid cancer
  • I have seen and treated every stage of thyroid cancer
  • I have a thyroid nodule myself, and the possibility of thyroid cancer is very real to me!

So, in my biased opinion, thyroid cancer needs to be treated like guns are treated. They should be respected, handled appropriately, and you should never forget that they can damage and even kill people. The good news is that most thyroid cancer can be effectively treated. While there are certainly worse cancers that can be faced, that doesn't make recovery from thyroid cancer any less serious. I have seen very aggressive thyroid cancers, even ones that are in the papillary category - the most common and most curable. Because papillary usually has good outcomes, patients and even doctors can slip into the false understanding that they aren't threatening. It would be like thinking that guns can't kill people because you have a friend with a gun that hasn't killed them! 

Several years ago, I had two cases that illustrate the point - the first was a 55 year old gentleman with 6 months of hoarseness. He had been seen by another ENT who diagnosed him with a vocal cord paralysis and told him nothing could be done to fix the voice. But, he missed the lump on the thyroid that was causing the problem! His internist sent him to me for a second opinion. After a quick work up I operated to remove his thyroid cancer and found it invading his airway! I had to remove and reconstruct a portion of the trachea to get the cancer out! His cancer was a papillary - yes, the same type that the writer at the Huffington Post said to sign her up for! My patient has survived for 10 years now, but has metastasis to his lungs and possibly spine. Thryoid cancer will likely take his life and you have to wonder how the 6 month delay in diagnosis changed his chances. 

The second case had a similar presentation. A 33 year old mother of three young children was sent to me for her hoarseness. On exam her vocal cord was completely paralyzed and she had a lump in her thyroid. This is thyroid cancer until proven otherwise - by surgical biopsy if necessary. Well, I don't know her outcome because she was resistant to my surgical recommendation. Why? Because her local endocrinologist had referred to thyroid cancer as "fairly benign!" Since it was only a possibility, not yet proven, that she had cancer, she decided to wait and see if her paralysis got better. Not comfortable with her decision, I called her the next day to discuss matters again. To make a long story short, her husband ended up getting on the phone and telling me to never call again because I was upsetting his wife. Thyroid cancer, afterall, was a "good cancer." I don't know what happened to her but the memory of the encounter haunts me. I confronted the endocrinologist about his comments - I no longer see referrals from him but my conscience is clear. That family saw me as an overly aggressive surgeon and the endocrinologist likely agreed. 

So, I admit that I'm biased. I have seen the vast majority of thyroid cancer patients do really well. Most return to their endocrinologist for follow up and management. But some, have aggressive disease and they end up in my care for the remainder of their life. These really bad exceptions aren't often seen by the PCP or endocrinologists. But for the surgeon, they are burned into my memory and their experiences shape my practice. You can' see what I have and lack respect for this disease. 

Finally, what is most troubling about the article is the lack of recognition of so many who struggle or succumb to this disease. The family and friends of these patients know the hardships and loss that thyroid cancer can bring. The responses to her article demonstrate just how many sad stories there are that can be told. I spent some time yesterday reading through them - a good reminder that this disease is neither benign or good. 

Is Socialist Health Care a good thing?

American citizen, Heidi Terselic, comments on her personal experiences with socialist Canadian health care in Quebec, Canada and how the care differs from what she is used to in the United States.

New Tonsillectomy Guidelines

There is a new set of tonsillectomy guidelines put out by the American Academy of Otolaryngology/Head and Neck Surgery. For kids with sore throats or strep throat, the guidelines suggest 7 or more in a single year indicates the need for tonsillectomy. Here's a CNN article related to this.

Hopefully, these will remain guidelines and not be misused as strict rules. I'd hate to see a kid who has had 6 infections causing 24 days of missed school not get treated until they've had one more. Unfortunately, sometimes these guidelines are used by insurance companies or government agencies to dictate a cookbook style of medicine. I still believe each patient presents a unique set of problems and circumstances that needs to be considered. Each family presents different things to consider.  What about a parent who has to leave their job frequently to pick up and care for their sick child? What impact would losing their job have on their family and the child's health? Should these factors be considered? These are the problems with guidelines; they can and often are misused and abused. I hope I can continue to practice medicine in a highly personalized manner; putting the individual patient and their family first is my job as their healthcare advocate. 

What is sleep apnea?

 An excellent video explaining obstructive sleep apnea in adults.

For pediatric sleep apnea concerns check my tonsil page by clicking on the link on the right side of this page.