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A Sam update

We took Sam in to see our regular vet today. Dr. Jones is an older vet and generally pretty no-nonsense. We've valued his willingness to whip out the staple gun after to patch up injuries from various dog shenanigans in the past, where other vets have insisted on anesthesia and an overnight stay. He also really obviously likes dogs, which should be a no-brainer in a vet, but yet doesn't always seem to be. We'd tried another vet last week (for what ended up being Sam's osteosarcoma diagnosis) mostly because he's been scaling back his hours and we don't like the other vets in his practice nearly as much as we like him.

Faced with the osteosarcoma diagnosis and trying to figure out what to do, we decided we wanted to go back to Dr. Jones for his opinion, and I'm glad we did.

Dr. Jones was far less in favor of doing an amputation or chemo. His definition of dog quality of life, which he shared today, is: Able to get up and move around, able to eat and drink, able to use the bathroom outside. Yes, he said, young dogs with three good legs do fine after amputation, but currently Sam is able to do all three things, and if he has the amputation, that might or might not be true, and the potential gain in survival time from the amputation is not very large, and there's some definite recovery time.

So the current plan for Sam is to continue to medicate for pain and to take things as they come. Dr. Jones certainly didn't think it was time to euthanize Sam now, and his confidence that we'd know when it was time made me feel better about the whole thing.

Sam is currently taking Tramadol for pain. He seems to feel pretty good. I won't say he's 100% pain free, but he doesn't seem like he's actually worse than he was six months ago, before the tumor and before the Tramadol. He pulls on the leash, spins in circles to go out, carries toys around the house, and occasionally trots around in the yard (if Tim carries him down the stairs or I walk him around from the front), rolls over for more tummy pets if the human sitting next to him gets distracted, and jockeys for position under the high chair when scrambled eggs are falling from the sky. Perfect? No. But good enough. He may not live to next summer, but at the moment, he seems to still be enjoying being a dog in our house, particularly now that his people are lavishing extra attention on him.

Missing the point

A New York Times article about people picking and choosing which prescriptions to fill was interesting.

AHEM. I never give medical advice. I'm not that sort of doctor! If any of this sounds like medical advice, well, it ain't.

Obviously, it really stinks that someone would be forced to choose between needed medicines and groceries, but then I started looking at the specific drugs given as examples. Here's what's specifically listed.

Lipitor is a statin. It is on patent for several more years, and so it is expen$ive. (About $100/month, depending on dose.) But Lipitor is just one of many me-too drugs. A very thoroughly marketed me-too, but not necessarily anything special. There are other options on generic statins, and it isn't hard to find a pharmacy doing $10 for 3 months of generics. (Walmart, Target, others...) And statins are good candidates for pill-splitting, which could lower the cost even further. (Pill-splitting is where the doctor prescribes tablets at twice the strength and then you take half tablets, which means that "90 days" of pills actually lasts 180.)

Provigil is under patent under bizarre circumstances, but I can't reconcile the numbers in the NY Times article. ("costing $1,695 every three months") with what I'm seeing. It is usally taken once daily, and I show a 90 day supply (mail order) running about $750 for the higher of the two available doses. (That means that if it can be split, that $750 could actually buy a 180 day supply if she doesn't need the higher dose, but I'm not sure if this one is actually safely splittable.) $250/month or $125/month (if split) is still a mighty big number, but it doesn't rival $1695 per 3 months!

Unfortunately, all the other examples aren't specific about the drugs involved.

Do I have a point here? Yes, actually I do, and here it is:

Some of what makes prescription drugs ghastly expensive is crappy prescribing habits. Doctors have almost precisely zero motivation to prescribe the cheaper generic, since they don't pay for the prescription. Doctors get hounded by drug reps to prescribe what they're touting as the newest, latest, greatest drug, when often there's something equally good (and with far more safety data) already available off-patent.

Too bad the NY Times missed the opportunity to discuss what patients could actually do if they find themselves on unaffordable drugs, besides not filling prescriptions. The Consumer Reports health site has a bunch of information on cheaper alternatives.

While I'm ranting about the pharmaceutical industry, let me point out this article about sampling, and how it harms patients, and this one about kids and free samples. The basic gist is that free samples are only available for drugs on patent, which means that if your doctor "saves you some money" by giving you some samples today, you're going to be paying much more when you finally do fill the prescription for the drug you've started taking as samples.

I think we ought to have universal health care and real prescription drug benefits (with none of this doughnut hole cra-penguin), but any solution is going to have to address this disconnect where the person who decides what to prescribe has no incentive to keep costs down.

OK, now I'm done ranting. Time to grade some more papers.

He dressed himself...honest!

Dalton has strong opinions about lots of things. I have two general rules for acceptable behavior.

1. The activity must not be inherently dangerous.
2. The activity must not have a high probability of resulting in a claim on our home owner's policy.

If a proposed enterprise meets the two criteria above, I generally go along with it. Of course, there are exceptions. There was the cluster of days where Dalton was throwing fits when Mommy or Daddy mixed yogurt with fruit (our meals, not his). There are also schedule restrictions. We need to get to work and he needs to get to school by a certain time. We also need to get home by a certain time to let dogs out.

The picture above is an example of Dalton getting what he wants. We finished up with a bath that started when he insisted he needed to wash his beach ball. After, I was trying to get him to put some clothes on. I was pleasantly surprised that he was interested in putting on clothes. He was, however, also interested in picking out the clothes on his own. One iteration on the way to this outfit involved putting a shirt over the overalls. Unfortunately, that fashion statement was not long for the world and this is where we ended up before bedtime.

This is not a good year to be a dog in our house

Tim took Sam to the vet today. Sam's been limping worse than usual for a week or so, and his wrist was swollen. I figured it was his arthritis acting up, but the vet's pretty sure it is actually bone cancer. They don't see metatheses on the lung x-ray, but 90% of bone cancers in dogs have already micrometathesized upon diagnosis.

So we're going to get to make some fun decisions about treatment.

We can do nothing about the tumor and put him down in the very near future, since the vet doesn't think she can adequately control his pain without amputating.

We can have the leg amputated, which will resolve the leg pain and may get Sam four good months (average, damn statistics), but won't do anything for the metatheses that are likely already present and will ultimately kill him or lead us to having him euthanized. I have some serious doubts about whether or not he can manage to get around ok on his three other legs, given that he's got some arthritis in what would be the remaining foot. I'm trying to remember as I type this if it is the "good" front foot or the "bad" one that he'd have left. He's babied one leg, I think the one without cancer, for several years now, so he'd have to carry his full front weight on one gimpy front leg if we go this route. What if we put him through the amputation, only to end up deciding that his quality of life is too poor?

We can amputate and do chemo and have a life expectancy of about a year, but with some number of days spent at the vet receiving chemo, and some number of days feeling sick from chemo. Sam is spazzy when we've kenneled him. He's the reason we've always hired pet sitters, ever since the kennel I used to take TY to (when he was an only dog) told me not to bring Sam back. I'm having a hard time picturing him being happy confined at the vet for a whole day and night every few days. We'd also have a hard time schlepping him back and forth to the vet, given the realities of jobs with late hours and a car that doesn't easily hold a toddler and a dog simultaneously. Sam has previously demonstrated just how much damage a dog with intestinal distress can do to a house.

I'm reading this and thinking how shallow it sounds to say chemo's too expensive or I can't be bothered to do the vet appointments and deal with (and clean up after) a neurotic, arthritic dog trying to figure out how to walk on three legs, but regardless of what we do, we're looking at a life expectancy of a year at most.

*sigh*-

I may be too jaded and cynical to teach this course

So I'm gearing up to teach two general-interest courses. One, in May, on the drug approval process and pharmaceutical industry. The other, possibly some time next year (but I'm at a workshop to develop it this week) on "medicine in america", or whatever the title morphs into by the time I actually teach it.

Have I mentioned that I don't actually trust doctors a whole heck of a lot? It may be an interesting course. As you might guess from the book list on the left, there's a certain large amount of jaded skepticism going into my course planning - and my copy of "Pushed" hasn't even arrived yet!

Singing the ABCs

So Dalton has become very good at singing the ABCs. Actually, he probably has 30+ songs that he sings, at least half of which we recognize. Since I've been working on uploading the old pictures of him walking, it seemed like time to update our video collection. Here's my first attempt:


And my second attempt:


And then it got really silly (ABCs with the tongue out, while being fed cheerios, anyone?)



Other than totally failing to take any decent video, we had a nice day today. We took the usual Baby Dal whirlwind tour of the coffee shop, playground, and library (on foot, with D in the backpack for most of it), and now D's conked out taking a nap, at least for the moment. Time to grade some chemistry quizzes....

(Want to see those old videos? Click the "multimedia" link at the bottom of the post.)

Whoa, what's a boobie shot doing in my WORK mailbox?

I get several magazines at home (Mothering, New Beginnings) that often include pictures of nursing babies, but was surprised to see one in my work mailbox today. C&EN was running a story on breast milk composition as their cover story. I wonder if they'll take flak for the image. Story here: http://pubs.acs.org/subscribe/journals/cen/86/i39/toc/toc_i39.html

Aside: it occurs to me as I write this that this isn't an especially little baby, either. Maybe I'm getting my money's worth out of C&EN after all...

Voting Obama, but not a yippie?

A friend just posted this list, of things Obama supporters are supposed to do/like:

Your exercise regimen involves trail running.
You like burgers made from grass-fed local beef.
You use Sugar in the Raw as a sweetener.
Your favorite supermarket cookie is a soft chocolate chip.
Your fast food restaurant of choice is Panera Bread.
You shop at your local farmers' market.
Your shopping cart includes the following products:

• Bear Naked Granola
• Lara Bar energy bars
• Olive Oil
• IZZE Sparkling Juice drinks
• Wolfgang Puck All Natural frozen pizza
• Kettle Chips

We're at 2 for 12 on that list. (Olive oil and Panera.) We might make 3 for 12 if the "local" farmer's market at home weren't 20 minutes away and closed about when we can manage to get moving on Saturday mornings, but since we never make it to the one in Salem, which is blocks from work, I guess we don't get a pass on it.

But we're voting for Obama, really! Honest! It's just that our grocery store cart contents are weird-looking.