ALCON: The Botox has worn off, and I have two more weeks until the next treatment. I’m back to spending my days strung out on the couch. Blog posts will most likely be scarce for the next few weeks.
Author: Crew Dog
Desert Storm era veteran. SAC trained warrior.
Book Review: The Simple Path to Wealth
As a certain TV show used to say, “And now for something *completely* different!” Not only is this the first book review on this blog, but the book is about Money, not Health.
Rest assured, there is a method to my madness (at least, that’s what I tell Spousal Unit). Money is related to heath directly, such as when you can’t afford the healthcare you need, and indirectly. Indirect effects of money on health include the physical and emotional stress that comes from not having enough money to meet your needs, and the strain money problems can have on your relationships.
Therefore, I decided when I was a young lieutenant that understanding the world of finance and mastering my money was a critical life skill.
I started reading personal finance books in the early 90s: Your Money or Your Life, The Wealthy Barber, The Millionaire Next Door, The Tightwad Gazette, and the Bible of personal finance: Making the Most of Your Money, by Jane Bryant Quinn. Over the years, I put what I learned into practice. I started saving and investing. I tried to fight the impulses to buy (too many) cool toys, and the peer pressure to live an affluent (some might say hedonistic) lifestyle. I made a few mistakes, and I got smarter. I kept reading books and articles about personal finance. And then the internet happened.
In 2011, I started reading a personal finance blog – Mr. Money Mustache. That lead to other personal finance blogs: Early Retirement Extreme, The Military Guide, Get Rich Slowly, madFIentist, The Military Wallet, Root of Good, and many more.
And I noticed this guy, jlcollinsnh, in the comments section of many of these blogs. He was making comments that were insightful, with a wry sense of humor. I followed him back to his blog, jlcollinsnh, and I’ve been reading it ever since. In fact, it is my favorite personal finance blog (no offense, Nords!).
At the same time, and even prior to reading personal finance blogs, I was reading blogs about Simplicity and Minimalism.
I remember thinking, “If only there were a way to simplify personal finance”…
“Why can’t there be a simpler way to invest than holding a diversified portfolio of growth and value stocks, small-cap, mid-cap, large-cap, international, and sector stocks, short-term bonds, intermediate-term bonds, long-term bonds, and cash, spread across retirement and non-retirement accounts?”
JL Collins provided the answer: There *is* a simpler way to invest.
**Financial Independence is not incompatible with Simplicity.**
JL Collins gave me my financial freedom: I didn’t have to worry about asset allocation (Is this blended fund more growth or value? Do I have the right percentage of each asset class?). In fact, he blew my mind when he advised his daughter that she’d do quite well financially if all she ever did was live within her means and invest in just one fund. ONE fund??? Inconceivable!
But what I like best about JL is that he backs up his assertions with logic and data.
He “shows his work.” He doesn’t ask his readers to take his word for it. He explains how he reached his conclusions, and he welcomes challenges because he knows he’s not infallible and he just might learn something. He’s not the Oracle; he’s just a smart guy with a knack for explaining personal finance in a very accessible way, and he’s interested in having conversations with like-minded folks so that everyone can learn from each other and get smarter about our money.
That’s why I did a happy dance when I heard JL Collins was releasing his first book, The Simple Path to Wealth. [Disclaimer: I was sent an advanced copy of the manuscript in exchange for my honest review. JL doesn’t hustle his readers, and I don’t either.]
To be honest, I think it’s very difficult for authors to transition from a column/blog post format to a book format.
I loved Dave Barry’s newspaper columns, but was disappointed by a few of his books (although others were brilliant). I was slightly disappointed by Jenny Lawson (aka The Bloggess)’s first book, but feel she really hit her stride with her second book. (Read it. She talks candidly but humorously about health issues, including depression.) I will admit I felt that slight prickle of disappointment initially with JL Collin’s book, The Simple Path to Wealth, as well.
The first section (Part One) felt a bit meandering – not the usual tight, crisp prose I’m accustomed to on his blog. But perhaps this is because I am already well-acquainted with the financial fundamentals and philosophy he outlines in this section. If you are still learning the basics, and the whys and wherefores of personal finance, you may benefit from Part One much more than I did.
However, Part Two is classic Collins: the clear, no-nonsense financial advice that I recommend to others, because it is easy to understand and will get them to where they (presumably) want to be – Financial Independence. And it will get them there with a minimum of hassle.
Collins speaks with the wisdom of someone who has spent a great deal of time thinking about personal finance, and has learned some lessons through trial-and-error. And he shares his hard-won wisdom so that, if you will listen, you can avoid his mistakes.
Furthermore, he understands that most people want to save for retirement, but don’t want to (or are so busy they cannot) spend a bunch of time figuring out how to do it. In Jim’s words, “Financial geeks like me are the aberration. Sane people don’t want to be bothered. My daughter helped me understand this at about the same time I was finally understanding that the most effective investing is also the simplest” (p.111).
Collins continues, “Complex and expensive investments are not only unnecessary, they underperform. Fiddling with your investments almost always leads to worse results. Making a few sound choices and letting them run is the essence of success, and the soul of The Simple Path to Wealth” (p.111).
Read that again: “Making a few sound choices and letting them run is the essence of success, and the soul of The Simple Path to Wealth.”
You can simplify your life by simplifying your investments (including retirement accounts), and you’ll probably reach financial independence sooner than your peers with complicated investment strategies who spend a great deal of time, effort, and emotion fiddling with their finances.
Also in Part Two, Collins is one of the only non-military personal finance educators to actually cover the Thrift Savings Plan (TSP) in his discussion of retirement accounts. He highlights the often-overlooked consideration that TSPs *not* be rolled over to IRAs after separation from the military/civil service because the fees are so low – often lower than industry-leader Vanguard’s IRA fund fees.
He also includes a case study in Part Two. Case studies are always fun because you get to see the practical application of the theoretical. In other words, what does this advice translate to in real life? Go to Chapter 22 to find out.
Part Three contains more whys and wherefores. In Part Three, Mr. Collins discusses several hot topics and “shows his work”.
Finally, Part Four of The Simple Path to Wealth talks about what to do once you’ve reached financial independence. Many talk about how to save and invest to reach retirement/financial independence, but few explain what to do once you get there. This section talks about the nuts and bolts in such a way that you will feel confident you know what to do once you’ve “arrived”.
Afterword: Chapter 33 contains JL Collins’ blueprint for financial independence.
The Big Idea: “Over the years I’ve come across any number of people embracing life on their own terms. They are intent on breaking the shackles of debt, consumerism and limiting mindsets, and living free. They are filled with ideas and courage. This freedom, to me, is the single most valuable thing money can buy and it’s why I offer you the strategies in this book” (p.138).
[NOTE: This book is written for a general audience, not a military one. For military-specific financial advice, see these blogs: The Military Guide and The Military Wallet. And this book: The Military Guide to Financial Independence and Retirement. These resources discuss topics such as military pensions, SBP, TSP, VGLI, and many other military finance alphabet soup words. However, the basic information and the advice in The Simple Path to Wealth still apply to a military audience.]
Bottom Line: The Simple Path to Wealth is exactly what I hoped it would be: a solid financial reference book that I can confidently recommend to people who want to learn a simple, but effective, way to manage their money and to progress toward financial independence. I like the website, www.jlcollinsnh.com, because I still learn useful things about personal finance, despite having decades of experience. This is true of JL Collins’ book, The Simple Path to Wealth, as well.
Read this book. Get smart about your money. “Remember that nobody will care for your money better than you” (p.101). The Simple Path to Wealth will show you how to manage your money simply and effectively.
Health Hack: Travel First Aid Kit
When I was much younger, I travelled the world without a care. I took for granted that I would always be healthy. Then came the time that I got food poisoning (salmonella) on a trip. I had no first aid kit with me, and I didn’t know how to get medications in another country.
I had a two-day layover in the UK and no way to get even an aspirin – the hotel staff said it was illegal for them to give me any, not that they had any in the hotel. After a very miserable 48 hours (plus the interminable flight home), I decided to start taking some over-the-counter medications with me when I travel.
The list of remedies I pack has grown with subsequent experiences (an epic hangover in Russia led to the inclusion of an antacid, for example).
My travel first aid supplies currently include:
- A pain reliever/fever reducer (aspirin/Tylenol)
- A non-steroidal anti-inflammatory (NSAID; such as Ibuprofen/Alleve)
- An antacid (Pepcid/Rolaids/Tums)
- An anti-diarrheal (Imodium)
- upset stomach medicine (Pepto-Bismol)
- sleep aid/jet-lag remedy (Melatonin)
- decongestant/expectorant
- cough/sore throat lozenges (Cepacol)
- a travel thermometer
- tweezers
- alcohol swabs
- band aids
You could also include an anti-histamine (Benadryl). [Update: having had my first allergic reaction, I am adding Benadryl to my kit.]
If you know you will be walking or hiking a lot, you might also want moleskin and an ace bandage. Depending on local conditions, you may also want to include some travel toilet paper (think MRE TP, but commercially available).
[NOTE: Brand names are included for familiarity. I buy bargain-sized generic versions of these drugs whenever possible.]
[NOTE: When possible, I buy these drugs in blister packs. I can take a few sheets of the blister packs with me, instead of an entire bottle, to save weight in my bags.]
[NOTE: I don’t include polysporin because of TSA liquid/gel restrictions. Soap and water and alcohol swabs are usually sufficient. You can include polysporin if you place it with your other liquids for screening, and if the container is 3 ounces or less.]
[CAUTION: Do not mix aspirin and NSAIDs. It can cause stomach ulcers or other problems.]
[CAUTION: Medications which are over-the-counter (uncontrolled) at home may not be uncontrolled in other countries. For example, Melatonin is only available by prescription in Australia.]
In addition to my travel first aid kit, I always take a bottle of Afrin nasal decongestant spray with me when I fly.
It is a very bad idea to fly with a head cold, but sometimes you don’t realize you’re coming down with a cold until you have trouble clearing your ears on descent. Afrin can help relieve congestion, which should make it possible for you to clear your ears (equalize the pressure). If you cannot equalize the pressure, you could rupture an eardrum. This is why I always carry a bottle of Afrin in my carry-on luggage, just in case.
Even better than having remedies with you when you travel is to avoid needing them in the first place.
I will talk about ways to maintain your health while traveling in another post.
[DISCLAIMER: All information is provided for educational purposes only. I am not a trained healthcare provider or medical expert. Use common sense, know what works for your body, and if you have any questions, consult with your healthcare provider. Many medications, including over-the-counter medications, are contraindicated for patients with specific health conditions. Do not take a medication if it is unsafe for you or may aggravate other health conditions you have.]
CALL TO ACTION: If you currently do not travel with a first aid kit or over-the-counter remedies, I encourage you to assemble a kit before your next trip, TDY, or deployment. You don’t need a fancy container – I keep mine in my toiletries bag.
What do you pack in your travel first aid kit?
Medical Procedures: What It’s Like to Undergo a Sleep Study (Polysomnogram)
“So, why are you here?,” the technician asked me. “My spouse says my snoring is pretty bad,” I responded sheepishly. The technician laughed. “That’s the number one reason we see people here. If it weren’t for spouses, a lot of people wouldn’t realize they have a problem.”
Well, I didn’t think I *had* a problem, but Spousal Unit did not agree. A discussion with my PCM led to a consultation with a sleep doctor, who decided a sleep study was in order.
I arrived for my sleep study one evening after dinner. I was told to bring my pajamas, toiletries, any medications I normally took, anything that was part of my normal night routine, and clothes for the next day. I was also told that I could bring my own pillow if I wanted.
In preparation for the sleep study, I was told not to have any caffeine or alcohol after noon on the day of the study, since caffeine and alcohol can disrupt sleep patterns.
[For more information on preparing for a sleep study, see this article from the UCLA Sleep Disorders Center.]
A technician showed me to my room, which was something between a hospital room and a hotel room. It had a linoleum floor, industrial fluorescent overhead lighting, a double bed, nightstand with lamp, dresser, television, and private bathroom.
The technician explained the sleep study procedures and asked if I had any questions. Then he told me to change into my pajamas and do my evening routine to get ready for bed. He told me to open my bedroom door when I was done, and he’d be back to get me hooked up to the monitoring equipment.
When he returned, the technician placed electrodes on my face (including the corners of my eyes) and scalp. The electrodes have sticky backs, and attach directly to your skin/scalp. The electrodes are connected by a tangle of individual wires to a relay that sends electrical signals from your brain and muscles to a computer. These electrodes monitor various aspects of your sleep.
Next, the technician fastened bands around my chest and abdomen to measure breathing. Then he attached a clip to my finger to measure the level of oxygen in my blood and monitor my heart rate. (You’ve probably seen this clip before at your doctor’s office or in a hospital room – I call it the E.T. finger because it glows at the tip.)
None of the monitoring equipment was painful or particularly uncomfortable – it was just incredibly awkward.
Two sleep study warriors wired up for their studies:
After the technician got me all wired up, he gave me a call button in case I needed to summon him and told me to get comfortable, watch a little TV or read, and try to go to sleep around my normal time.
If I needed to go to the bathroom, I was supposed to summon him, and he would come and unplug some wires so I could get to the bathroom. Everything would remain attached to me (electrodes etc.), so it would be a fairly simple process to disconnect and reconnect a few connections.
After he left, I watched TV for a while, then turned off the TV and the lamp and tried to sleep.
I know veterans are supposed to be able to sleep anywhere, but I have never been able to sleep lying flat on my back. I can sleep sitting straight up, I can sleep on top of a cargo pallet in the back of a C-130, and I even fell asleep standing up once, but I cannot sleep lying on my back. This was a bit of a problem, since I had all of the monitoring equipment hooked up to me, which made it difficult to sleep on my side, and impossible to sleep on my stomach.
To make matters worse, I was hyper-alert because I was sleeping in a new place, with lots of unusual noises, and I knew I was being monitored via a video camera. Try sleeping while someone is watching you.
At one point I heard some commotion in the hallway – I found out later that one of the other patients had been sleepwalking. How they managed that with all the equipment hooked up to them, I do not know.
Several times during the night the technician came over the intercom and encouraged me to try to sleep. I must have fallen asleep eventually, because he woke me up in the morning and said it was time to go. I asked if I had had a long enough sleep-cycle for him to get sufficient data, and he said just barely.
The technician disconnected and detached all of the monitoring equipment and left the room. I took a shower, got dressed, packed up my gear, and was shown out of the sleep center.
Once all of my data was processed, I had a follow-up appointment with the sleep doctor. The sleep doctor informed me that I have sleep apnea, and that I needed to remedy that by sleeping with a continuous positive airway pressure (CPAP) machine.
This diagnosis meant that I had to return for a second night at the sleep center, to determine what CPAP machine air pressure settings would alleviate my sleep apnea. Oh joy.
The second visit was pretty much like the first. Because I had had trouble sleeping the first time, they gave me a room down a dead-end hallway, which had less traffic and was darker and quieter than my first room on the main hallway.
This time, in addition to all of the monitoring equipment, I also had to wear a CPAP machine mask. The mask allows the machine to provide pressurized air through your passageways in order to keep your airway open and provide enough oxygen to your lungs while you sleep.
I had tried on several types and sizes of masks during my follow-up appointment with the sleep doctor, and we had settled on a specific type and size. The technician had this type and size mask ready for me to try the second night, as well as some others if the first mask didn’t work well for me during the second sleep study.
The technician adjusted the mask straps and fitted it for me, then showed me how the CPAP worked. Like many of the newer CPAP machines, the one I used that night had a “ramp” feature that lets the air come through the mask at a lower pressure, and then gradually increases the air pressure to your prescribed setting.
This gradual increase usually takes about 15 minutes, and is supposed to give you time to fall asleep as you gradually adjust to the pressure. If you have not fallen asleep by the time the machine reaches full pressure, and it is uncomfortable for you, you can press the ramp button, which will drop the pressure and start the gradual increase again.
The purpose of this second night was to determine at what air pressure my sleep apnea symptoms would be alleviated. This meant that the technician would try various settings, and then I was supposed to fall asleep and the technician would see if the setting worked.
I got even less sleep the second night than I had the first night. In addition to the awkwardness of all of the monitoring equipment, I now also had a mask strapped to my face with straps that went across my cheeks and over the top of my head. The mask forced air through my nostrils, and the air flowing through the hose made noise. It was nearly impossible for me to sleep with all of this stimuli.
A few times I dozed off and then the machine reached full pressure, which startled me awake. By the end of the night, the technician was frustrated (although he wasn’t rude about it). He said he barely had enough data to be able to calibrate the machine, but called it good enough. None of us wanted to try that again on a third night.
As before, the technician removed all the equipment, and I got dressed and left. I was glad I didn’t have to work the day after the second sleep study, because I was wiped out.
Results: As a result of my sleep study, I was diagnosed with sleep apnea and prescribed a CPAP machine for home use. The mask was fitted for my head, the machine’s air pressure settings were adjusted for my required level, and I was told to sleep with this machine every night for the rest of my life.
Do you sleep with a CPAP machine? Have you found a way to make peace with it? Any hacks to make it less awkward? Please share with us below.
Health Hack: How to Select Properly-Fitting Eyeglasses
Long ago, when I was young and had better than 20/20 vision, I sat in a briefing room for training day and the flight doc announced to us all that, despite our current acute vision, we would all need reading glasses someday – probably by the time we were forty. Most of us, including me, scoffed. “No way! My eyes are great. *I’ll* never need glasses!”
Sadly, the flight doc was right. Just before my 39th birthday (didn’t even make it to 40 – bogus!) I started needing longer arms to read things. Teenagers would bounce up and shove phones in my face to show me something, and I’d have to make them back up. Whippersnappers!
I didn’t want to start wearing glasses because I didn’t want the hassle. And I only needed them to read up close. Solution?
I remembered a Marine aviator from my impressionable youth who used to brag that he just bought “cheaters” at the drugstore.
So I went to my local superstore and tried on the sample glasses by the pharmacy to find the right magnification, and bought a multi-pack of those magnifying reading glasses. I don’t remember if they were one-size-fits-all, or if they came in small, medium, and large sizes. I just opened one of the (resealable) packages, tried them on, and decided the fit was ok.
I put a pair on my desk, a pair in my pocket, and a pair in my vehicle, and that solved my problem for several years. They didn’t look spectacular (ha!) but they did the trick. They tended to slide down my nose a bit when I was reading for an extended period of time, but they were cheap and easy.
The cheaters solved my problem for several years, but my near vision gradually got worse. Eventually people started to get blurry at conversational distances. They started to feel like “close-talkers.” I’d try to casually back up so they weren’t blurry any more, but they’d close the distance. Can’t do that dance for long without looking like a freak.
Since I now needed glasses for more than just reading, I decided it was time to start wearing glasses full-time. I went to the optometrist and got my prescription, but of course Tricare doesn’t cover eyeglasses. So I went to a local eyeglass store and got totally screwed. In the interest of blog length, I will spare you the gory details. Let’s just say I wound up several hundred dollars poorer with a pair of glasses that didn’t fit correctly, didn’t solve my vision problems to a satisfactory level, and, therefore, didn’t ever get worn. I went back to my cheaters.
My first pair of prescription eyeglasses are still rotting in a desk drawer.
Life went on, and I made due with the cheaters for a few more years. My near vision continued to deteriorate, but Tricare will only pay for an optometrist visit every two years so I had to wait. Two-plus years later, I got my new prescription and decided to buy new glasses from a membership warehouse. I figured the glasses would be cheaper there, and they wouldn’t try to pressure-sell expensive designer frames to me.
I went to the membership warehouse and was shown a couple of frames that were reasonably priced and looked decent. My optometrist had suggested that, instead of trying to make one pair of glasses work for everything (a tri-focal progressive lens), I get two pairs of glasses – one for computer work and reading, and one for everything else (both bi-focal progressive; one mid & near distance and one mid & far distance). The salesperson suggested I get two different styles of frames, so I could easily tell them apart.
For less than I paid for my first pair of prescription eyeglasses at an eyeglass store, I got two pairs of prescription glasses from the membership warehouse. Unfortunately, neither of them fit. After several months of returning my glasses to the warehouse for adjustments, I spent a day researching eyeglasses fit (see previous post, How Many People’s Jobs Do I have to Know How to D0?). I learned quite a lot.
I had repeatedly told warehouse employees that my glasses felt too tight on my nose. They responded by adjusting the glasses’ arms/temples, repeatedly. Did you know that glasses come in different bridge sizes (as in, the width of the bridge of your nose)? I didn’t. Apparently they didn’t either.
I learned I had frames that were ~2-4mm too small across the bridge. The temples, that I had repeatedly suggested were too short, were at least 5mm too short.
Armed with my newly acquired knowledge of frame fitting, I returned to the membership warehouse. The pair of glasses that fit least-badly were finally adjusted to my satisfaction (more or less). The other pair (with a smaller bridge size) were returned, and I selected a replacement pair with a wider bridge and longer temple pieces. I would have preferred to return both, but that was the best compromise I could get. (Initially they were refusing to replace either pair.)
How can you avoid my mistakes? Knowledge!
Although I am not endorsing this company, this page provides a decent overview of eyeglasses frame measurements/fit. Unfortunately, none of the websites I could find had information on how to determine your eyeglasses size if you didn’t already have a pair of glasses. One recommended I use a ruler to determine the width between my temples, which would give me an idea of total frame width. Others recommended I just go to a store and try a bunch on.
It turns out, when Spousal Unit got glasses for the first time, the technician used calipers to measure Spousal Unit’s various facial dimensions. Spousal Unit’s first pair of glasses fit perfectly. Go figure.
Eyeglasses frames are typically labeled with their dimensions: the lens width, bridge size/width, and temple length (in that order). These dimensions look like this: 52 [symbol that looks like a hollow square] 18 140. The dimensions may be on the temple piece (arm) or the bridge. Sometimes the first two dimensions are on the bridge and the temple length is on the temple piece. They might even be on the ear piece! For examples of what you’re looking for, see here (again, not a product endorsement).
Lens width (aka eye size) is the horizontal width of the frame’s lens (in millimeters). Lens width typically ranges from 40-62mm. This dimension is given for one lens, so you must double this and add bridge size and end piece size to get total frame width. [The end piece is the part of the frame that connects the outer edge of the lens frame to the temple/arm.]
Bridge size is the distance between the closest points of the two lenses (in millimeters). This is the space where your nose goes. Bridge size typically ranges from 14-24mm. Temple (arm) length is measured along the length of the temple from one end to the other and also includes the bend. Temple length typically ranges from 120-150mm, but often only by multiples of five (130, 135, 140, etc.). It is important to have enough length so the temple sits horizontally and does not tip up over the ear.
Lens height is often not labeled on eyeglasses frames, but may appear as the last number of the sequence. It is the height measured vertically from the top to the bottom of the lens. Lens height is important for bi-focal or progressive lenses as there needs to be enough area for the multiple parts of the prescription.
Once you get a pair of glasses that actually fits, write down the dimensions! (The printing may wear off your frames over time.)
When you shop for your next pair of glasses, make sure you select a pair that is +/- 2mm for the lens width, +/- 1mm for the bridge size, and +/- 5mm for the temple length (different styles may fit a bit differently).
If you are concerned about your cosmetic appearance while wearing glasses, it is recommended that your eyes be nearly centered within the width of each lens. This site (again, not a product endorsement) gives more information on fitting glasses for various types of faces (close-set eyes, wide face, etc.). In particular, their information on bridge location was very useful to me. You can also google information about face shape and corresponding frame shapes.
I’ve settled for a look I call “Goofy as hell, but at least I can see and I’m not in pain from glasses that are too small.” I think it’ll catch on. #trendsetter #form_follows_function
How to be attractive: I still don’t know. I think I’ll just hide Spousal Unit’s glasses.
Have you figured out how to procure glasses that fit, are attractive, and don’t cost an arm and a leg? Please share your knowledge with us. I need all the help I can get.
Medical Procedures: What It’s Like to Have Medical Botox Injections
In my experience, this was one procedure it was best not to think too much about ahead of time: having a 30 gauge needle stuck repeatedly into your head in order to inject multiple doses of neurotoxin.
Most people think of Botox as a cosmetic procedure that reduces wrinkles. But Botox is used medically to treat several conditions, such as repetitive neck spasms (cervical dystonia) and chronic migraines. Botox injections work by weakening or paralyzing targeted muscles or by blocking specific nerves. Although scientists still don’t know exactly how Botox works for chronic migraines, according to The Migraine Trust:
A recent US study by Rami Burstein et al using animal models suggested that botulinum toxin inhibits pain in chronic migraine by reducing the expression of certain pain pathways involving nerve cells in the trigeminovascular system…
Unlike many of the other conditions in which it is used, it is not thought to work by relaxing overactive muscles.
In my case, the Botox injections were prescribed to treat chronic migraines (more than 15 headache days per month) which had not responded to any prescribed medications.
Since I was a bit apprehensive, I did research prior to the procedure, and watched several YouTube videos about the procedure, which made me think a little too much about needles going into my scalp and face.
I couldn’t find a good video that demonstrated the procedure for patients – most of the videos are either commercials for the product, technical demonstrations for healthcare professionals, or patients talking about their experiences. This video is a technical video produced for healthcare professionals, but it gives you a good idea of the procedure:
My treatment began with me lying on my back on the examination table, and receiving injections in my forehead, temples, and scalp. After that portion of the treatment was done, I was asked to sit in a chair and put my head on a pillow on the exam table. (My arms were crossed, and my head was resting on them, like in the elementary school game of Thumbs up, 7-up.)
While I was sitting in the chair, injections were administered to my scalp and trapezius muscles.
Unlike in the video, my provider did not use ice packs to numb the injection sites. Some of the injections stung a bit as the Botox went in, but they didn’t hurt as much as some of the patients on YouTube had said they would. Also, some of the injections were more painful than others. For me, the injections in my left temple and behind my left ear were the most painful. That’s the side on which I get most of my migraines, so the nurse practitioner figured those nerves were hyper-sensitive.
One of the injection sites on my face bled onto the pillow a little bit when I was getting the injections to the back of my scalp, and the injection sites were a little bit red and swollen for about an hour after the injections, so I kind-of looked like I had hives (or bee stings?).
But the staff was very careful to follow sanitary procedures, including cleaning the sites with antiseptic and treating the site that bled with clean gauze.
Also, I had no negative reactions to the Botox, so it turned out to not really be a big deal at all, and my apprehension was for nothing.
The entire procedure took about 20 minutes, and the effects should last for about 3 months. Botox injections are not a cure for migraines – they are a treatment, meaning that they don’t fix what’s wrong; they only treat the symptoms. If the injections work to lessen my migraines, I will have to continue getting injections once every three months for the rest of my life.
After injections, results are typically felt within 3-4 days. However, studies show that most people do not experience the full effect until 6 months of treatment, which would be after the second or third series of injections.
(In other words, like other treatments, Botox for chronic migraines doesn’t work for everyone.)
Potential Side Effects of Botox treatment: Pain, swelling, or bruising at the injection sites. If the person administering the shots isn’t careful to avoid certain muscles, you could have a drooping eyelid – or be unable to hold your head up – until the Botox wears off.
NOTE: Even though the injection sites might feel a little weird (slightly swollen, numb), it is very important not to rub the injection sites, as this can cause the toxin to spread outside of the designated areas.
[For more information on Botox, see this 2009 New York Times article. Note that Botox has been approved for chronic migraine treatment subsequent to this article.]
Have you had medical Botox injections? What was your experience with them? Please comment below.
Update: One week after Botox
Still having debilitating migraines, but I’ve started to feel a little bit better. Still very light-sensitive. Less motion in my forehead muscles – can still make a Spock eyebrow, but the eyebrow doesn’t go as high. Slight furrow when I frown. Shoulder tension noticeably reduced; able to activate shoulder muscles that had been constantly tense. Puffy eyes.
Update: Two weeks after Botox
Still having debilitating migraines, but also a few productive days. Still very light-sensitive. Very little motion in forehead muscles – can’t make a Spock eyebrow anymore. Almost no motion when I frown or try to look surprised. Shoulder tension noticeably reduced, with better range of motion of shoulder muscles. Eyes still very puffy – but not drooping.
Update: ~ Nine weeks after Botox
My provider had informed me that, for some people, the effects do not last the full 12 weeks. For these people, he said, Botox wears off a week or two before the next treatment. For me, the Botox wore off 2 1/2 to 3 weeks before my next treatment. My migraines returned with a vengeance, like they were making up for lost time. While I appreciated the reduction in migraine symptoms and migraine frequency for nine weeks, having them return and knowing there’s nothing I can do about it for nearly three weeks until the next scheduled treatment sucks.
[The FDA approved Botox for migraine treatment at a 12 week interval, so even if it doesn’t last the full duration, the provider cannot shorten the interval.]
Health Hack: Evening Checklist
It’s easier for me to run my nightly health and hygiene routine without needing a checklist, since I’m a night owl, not an early bird, and since there’s less to the night routine. However, on a bad day all bets are off.
So, in the interest of symmetry, and since early birds (or off-their-game night owls) might find it helpful to use checklists at night when they’re tired and thinking less clearly, I have also created an Evening Health Checklist:
Evening Health Checklist – One Sick Vet
Again, feel free to print it out and use it, or create your own.
What will you do to hack your health today?
[In case you missed it, the Morning Health Checklist is here.]
Managing Your Own Healthcare: How Many People’s Jobs Do I Have to Know How to Do?
My personal Tricare experience: I have received several years of harmful care, after decades of inadequate care, from Tricare.
Recently, my soon-to-be-former PCM defended his negligent/health-threatening care by telling me that I had not been aggressive enough in managing my own care. I countered that aggressively managing one’s own healthcare is very difficult when one has a chronic debilitating condition (especially a condition that affects one’s cognitive abilities).
But today I’m having a good day, abilities-wise, so let’s talk about fighting fire with fire. You want me to aggressively manage my own healthcare? Look out, buddy, you just summoned a pissed-off veteran, and you’re about to regret it very, very much.
A friend of mine has a saying about dealing with others, especially those who work in any area interacting with clients/customers. When encountering roadblocks in daily life having to do with the ignorance, apathy, or incompetence of others, my friend asks exasperatedly, “How many people’s jobs do *I* have to know how to do???” (Meaning, since you can’t do your job correctly and give me the information and assistance I need, I will have to learn all of the information, procedures, laws, regulations, etc. myself in order to get the result I need.)
We have decided that the answer to this question is “ALL of them.”
ALL of the People. ALL of the Jobs.
To be fair, there are some *awesome* people in this word who like their jobs, know how to do their jobs well, and like helping others. When these magical unicorns cross your path, you do whatever you can to make them stay in your life, and you let them know how appreciated they are.
For the Non-magical-unicorn days, which is most of them, you learn how to do ALL the jobs.
Alright, soon-to-be-former PCM, you want me to aggressively manage my healthcare? You got it.
Today I visited a Tricare Patient Advocate. I walked in to the largest MTF near me, went to the information desk, and asked for the Tricare Patient Advocate and they hunted around until they found one, who came out and spoke to me face-to-face.
[I had previously located a Tricare Patient Advocate email address for a local advocate. I emailed in November, and am still waiting for a response over five months later. (Not the same advocate as the one I spoke to today.)]
The Patient Advocate gave me the contact information for the DoD’s Interactive Customer Evaluation (ICE). I am going to contact ICE and provide “customer evaluation” on the negligent care I have been receiving, such as waiting 27 months for an MRI/Arthrogram of my wrist, even after I specifically told my soon-to-be-former PCM that my shoulder orthopedic surgeon suspected that I could have a torn ligament in my wrist, and then requested that my PCM submit a referral for an MRI and Arthrogram, which he did not do.
I will tell them that I gave up on ever receiving the care I needed from Tricare, and instead requested an MRI/Arthrogram from the VA, which I received within 6 weeks and which confirmed that I have *two* torn ligaments in my hand/wrist.
There are a few other things I will discuss with ICE about the inadequate care I received from this PCM…
But, next, after speaking to the Patient Advocate and confirming that my PCM did submit a request for referral to a wrist orthopedic surgeon after I confronted him with the results of my (VA) MRI/Arthrogram, I went home to aggressively manage my referral.
I called my Tricare region’s customer service number. I never reached a human being. (ALL of the People. ALL of the Jobs. ALL of the Computers?) I chased menu options long enough (15-20 minutes) to figure out that I would not get the level of information I needed from a machine.
So I bit the bullet and created an account on my region’s Tricare website. I had been avoiding creating an online Tricare account, given the government’s track record on protecting personal information. I don’t want my health information compromised.
But I needed access to the information, which I got after I created my account. I was able to see the referral letter and, most importantly, the authorization number.
There are several useful pieces of information on Tricare referral letters. If you keep reading past the name and contact information of the healthcare specialist to whom you have been referred, you will see this sentence: “This authorization is valid for the dates and service codes that follow on the back page.” Keep reading until you reach the dates and service codes. Make sure that your treatment takes place with the date range, and that you do not receive any treatments that were not authorized, or you will have billing problems with Tricare (as in, they may refuse to pay).
If you keep reading past that section, you will see a section titled “If You Would Like to Choose a Different Provider.”
Did you know that if you are not referred to an MTF, but are instead deferred to network, you can choose to see *any* in-network provider of the same specialty?
Also, as per the referral letter, “if your authorization number begins with a 7, you do not need to notify us of a change in provider.”
[Authorization numbers can also begin with a 4, in which case, you *do* have to get prior authorization to switch providers.]
***CAUTION: “You may not switch providers if you have already begun seeing a provider for the service authorized in this letter.”
Armed with that information, and all of the research I had done on orthopedic wrist and hand surgeons since my (very-belated) diagnosis, I called the office of the in-network surgeon I had selected, and scheduled an appointment for later this week.
This probably shaved several weeks off my wait-time, instead of waiting for the referral letter to come in the mail and then trying to figure out how to change providers.
The Patient Advocate also gave me advice on how to switch to a different PCM, given the current constraints of the system (patients being forced to use PCMs at MTFs only; no network PCMs; MTFs not accepting new patients due to being over-capacity). We decided it would be best to remain with my soon-to-be-former PCM until the wrist/hand surgery is complete, so as not to cause hiccups in the system. But I will be switching to a different PCM and a different MTF as soon as that is complete.
Meanwhile, I continue to receive excellent care for my other health issues from the local VA facility.
As far as resolving my issues with Tricare, I followed the chain-of-command, as well as rules of common decency. I tried resolving my inadequate healthcare issues first with my PCM, who got defensive and hostile. Then I went to the Patient Advocate. Next I will file an evaluation with ICE. I will also be completing an Army Provider Level Satisfaction Survey (APLSS). If I still don’t receive a satisfactory resolution, I will continue to pursue the matter (on the days my health permits me to battle).
I have no illusions that my PCM will change his methods as a result of these actions. He is impervious to feedback, and I’ve seen much worse healthcare providers remain in the military healthcare system, sadly.
The best I can hope for is:
- To insist I get the care I need for my health conditions and injuries
- To insist the providers of this care are highly competent
- To hold this PCM accountable for his negligent care by reporting it
- To provide helpful information to others who are dealing with similar situations
I suspect by the time I am done, my soon-to-be-former PCM will regret having ever told a pissed-off veteran to be more aggressive about their healthcare. Mischief, I mean Healthcare, Managed!
Medical Procedures: What It’s Like to Have an Echocardiogram (with “Bubble Study”)
Some things are scary. Like when your healthcare provider refers you for a procedure that involves bubbles injected into your veins and flowing through your heart.
I told my PCM the thought of it kind of freaked me out. She said it was perfectly safe. Just a routine procedure. No big deal.
So I went home and researched the procedure. I found an article from a reliable source that explained the procedure simply and thoroughly and assured patients that “The bubble study is extremely safe.”
And the rational part of my mind believed them. But some other, irrational, part of my mind kept thinking of all the TV shows in which the villain kills someone by injecting an air bubble into their IV. (Medical personnel hate Hollywood for this, by the way.)
I’m not the type to worry about things and get anxious, so I didn’t spend the days between the doctor’s visit and the bubble study obsessing about it. But I didn’t sleep very well the night before, and I was pretty anxious on the ride to the hospital. I did breathing exercises to try to relax, and, of course, cracked dark jokes about things Spousal Unit needed to know in case I didn’t survive. (Not sure Spousal Unit appreciated that.)
What ultimately helped me relax was talking to the tech who performed the bubble injection part of the procedure. She told me three reasons not to worry:
1) The saline solution is being injected into a vein, not an artery, and therefore there is less risk;
2) The bubbles are very small, and could not block a vein;
3) The bubbles go through your heart to your lungs, and your lungs handle them just like they handle every other gaseous fluid (bubble). That’s what lungs are made for.
In other words, your body knows what to do with the bubbles, and it’s no big deal.
That’s when the rational part of my mind won, the irrational part of my mind stopped freaking out, and I relaxed. More breathing exercises helped me release the tension as well.
So, what exactly *is* an echocardiogram? It’s basically just an ultrasound of your heart.
Most of us have seen an obstetric ultrasound on TV, where the technician looks at a pregnant woman’s fetus in the womb. The technique for an echocardiogram is pretty much the same – sound waves are used to get images of your heart.
But unlike an obstetric ultrasound, where the woman lies on her back, for a cardiac ultrasound you lie on your left side. This helps the technician get a better image of your heart.
My technician explained to me that the ultrasound cannot get images through your bones, so they have to manipulate the wand around all the bones in your chest, like your sternum (breastbone) and ribs. The ultrasound also cannot get images through air, so they have to avoid your lungs as well.
Since your heart is already off-set to the left of your chest, lying on your left side allows the heart to fall a bit further left, away from your sternum.
So, you take off your shirt and put on a hospital gown (open to the front), and the technician attaches some electrodes to your chest with sticky patches so they can monitor the electrical currents of your heart. (For a good overview of the entire procedure, see this Mayo Clinic article.) Then you lie down on your left side, and move your left arm up near your head.
The technician lubes up the wand (a.k.a. probe or transducer) and moves it around on your skin until they can get clear images of your heart. (The gel helps improve the conduction of the sound waves, and makes sure there’s no air between the wand and your skin.)
Since they are dodging your bones and your lungs, the wand can wind up feeling like it’s trying to dig under your ribs as the technician attempts to get the clearest image, which can be a bit uncomfortable. It’s not really painful, just a bit…insistent. This is another time when the breathing exercises can come in handy. Although it was rather uncomfortable a few times, I didn’t have any bruising afterward.
The technician takes a series of images from multiple angles, so they move the wand around and dig it in to new uncomfortable places to get the various images. This may cause them to re-apply more gel as well. My technician also asked me to take a deep breath, hold it, and exhale at various points in the procedure. (She only forgot to tell me to resume breathing once.)
I appreciated that the technician explained to me what she was doing as she was doing it, and didn’t mind me watching the monitor as she was working. An echocardiogram allows you to see the heart beating, and the heart valves opening and closing, and it’s fascinating to watch.
I particularly enjoyed watching the Doppler portion of the procedure:
The first part of the procedure took about 20-25 minutes, and then it was time for the Bubble Study (a.k.a. saline contrast study). My PCM ordered a bubble study because she wanted to determine if there was a hole in my heart.
In a normal heart, the bubbles that are injected for the test enter the right side of the heart through the vein and then go through to the lungs and are removed from the bloodstream before the blood circulates to the left side of the heart. If there is a hole between the right and left sides of the heart, the technician can see the bubbles flow through the hole to the left side, where they don’t belong.
Don’t Panic! The bubble study is less freaky than it sounds. Nothing is injected directly into your heart. (Also, if you do have a hole in your heart, and the bubbles leak though to the left side, it’s ok. Your body will still process the bubbles safely.)
A second technician came into the room, we had the conversation about bubbles and why they aren’t dangerous, and she inserted an IV line into my right arm (since I still needed to lie on my left side for the procedure). The IV line had a valve, so that the tech could start and stop the flow of the saline contrast solution.
The second tech told me that at several points during the bubble study, I would need to do a valsalva maneuver, but she described it as “the way you would bear down during a bowel movement”. Well, that’s not the way I learned to do a valsalva maneuver during aerospace physiology, so we had a conversation until I figured out that what they *really* wanted was an anti-G straining maneuver (except they wanted me to hold my breath during the maneuver, and not exhale in a big gust when they told me I could exhale).
With that cleared up, we proceeded with the bubble study. The first technician would signal that she was ready, the second technician would release a stream of bubbles into the vein near my elbow, and they would tell me when they wanted me to do the straining maneuver.
Then we would watch the stream of bubbles rush into my heart. The bubbles appear white on the monitor, and they are very obvious. Sometimes the second tech would massage my arm a bit to help the bubbles flow faster or something.
The saline bubble solution felt a little bit weird when it first went into my arm, but then I didn’t feel it anymore. The first batch of bubbles felt weird when it entered my heart – my heart seemed to flutter a little bit. But it didn’t hurt, and I didn’t feel it with the subsequent bubble batches.
We repeated the sequence four or five times, until there was no more saline solution, and the first tech was satisfied that she had all the images she needed. They were both very impressed with my straining technique. 🙂
Then the second tech removed the IV line, the first tech removed the electrode sticky pads, and they left me to wipe the gel off my chest and get dressed.
The whole procedure took about an hour, and I had no residual effects. Turns out, the bubble study really *was* no big deal.
Also, since having a hole between the two sides is congenital (something you’re born with), I’ll never have to have this procedure again. Once they’ve determined whether the hole is there or not, that doesn’t change and you never need to check again.
TL;DR:
Tired to the Bone
I try to be optimistic and proactive about my health. But some days I’m just tired to the bone.
Last week I had three medical procedures. One was a new treatment, and two were diagnostic. It may take days, weeks, or months before we know if the new treatment is having an effect. So I wait…
Meanwhile,
The diagnostic procedures revealed that I have been correct for the past 2+ years that there is something wrong with my wrist.
More than two years ago I fell violently on a wet ceramic tile floor. Ever since, I have been telling doctors and therapists that I have pain and malfunction in four areas: my scapula, my shoulder, my elbow, and my wrist.
Although my doctor ordered x-rays immediately after the fall, once those came back negative for broken bones she refused to send me for additional imaging (MRI/arthrogram). Nearly one year later, after I had “failed to progress” in physical therapy, my doctor finally sent me for a shoulder MRI/arthrogram, which revealed that my labrum was severely torn and would not heal without surgery.
By that point, nearly one full year after the injury, I was in severe pain and could barely do my job. Some days I left work early due to the pain, and I wasn’t getting much sleep either. I could sleep in one position on the couch, surrounded by pillows that held my shoulder in the least-painful position, but if I shifted in my sleep the pain would wake me up.
I was taking a strong NSAID and a narcotic, but that wasn’t enough to control the pain. I was getting pretty desperate for relief. For months I requested that my doctor refer me for pain management, but she refused.
Fortunately, once I received the diagnosis of the torn labrum (a.k.a. SLAP tear/SLAP lesion) things happened a little more quickly.
The story of how I selected my orthopedic shoulder surgeon is a saga for another post. But once I had authorization to receive care from him, I was able to see him a few days later (one month after the MRI).
At this point, I was desperate for relief, and I didn’t care if it cost me my job. I told the nurse I would take the first available surgery slot, and asked her to look for cancellations. She found a cancellation for the following week, which gave me just enough time to stop taking all medications, vitamins, and supplements and get them out of my system so they didn’t interfere with the surgery or the recovery.
I told my boss that I was having surgery the next week, and would probably be out for at least 6 weeks since I couldn’t drive with my arm in a sling. Although I was an hourly worker, and would not get paid while I wasn’t working, they didn’t fire me. They told me to get the help I needed and come back when I was better.
I had the surgery, and it was successful. The surgeon discovered that my labrum was completely severed, and he had to trim it, re-attach it, and anchor it to the bone. However, the biceps tendon was not torn, and the rotator cuff was not damaged either.
Even immediately post-surgery, the pain level was so much lower than before the surgery. I was able to stop taking narcotics after about two days.
I started physical therapy seven weeks after surgery. My surgeon wanted to give the labrum plenty of time to reattach to the bone and form a strong connection.
We noticed in physical therapy that I was still having pain and malfunction in the scapula, elbow, and wrist. My doctor and physical therapist wanted to give it some time, to see whether this would shake out as physical therapy re-trained the muscles to function as they had before the fall.
My surgeon said that if the pain and swelling in my hand and wrist had not gone down in three months, I should probably see an orthopedic wrist surgeon, as I might have a tear in my triangular fibrocartilage complex (TFCC).
Then a whole lot of life happened. Moved twice. Different states. New PCM. New PCM refused to refer me for MRI/arthrogram of wrist, which was still discolored, swollen, weak, and painful, but did refer me to a new physical therapist. Physical therapist wanted to try treatment first, but after I “failed to progress” with elbow and wrist function, PT agreed it was time to get diagnostics and see an orthopedic specialist.
Meanwhile, I had finally gotten my VA disability claim processed, and after a seven month wait for an appointment had finally seen a VA PCM. Since I had not been able to get my Tricare PCM to follow-up on the wrist, I asked my VA PCM to treat it. She sent me for x-rays immediately following our appointment. The x-rays showed my ulna was mis-aligned.
Less than two weeks after I saw my VA PCM for the first time, I had EMG and CNS procedures to determine if there was permanent nerve damage in my left arm/hand, and to determine whether the problem was due to a pinched nerve in my neck.
A few days later, I had an appointment at the VA hand clinic. The x-rays had indicated a problem in my wrist, and the examination at the hand clinic confirmed it, so the hand clinic referred me for a wrist MRI/arthrogram. FINALLY!
Three weeks later I had the MRI and arthrogram (post pending). It was more than two years since I had been injured, and more than a year since the shoulder surgery.
The arthrogram revealed not only that I have a TFCC tear, but also that I have a scapholunate (S-L) tear – two torn ligaments in my wrist.
Initially, I was happy to finally have diagnostic evidence to support the injury claims I have been making for the last two-plus years. And I was excited by the possibility that I could get the ligaments repaired and finally begin to heal.
But today I am just tired to the bone. I have to find a new orthopedic surgeon in the state where I now live. Someone I can trust to work on my wrist – a very delicate and complex part of the human body. Someone in either the Tricare or the VA system. And I have to get authorization 1) to consult with them and 2) to have surgery, if necessary.
Plus, I still don’t know whether I have a torn ligament or ligaments in my elbow. My physical therapist thinks that I do. But I haven’t been able to get Tricare or the VA to send me for diagnostics of my elbow yet.
On a better day, I will conduct more research on orthopedic wrist surgeons, and I will fight to get the referrals and the treatment that I need. On a better day, I will take positive action to resolve this injury.
But today I am tired. Today I will rest and regroup, so that I can resume battle recharged and equipped with knowledge.
Bottom Line: It’s ok to be tired. We all need rest. We all need self-care. Resting does not mean we are weak.
Lessons Learned:
- Keep fighting until you get the care you need. There will be good days and there will be bad days, but you deserve to be heard and to be treated.
- You don’t have to go it alone. Get a Patient Advocate, Case Manager, or lawyer to assist you.
- “If you haven’t got your health, you haven’t got anything.” I delayed my first round of physical therapy because I was busy with work and school. If I had “failed” PT sooner, I probably would have gotten my shoulder MRI sooner and my shoulder surgery sooner. I wish I had made my health more of a priority sooner. Problems don’t go away when you ignore them.
- Learn the administrative procedures. HMOs typically have set procedures for dealing with illness, injury, etc. PCMs have to follow the sequence when treating patients. Even though I knew I needed shoulder surgery, I had to “fail” PT first. It will do you no good to try to pre-empt procedures – you won’t get authorization to do things out of sequence. So find out the sequence and get it done so you can get to the end-state you need.
- Trust your gut. Various healthcare providers gave me various ideas on what might be causing my symptoms – only one of them was (partially) correct. I knew from the beginning that something was wrong with my wrist and that I needed imaging to find out what it was. You know your body better than anyone else. If you know something is wrong, keep demanding treatment until it’s fixed to your satisfaction.
- Watch out for wet freaking ceramic tile floors! Or any other slip, trip, or fall hazard – you don’t want to jack yourself up like I did.