A Dog Story

I am not in the habit of writing obituaries for dogs.  But some things you just can’t let go of.  Maybe it is because Thanksgiving is approaching, and Thanksgiving four years ago was the start of all this dog’s troubles, or maybe it’s just that the shorter days and longer nights give cause for contemplation, but today I am going to tell you a dog story.

In May of 2002, we lost our big male deerhound Timber quite suddenly.  He was found to have a rare cancer, a hemangiosarcoma, that arose from the left atrium of his heart, and his demise was swift and completely unexpected.  Although we had three other deerhounds at the time, I’ve never liked odd numbers and so I contacted a breeder/friend in Oregon and two months later we brought home Izzy, a four month old fuzzy gray puppy, who looked, with his proportionately small head, dark eyes, black nose and huge legs and feet, like nothing more than a gray lamb. The three adult deerhound females of the house, not to mention me and my teenaged daughter, doted on him.  Izzy grew up as the “man” of the dog yard and took his responsibilities seriously.  He kept everyone in line, and helped raise six puppies over the subsequent 10 years—two for his breeder back in Oregon when he went back there to be shown, and two more sibling pairs for me.  You don’t need to do a lot of obedience work when you’ve got a smart older dog showing the “young ‘uns” what to do.  He finished his championship easily at age two, got a beginning lure coursing title (although speed was not his forte) and then retired to do what he did best, guard the house, watch out for the kids, and keep the rest of us in line.  I’ll never forget how, one night on our “evening patrol”, he frightened a peeping Tom who was staring into my daughter’s bathroom window.  My screaming and his furious barking roused my teenaged son, who ran outside with his huge hunting knife ready to defend us.  He needn’t have bothered—one look at a giant hairy dog weighing well over 100 pounds was enough to ensure a quick flight over the fence for our unwanted guest.

Thanksgiving being what it is, we all overindulged four years ago and so when Izzy appeared to be having difficulty moving his bowels after the holiday, I chalked it up to dietary indiscretions until it became clear that something was dreadfully wrong.  Off he went to the vet, where sedation was administered and an enema was performed, revealing that the dog had developed perineal hernias which had weakened the pelvic floor to the extent that he could not perform his usual “duty.”  As the vet techs were getting him off the table, however, an accident occurred and they managed to dislocate this dog’s heretofore perfectly normal left hip.  Four anesthesias–a CT scan, two closed reductions and one open reduction/internal fixation which took six hours– later, I brought my big crippled dog home, still with the unsolved problem I brought him in with.  Twelve weeks after that, he had recovered from his hip repair sufficiently to undergo repairs of the perineal hernias, another complicated and painful surgery.  In between, I contemplated putting the big guy to sleep, but he was only six years old.  My veterinary surgeon came to the house and said, “This dog wants to LIVE.”

And live he did, quite happily, for another four and a half years, until we finally “did the deed” due to recurrent hernias.  Although he never fully regained his mobility, he loved to play with the new puppies I bought three months after his surgery, bounding after them with his awkward gait and lying belly up in the horse pasture while the puppies “attacked” him.  He never showed us how much pain he felt and he never met a stranger he didn’t like (as long as they came through the door, and not over the fence!) On the day we killed him he greeted his veterinarian with a wagging tail, to the point where my husband nearly backed out of the planned euthanasia.  This dog enjoyed life to the fullest, despite his significant and many disabilities.  This dog wanted to live.

I think often about my friends and colleagues who will not allow their children to have a dog—I’ve heard all the excuses—allergies, too much work, not enough space, too limiting in terms of travel.  I think they are wrong, and I am obnoxiously vocal in my judgment of them.  I think that our dogs teach us so much about cheerfulness, stoicism, willingness to play–even as adults, acceptance, love, loyalty and compassion.  I hope that when I am old and infirm I will bear the burdens of age and disability with as much dignity as my Izzy did.  But I sincerely doubt that it is “humanly” possible. We love all our animals, but some take a giant piece of our heart when they go.  Happy Thanksgiving Izzy.  We miss you.

The Things They Put on Their Skin

When patients start their radiation therapy, one of the side effects that we tell them to look for is a skin reaction.  Depending on the area of the body treated, and the dose given, the skin reaction at the end of treatment ranges anywhere from a mild sunburned look all the way to what we call moist desquamation, where the skin literally sloughs off, yet ultimately heals without even a scar. My nurse spends a great deal of time educating patients about taking care of their skin.  The instructions are simple—do not get a sunburn on irradiated skin (breast and prostate cancer patients take note:  NO NUDE SUNBATHING!), do not use perfumes or deodorants on irradiated skin, do not use harsh soaps or detergents, and DO use a fragrance free product that helps the skin retain moisture.  The two tried and true products which have been on the market for over thirty years are Aquaphor ointment, and Eucerin cream (which, for the record, is just Aquaphor whipped like egg whites turning into meringue!)  When I was a resident, we had giant vats of the stuff stored in a back room and when a patient would start his treatment, my job was to go and get a sterile urine cup, and a sterile tongue depressor and scoop the ointment or cream out with the tongue depressor, fill the cup, put the top on and voila,  hand it to the patient. Simple, and very cheap.

It seems that there is now a cottage industry which provides skin care products for radiation therapy patients.  Many of the concoctions are “all natural” and as a result, some are very expensive.   A few are made by the big pharmaceutical companies and tout ingredients with chemical names that only a terrorist would recognize. One of the “natural” creams made locally contains aloe, lavender and calendula—it was light, smoothed on well, and was very popular with me and my patients until it came to my attention that it was made and marketed by a competing radiation oncology group. This seemed a bit devious and self-serving to me—make money off treating the cancer, then make more money off of selling skin care products.  I dropped it from our “line up” and went back to the old tried and true.

Despite getting very explicit written instructions at the beginning of treatment along with a few samples, I am always completely astounded by the variety of unprescribed substances that patients find themselves compelled to put on their skin.  Just in the last few months, I’ve had grown men who fought in wars extolling the virtues of jojoba oil, coconut oil, crisco and almond butter.  It makes me wonder if the discovery of the healing properties of these substances was actually a by-product of a different sort of usage!  And the women too get into the act—women who think nothing of spending four hundred dollars for a small vial of a wrinkle cream waltz in and tell me that they used rubbing alcohol on their skin reaction, or betadine, not to mention products from their spice rack including turmeric and cayenne pepper.  And these are the things they will admit to!

Let me tell you two little secrets.  First, there is NOTHING that will prevent a radiation skin reaction.  So don’t waste a lot of money trying.  And second, no matter how bad it gets, it will heal quickly.  Without a scar.  So use your Aquaphor, and please, try not to scratch!

What to Hold On To

Make me an angel, that flies from Montgom’ry
Make me a poster, from an old rodeo
Just give me something that I can hold on to
To believe in this living, is just a hard way to go.
John Prine

I had the day off today for Veterans Day and I had few things on my agenda—get some exercise, throw away the junk mail that has accumulated on the kitchen table, and start to get my house in order for the kids and company that will be arriving for the holidays. I have a problem with newspapers, magazines and catalogues—I am completely incapable of throwing them away without first leafing through them. As a consequence, I waste a lot of time. As I quickly paged through our small town’s newspaper before tossing it in the trash, an article about de-cluttering and downsizing caught my eye, and I quote: “De-cluttering in a meaningful way is key to a successful transition from one stage of life to the next and will allow the individual to let go of some possessions in order to enjoy the future. The goal is to prevent possessions from becoming impediments to change.” Right.

 
I have moved around quite a lot in my life—born in Georgia, moved to North Carolina for my father’s general surgery residency, spent the bulk of my childhood in Texas, then in quick succession—Connecticut, back to Texas, Massachusetts and then California. I have always welcomed change, and saw it as a chance to shed old skins both physical and emotional, and make new friends and create a new sense of place and space. My husband and I have lived in six different houses in thirty two years of marriage, seven if you count my apartment in Brookline. Each move has been an opportunity to sort through the detritus of past lives, to cull our “things”, to figure out what to give away, and what to hold on to. This worked well, until we got here. We have lived in our current house for nearly fifteen years, and this place is beginning to sag, quite literally, under the burden of our accumulated possessions, not to mention the emotional freight of children’s rooms now abandoned. How does one even begin to decide what to give away, what to sell, and what will be forever missed once it is gone?

 
I got a little taste of how to choose during the Witch fires here, October of 2007. My first priority was to get my family and my animals out—the fires moved very quickly and burned to within 100 yards of our place. Friends will remember the photograph of me broadcast around the world—like General Patton in World War II, leading Norman, our little Lipizzaner, and my two Quarter Horses to safety—my brow creased with worry, his nostrils flared with fear, mane flying, air smokey. The news crews were there because we were the last to be evacuated. I brought no clothing, none of the art on the walls, the sculptures, the books accumulated over a lifetime. The only things I grabbed on the way out were my photo albums and the few pieces of good jewelry my grandmother left me. Oh, and of course my sixteen year old son and our four dogs—the cat was nowhere to be found as sirens were blaring, but seeing as how he’d only lived one or two of his lives at that point, he survived just fine on the food and water I left.

 
But how to lighten the load and clear out the spaces when there is no urgency, just a need to see my way clear of the “stuff”, to get to the essence—that is the question. I am hopelessly sentimental. Every picture tells a story, every object a novel. I need guidance. Anybody? Anybody?

Veterans Day

IN FLANDERS FIELDS
JOHN McCRAE, PHYSICIAN, WARRIOR, POET

In Flanders fields the poppies blow
Between the crosses, row on row,
That mark our place; and in the sky
The larks, still bravely singing, fly
Scarce heard amid the guns below.

We are the Dead. Short days ago
We lived, felt dawn, saw sunset glow,
Loved and were loved, and now we lie
In Flanders fields.

Take up our quarrel with the foe:
To you from failing hands we throw
The torch; be yours to hold it high.
If ye break faith with us who die
We shall not sleep, though poppies grow
In Flanders fields.

Earlier today:

As I am writing this, it is nearly the eleventh hour of the eleventh day of the eleventh month—Armistice Day in 1918, celebrated as Remembrance Day in Great Britain and Veterans Day here. Solemn ceremonies are taking place across the country and all over the world to honor the fallen and to celebrate the living. Reading and watching some of the news stories about these events brings not only tears but also memories to me of a different kind of war—the war in Vietnam. I came of age during the height of that conflict. My friends and I listened as student deferments ended in 1971 and the results of the first draft lottery without them were called out in our college football stadium. We were the “Hell, No, We Won’t Go!” generation.

 
Insulated as I was by my sex and the fact that I was lucky enough to grow up in a family that could send me and my siblings to college, I had no direct contact with those who actually served until much later when I was in medical school. In 1976 I was on Dr. Michael DeBakey’s cardiovascular surgery service as part of my general surgery rotation. The cardiac fellow was a man named Denny—I’ve long ago forgotten his last name, but I’ll never forget a certain day in the operating room. The fellows, who had already completed their general surgery training, were responsible for opening and closing the chest, and then assisting the “boss”, Dr. DeBakey himself, during the bypass surgery or valve replacement. There is always a certain amount of banter in an operating room, especially during non critical parts of the operation, and on that particular day the talk turned to the prosecution of Vietnam war criminals. Considering that I was completely ignorant on the subject, I should have remained silent. But instead I voiced my opinion that the “baby killers” should all go to jail. At that particular moment, the heretofore mild mannered and quiet surgical fellow raised his head, glared at me and said, “You don’t have ANY idea what you are talking about. I was there. I flew the helicopters that carried the wounded from battle. I saw things that you will never see in your life. Now get the hell out of my operating room.” Sometimes humiliation is truly the best teaching tool.

 
More than thirty years later, I live in a military town. Many of my colleagues and some of my best friends have served, and continue to serve both on active duty and in the reserves. I have worked hard to establish a good relationship with the VA Hospital here, and so I am privileged to treat veterans in my practice. They are treated with the best technology available, but even more importantly they are treated with the respect they deserve for having served their country. I have cared for many of them– retired generals who are West Point graduates and enlisted men from small midwestern towns, veterans who are homeless and those who have been tremendously successful businessmen, lawyers and teachers. But when I treat a Vietnam veteran, I feel a special sense of responsibility though our parallel lives were lived through very different prisms, our histories unshared. There but for the grace of God….

 
A heartfelt thank you to all of our veterans.

Best Dick

In some of my previous entries, I have mentioned how important it is for patients to bring a friend or relative to their first appointment.  Most of the time, we welcome the spouse or best friend who is able to hear and process the information we are giving, especially if the patient herself or himself is still in the “deer in the headlights” phase of cancer awareness. Personally, I don’t mind if you bring a recording device—I realize that there are complex facts to be absorbed and difficult decisions to be made. There are occasions, however, where the addition of extras can be counterproductive. Bringing your mother in law along with your grandchild still in diapers can be distinct distractions to the doctors and nurses involved in your care, especially if the latter leaves stains on the newly upholstered chairs.  There are those “significant others” who are actually adept at alienating the people you most want to make friends with. Those are the personalities that can make your doctor and nurse retire to the back room where they punch holes in the drywall while considering their escape plan.

First there are those I call the pirates.  These are the people who commandeer the ship and make it all about themselves.  Each time I ask the patient a question regarding a symptom, the pirate pipes in about the time he or she had that very same symptom, and what it meant.  If I ask about a family history, I get the story about the time the pirate’s Aunt Nellie had this same kind of cancer, and about all of the terrible awful side effects she had from treatment.  These are the guys and gals who will tell you that your patient can only have an 8:15 appointment; because that is the only time their ship can sail over to radiation therapy to give the friend or spouse a ride.  They are often pleasant but always insistent—they want to make sure that I know how disruptive this disease has been to their sense of self importance and their place in the patient’s universe. By the consultation is over, I have a complete medical history on the pirate, and know their allergies, sexual deviations and food preferences, whether I actually know about the patient or not.

Worse are the pit bulls (and I mean no offense to the breed—you know I speak metaphorically here.)  These significant others come in with the assumption—no, the CONVICTION– that the doctor is negligent, ignorant, and literally out to harm their spouse or friend.  They are prepared to fight to the death.  When I ask the patient a question, the pit bull answers with a snarl.  The pit bull assumes that he must protect the patient at all costs, even if that means literally biting the hand that is offering help.  These are the friends and relatives who are actually dangerous.  They are usually engineers, scientists, professors, and mathematicians who have been on the internet, calculated the risks, and are going to teach you how to do your job so that they can make sure you don’t kill their special person. They are smart and they have done their homework.  They have completely forgotten that I am here trying to help.

We had such a pit bull recently, who accompanied his girlfriend, a lovely patient with cancer of the pancreas.  For the most part, I have stopped giving my email address to patients and families due to their propensity to spam me and my unwillingness to read every internet joke every passed around, and don’t even get me started about those chain emails. In a momentary lapse of judgment, I did however give mine to her significant other. After all, his earnestness was compelling. He wrote to me daily with each incident that his girlfriend experienced, his theories of why she experienced that particular thing, and his antidote for the problem.  And each time I replied with advice, he wrote me back with the reasons that I could not possibly know what I was talking about. Despite our differences, in the end, we tamed him with kindness.  His girlfriend did well through treatment, and four months later she is still in remission.  Our pit bull became a pussycat.

One thing I will never forget is his email signature. Improbably, and without a trace of irony he signed each email, “Best, Dick.”  Really?  I sure hope so, for her sake!

So It Goes

It was only natural that in a large urban radiation therapy department, such as the one where I did my residency, the residents often turned to black humor in order to escape from the realities of death and dying that we were witnessing.  Despite one of my attending’s iron clad rules—“Never treat a patient on his last day of life”—occasionally a patient would indeed expire right in the department.  Once the relatives were consoled, and the gurney and body departed, inevitably one of the students or residents would feel compelled to add a new euphemism to the secret list we kept hidden in our cubicles.  And so the list grew over the years we trained there.

There were always the “good old boy” standbys—he “bought the farm”, “kicked the bucket”, “cashed in his chips”, “bit the dust”, “gave up the ghost”—and of course the simple but expressive “he croaked.”  And then there were a few with more sensitive connotations—she is “pushing up daisies”, “took a little slumber”, went “six feet under”, “played harps with the angels” and “shed the mortal coil.”  Not to mention the vaguely piscine morsels, such as he “went to Davy Jones’ locker”, and is now “sleeping with the fishes”.  Depending upon occupation, cowboys always “went to the last round up” and hunters to that “happy hunting ground.”  Little did we know that we had already been trumped long before when Monty Python did the “Dead Parrot Sketch”, introducing the inimitable “pining for the fjords”, and “rung down the curtain and joined the invisible choir.”

By the time I got to California, I thought that I had heard them all.  In my new department I had a licensed vocational nurse who was responsible for taking vital signs and putting the patients in rooms on our on treatment visit days.  Every couple of weeks, I’d come in on a Monday and a patient would be missing from the schedule. I’d ask our nurse, “Where is Mrs. So and So?”  And she would say, “She went to Texas.” After the first couple of months at my new job, and the third or fourth time our nurse said, “He went to Texas”, I finally got exasperated.  I said, “PLEASE tell me why all of these patients are moving to Texas!”  The room was silent, all eyes on me.

Apparently there are significant regional differences as to how one expresses that a patient has “passed on”.  What do they say in your neck of the woods?

Showing a Little Restraint

 For Jack Oberdorf

In 1986, Hybritech released its first commercially available screening test for prostate cancer– the PSA test—triggering a torrent of newly diagnosed cases of this disease, and in turn, a flood of new technology to treat it, including the Da Vinci surgical robot, and proton beam radiation therapy.  In recent years, however, the medical community has come under significant scrutiny for the overtreatment of this cancer, which in most cases, men “live with” and don’t “die of.”  Although its report remains highly controversial, in May of 2012 the United States Preventive Services Task Force gave the PSA test a “D” rating, meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.  My friend Jackie Widen’s story illustrates the point better than I ever could.  For you, from Jackie.

<<On Sunday March 19, 1995 my parents played their weekly round of golf with their “regular Sunday group” – about a dozen golfing couples who all lived in a gated community just north of Houston.  Mom and Dad had retired in 1984, moved from their suburban home in Houston and built their dream house in this peaceful golf course community.  They played the game they loved 5 days a week, traveled on golf getaways and centered their social lives around this colorful group of friends.  Sunday play days were followed by burgers and beer at the Clubhouse.  This particular Sunday gathering however was special– a cheerful send-off to my Dad – because on Tuesday he was scheduled to have a prostate cancer “procedure” done at Methodist Hospital in Houston.  Toasts were made for him to hurry up and get home because the next big golfing trip was already being planned. Exactly one week later these same men were dressed in their Sunday best, standing shoulder to shoulder in the first pew of our Church, honorary pall bearers at my Dad’s funeral.  What a week.

A couple of months prior my Dad had dutifully had his annual physical.  Most men avoid and procrastinate about doctor appointments, but he always paid attention to these check-ups.  At age 75 he had some predictable aches and pains, but nothing really serous.  His PSA had risen to a concerning level after having been monitored the year prior, and after consults with his urologist it was decided that yes this was cancer and yes it required more than a “watch and see” choice.  The urologist scheduled an appointment where my parents were presented with the options.  Apparently having the prostate removed was not something either of them wanted, so they agreed that having radioactive “golden” seeds implanted with follow-up radiation was their preferred course of action.  I did not know about this until the week prior to his surgery.  Cancer is a hideous word, but combining prostate in the discussion with your daughter makes things rather delicate.  My mom would later bemoan the fact that I didn’t accompany them to the Discussion/Assessment Appointment.  But because there were of course sexual consequences being discussed for each procedure, my Dad would not have felt comfortable with his eldest daughter in the room.

Mom stayed with us in Houston while Dad had his surgery.  Things went well, and relief was palpable.  Wednesday evening after we visited him in his room, my sister and my mother and I celebrated with dinner and champagne at a nearby restaurant.  The phone rang at 4:00 AM – a doctor who I did not know was babbling that he was very sorry, but my Dad had passed away.  I asked a few questions but then immediately called my sister who lived nearby to come over –we had to get to the hospital.  As I stood in my room, in my nightgown, shock ran through my body.  I knew it was this moment was the last remnant of peace my mother would ever know.  I will never forget walking upstairs, holding my mother’s hands, and telling her that Dad was gone.  Even my children remember the primal scream that followed.  I remember at the hospital that we were all dressed in the same clothing that we had worn the night prior.  I remember the nurses quietly crying at the station.  One of the nurses told me that most of their patients were cranky and difficult but my Dad was pleasant and polite even though they knew he was uncomfortable and scared.  I remember going into the room and seeing my Dad for the final time, quiet and still, cool.  I remember kissing him good-bye.  A bit later I had to go down and formally pick up his personal belongings in a bag marked with a “Personal Effects” tag.  Horrible, miserable, gut wrenching.

It is almost impossible to describe the grief that rippled through my family.  My mother was lost. My parents were that special type of couple; two sides to a coin I always described, and now she had lost her anchor.  Sorrow hurts almost like a physical knife, tearing your heart into pieces and you wonder if the pain might kill you.  And thinking/hoping it might.  It was that awful.  As it turned out my dad had likely suffered either a heart attack or an aneurysm after the surgery. I declined an autopsy, I couldn’t handle it.  Later when the dust settled I wish I would have agreed as I will never truly know what happened.  What I learned later was that he was smoking secretly without my mother knowing – and of course when the doctor asked in front of her “Are you a smoker?” he fibbed and said No.  Did this play a role?  I don’t know.

It’s been more than 15 years, but that event has forever changed my life.  I was told by one friend how lucky I was to grieve so much, and I thought she was crazy.  But you see, she explained, you must have had a very special father to grieve so deeply.  Some of us are not that fortunate.   She was absolutely right on that score.   I have replayed this over and over in my mind since he died.  Was the surgery necessary?  If the doctor had known he was a smoker would he have proceeded?  If left unchecked would the cancer have spread, or would he have had more active years?  I will never know.  But this I do know – in some ways my Dad got the best deal.  He lived life to its fullest and went from a round of golf one Sunday to meeting his Maker the next.   He went out at 100% and loved his life until that last breath.

I still have that Personal Effects tag on my bulletin board.  Love you, Dad.>>

In an email to me that accompanied this story, Jackie wrote “There is so much more to this story, of a daughter’s love and of the loss of the little things that you take for granted until they are gone.  When I went off to SMU it was the first birthday I had ever been away from home.  I was taking finals still during December so he called me and said “Do you know what I got 18 years ago today, at 6:30AM?  The most wonderful daughter in the world.  Happy Birthday honey”.  He continued doing that every year because I was either at college or then I got married in 1974 and moved to San Antonio.  Regardless, I was never at home at 6:30 AM on my birthday ever again, so he would make this phone call a ritual.  December 18, 1995 I didn’t get a call.”

When I was at ASTRO in Boston, I had a chance to chat briefly with Dr. Anthony Zeitman, past president of the society, the head of genito-urinary radiation oncology at Massachusetts General Hospital and a true leader in our field.  He said that he is recommending “active surveillance” (the new term for “watchful waiting”) for most of his patients with prostate cancer now, rather than treatment.  I was with my best friend from residency who knows Dr. Zeitman well.  She asked him, “Do you get PSA testing?”  His answer—“No.”

 

Like a Freight Train

Sometimes, you can see cancer coming.  What I mean is that when we sign up for that mammogram, or that PSA blood test, there has to be some tiny little part of us that says, “Ok, this time it’s my turn.  This time I’m the one who’s going to get the call.”  Sometimes the cancer sneaks up on us—that nagging little cough that makes us want to—suddenly and belatedly—quit smoking.  Or that little bit of blood in the stool that we’d rather think is a hemorrhoid, or that lump in the neck that doesn’t go away even when our doctor treats us for the strep throat that we know we don’t have.  But sometimes, as it happened to my patients yesterday, that cancer hits us like a freight train.  Just flattens us and leaves us in fragments, speechless in surprise and terror.  And when that train hits, we know in an instant that life will never be the same again.

I had two of the freight train kind of patients yesterday.  The first was a man in his 70’s, previously healthy, an avid stamp collector.  One day in August, he suddenly had difficulty finding his words.  A CT scan done without contrast dye showed no stroke or bleed in his brain, and he was sent home from the emergency room.  His wife persisted with the primary care doctor—“My husband is just not right!” she said, and last month an MRI was ordered which revealed a  large ugly looking brain tumor, and the patient was taken to surgery.  The pathology returned as glioblastoma multiforme, the most aggressive type of brain cancer.  He was seen in outpatient oncology clinic by a young neuro-oncologist, just out of his training. By the time the patient came to me, every shred of hope was gone.  The man, still having difficulty with his speech, told me that the doctor said that at most, he would live a year, if he chose treatment, a few months if he did not.  He said that the doctor told him that the tumor would spread like a spider web over his brain, and that he would lose all function.  The patient cried when he told me this.

The second patient was a very fit man in his early sixties, a retired school teacher who had surfed and been a life guard all his life.  In July, he had a surfing accident (his wife said, “Can you believe it?  He surfed some of the greatest waves in the world and he wiped out in two feet of water here at home.”)  He broke his collarbone in three places, which required surgery to repair.  His pain got worse however, and he started to have back pain.  Spine films showed a compression fracture, also thought to be related to the accident.  As this tan, fit, athletic man began to seek more and more narcotics for his pain, an MRI of the spine was obtained, which showed the bones to be brittle and riddled with tumors.  Yesterday the biopsy of his sacroiliac area came back positive for multiple myeloma, a disease of plasma cells in the bone marrow which destroys the bones that cultivate it.  In an instant, this nice couple’s dreams of a happy retirement were shattered.

When we first moved to the West Coast, I was offered two very different jobs.  In one practice, I was to be the person that rotated through six different outpatient facilities, covering the regular doctor’s vacations.  I would see the patients for consultation, and perhaps treatment planning, but would never see them through their treatment or in follow up.  The other job was a hospital based practice where I would be the director of the department and have longitudinal care of the patients.  I chose the second, of course, because being the linear task oriented person that I am, I could not conceive of not seeing each patient through from start to finish to follow up.

I see things differently now, twenty years later.  I have a calling in life.  I want to be there when that freight train hits.  I know I can put the pieces back together, and I know that when that shattered patient leaves my office, for the first time in hours, or days, he will be able to notice the sun shining in our Southern California sky, and taste a faint flavor of salt on the warm breeze flowing from the Pacific. In turn, I will have the deep satisfaction of knowing that I did something good that particular day.  And that, actually, is quite enough.

Hurricane Season

Watching the events of Hurricane Sandy unfold from a safe distance this past week, I was reminded of the great hurricane that occurred in my own youth, Hurricane Carla. At the time the largest hurricane ever recorded in the Atlantic basin, Carla made landfall on the coast of Texas on September 11, 1961. I was seven years old, and had just started third grade. Before the lights went out, I remember taping up the windows and watching the news where our local KTRK news reporter, Dan Rather, reported live from the Galveston Seawall as the winds were howling and the surf was picking up. That broadcast was the one that launched his career. At the time, my family was living– all five of us– in a two bedroom apartment on North Braeswood. As the eldest child, I remember feeling responsible for the younger ones, so that they wouldn’t be afraid of the dark. It was exciting that our little family consisting of my mother, myself, and my brother and sister could huddle around a candle flame, with Mom reading stories and playing games. We ate lots of peanut butter and jelly sandwiches and the heat and humidity were oppressive at the end of a long hot Houston summer. I don’t recall my father during that time at all–as a surgical resident I am certain he was at the hospital tending to victims of the deluge. When it was all over, the damage estimates were over 2 billion dollars, but I was a child, and that meant nothing to me. The sun came out, and I went back to school.

Times have changed now, and every tragedy is played out on every computer screen and wide screen television in the country and around the world. From the twenty sixth floor of the Boston Marriot Hotel, I watched in horror as the New York University hospital’s backup generator failed, and nurses, medical students, interns and residents used Ambu bags to help premature newborns and the sick elderly breathe. My heart broke as I read of the woman whose four and two year old sons were swept away by the surge, and who was ignored by frightened homeowners in their darkened houses as she screamed for help. And just today, I read a handwritten note from a young man who was standing in his kitchen as it washed away, and who nearly drowned before taking shelter in a stranger’s house, where he found blankets to cover himself as he wrote what he thought was a last letter to his father. My sister in New Jersey still has no electricity.

When we are children, we are incapable of truly imagining a world beyond our own four walls and our immediate family and friends. Playing games by candlelight, we are shielded from darkness. When we grow up, we struggle against being paralyzed by the same imagination that insulates us when we are young—we see too much, read too much, know too much, and sometimes we feel too much. Hurricane season officially ends on November 30, and hopefully there will be a brief respite before the winter storm season brings the North to its knees again. Watching the election results tonight, I was happy that this too has come to an end. We are adults now, and know that despite the tumult and acrimony that enveloped the last several months, it is time to band together– like the good people of New York and New Jersey–and rebuild. Our future really does depend on it.

Just Give Me the Gist of it Please

I recently saw an orthopedic specialist who proposed to operate on my arthritic feet, which have been quite done in by my favorite pastime for thirty five years of jogging miles on pavement combined with the wearing of high heeled shoes to work every day to make my short self taller and thus more powerful. The surgeon described to me in detail a procedure designed to take the pressure off the big toe joint, and increase the mobility.  When I got home, my husband had many questions such as “will this be done under general or local anesthesia?” and “will you need to wear special shoes afterwards?” and “how long before you can swim?”  I stared at him slack jawed—I had not written down a list of questions before my visit, and I certainly couldn’t answer his.  How quickly does the doctor become just like her patients who can’t remember what they have been told, despite the consultant’s serious attempt to educate and inform?  Very quickly, it seems.

Some of my patients have taken the opposite approach to the consultation visit, presenting  with dossiers full of notes and questions and treatises printed from questionable internet sites.  This causes me to settle deep into the comfortable chair in my consultation room—I know that I’m in it for the long haul.  I’ve grown to expect this at the first visit, but when the habit extends to the weekly “on treatment” visits, I know I am in trouble. The French have a saying for a particular type of patient—the patient that comes in with a long list of detailed handwritten notes each time he or she is seen.  They call it “La maladie du petite feuille de papier”, or “the sickness of the little piece of paper.”  The great Sir William Osler commented on this type of patient in his aphorism Number 309—”a patient with a written list of symptoms—neurasthenia.” Translate that to mean “anxiety disorder.” I recently had a breast cancer patient whose husband came with her for each on treatment visit.  They had matching notebooks and matching pens, and they each studiously, meticulously and separately transcribed every word I that I uttered into their respective college ruled 100 page blue books.  And when we were all done they asked me the questions that I had just painstaking answered, because neither of them had heard a word I had said—they were too busy writing!

There must be a happy medium in there somewhere.  If you (or I) have specific questions about the risks, benefits and side effects of a proposed treatment, by all means, write them down and get them answered!  But I do not need to see your journal of the quality, quantity, consistency and timing of your daily bowel movements.  Really I don’t.  Just give me the gist of it, please!