Something Old, Something New

When I was a radiation oncology resident in Boston in the early 80’s, a few brilliant minds in physics and medicine came up with the notion that it would be a good idea to treat certain cancers with a beam of protons.  Protons are the positively charged particles which are created with a hydrogen atom is split into its component parts, a proton and an electron.  When accelerated towards a human being by means of a cyclotron, the proton has a unique characteristic compared to the regular X-ray beams we radiation oncologists use—it rolls into the body creating very little disturbance at the surface, comes to a stop at the tumor to do its damage, and unlike an X-ray, or photon as we say in the business, it does not exit the body leaving injured cells in its wake.  It just stops.   This makes proton radiation therapy ideal to treat children, where the entrance and exit doses of radiation can cause growth defects and trigger secondary malignancies years and years down the line.  But the first patients treated back at the old Harvard Cyclotron were not children—they were old men with advanced prostate cancer, where conventional therapy with the doses needed to control the disease had a high likelihood of rectal damage.  My job, as the resident, was to insert a balloon into the rectum of said patients, to separate the posterior rectal wall from the prostate gland.  Each day I would hitch a ride with our physicist over to the huge brick building which housed the cyclotron, insert and inflate the balloon, and wait while the patient was treated.  I didn’t mind a bit—the technology was new and exciting, and the physicist was very handsome.

Tonight, thirty years later, I toured the new proton facility in San Diego, where my university, along with other institutions will soon be allowed to treat patients.  The building itself is massive, over 100,000 square feet.  There are five gantries and treatment rooms, and once the facility is up to peak capacity, the cyclotron will run sixteen hours a day, treating over 2,000 new patients a year.  At 8 pm this evening, a team of six engineers was still hard at work in the control room, honing the precision of a beam which will be responsible for curing cancer, for saving lives.  Patients with every kind of cancer will be treated here, but in the end, the population which has lived the longest and has the economic wherewithal to seek out the best and the latest treatments—our prostate cancer patients—will be the bread and butter volume income supporting the treatment of the youngest and most vulnerable of our patients, the pediatric cancer patients.  As one of my old colleagues who treats the kids at Massachusetts General Hospital said to me a few years back, “Finally we have protons in the clinic, and I can sleep again at night, not worrying about the horrible late effects of radiation on my pediatric patients.”

Many things have changed about the way protons are produced and utilized in radiation therapy over the thirty years since I was a resident, but some things remain the same—as we were touring, one of the physicians mentioned that rectal balloons are still used to stabilize the prostate away from the rectum during prostate cancer treatment.  I smiled inwardly and thought to myself, “Yes, but this time it won’t be ME putting the balloons in.”   San Diego is about to join a small cadre of cities that boast the best, most advanced and safest radiation technology available to cancer patients. And I say, “Long live the Brotherhood of the Balloon!”

Memories of Boston

“Today the road all runners come,

Shoulder high we bring you home

And set you at your threshold down

Townsman of a stiller town.”

A.E Housman

As this afternoon’s events unfolded, I sat glued to my computer screen between patients.  My life has really been a tale of three cities—Houston, Boston and San Diego.  Boston was where I did my residency training, met my husband, had my three children and my first “real” jobs.  I wrote to my best friend, a physician and lifelong resident of Brockton and Boston—I was worried, since her two kids, now in their late 20’s are active, athletic and in a waking nightmare, I pictured them at the scene.  I received this reply from her: “Fortunately, we are all safe.  Boston is quite crazy right now.  The hospitals are in lock down, and there are amputations going on in every OR.  Thank goodness we have so many fine institutions in the area.  Everyone is stunned.  So very, very sad.”

Every year since we met, in 1982, until the time I left Boston in 1993, she and I would watch the Boston Marathon together.  But we didn’t go downtown—we always went exactly to the halfway mark, thirteen miles in, where the route goes directly in front of Wellesley College.  My friend had gone to Wellesley, and in fact had married one of her professors and they lived close by on the appropriately named Lovewell Road, a block from the marathon course.  I have happy photos from the time—I did not have children yet, but she had a beautiful little girl, blonde and blue eyed, who would sit perched on her Daddy’s shoulders to get a good vantage point.  Tuppence, their stubby little rescued pound pup was in attendance also, and all together we would cheer as the runners went by, and the Wellesley girls, dressed like Greek goddesses in their togas would flash their beautiful smiles, and occasionally their beautiful breasts at the runners.  The guys always picked up their pace a little when they made their way through Wellesley.  Thoughts of terrorism had never entered our minds.

That all changed on September 11, 2001, when our nation and people collectively lost their last thread of insular optimism and belief in the goodness of mankind.  But what happened in the world of medicine—specifically in the world of hospital based emergency medicine—in the wake of 9-11 has doubtless saved many lives in Boston today.  The ER and surgery residents and attendings of Massachusetts General Hospital, The Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Boston Children’s Hospital, Boston University Hospital and Tufts New England Medical Center earned their keep today and are still earning it as I write tonight.  They are treating shock, and abrasions, and contusions, and head trauma, and learning to triage under real disaster conditions.  And sadly, many of them are learning to perform amputations for the first time.  On video footage I watched physicians wearing yellow coats who thought they were there for the fun of it– to administer fluids to dehydrated runners and wrap them in thermal blankets and congratulate them—jump the barriers with EMTs and National Guardsmen to staunch bleeding and administer CPR.  I know that the survivors are in the best of all possible hands tonight.

Boston, like New York City, will overcome this tragedy.  But I don’t think anyone will watch the Marathon with the same innocent enthusiasm that we had so many years ago ever again.

Denial Redux

Today I saw a new breast cancer patient in clinic.  She was a lovely lady of 64, who had retired last year from her job as a special education teacher.  Her medical history had been unremarkable until last November when she began to gain weight inexplicably.  She was also short of breath, but did not want to seek medical attention during the busy holiday season.  When she finally did see her primary care doctor in January, she had gained seventy pounds.  Her primary took one look at her bulging neck veins and swollen ankles and called an ambulance to take her to the hospital–she was in florid congestive heart failure.  She refused the ambulance, saying that she was fine, and that she needed to go home and take care of a few things, but that she would get to the hospital shortly on her own.  And so she did.

When she was being examined in the emergency room, the resident noticed a very large breast lump on her left side.  He asked her, “How long has THIS been here?”  She was vague in her response–it may have been “a few months” or it may have been “a few years”. It wasn’t hurting her, and she had other things to worry about–namely her 70 pound weight gain.   Mammograms and ultrasound while she was an inpatient led to a biopsy which showed malignancy.  Cardiac echo showed both coronary disease and cardiomyopathy.  She was treated with multiple cardiac medications and began to diurese, and her heart function improved dramatically, especially after a stent was placed in her left anterior descending coronary artery.   Finally she was able to go to surgery to remove the breast mass, and today she showed up for her consultation looking very chipper indeed–a slender 134 pounds down from 206, breathing normally, with no ankle edema.  The breast cancer turned out to be stage I, and she will receive radiation therapy in the next few weeks.

When I walked into the consultation room, I introduced myself and asked her to say her name, which was somewhat difficult to pronounce.  She laughed and said, “Just call me Cleopatra, because I am the Queen of Denial!”  Fortunately, I think she is going to be just fine.

Return to Forever

Tonight, a guest blog from my husband:

 
I may be dating myself but I vividly remember hearing Chick Corea’s Return to Forever band play a set in Boston in the early 1970’s. I was in medical school at the time, but that didn’t stop me from scraping together the ticket money to hear the group do some of my all-time favorites like Spain and Crystal Silence. In the 1980’s Return to Forever was re-configured as a jazz rock group with Chick playing synthesizers instead of the acoustic piano. I was particularly fond of the Romantic Warrior album which I listened to on my way to the hospital as a young physician. In 2011 the band was resurrected for a world tour. Although I didn’t get to see the live concert, I enjoyed the YouTube videos. Listening to this music again was magical, and brought me back to the earlier days of my medical career. Like déjà vu all over again, so to speak.

This past week I’ve had another “Return to Forever”experience. It happened when I entered a skilled nursing facility where my father-in-law was staying to recuperate after cardiac surgery. Here’s what I noticed: the name of the facility is the Goldberg Center and the first patient room I came to was occupied by Gussie and Sadie Schwartz, one of whom was screaming “I’ve got a sore somewhere! Get me out of here!” Instantly, I was transported back in time to the decade or so I spent as a young doctor at Boston’s Beth Israel Hospital. Some of you may know this as the “House of God”, the title of an (in)famous book about the mostly funny and sometimes outrageous fictitious exploits of the young doctors in training there. Our present day Gussie and Sadie would have felt right at home there in the House of God.

While I was an intern at the House of God I had my own outrageous exploits which (thank God!) did not make it into the book. My favorite involved an elderly man who was brought by his wife to the ER late one night with chest pain. When I told him that the diagnosis was a heart attack, his wife shrieked and clutched her chest. She, too, was having a heart attack, and like her husband was admitted to the Coronary Care Unit, where they ended up sharing the same room. The following morning as I entered the Unit I found the staff standing in front of their room not reviewing their cardiac status as expected, but laughing uncontrollably and pointing at the name plate on the door. It read “Ike and Tina Weiner” (I swear).

The House of God had a serious role in my life, too. It’s where I met my wife, and where my children were born. Recently, our daughter learned that she will be a resident in medicine there. My wife and I are thrilled by this. We hope her experience there is as meaningful for her, as it was for us. Now, let’s see if she can top the “Ike and Tina” story.

Empty Nest

My sister was here recently to help me out while my father was in the hospital.  She is much kinder and more patient than I am, so I was very grateful for her help. She is leaving to go home to New Jersey tomorrow.   Tonight before dinner we took the deerhounds for a walk.  In my better days, I could walk four at a time.  Last weekend, I tried three on three leashes and it did not work out too well.  They spotted a man they did not know walking up our street.  Perhaps they found him threatening.   With three hundred pounds of dog lunging and barking, it took all my strength to maintain control.  It turned out to be a very short walk.  Today, my little sister took Magic, who outweighs her by at least 20 pounds, while I took the two Q’s, Queen and Quicksilver.  We had a pleasant time.

As we ended our walk this evening by coming through the back gate, near the barn, Norman the Lipizzaner stuck his head out the stall door and nickered softly.  I said to my sister, “Let’s go visit the horses before we cook dinner.”  Into the barn we went, where the two old geldings called to us with some degree of impatience.  We loaded their mangers with Purina Equine Senior and horse treats and prepared to close up.  As we walked by the closed door of the tack room, I stopped.  I said to my sister, “Do you want to see the saddest thing?”  She looked at me, her eyes questioning, then said yes.

I pulled open the door to the tack room.  In that room there were five closed tack trunks, each stamped with the initials of a family member.  Saddles were cleaned and covered and neatly perched on their racks, ranging in size from a small child’s Western saddle with full Quarter Horse bars, to my husband’s beautiful dressage saddle.  Blankets were washed and wrapped in plastic.  Shipping wraps were bleached white and stacked in place.  Bridles were oiled and ready and bits were gleaming and polished.  But there was no one home—just old framed photographs on the walls.  I said to my sister, “Enjoy your children while you may.  This room is the ghost of childhood past.”

I hope that my children appreciate and look back with fond memories on the years when we would saddle up and ride out together.  It was a special time to me.  Lucky and Harmony and Veronica are gone now, but Dash and Norman and the memories remain.  To me, it was time and love and money well spent, and I hope that my kids, now grown, feel the same.

Wilderness Medicine

A few years ago I was at a horse show on a really hot day.  As “horse show mom”, my duties were simple:  get up early, drive child to show, groom and saddle horse, and stand around all day while trying NOT to offer helpful advice to said child.  On this particular humid day the temperature was in the nineties, and at high noon, the halter classes were taking place.  Twelve or thirteen little girls, and one lucky little boy (my son) were lined up side by side with their horses, standing rigid in the heat while the judge performed a detailed inspection.  As he made his way to the last pair, the little girl who had been patiently waiting her turn keeled over in a dead faint.  And then I heard the dreaded words called out in a panic—“Is there a DOCTOR in the house?”  I sent my son dashing to the car for my first aid kit, which contained a thermometer and smelling salts, and the trainer for ice.  Soon the girl was revived, having suffered only heat exhaustion and not the more serious heat stroke.  I had realized long ago that there were situations I would find myself in where I would be the only doctor, and somehow saying, “Sorry, I can’t help—I’m a highly specialized radiation oncologist” just doesn’t pass muster.

I bought that first aid kit already prepared and loaded with the necessities at the first Wilderness Medicine conference I ever attended, in Aspen Colorado.  In three or four fun filled days, my husband and I learned about snake bites, and heat stroke, and shark attacks, and how to make a makeshift splint, and what causes weird rashes on your nether regions (squatting in a bed poison ivy, or stinging nettles) and how to treat altitude sickness and traveler’s diarrhea and all of the other practical things one needs to know if venturing outside the confines of one’s sheltered home.  We learned about wilderness survival from a very articulate and handsome man who taught the SERE (Survival, Evasion, Resistance and Escape) course that saved the life of Captain Scott O’Grady who was shot down over Bosnia in 1995 and who survived for six days on bugs and rainwater.  We learned that being lost in the wilderness due to weather, accident or injury is more common than we could ever imagine, and to this day I carry a flashlight, a solar blanket, a heavy plastic bag, matches, water and a whistle in every vehicle I drive.  Fifteen years after our first Wilderness Medicine conference, we went back last May to the same conference, this time in Santa Fe.  The basics were the same, but there were new classes in how to deal with an urban disaster such as a terrorist attack, or an earthquake.  This time I learned that the Space Station carries pregnancy tests in its medical kit—apparently despite the anti-fraternization rules for astronauts on duty,’ tis better to acknowledge the possibilities than deny them.

On Wednesday,  I sent my daughter to Hawaii for her first Wilderness Medicine conference—a vacation and graduation from medical school present.   She sent me a bubbly text message after the first evening of lectures—she had already learned some sage advice –and I would like to attribute it properly but she didn’t tell me which lecturer coined it: “ Don’t get bit, don’t eat shit, don’t do “it” and take your own kit!” Robert Baden-Powell, the founder of the Boy Scout movement, said it a little more simply:  Be Prepared.  Words to live by.

Pass the Butter Please

 

With gratitude to Doctors Rafael Espada and Michael Madani, for fixing my father’s heart, twice.

 

When Michael Phelps was interviewed during the Beijing Olympics, the world first learned about the extraordinary amount of food needed to fuel the swimmer with the wingspan of a pterodactyl. He said that he ate 12,000 calories a day, and no one believed him except for me. I believed him because I too was a swimmer in my youth, and a distance swimmer at that. Breakfast consisted of two scrambled eggs with cheddar cheese, a few slices of bacon, buttered toast, and a half grapefruit or cantaloupe. Lunch was a sandwich and chips followed by a whole package of Hostess cupcakes or snowballs—I particularly liked the snowballs because I would peel the pink marshmallow and coconut topping off the chocolate cupcake and eat that separately “for dessert.” Dinner was typically a slab of beef, potatoes au gratin or baked with butter, cheese and sour cream on top. Oh, and there was always a vegetable—to this day I can eat two heads of broccoli all by myself. After dinner, an entire bag of Chips Ahoy cookies usually kept me company while I did my homework. And this being Texas, barbecued beef or ribs, or both, fried chicken and biscuits slathered with butter and honey were Sunday treats. I swam four to five hours a day, and I was skinny, and I never gave heart disease a single thought, not even when my granddad dropped dead of a massive heart attack at age 75.

When my father turned seventy five, the same age we lost Grandpa, he thought that maybe he should have a stress test. He never had any symptoms—he was just a tiny bit superstitious about the fact that seventy five seemed like a good age to have a heart attack, or perhaps to avoid one. His internist obliged, somewhat begrudgingly since there was no history of chest pain or palpitations. His stress test was floridly positive, and before he could say “Boo” he was in the cath lab having a coronary angiogram. As the dye flowed, the images showed triple vessel disease, with greater than 90 per cent occlusion of the left main coronary artery. They call that lesion “The Widowmaker”, and that’s what it had done to my Grandma. As the interventional cardiologist tried to pass a stent, my father experienced a run of ventricular tachycardia—an arrhythmia which is basically “pre-death.” The next thing he knew, he was waking up from triple bypass surgery and he was madder than hell at all of us, his family, because he knew all along that there was nothing really wrong with him and we made him go through with surgery.

 

A week ago at age 87 my father had his second open heart surgery, to replace a worn out stiff old aortic valve. He’s a pretty tough old bird, and he made it through, although his post-operative course has been a little rocky. About a month ago, before the surgery we went out to dinner with some new friends that Dad had made in San Diego, a couple that live across the street from me. They warned us ahead of time that they were a little bit “fanatic” about their diets. I did not know what they meant. He, like Dad, is a retired plastic surgeon, handsome and fit. She is a realtor, elegantly dressed, thin and very persuasive. We went to an Italian restaurant, and as drinks were served, the waiter brought out warm freshly baked bread and butter. As is our habit, my father and I reached immediately for the bread and butter. Our hostess eyed the butter Dad had placed on the little bread plate, and then proceeded to snatch both butter and plate, depositing them on the other, unoccupied side of the table. She said authoritatively, “Mel, you can NOT go on eating butter. Not with your heart being the way that it is.” I was astonished. I had never seen anyone do that to a virtual stranger in a restaurant. Not to mention the fact that it was a tiny bit late to be taking the butter away from my father. He was not happy about it either.

 

This got me to thinking. I haven’t been particularly good about restricting my calories, watching my fat intake or about exercise as I have gotten older. The pounding of my hip joints repeatedly against the cement walls of the pool during endless flip turns, coupled with another 30 plus years of jogging on asphalt roads, taken up when my swimming years were over, have taken their toll on my joints. I adore butter and ice cream and red meat. I’ve gained 20 pounds over my “fighting weight” and love comfort food in the truest sense—I use it for comfort in times of stress. But it seems now, as I sit by my father in his hospital bed, that there is a choice to be made, since my genes have declared themselves as least as far as heart disease is concerned.

 

When we lived in Boston thirty years ago, we used to like to eat at two restaurants in Somerville. There was a barbecue place right next to a health food restaurant. I can’t quite remember the name of the barbecue place but I think it might have been Sam’s. The health food restaurant was called Jaye’s. Each of them had a big sign out in front—they were competitors of course. The health food restaurant sign said, “Eat at Jaye’s, Live Forever!” The barbecue restaurant sign said, “Eat at Sam’s, Die Happy!” The question for me, and in fact for all of us is, “What’s it going to be?”