The Dentist Will See You Now, or Why I am Not a Veterinarian

I’m usually pretty good at keeping track of all things medical—when my kids were vaccinated, when I need my mammograms and PAP smears, when the girl dogs come into season and when the horses need to see the dentist.  So when Norman the Lipizzaner arrived home from the boarding stable underweight, and two weeks later when he didn’t seem to be eating all of his hay, my thoughts turned to his teeth.  Unlike humans, domesticated horses’ teeth grow throughout their lives, and when people refer to an aged horse as being a bit “long in the tooth,” they aren’t kidding.  Lacking the need to forage 24/7, our stabled companions need the regular attention of a horsey dentist who will come in and do what is euphemistically called “floating the teeth.”  Think of the drill your dentist uses and multiply its surface area and sound by 100, and you’ll get the idea.  Reaching into twenty four year old Norman’s mouth, I felt sharp “points” on the molars, and realized why he wasn’t gaining weight.  I checked my records and realized that he and his buddy Dash were six months overdue.

 

If you’ve ever taken your three year old for his first dental appointment, you have an idea of how hard a tiny body can struggle.  Same with horses, only they are a lot bigger than we are.  None of them willingly open their mouths wide and allow insertion of a drill—the mere sound of it is terrifying.  So they must be anesthetized.  And just like with elderly humans, the trick with an old horse is to give them enough anesthesia that they tolerate having a vice put into their mouths and cranked open, yet not enough to kill them.  This, apparently is not an exact science.  The first shot directly into Norman’s jugular vein did exactly nothing.  Although he was restrained, the whites of both wide eyes were showing as he chomped down on the dental device.  The second shot seemed to have a light sedative effect.  But the THIRD shot—well, that was the one that did the trick.  Same thing with good old Dash.

 

Now here’s the thing—I was SUPPOSED to go to work after the dental appointment.  Our machine was down for maintenance, and I had a lot of paperwork to catch up on.   After the requisite 45 minutes, I released their halters, tied to the bars in their stalls. They both tried to fall down.  How do you leave when you’ve got two horses staggering around their stalls like drunken sailors?  You don’t.  With Norm, the younger of the two, the drug seemed to wear off quickly.  But with Dash, I spent the next two hours hanging on to his lead rope and elbowing him when the head got too low and the front knees threatened to buckle.  Finally he too came around, and I left them munching grass in the pasture, a full three hours later than I had planned to be at work.

 

Sometimes our head and neck cancer patients are really claustrophobic in their immobilization masks, much like my horses getting dental work.  I usually prescribe a light sedative, and then if that doesn’t work, I tell them to take another.  Sometimes, the family gets into the act with great enthusiasm and has the patient take a third, unbeknownst to me.  So far, I’ve been lucky.  I’ve heard a few snores, but no one has aspirated or fallen off the table from what we used to call “the neurosurgery height.” But watching those old horses yesterday, I realized once again that there’s a fine line between “not enough” and “too much.”  Come to think of it, that probably applies to radiation therapy and chemotherapy too, along with a whole lot of other things in life!

This is Not a Lending Library

The first time it happened, I was convinced that the book was somehow misplaced.  We had had an open house in the department, with large groups touring our new and very high tech facility.  I thought perhaps the cleaning service had tucked the book away for safe keeping.  But it was odd that of the three large format coffee table books in my consultation room, only one particular book went missing. The second time it happened, I was shocked because the inevitable conclusion was that a patient had taken it. The third time—well, it almost happened again on Thursday but it didn’t because now I am on high alert.  This, in spite of the fact that I wrote inside the blue cover, “Dr. Fielding’s Book—please do not borrow!”

When new patients come into my department for their first visit, they are taken into a comfortable room, furnished with a couch, two armchairs, a coffee table and two end tables.  There are large framed photographs on the wall, seascapes and landscapes with bright horizons. Sometimes patients have a little wait between the time that my oncology nurse takes their vital signs and gets the basics of their history, while I am looking at CAT scans and PET scans and bone scans so that I can better make recommendations. When we opened five years ago, I thought it would be nice if I brought in some picture books for patients to look at, because I know that when I am at the doctor and am nervous about a test, or frightened by a possible diagnosis, I can’t concentrate on words.  I would rather look at pictures, especially calming, soothing pictures.

Since the beginning, there have been three books on that coffee table.  The first, a gift from my daughter, is Eliot Porter’s “The Color of Wildness.”  The second, a gift to myself, is Alison Shaw’s “Vineyard Summer.” And the third, a gift from a friend, talented photographer Karla Ogilvie, is simply called “Encinitas InSight.” The cover of Karla’s book is irresistible. The picture is of two boats, painted blue, each with a name and number, long since pulled onto dry land and converted into houses. Nothing speaks to the off-beat and wonderful character of our town the way these grounded boat houses do, except perhaps the Cardiff Kook, a bronze life sized surfer who is dressed up for every major holiday.  Since our department is in Encinitas, I guess it makes sense that it is that book which keeps disappearing.

On Thursday, I saw an 83 year old woman with an early stage skin cancer.  My medical student took her history in the consultation room, and then he moved her into an exam room where he did the basics of the physical exam.  When I came in, the first thing I noticed was that she was clutching the Encinitas book, having moved it from one room to the next.  I greeted her, and trying very hard not to be too obvious, I gently pried the book from her hands and placed it on the chair beside her, while I spoke to her about radiation therapy and took a look at her skin.  We covered all the basics, and she elected to proceed with treatment.  As she got up to leave, I saw her glance sideways at the book, and I dove for it.  Handing it off to the medical student, who understood the subtle hand signal as I waved him to return it to its rightful place in the consultation room, I escorted her to the front desk to make her treatment planning appointment.

Karla has been a great sport about all of this.  Every time the book disappears, she pretends to be flattered, and she comes back to the department with a new copy.  I’ve stopped asking her to autograph the book for me personally though.  It’s only a matter of time before the book goes on walkabout again.  Karla, if you’re reading this, maybe it’s time we started selling your book.  On the other hand, knowing you, I am sure that you are thinking that if that’s what a new cancer patient needs to be calm, comfortable and happy, so be it.  Thank you from the bottom of my heart.

Old Dog Lying In The Sun

The old dog barks backwards without getting up.
I can remember when he was a pup.

- Robert Frost

If you live in a multi-pet household, as I do, you will know the one I am talking about.  The dog that never caused anyone any trouble, never barked, never bit, never peed in the house, never strained at the leash or dragged you across the street on your elbows or knees, but also never caught your attention by his rare antics and sense of humor.  Or the cat that never came when you called, or greeted you at the door, or liked to be picked up, but who came into your bed at night while you slept and cuddled until morning before disappearing behind your laundry hamper long before dawn.  The silent ones of the household, the invisible ones, the ones sadly, that you paid the least attention to.  It is the fallacy of the multi-pet household—we like to believe we love them all equally, but we never do. Our time is limited, and sometimes the quiet ones are overlooked.

I run errands on Saturdays and sometimes Saturdays can be even more hectic than my weekdays.  There is the grocery shopping, the laundry, the dry cleaners—things to be dropped off, picked up, and in weekend warrior fashion, there is exercise that needs to be done. As I headed out to the hardware store this afternoon, I realized that two of my dogs—Magic, the largest and Yoda, the tiniest had not been outside for a while.  It’s a beautiful day here in sunny Southern California, 70 degrees with no clouds in the sky and a light breeze.  When we stepped out the screen door, Yoda immediately ran to “do his business”, which besides the obvious includes chasing lizards, grabbing twigs, snatching low hanging rosebuds off the bushes and barking at the old horse, Dash, in the pasture.  As I walked towards the little dog, I realized Magic was nowhere in sight.  Turning around, I saw that he was lying peacefully on his side on the little hill that leads down from the house, basking quietly in the sunshine.

When did my oldest and largest deerhound get so old?  Magic, aka Champion Caerwicce’s This Rough Magic, was a magnificent animal in his prime. At thirty four inches at the shoulder, and 125 pounds of pure muscle, he fractured a metatarsal bone in his foot running through the pasture as a six month old and had it surgically pinned and repaired.  He quietly bore his six week confinement with nary a complaint, and when the cast came off, his toes were lax, his foot terribly deformed. Within weeks he was off and running again, and when we brought him out to show as an eighteen month old, not a single judge ever commented that his left front foot was flatter than his right, because he floated with the movement described in the Scottish Deerhound standard—“easy, active and true.”  Being a homebody, when he finished his championship easily we brought him home, where he has remained, happy, quiet, healthy, and no trouble at all.  Today, for the first time, I looked at him lying in the sun, on his side, his eyes clouded with cataracts, his once dark mane silver with age, and I saw a very old dog.

Treasure them all while you have them, the big ones, the little ones, the funny ones, the ones that do tricks and always make you laugh.  But also cherish the quiet ones, the shy ones, the ones that never grab your attention—because they too, age and will be gone and you, like me, will wonder why you did not appreciate that they, of all, loved you best.

Cast A Cold Eye

“By his command these words are cut:

          Cast a Cold Eye, on Life, on Death.  Horseman pass by.”

“Under Ben Bulben”, by William Butler Yeats, inscribed on his tombstone.

Yeats has always been my favorite poet. From the full upper lip depicted in early photographs and paintings of him, to his unrequited love for Maud Gonne and his patriotism for Ireland—his very being and thus his poetry radiated passion.  I named my first deerhound Aengus in his honor, from “The Song of Wandering Aengus.”  Ten years ago at Del Mar I placed a two dollar bet on an imported Irish turf filly called “Golden Apples” from the same poem, never raced in the United States. She went off at 80 to 1, started dead last, and thundered home to win by three lengths.  I should have had more faith.

So I have never understood why a man of such extravagant emotion would insist that his gravestone be inscribed with a blunt command against emotion, against passion, against even stopping to consider the life lived so fully and buried in that ground.  Was it regret at the end of his life?  Was it a warning to those of us who feel too deeply, who care too much?  Was it meant to be ironical, or perhaps even romantic—if ashes are ashes and dust is dust and love is over, what is the point of stopping to weep over a grave?  I will never know.

What I do know is that my own life as a radiation oncologist is a daily struggle NOT to cast a cold eye. Thirty one years out from the beginning of my radiation oncology residency, I sometimes think I have seen it all, from the early stages of disease where I just KNOW that the patient will be fine, to the patient with late stage malignancy, where it would take a miracle to cure, or even help the patient, and miracles are in short supply.  Some days I have to remind myself that even though I have given that speech about a particular disease and treatment options thousands of times, each new patient is hearing it for the very first time, and it is terrifying.

In the Jewish religion, these last ten days have marked the beginning of a New Year, and a time for repentance.  I’ve never been a particularly observant person, but I do find the concepts of renewal and atonement useful both in my personal, and in my professional life.  For the times when I was too rushed with my explanations, too self-absorbed or self-conscious for a healing touch, too worn out for sympathy, I am sorry.  For the New Year, anno mundi 5774 on the Hebrew calendar, I pledge to try to never, ever cast a cold eye on life, or on death, and just pass on by.

Love, Loss and All That Remains

“Don’t ever tell anybody anything—if you do you start missing everybody.”  Holden Caulfield

From The Catcher In The Rye, by J.D. Salinger

I don’t know whether it’s fitting, or selfish that on this anniversary of the 9/11 terrorist attacks I was remembering my friend Catherine Doyle, who died last December 18.  I had gone into the local branch of Wells Fargo, to finally close out a couple of accounts we held jointly—as Catherine said, “In case you have to pay for my funeral.”  I don’t know why it took me so long—after the cremation, and the payment of the legal fees of the estate, there were only a few dollars left and it seemed like a lot of bother until the service fees started coming in.  As it turned out, I owed the bank $6.95.  Perhaps I expected that with time, I would not mind the finality of it.  Instead I found myself telling the bank teller the story of Catherine’s life, and much to her dismay, crying while I did it.  Some things just don’t get easier, and presenting a death certificate is one of them.

The annual Western Regional Scottish Deerhound Specialty was dedicated to Catherine this past July.  She had been a longstanding member of both the National and Regional deerhound clubs and it was important that we honor her service to the breed.  I gave a eulogy, and others spoke as well, and our comments are too lengthy and at this point, too foggy to reproduce here. But there is one thing that lingers in my head, and so, with apologies to those of you who were there, I will repeat myself here.

After Catherine died, her jeweler Barbara called me and said, “I have something of Catherine’s that you will want.”  She mailed me a plain gold wedding band, worn thin from use, that she thought had belonged to Catherine’s mother.  As it turned out, that was not the case.  Inside the old band was inscribed “F. J. Malone to Clara, 1917.” As I turned over the ring and read the inscription, it seemed as if I was suddenly flooded with images and snippets of conversation from the past, across two continents and two World Wars:  Franklin J. Malone, a young Irish soldier presenting this ring to his betrothed, Clara, in a hurried ceremony just before departing for the Continent to fight and perish in the trenches of World War I.  Clara Malone, pregnant with her only child Alice, poor, bereft and with no means of support, booking steerage to come to America to find work as a seamstress and a better life.  Alice Malone, growing up fatherless, marrying a military man, Pierce Doyle, whose blue eyes and strong jawline reminded her of the only photograph she had of her father.  Alice, alone and in labor at a military hospital stateside, giving birth to Catherine while her husband served his country until the bombs we dropped on Hiroshima and Nagasaki brought him home to his wife and only child.  Alice, Pierce and Catherine moving to New Mexico so that Pierce, now a high ranking Army officer, could oversee the nuclear test sites in the southern part of the state.  Catherine, smart, multilingual and witty going off to Barnard before a taxi cab hit her on the streets of New York, shattering her legs, and her dreams.  Catherine, coming home to New Mexico to live out her life in a place they had all grown to love.  And finally, Catherine in a photograph, imposing in her cape and tartans, holding a leash of deerhounds against a mountainous landscape of endless sky.

Sometimes, an act of war or terror changes the entire history of an individual, or a family, as it did for my friend Catherine’s grandmother Clara, and for the survivors of 9/11, and Iraq, and Afghanistan. I have nothing but the deepest respect for those who fought, those who rescued, and those who were left behind.  Someday, I hope that I hold that gold ring, and the fleeting images and fragmented conversations take the shape and form of a real story played out over the last hundred years.  And then, I will write that novel.

The Youngest and Oldest Man in The Room

Another guest blog tonight, this time from my husband.  Enjoy!

 

This week I was making a business presentation when the audiovisual system crashed.    Since no one jumped up to fix it, I joked, “Who’s the youngest person present?  Bet they can fix it.”   This supposition is based on long-term personal experience in our household.  Without any doubt the go to person in our family when something electronic breaks is our youngest son, Evan.  Whether it’s a computer problem or a plug-in appliance, he just seems to know how to make it work.   He’s now 22 years old, and has been able to work his magic for nearly a decade.    So, I’ve gotten the message that it’s the young who are motivated to learn new technology and master it.   If you disagree, go to any Apple store and see how many pre-teens are playing with i “devices.” It’s what young people do.

 

Now, fast-forward to my business meeting.  I ask my question about the youngest person in the room, and to everyone’s surprise, up jumps a 68-year-old balding guy who claims, “I’m the youngest and the oldest person here!”  And indeed, he was.

 

This individual is an icon in Silicon Valley who is known for his ability to identify early stage technologies that have a way of becoming part of mainstream life.    As you might imagine, he’s made a substantial fortune by investing in such companies.  Even though he’s now semi – retired, it hasn’t dampened his interest in learning new things.  I’ve been working with him for the past few months, and really enjoy watching him approach technology for the first time.  He does it with a sense of wonder and exploration reminiscent of how kids approach their first iPad:  “Just think about how many cool things I can do with this when I learn how it works”.    When you mix this youthful exuberance with a highly successful sixty-something, you get something truly special.   The “cool things” a pre-teen might think of doing with new technology, now become some highly original out of the box ideas for applying technology in ways no one ever thought of.   The result is nothing short of “WOW!”.

 

 

I spent a good deal of my life trying to be the smartest person in the room.  This was basically the key to survival – and promotion – at Harvard Medical School where I spent nearly 20 of the most productive years of my life.    But now, I aspire to a different goal.  I no longer strive to be the smartest one around (I couldn’t accomplish this even if I wanted to).  But rather, my new goal is to be both the youngest and the oldest person in the room.  I’ll wager that the younger and the older I can become, the happier I’ll be.   Anyone willing to take this bet?

A Brief News Update From the Animal House

If you’ve been reading this blog for a while, you know that I have quite a little menagerie here.  In my animal loving prime, when I had a lot more energy than I do now, we had 5 Scottish deerhounds, one Brussels Griffon, two cats, two guinea pigs and eight horses, at least one of which I kept a secret from my husband who I feared would think that perhaps things were getting a little bit out of hand.  One day at the barn, he spotted a horse that he just KNEW I would love, and he inquired of the trainer whether the horse was for sale.  She didn’t quite know how to tell him that I already owned that particular animal.

The zoo has been winding down a bit here, mainly because the kids are gone and I am less prone to temptation without their little voices clamoring for that kitten for sale in the parking lot at the grocery store.  The cat with nine lives, eighteen year old Timmy Tom, was put to sleep in August when we could not control his thyroid disease, weight loss and vomiting.  Many of the horses have moved on to greener pastures elsewhere, where new children could learn to ride from the safety of their well-trained backs, and some of the best have passed on to that great green pasture in the sky.  Stormin’ Norman, the little Lipizzaner who carried my daughter through many a dressage test, left in late June to be leased by a beginning dressage rider.  In August she called to say she wanted to extend the lease to six months.

So I was surprised yesterday to get a call from the trainer to say that they would like to send twenty four year old Norman home.  She said that no matter how much she fed him, she couldn’t keep weight on him, and besides, an old stifle problem was recurring.  Fearing the worst, I went over to the boarding/training facility last night to have a look at him.  Now, mind you, this is a horse who has lived in my back yard for the better part of twelve or thirteen years.  Always a personable animal, with a beautiful expressive face and eyes, he knew me as well as any horse can know a person.  So I was surprised last night when I approached him with a bag of carrots and I heard no welcoming whinny.  His head shot up, and if horses can glare, this one positively glared at me.  His expression, plain as day, said, “Where the heck have YOU been, and when are you getting me OUT OF HERE?!”  And then he munched on his carrots.  He looked a little thin, but otherwise fine.

Norman’s coming home to join twenty eight old Dash on Wednesday, and I must say I’m glad.  The two old souls deserve a nice retirement, despite the fact that they really don’t like each other. And Labor Day weekend I visited a friend in Albuquerque who had a litter of eight week old deerhound puppies– it was hard to leave without one but they were all spoken for.  One day soon, I might be hearing the pitter patter of new little feet around these parts. After all, what’s a new carpet for?

The Gift of the Magi

When I was young, one of my favorite stories was O. Henry’s “The Gift of the Magi.”  Originally published in 1905, the short story became standard fare in public school reading classes and I doubt that there are any of you out there who have not read it.  But just in case– the story is about a young couple, poor and deeply in love.  At Christmas, they have no money to buy each other gifts.  She cuts off her long golden hair, her prized possession, to buy him a watch chain for his own treasure, the pocket watch his grandfather left him.  He sells the watch to buy ornamental combs for her beautiful tresses.  In a classic example of cosmic irony, the two are bereft of everything except their enduring love for one another.

Yesterday, an eighty five year old man was crying in my office.  A month ago, he completed a grueling seven weeks of treatment for head and neck cancer. Otherwise healthy, he endured the side effects of treatment with great equanimity—the loss of taste, the sore throat, the dry mouth, the hoarseness, the skin reaction, the fatigue and the weight loss associated with treatment.  His reward is great—he is free of disease and very likely to remain so.  He drove himself to every treatment, clearly motivated to complete his therapy despite his advanced age.  I never had to cajole him into continuing and finishing the treatment—he was clear that he was doing this for his wife of sixty three years, and for his family.  He wanted more time, and more healthy time with them.

When I saw him in follow up, I asked him how his post treatment time had been.  Many times for radiation therapy patients, the week or weeks following treatment are even more difficult than the treatments themselves—the side effects may worsen before they improve.  So I was not surprised when he said, “It’s been TERRIBLE.”  I patted his arm and said, “Tell me about it.”  He replied, “Right after I finished, my wife was hospitalized and now she is in kidney failure.  She started dialysis on Wednesday.”  Somewhat surprised that an eighty five year old woman would choose to go on dialysis, I asked him, “Do they expect her kidney function to improve?”  He said, “No, the doctors said there is no chance of improvement.  The hospital doctor said that under no circumstances would he recommend dialysis for her.  But the kidney doctor said it was her choice—to have dialysis and live, or to be made comfortable and die.  She chose to live, for me.”  And then he wept.

We can all be cynics or pragmatists if we choose.  We can talk about the escalating cost of healthcare, and the wisdom or folly of treating eighty five year olds with intensity modulated radiation therapy and daily image guidance and their wives with hemodialysis.  But what I saw yesterday was an affirmation of enduring love, in two elderly people, who gave one another a gift not unlike “The Gift of the Magi”—the gift of sacrificing self to continue to live.  It’s hard to be cynical about that.