How to Save a Life

And I would have stayed up with you all night–Had I known how to save a life.

The Fray, “How to Save a Life”

The tenth season of Grey’s Anatomy premieres tomorrow night.   For the cognoscenti, this means we will find out what happened after the cliff hanger of last season:  Will April really leave Matthew at the altar, for her first love plastic surgeon Jackson?  Or will the handsome paramedic who loves the doctor unconditionally and quite unbelievably without ego issues, win his lovely bride?  After all, he organized a flash mob for his proposal to her.  He deserves his beautiful red headed pig farming sweetheart.  And why do I watch these things?  Is it because the women wear makeup and heels and do their hair and the men are so very handsome and no one looks tired, and lives are saved quickly, with great valor. As Hemingway’s Jake says at the end of The Sun Also Rises, “Isn’t it pretty to think so?”

The song, “How to Save a Life” by the Fray, was used in an episode of Grey’s second season, and afterwards became an anthem for the show itself.  My favorite rendition is a home video with a hand held camera, of the actual cast singing the song at a benefit—you can view it here:  http://www.youtube.com/watch?v=KX3AjiqFA1s   Yes, I know they aren’t “real” doctors. But I suspect that if you act like a doctor for ten years of your life, it might be hard in the end to tell the difference.  The emotions are all right out there, in the video and in the show.  And that’s the real answer to why I watch Grey’s Anatomy—I get it all out in front of my own television set so I don’t have to do it in front of my patients.   I don’t think it’s helpful to have your doctor cry while she is giving you bad news.

Friday, February 28 will be my last day at work.  I am officially retiring, at age sixty. My staff and my patients have been asking me why for several weeks now.  They make very complimentary proclamations like, “But you look so young!” and “But you’re so GOOD at what you do” and “How can we replace you?”  The answers to these questions are “thank you,” “thank you,” and “No one is irreplaceable.”  The truth is that I feel like time is running out.  I have had some extremely joyful experiences over my last thirty two years in Radiation Oncology and I have witnessed some incredible success stories, many of which I have told here.  I know that miracles DO happen.  But I have also seen some terrible things, and there is not a doctor alive who would say that we don’t take our failures personally.  We do.  What I have come to realize, at least for me, is that the sad times are not getting easier as I am getting older.  Facing the deaths of loved ones this past year–patients, relatives, friends and pets—has left me with an acute sense that the clock ticking in the belly of the crocodile is ticking for me, and  I am no Peter Pan.

So I will leave my practice in the best of hands, and I will read and I will write and I will travel and see more of my children and all the other people I care about.  There is a line in “How to Save a Life” which goes, “And you’ll begin to wonder why you came.”  There is one thing that I am certain of, when it comes to my career.  I will never ever wonder why I came.

A Different Kind of Mask

“I want them to live again to the point where pain becomes art.”

Lawrence Durrell,  “Justine”

I have always loved masks.  Near sighted likely from birth, a fact which was discovered significantly later, I never minded stumbling around our neighborhood on Halloween, my already deficient depth perception further stunted by my Bugs Bunny mask.  To don a mask was a chance to become someone else,  and as I grew older my disguises became more exotic—a gypsy fortune teller with gold hoop earrings in high school, a Turkish harem girl in college.  My imagination, fueled by the old stories of the Venetian Carnivale dating back to 1162, knew no bounds, and I secretly dreamed of a masked ball where I would glide gracefully and soundlessly, recognizing and being recognized by a handsome prince, by touch and scent alone.

 

In 2002 I took the occasion of my daughter’s graduation from high school as an opportunity for us to visit Venice, and more specifically, the mask shop known as La Bottega dei Mascareri at the base of the famous Rialto Bridge where a lively market persists to this day.  Elizabeth Barrett Browning may have been speaking metaphorically when she said, “the soul’s Rialto hath its merchandise,” but I was subject to a more literal interpretation.  I wanted to buy a mask from the famous brothers Sergio and Massimo Boldrin, who fashion papier mache masks in the old Venetian tradition.  I picked out a good one, made by Massimo himself, and given the history it depicts—perfect for a doctor.

 

The mask is larger than my face and flat, hand painted with a crackle glaze to look very old, and it pictures a man in medieval clothing dancing around a bonfire,  wearing the peculiar bird beaked mask known to physicians of the plague years.  The beaks were stuffed with medicinal herbs thought to ward off the dread disease.  In just one scene, the mask depicts the horror of bubonic plague—the bird beaked man, the fire to burn the contaminated bodies and clothing, the “ring around the rosie” cheeks of the afflicted.  With some difficulty, I brought my prize home in a suitcase, only to find that it gave me nightmares.  Today it sits on a bookshelf in the study off our garage.   I can’t have it in the house.

 

My patients with head and neck cancer are all too familiar with the concept of the mask, but for them the mask has a different significance.  Fashioned of a material called Aquaplast, the mask starts as a thick sheet of perforated plastic.  Warmed in a hot water bath, the material becomes soft and pliable, and is stretched over the cancer patient’s head and shoulders where it shape shifts to appear like a woman’s fish net stocking, but without the softness.  The mask hardens to become a rigid immobilization device which is bolted to the treatment table.  In my field, precision is everything and the mask, custom made for each patient, allows the radiation oncologist to accurately target the cancer while sparing critical structures such as the spinal cord and the eyes.  Not for the claustrophobic, the mask is a temporary prison for seven weeks of daily treatment.  At the end of treatment, each patient is offered the opportunity to take his or her own mask home.  Most actually do.

 

Today at the biannual Multidisciplinary Head and Neck Cancer Symposium in Scottsdale, AZ, I saw something quite extraordinary.  In order to assist patients financially with these cancers, an organization out of Washington DC called 911 4 HNC mounted an exhibition called “Courage Unmasked”  (www.courageunmasked.org).  Cookie Kerxton, an artist who was treated for head and neck cancer herself enlisted other artists to transform radiation masks into works of art.  The results, several of which are on exhibit at the meeting, are objects of exceptional beauty, turning human suffering into inspiration and hope for others.

 

At the meeting, volunteers were handing out free posters depicting forty two of these beautiful masks.  When I get home, I will have my poster framed and I will hang it in the room where I examine my head and neck cancer patients.  I am hoping that the bright colors of the beautiful masks will lessen their fear, and transform their pain.  There is indeed great progress in the treatment of their cancers.

The Glass Is Half Full

A couple of weeks ago my nurse came to me with a request for a consultation.  Since our schedule has been packed full lately, she’s been asking me where I can squeeze patients in.  She said, “I’m not sure about this one—he says you treated him twenty years ago and he wants to see you.  But there is no new pathology so I don’t know how urgent it is.”  I looked at the consult request and did not remember the patient but there were several handwritten jottings on the cover sheet from the referring physician that listed phone numbers and beside them, “no answer at this number X 3,” and “Dr. Fielding hasn’t worked here since 2004.”  Apparently some effort was made to track me down, since I have changed jobs a few times in the last twenty years. I said, “Well get the latest information on the patient and put him in the open emergency slot a week from Friday.”

So Friday came yesterday and this patient was scheduled at one o’clock.  I like to review the charts before I see new patients, so I picked up the chart during a hurried lunch and read through it with a growing sense of recognition, and no small amount of dread. The man had been treated for advanced head and neck cancer back in 1994.  He had presented with cancer on the lateral aspect of his tongue, which was excised by his surgeon.  Six months later, he recurred both on the tongue, on the soft palate, and in his neck, with a large tumor wrapped around his jugular vein.  His surgeon tried, even sacrificing the large vein, but he could not resect all of the cancer and the patient was referred to me for post-operative radiation therapy.  Given that the man was only fifty one years old, his medical oncologist made the decision to give him chemotherapy along with the radiation, a decision which was considered quite radical at the time.  Treatments for head and neck cancer back then were crude by today’s standards, and fraught with complications, and this man had had all of them.

By 2000, he could no longer swallow, and his esophagus had to be dilated.  This happened again in 2008, and another procedure provided relief.  His saliva never fully returned after treatment, and so in 2012, plagued with tooth decay, he began a series of extractions, augmented by hyperbaric oxygen therapy to prevent osteoradionecrosis of his mandible.  Unfortunately this did not work, and he ended up having a portion of his jawbone removed.  A year ago, he began to have a new issue—when he tried to swallow the food was going down “the wrong way” and causing him to choke, resulting in several episodes of aspiration pneumonia.  It was becoming hard for him to go out socially, and enjoy a meal with friends and family. His carotid and vertebral arteries were narrowed, putting him at risk for stroke. Multiple recent studies showed no evidence of recurrence of his cancer, but there was scar tissue in the back of the throat which prevented the epiglottis from closing over the trachea when he swallowed.  These were the things I read in his chart before I saw him, and I anticipated that our session together would be an angry one.

Tall, older and thinner than I had last seen him, the patient greeted me with a huge hug.  His wife smiled warmly.  As we sat and talked in our sunny consultation room, he described his current difficulties and told me that his surgeon had referred him back to me for electrical stimulation therapy of the throat muscles, which might help his aspiration.  Our institution has an entire department for the rehabilitation of head and neck cancer patients.  I groped for the right words to say to this man who had suffered through complications which are rare by today’s standards of care.  I apologized profusely, and explained that now we have better ways of shielding normal tissues to spare patients the terrible late effects of treatment.  I told him I would be happy to put in a referral to our swallowing and speech rehabilitation specialists.  He looked at me in surprise, and said, “Doc, I didn’t come here for that.  Dr. M (the surgeon) already put in the referral. When I found out you work here, I came to say thank you.  I was fifty one when I was told that my chances of survival were 10 per cent.  Now I’m seventy one years old.”  He squeezed his wife’s hand and said, “We’ve traveled the world together.  We’ve seen our grandkids graduate high school.  We’re going on a cruise to San Francisco next week.  Yeah, I’ve had my problems but we’re still having fun!”

Some folks are just “the glass is half full” kind of people.  Having always thought of myself as one of them, I’m surprised it took me a whole consultation to recognize that in my patient. Taking care of cancer patients has always been a good way to remind myself that my own life is not so bad.  Lesson learned, again.

Facebook Flicks

Fourteen years ago, writer/actor/director Christopher Guest made a little movie called “Best in Show”, supposedly a movie about dog shows, but more accurately a very funny movie about people who show dogs.  The film was eagerly anticipated in the dog show world, since many of us knew which dogs of each breed had been chosen to represent their kind at the penultimate show, a spoof of the upcoming Westminster Kennel Club extravaganza happening in New York City next week.  When the film premiered, murmurs of disappointment echoed through the hallowed halls of the AKC and crescendoed into harrumphs of “We’re not like THAT!”  Ever the klutzy owner-handler, I stood on the sidelines thinking, “Oh yes you ARE!”

Today, thanks to Facebook, I experienced a deja-vu of that moment when I watched my very own Facebook movie.  For the few holdouts reading this who eschew the “social media”, Facebook describes itself as “a social utility that connects people with friends and others who live, study and work around them.”  For many people, “around them” today literally means the whole world, and folks with interests in common, say, Scottish Deerhounds or thimble collecting, find themselves as fast Facebook friends with likeminded ladies and gents around the globe.  In honor of Facebook’s tenth anniversary, the shadow minions of Mark Zuckerberg decided to celebrate by making a movie of each of our very own lives.

The movies starting rolling in on my news feed late last night, and finally this morning, I could stand it no longer—I hit the little arrow indicating the start of my personal Facebook Odyssey.  Exactly one minute and two seconds later, I had to greet the contractor working on my house with tears streaming down my face.  My life was before me–so “poignant”, so “in the moment”, so “true.”  Or so my Facebook friends said.  It was only after the second or third viewing that I began to realize that my movie was all about three things, in descending order of frequency:  my dogs, my Dad, and my youngest son.  But especially about my dogs.  By the end of the day, I noticed more and more comments from my Deerhound friends that their own movies were dominated by their dogs.  “Where are all my people?” one friend asked.  “Maybe the little computer elves making the movies just happen to LOVE Scottish Deerhounds,” I joked.

At last viewing, I found myself asking the same question.  Where are all my people—my husband and my two older children?  Where are the horses?  Where are my colleagues?  Where is my belated and much missed cat Timmy Tom, and where the heck is my red Corvette?  It was then that I had my Best in Show moment.  If my Facebook flick says it’s all about the dogs and Dad, then maybe it is…perhaps just a little bit too much.   Maybe I need a psychiatrist.  But maybe, just maybe, I need to spend a little less time on Facebook and a little more time on what matters most—living life.  I’d best get on with it.