And Speaking of Plastic Surgery

I have a new favorite doctor show, “The Knick” on Cinemax, airing on Friday nights.   The show stars Clive Owen as the charismatic cocaine addicted Chief of Surgery Dr. John Thackery at a fictitious New York City hospital called The Kickerbocker at a time when surgery was one foot out of the barbershop.  The tagline is, as they say, priceless– “Modern medicine had to start somewhere.”  On the third episode, last Friday night, Dr. Thackery performs a pedicle skin graft from the upper arm to cover a gaping hole in a woman’s face where her nose used to be, before she got syphilis.   Back in those days, this was a marvelous feat.  Real progress in what we now know as reconstructive surgery didn’t come until the end of World War I, when Sir Harold Gillies, a New Zealand otolaryngologist later known as the “father of plastic surgery,” established the first hospital ward for the facially wounded in Queen Mary’s Hospital in Kent.

For over fifty years, I have been a bystander to the evolution of plastic surgery.  As a teenager I remember the heady early days of microvascular surgery—my father, Dr. Melvin Spira reattaching the scalp of a man whose hair got caught in machinery, then the tales of sewing back severed fingers and ultimately entire limbs with gradually improving functional results.  In the 1970’s the great French surgeon Dr. Paul Tessier, pioneer in techniques for cranio-facial surgery to correct birth defects came to the United States to teach, and I remember a Saturday morning clinic at my father’s office, where mothers whose children’s facial deformities were so severe that these kids had, literally, never seen the light of day waited in line to be seen by the great surgeon who could give them back a normal appearance, and thus a life.

Plastic surgery, like my own specialty of Radiation Oncology, has become one of the “lifestyle” specialties to which medical students aspire, particularly those with an artistic bent and good hands, and for good reason.  Cosmetic procedures are highly reimbursed, and are done during “regular” working hours. Walking around here in San Diego and Los Angeles, surely two of the plastic surgery capitals of the world, it’s easy to spot who has had “a little work” done.  Having one face lift might be a good thing (I wouldn’t know because, as I’ve covered in previous blog pieces, my imagination runs wild with the possibilities of complications and I am far too chicken for elective surgery), but have three and you become one of “Our Ladies of Perpetual Surprise”, eyebrows at the hairline.  Same goes for breasts—it is not normal for the “girls” to be rigidly immobile as their owner pounds away at the Stairmaster.

Last year I mentored a medical student who had started his medical education thinking that he wanted to become a plastic surgeon.  After a beloved aunt developed breast cancer and needed radiation, he started to think that perhaps he would rather become a radiation oncologist because he enjoyed dealing with cancer patients.  He was an outstanding student, and I was quite sure that he would be accepted, and do well in either specialty.  I assured him that with his gifts, and his compassion, he could combine his interest in helping cancer patients with his interest in reconstructive and restorative surgery. Residency interviewers for plastic surgery residencies have a difficult job these days: all of the applicants SAY they want to do reconstructive surgery, but most end up doing cosmetic work.  Apparently my student was convincing when he said he wanted to do plastic surgery to help cancer patients.  He started his plastic surgery residency at Stanford last month.  Dr. John Thackery of “The Knick” may be fictional, but I hope that my student leads the way in new innovations in reconstructive surgery.  My cancer patients may depend on it.

You Can’t Keep A Good Man Down

It’s been awhile since I got my readers up to speed on the adventures of Dad.  For those of you who are new to this blog, my father is a plastic surgeon who retired from full time practice about 15 years ago after a very successful academic career.  He turned 89 years old in July and the last couple of years have not been kind to him:  my mother passed away in January of 2013, and shortly after that Dad had an aortic valve replacement followed eight months later by a hip replacement.  These surgeries were in addition to coronary bypass surgery ten years ago, a splenectomy a few years later necessitated by his penchant for running red lights, and a badly fractured collarbone after taking an expert ski run a little too fast at age 85.  Despite all of this, I was not surprised when he told me a few months ago that he planned to go to Guatemala last week with Surgicorps International, a group that performs plastic and reconstructive surgery in developing countries.  What DID surprise me however was his announcement that he was taking his 84 year old girlfriend Evelyne with him.  He was positively gleeful—he proclaimed over dinner that he was going to teach her to clean instruments and prepare the OR between cases. I did not think this was a good idea, and my opinion was backed up by my sister who has never been a big fan of medicine in general, blood and guts in particular.

A week after the big “reveal”, I took Dad aside and told him that while I had no objections to Evelyne accompanying him on the trip, I thought it was a TERRIBLE idea for him to consider taking her into the operating room.  I said, “Dad, Evelyne was a piano teacher, not a nurse!  And don’t you remember what happened the first time you took ME into your operating room?”  He remembered.  I was seventeen years old, a high school student mildly interested in medicine, at least to the degree that I was volunteering at a local hospital as a candy striper (do they even have those anymore?). He invited me to watch a face lift, being performed under local anesthesia.  I was fine for the first 30 minutes or so—the slice of the scalpel, the smell of the Bovie, the careful undermining of tissue between the skin and the soft tissues of the face.  But when he then peeled back the loose skin to reveal those sinewy muscles below—well, the last thing I remember hearing was—“QUICK!!  Somebody catch her!”  I fainted dead away.  I could only imagine poor Evelyne doing the same, and cracking her head on the instrument cart.  Dad smiled and nodded.  A week later he announced that they had driven to San Marcos so that she could pick out scrubs.

Dad and Evelyne returned home from Guatemala on Saturday night.  On Sunday afternoon, I went over to their senior community to return their cat, whom I had been keeping during their trip.  Well, actually it’s my daughter’s cat, but that’s another story.  I loaded kitty into his carrier, and the litter box, the unused kitty litter, the big bag of food, the two stainless steel bowls, and numerous cat toys into the back of my car.  I called and gave Dad the 15 minute warning:  “Meet me downstairs because there is too much for me to carry.”  He dutifully met me in the parking lot, but there was still too much paraphernalia.  I said, “I’ll just run the cat up to Evelyne’s place.”  So I did.  I knocked on the door, cat in hand.  No answer.  I rang the doorbell.  No answer.  I knocked again, louder.  Still, no answer.  I dropped the cat carrier and ran back downstairs.  I said, fearing the worst, “Dad, when was the last time you SAW Evelyne??”  He said, “Last night—why?”  I said, “She’s not answering the door.”  He said, “Well, I think she’s been on the phone for a long time.  I keep calling her but the line is busy.”  At this point, I am completely unhinged.  I said, “DAD—SOMETHING COULD HAVE HAPPENED TO HER!!!!  WHAT IF SHE IS UNCONCIOUS AND DROPPED THE PHONE??”   At this point, even he is looking a little scared.

I ran back upstairs.  The cat is meowing in his carrier.  I knock, no, I BANG on the door shouting, “Evelyne, it’s me, come to the door!”  I ring the bell again and again.  And finally, I hear stirring and a small voice inside the apartment.  Evelyne appears at the door, a little bewildered that I have made such a fuss.  She says, “I’m sorry.  I didn’t hear the door.  I’ve been on the phone all day, telling EVERYONE about my adventure!”  As I sighed with relief, I said, “Oh, you enjoyed yourself?”  She said, “It was the greatest experience of my whole life.  I even got to see a gall bladder being removed.  And when they cut open the gall bladder, I got to see REAL gallstones!  I had to call everyone I know and tell them ALL about it.”  She looked exhausted, and utterly triumphant.

Needless to say, they are already planning to go with Surgicorps to Viet Nam in October.  At age 89, he has found a soul mate.  And at 84, she has found a new calling in life.  There’s hope for the rest of us, for sure.  We’re planning one heckuva ninetieth birthday party for him in July.  That is, if his schedule permits.

In Pursuit of Perfection

“Upon what instrument are we two spanned, and what musician holds us in his hands?”

Rainer Maria Rilke

This past week was a very busy yet very interesting time for me.  Early in the week, I had a visit from an old medical school classmate who is now one of our nation’s leading researchers in diabetes and other endocrine diseases.  Although most of his time is spent in the lab, he still prides himself on being an outstanding clinician, and I can attest to that.  I would choose him for my own personal physician any day, were he not based at Duke in Durham, NC.  He told me the following story:  a few months ago he was the attending physician on the endocrine consultation service.  The fellow on duty was called for a consult on a middle aged man who needed an amputation for vascular complications related to his diabetes, and the surgeon needed to make sure his blood sugars were under control before taking him for surgery.  The endocrinology fellow assessed the patient’s insulin requirements, and also mentioned that the man was complaining of some mild upper back pain, which seemed insignificant at the time. The case was presented to my friend, was assessed to be routine, and the patient went to surgery.  Shortly after the operation, the man suffered a cardiac arrest due to a myocardial infarction in the posterior circulation.  He did not survive.  My friend, whose job was NOT to assess the patient’s cardiac status, but rather his diabetic control, is still beating himself up about the patient’s death, many months later.  He insists that he should have asked the surgeon for a cardiac work up prior to the surgery.

On Thursday, I flew to Kalispell, MT to attend my nephew’s graduation from Montana Academy, a boarding school dedicated both to academic excellence, and the therapeutic mission of helping teenagers with problems learn to cope in positive ways. At the graduation ceremony, I was moved to tears several times, first by the headmaster’s recounting of the tale of Odysseus and the Cyclops as an analogy for the importance of finding and declaring one’s true identity, and later by the speeches of some of the parents whose children had benefited from this school, set in the green pastures and foothills of Montana. Finally, and even more importantly, some of the students themselves spoke, hesitating at first and stumbling over their words, but gaining strength from the support of the gathered crowd as well as their teachers, counselors and the founders of the school sitting behind them.  The students spoke of the failures which led them to the academy, each small but increasingly significant success they met there, and their hopes and dreams for the future.  These students were articulate and impressively intelligent. The last student who spoke was particularly moving, when she said, “Here I discovered that I am worthy of love, and that I DESERVE to love and be loved in return.”

We all strive for perfection, and yet for most of us it is our failures which teach us the meaning of life and of being human.  Some of us are lucky enough to learn this at eighteen, but many of us are still learning these lessons at sixty.  Last night, as I prepared for bed a row of necklaces I have hanging from pegs in the bathroom caught my eye—fossil mammoth ivory turned blue from arctic hoarfrost, and set with a fire opal, lapis prayer beads from Bhutan, ancient carnelian beads from the mountains of Nepal, and an old Chinese quartz crystal set in silver with enameled symbols of yin and yang.  I wondered, for myself, for my nephew and for my old friend, what talismans are these which can keep us safe, which can protect us from our own demons?  And what great musician holds us in his hands?  We can only continue to do the very best we can.

Do Dogs Know They are Dying?

Labor Day, 2006, is a day I will never forget.  It was a gorgeous day here in San Diego—bright, sunny and nearly 90 degrees.  I decided it was a perfect day to give the dogs an outdoor bath.  At the time, we had Valentine, the matriarch at nearly twelve years old, Izzy who was four, and the two young  ones Magic and Angelina who were two years old.  We started with Valentine—at her age she’d had a little problem with urinary incontinence, and she needed her bath the most.  We knew that the coiled up hose sitting in the sun on that hot afternoon had enough warm water to bathe her in, so my daughter and I mixed shampoo in a bucket of hot water from the kitchen sink, and just outside the garage, we soaped her up.  She seemed to be enjoying herself, a nice soapy massage on a beautiful day, and then a quick rinse.  As I turned to get the towel to dry her, I heard my daughter say loudly and in a panic, “VAL, DON’T FALL DOWN!”  I turned back around and she was gone, down on the wet pavement, eyes blank.  She never felt a thing.   I spent the rest of the afternoon sitting on the driveway with my dead dog, brushing her hair until it dried and the crematorium people came to take her away.  Needless to say, no one else got a bath that day.

I once read an essay by an oncologist who said that she hoped that she would die of cancer.   I was baffled by this, because my personal preference would be to go suddenly, of a heart attack or a massive stroke, preferably while doing something I enjoy.  But her reasoning was quite clear:  she said that with cancer, when you know that your days on earth are numbered, you still have time—time to do the things you always wanted to do, time to say good bye, time to make amends.  This has actually been true for most of my patients—when they know that they are diagnosed with a life threatening illness, their priorities change.  If they have the means, they live the lives they always wanted to live, for as long as they are able.  They remember, they forgive and they forget.  The trivialities of daily life become unimportant, except insofar as they struggle to get through them.   Many become the person they always wanted to be, and I hope that if this is my fate, I have the grace to do the same.

Today we took old Magic to the veterinary cardiologist.  Magic is my eldest deerhound—a big male at 120 pounds, and nearly ten years old.  The last two weeks have been hard for him—we’ve had thunderstorms and he has always been afraid of thunder.  In desperation over his anxiety last week I called his vet for a prescription for a tranquilizer.  It worked temporarily, but on Tuesday we had strangers in the house and he was panting, salivating, and his heart was beating far too rapidly.  I laid a hand on his chest and I knew instantly that his big old heart was failing.  Today the diagnostic echocardiogram confirmed what I already knew—that my big guy has dilated cardiomyopathy, and that he is in congestive heart failure.  We started medication immediately, and I am hoping for a few more weeks, or a few more months with this grand old man who is, as my husband says, “the dog who never did anything wrong.”

Do dogs, like humans, know when they are dying?  I don’t think so.  And in fact, for their sake, I hope not.  Unlike us, they have nothing to apologize for, and perhaps their next meal, or a walk in the park, or in a dream a wild chase after a highland stag, followed by a soft bed and the touch of a human hand is all that they hope for and dream about.  As Magic slowly made his way out of the van today onto solid ground, he was greeted warmly by Queen, Quicksilver and little Yoda.  I can no longer promise him a life beyond his years, but I promised him today that every day from now on will be the best day I can give him—lots of treats, a comfortable place to rest, and with all certainty, no more baths.

Learning to Fly Without Wings

For Morgan

Two days ago, one of my daughter’s best friends from childhood lost her beloved horse Rumba.  This young woman is now a yoga instructor and for the past year she has been traveling and working in Australia.  The strange thing about this story is best said in her own words:

“I never sign up to go on trail rides when I travel because I know I will be disappointed when all we do is walk. But something drew me to this ride, it was for “advanced riders” with promises of cantering. I wanted to go a few days ago but it wasn’t available so I had to settle for yesterday morning. They gave me a horse named Big, I felt that was appropriate since I am used to riding my big mare. We rode for 3 hours through the streams, by the blue lake water and galloped across a field. Towards the end of the ride the horse started prancing back towards home exactly as Rumba would have done on a trail. In that moment I thought I was riding her and maybe I was. Maybe that was the moment she passed away. She was with me and I was with her.

I may not have wanted to buy her but we did anyways. I may not have liked her in the beginning but I rode her anyways. She taught me how to be strong and courageous. It seemed at times we had the same bitchy personality and in the end we knew each other better than anyone else.
I spent this last day with myself. Sometimes crying, meditating and just existing. I treated myself to some spa time, cupcakes and most importantly yoga. I’ve read all the loving comments and messages from near and far. And I am finally starting to feel better. Thank you all for the love and support. It literally means the world to me.”

With these words on Facebook she published several photos of herself riding her old horse.  In one of the photographs, they are mid-jump over a high double oxer– a difficult jump—together as one.  I can only imagine how she must have felt, airborne, in the split second it took the large bay mare to clear that jump.  It must have felt like she was flying.

I think that we all imagine ourselves flying as children. We dream about it and we try to live it.  From the first viewing of Peter Pan, to the teenage pursuits of riding racing bicycles, or motorcycles, or horses, or learning to sail or ski, we all grow our imaginary wings, and for the times that we are doing what we do, we feel pure joy:  we are limitless, unbound by gravity or sadness or sorrow.  We have wings.

For most of us, growing up is learning to fly without wings—to find satisfaction in our friends, our families, our pets, our careers, and our hobbies.  If we are lucky, we find solace in the daily small pleasures that surround us—the scent of a blooming rose, the wag of a tail, the taste of good food or fine wine.  My daughter’s friend is learning this now, traveling alone in a strange land far from the familiar neighborhood she grew up in.  The day after her horse died, she put another picture on Facebook, of a beautiful rainbow arching over the New Zealand road she was driving on.  I’ll never know for sure, but I think it was Rumba, telling her everything is going to be okay.