An Extraordinary Life

“Death, be not proud, though some have called thee

Mighty and dreadful, for thou art not so”—John Donne

On a Sunday in January, 2014, I opened the New York Times Opinion section and stumbled upon one of the most unusual essays I had ever read.  It was written by Dr. Paul Kalanithi, who at the time was a 36 year old neurosurgery resident at Stanford who had been battling metastatic lung cancer for eight months.  Here is a link to the essay, entitled “How Long Have I Got Left?”– http://www.nytimes.com/2014/01/25/opinion/sunday/how-long-have-i-got-left.html?_r=0    The author’s point was one well understood by cancer patients everywhere—if the doctors could not tell him whether he had a month, or a year, or ten years, how could he possibly determine what his priorities should be and how best to live his life?  Should he finish his residency?  Should he write a book?  Should he have a child?  In his worst moments he wrote that he fell back on his first love—literature.  In the last sentence of Samuel Beckett’s The Unnamable, Kalanithi found a mantra to live by: “I can’t go on.  I’ll go on.”

As it turned out, he did not have long.  Despite the optimistic and sometimes humorous tone of the essay, Dr. Paul Kalanithi died of his lung cancer 14 months later.  But not without first doing ALL of the things he mentioned in the essay.  He finished his neurosurgery residency as chief resident. He repaired a fractured marriage.  He had a child.  And to our great benefit, he wrote a book called “When Breath Becomes Air” published posthumously in January of this year—a book which despite my oft stated incredible reluctance to read anything I know will make me cry, I grabbed off the shelf the minute I spotted it in a local bookstore.   I was not disappointed, and yes, I cried.

The courage of cancer patients, and of all patients facing life threatening disease astounds and inspires me.  Many go through grueling and exhausting treatments and manage to put one foot in front of the other—they “can’t go on…they go on.”   Paul Kalanithi not only went on…he wrote about his experience in a book that will stand not only as a cancer memoir, but as a profound piece of writing.  When faced with dying, he chose life by completing his training, by having a child, by believing every day that he still had much to offer.  In an essay for Stanford Medicine he wrote words for his infant daughter which were included in his book: “When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.”

I hope you get a chance to read his book.  Even if it makes you cry.

How Old is Too Old?

Yesterday I saw a 90 year old woman in consultation.  She presented to the emergency room in September with abdominal pain, and in the process of working her up, a chest X-ray was taken which showed an infiltrate in her lingula, part of the left lower lobe of her lung.  As it turned out, there was nothing wrong with her belly, but a follow up CT scan of her chest showed this strange fluffy area in the left lung—not quite a tumor, but not quite a pneumonia either.  She had smoked for years but quit in 1980 and she had no symptoms of cough or shortness of breath.  The decision was made jointly between the patient and her primary care physician to just “watch it”.  A repeat scan was done two months later, in November, which showed that the area had “slightly” enlarged.  She was seen by a pulmonary specialist who recommended that she have a biopsy and she was referred to interventional radiologists who were asked to put a needle in it and withdraw cells for analysis.  They declined, unfortunately, citing that the risk of causing a lung collapse or bleeding was too great in this elderly woman.  The pulmonologist could have tried to reach it with a bronchoscope, but he doubted that he could—it was a little too far in.  So two months later, she was referred to me for consideration of radiation therapy, still entirely well, with no lung symptoms whatsoever–and no diagnosis of cancer.

Yesterday she and her equally intact and otherwise healthy 90 year old husband sat in my exam room as I explained to them that, while there is a high likelihood that this abnormality in her chest is indeed a cancer, to operate to remove it could be fraught with complications, even fatality, and to give her radiation without a diagnosis was equally unconscionable, given the fact that the area was very near her heart and that radiation itself can cause serious inflammation in the lung.  She looked at me without a trace of irony and said, “Doctor, all I want is another ten years.”

And there we have it.  Next week she will have a PET-CT scan to see if the abnormality is positive on PET (a clearer indication of cancer than a plain CT scan), and to rule out cancer elsewhere in her body.  If it is larger now, and PET avid, she will be referred to a tertiary care center for a specialized bronchoscopy which can reach the lesion for biopsy.  If the biopsy is positive for cancer, she will be treated with whatever modality is deemed most appropriate for her type of tumor, be it surgery, radiation therapy, or chemotherapy.  It is what she wants, and what her husband wants for her and they clearly understand the risks.  She is ninety.

People say to me all the time, “What would YOU do if this was your parent?”  The answer, honestly, is I do not know.

Cold Roast Beef

Just when you thought I had finished talking about Thanksgiving, here it is again. A few weeks ago, between patients, I was catching up with other physicians’ blogs. Yes, readers, I have discovered that I am not the only one, nor am I the most articulate or humorous or erudite MD to put fingers to keyboard. Some of my fellow writers are very very good, and when I can figure out to get a blog roll going on the sidelines of my page, I will share their sites with you. Anyway, I came across an essay by a medical student where she thanked her cadaver for allowing her to learn by his donation of his body “to science.” For those of you who don’t know what happens when one donates one’s body to science, I can tell you that most of the time the final resting place is the medical school anatomy lab. Here the alpha of gross anatomy is the human upper arm, where the ropey bundle of nerves which makes up the brachial plexus is dissected free in order for the student to understand the complexity of how we use that delicate instrument, the human hand. The omega, or the last body part dissected, is the brain.

 
So the thing about her essay which really struck me, besides her sincerity, was one sentence, paraphrased here—“I don’t think I’ll ever eat roast beef again.” That one line took me right back to medical school and my own gross anatomy lab where I too dissected a human being, thirty seven years ago. Back in those days, before the Health Information Privacy laws of 1996 gave us the right to keep sensitive health issues anonymous and long before we willingly gave up that right by broadcasting every sniffle and sneeze on Facebook, cadavers were actually sent to the anatomy lab still wearing their hospital bracelets. My man’s last name shall remain with me, but his first name was Herman and I even knew his birthday. Before you exclaim, “How AWFUL!” think about it. To me and the preceptor and the three other members of my team, this man was not just a body to be dissected—he had been a living breathing human named Herman who had thought enough of the process of training young doctors to give us himself—all of him. It was personal.

 
In death, the body gives up all of its secrets. Herman gave me my first experience of seeing cancer from the inside out. He died of lung cancer, and his lungs were full of tumors, as were his liver, his bones and even the soft tissues of the muscles of his body. We dissected and discussed our findings during the long days, reeking of formaldehyde. Gradually through the course of a semester, I discovered the evil and relentless nature of his disease. One night after anatomy lab I dreamed that I took him home with me. I laid him down on my living room couch. He did not talk; he did not move. He was just there, with flesh the color of old roast beef. The dream was very real and I woke up half expecting to walk into my living room and see him there on the couch. It was years before I could eat roast beef again.

 
Three years ago at Thanksgiving, I decided that I would cook a whole beef tenderloin, in addition to having the traditional turkey. After all, I’m a carnivorous Texan and red meat is not that bad for you if you don’t eat it all the time. This year, with a twenty five pound turkey, a four pound beef tenderloin and only nine people to feed, we had lots of leftovers. As I loaded a plate with sliced beef, done to a perfect medium rare, I had a transient moment of discomfort, a slight sensation of nausea, and a very brief flashback to Herman and anatomy lab. Next year, perhaps I will do a lasagna, or a nice fettucine alfredo instead!

I am the Grocery Store Doctor

I hate supermarkets—those bright fluorescently lit mega-stores where you seem to walk for miles, filling your cart as you go while constantly rearranging the contents to avoid flattening of the perishable fruits and bread.  There was a time ten years ago when the presence of three rapidly growing teenagers  mandated the use of two carts for each shopping experience, not to mention an assistant, usually my daughter, since one cart could not hold enough food for a few days, let alone a week.  And forget Costco—who knew that I needed a five gallon jug of ketchup with a matching jug of mustard, ten bargain DVD’s and oh, look at the deal on those sheets!  Whoever said that the road to hell is paved with good intentions was describing me shopping at Costco, no doubt about it.

So now that the kids are grown and mostly gone, I do my shopping at the corner grocery store—a place I pass every day on my way home from work.  It’s the kind of place that has homemade macaroni and cheese at the deli counter, and fresh stuffed cabbage, and garlic mashed red potatoes with the skins blended in and plenty of butter and salt and cream. The owners employ their own butchers, and since we are a house of hungry carnivores, the men behind the meat counter are my special friends. I’ve been going there so long that all of the employees know my name, and most of them can recite my kids and dogs names as well.  So it’s only natural that when they have a medical problem, they come to me–in the grocery store. I guess you could say more accurately that I go to them.  I’ve diagnosed allergies, ulcers, psoriasis and migraines, and on a few occasions, a cancer.

Last Thursday night, my favorite butcher—the one who calls me (and all of his other female clients) “Princess” and gives me the $5.99 hamburger meat for $2.99 when he’s out of the cheap stuff—comes up to me as I am waiting at the deli counter.  He says to me, “Look at this!” while pointing to his jaw.  I see a large abrasion on his chin, dark with dried blood.  I say, “What happened to you?”  He says, “I got up in the middle of the night to go to the bathroom and I must have fainted, because I woke up at 5 am with my head on the floor and my jaw is killing me and I came to work but it’s gotten worse all day and now I can’t swallow.”  My eyes widen with alarm as the girl behind the counter goes, “Tell her about the ear—TELL HER ABOUT THE EAR!”  I say, “What about the ear?”  He says, “Well, when I woke up there was blood coming out of it.”  I said to him, “You need to go to the emergency room, TONIGHT!  You could have a skull fracture.  You need some X-rays and a CAT scan right away.”  I don’t say what I am really thinking, which is that this same man had lung cancer a couple of years ago, and I am worried not only about the possibility of a fracture, but also about the possibility that a brain metastasis caused him to have a seizure and black out, hitting his head and face.  He seems reluctant—he wants me to tell him that he is fine so that he can go home and self-medicate with beer and tequila shots.

I realize I must do something fast or I will lose him.  I say, “Let me call it in.”  He says, “What do you mean?”  I say, “If I call the emergency room doctor and tell them you are coming, they will take you right in. You won’t have to wait”. He says, “Well, okay, but I have to finish my shift.   I get off at 8.”  It’s 7:30 pm. I go out to my car and dial the hospital and ask to be connected to the ER.  When they pick up, I say, “This is Dr. Fielding calling in one of my patients.”  I tell the ER doc, “I have a patient with a history of lung cancer here, who experienced a syncopal episode early this morning and now has a mandibular abrasion, swelling on the right side of his face and blood coming out of his ear.  I am worried about a fracture but also about whether he may have brain metastases that caused him to have a seizure.  He needs skull films and a CAT scan ASAP.  He will be at the ER by 8:30 pm.”   The ER doctor says to me, “Where is the patient now?” I say, “In the grocery store, with me.”  He says, “What?” I say, “In the grocery store.  He is my butcher.”  Silence on the other end of the phone, and then, “Tell me you’re kidding.”  I summon up my best authoritative voice, and reply, “I am not kidding.  We are in the grocery store and I am calling this in NOW.  Call me after the CAT scan.”  He says, “Yes ma’am!”

As it turns out, the butcher has a fractured jaw.  No brain metastases—it could have been a lot worse.  He will be fine.  And I am now the Madonna of the Meat Counter.  I hope I at least get some free dog bones out of this!

Hunger Strike

The Q’s will not eat.  My two female deerhound sisters, Queen and Quicksilver, aka Quibbets and Little Grey, are coming four years old in January.  They are both AKC Grand Champions and as such, I have not spayed them yet, thinking that perhaps I will breed a litter, my first since my only prior litter in 1997.  At that time, I discovered that it is much easier to BUY a nice deerhound than it is to raise a passle of poopy giant puppies. In some respects, I am a quick learner.  Anyway, when the Q’s come in season and go out without being bred, a month later they stop eating.  The veterinarians call this a false pregnancy.  I call it a hunger strike. Today I have cooked fresh ground beef, chicken, brown rice, green beans, and have shared some expensive Sargento shredded cheddar cheese. The fruits of my efforts have gone untouched.  Queen is now ensconced on the family room couch.  She is glaring at me.  Later, I will cook bacon and pretend it is for her.

I don’t know why I seem to spend an inordinate amount of time trying to get others to eat.  Although my children were never picky eaters, my youngest went through a period where he would ONLY eat jelly sandwiches for lunch.  Forget the peanut butter, forget protein, forget the healthy apple and the mozzarella string cheese.  It was gooey jelly sandwiches, or NOTHING.  Years later, he said to me, “Do you KNOW how unhealthy that was, what you fed me for lunch?”  I said, in my best Jewish mother voice, “Really?  I was supposed to let you starve?  Over my dead body would you go hungry at school!”  As a girl, I cleaned my plate, always, because of the starving children in Africa.  Still do.  I have a theory that if every time I reached for a bowl of ice cream, a touch screen in my freezer would give me a choice—eat the ice cream myself OR see the calories get deposited DIRECTLY into the mouth of an emaciated child—I and millions of Americans just like me would hit the “kid” button, walk away from the ice cream and make the world a better place.

Now the intended objects of my need to feed are my patients.  I plead with them, I entreat their spouses, I offer prescriptions for Ensure, Boost and Jevity.  In some cases, I recommend feeding tubes.   I tell them that they MUST not lose weight, because unintentional weight loss in many types of cancer can be a very poor prognostic sign.  I tell them to forget their cholesterol and focus on their cancer—eat protein, eat fat, eat sugar (yes, even sugar!), but please just eat.  I tell them that my job is to cure their cancer.  And then I tell them in no uncertain terms, that THEIR job is to EAT.  Even if it doesn’t taste good.  Even if they aren’t hungry.  Even if they used to be fat.  If my lung cancer and bowel cancer and head and neck cancer patients will just eat, their bodies and their spirits will get ahead of that thing that is eating THEM alive. And since most of my patients want to be good, to be cooperative and above all to live, they try.

As for me, age, arthritis and a very busy clinical schedule have not been conducive to keeping off the excess pounds.  My kids will know that indeed I am dying, if I ever miss a meal.  Especially if that meal is paired with a nice glass of wine and has a dessert course which includes chocolate.  But right now, I have to go.  There’s bacon to be cooked!

Go Ahead Kids!

Okay, I confess.  I have smoked a few cigarettes in my time.  In fact, more than a few.  While my teenaged brother was hiding his favorite smoking material  in the Encyclopedia Britannica under the letter “M” (much to the horror of my mother, who decided she needed to read up on this new scourge called  marijuana), I was trying to be the cool kid, the girl who knew how to—what did we call it?—French inhale.  The girl who watched films by Bunuel and Truffaut and made fun of the pretty cheerleaders in their short skirts.  In high school it was Marlboro Lights (I’m from Texas, surely you can understand!).  By college it was Dunhills, Warhol and Stan Brakhage, but only a half pack a day, and ONLY that much during the final exam period which required the pulling of “all-nighters” to make up for a semester of less than perfect attendance.  I have never been much good at getting up in the morning.

By the time I got to medical school, smoking was still considered marginally acceptable.  I spent six weeks on Dr. Michael DeBakey’s cardiothoracic surgery service, trying stay out of the way and not block the cardiac monitor while earnest cardiac fellows learned to transform saphenous veins into new coronary arteries. Senior surgeons would peek in the rooms periodically, pulling their scrub gowns up as shields to hide the cigarette dangling from their mouths, the ash dripping on the floor as they exclaimed, “Lord, please help this poor patient because OBVIOUSLY no one in this operating room can!” The OR lounges, where scrub nurses and residents took their breaks, were smokier than Las Vegas casinos on a Saturday night.

That all ended when I started my internal medicine residency, and fell in love with a pulmonary doctor.  One simply cannot be a smoker while dating someone whose idea of sexy is clean pink lungs without a trace of carcinogen. I quit completely in 1979.  I gave up those cigarettes and never looked back.  No, that’s not entirely true–I’m lying a little bit, we all do.  There is not a former smoker on the face of the planet who can say honestly, truthfully that they never EVER crave a cigarette.  But craving a cigarette is unbecoming of a radiation oncologist.  By the time I finished my second residency, in radiation oncology, I had seen enough lung and head and neck cancer to be permanently and forever in the nonsmoking lane of life.

Now, occasionally I have to stop at the gas station, or the pharmacy or the grocery store on my way home from work.  I see teenagers, barely “of age”, at the counter buying cigarettes and paying a lot more for them than I ever did.   I see them hanging around outside, enjoying a smoke, texting their friends.  Sometimes, in fact most of the time, I want to stop them—talk to them—invite them to spend a day with me at the cancer center up the road, where they can watch the lung cancer patients coughing up blood, or gasping for air, or wasting away from cancer related anorexia and weakness.  But I never do.  Even I know that you can’t talk to teenagers like that—besides, after all these years, I’m still a little bit shy.

At home, I still have an ashtray.  It’s a big one, blue and flat bottomed, and we use it as a candle holder because I love scented candles (have I mentioned I have four dogs and a cat?)  It was given to my husband by his college friend Garry Trudeau, creator of the Doonesbury comic strip.  On it is a picture of Mr. Butts, Garry’s fictional advice giving cigarette caricature, spouting his words of wisdom to the youth.  Mr. Butts says, “Go ahead kids.  You’re immortal!”  Would that it were true.

Follow Up

My new resident started working today.  He is the first radiation oncology resident to come to work in our facility, since the residency director felt that being out in the community was more like “real life”—I don’t have the luxury of treating only one or two types of cancer—out here in the suburbs I have to treat them all.  So it seemed like a good idea that the residents get a few years of experience under their belts before venturing outside of the white tower of academia.  Our residency training program is relatively new, and so we are feeling our way through this thing to make sure he has a valuable learning experience.

The issue came up as to whether or not my new resident would see follow up patients with me.  My own residency was like an apprenticeship—at the World’s Greatest Hospital, we residents would spend three months with each attending physician, every one of which was a professor at the World’s Greatest Medical School.  Three months of prostate cancer, then three months of head and neck cancer, then three months of lymphoma, and so on—we learned from each maestro in turn.  Since we moved on every three months, we never got to see the patients we planned and treated in follow up.  I think it was sometime during my lung cancer rotation that it occurred to me to read the obituaries.  I mean, how else was I going to find out what happened to those patients?  I kept the names of each new patient I saw in a little black book.  And over the next few years, I put a little red check mark next to the name in my book as it appeared in the Globe, usually with an old photograph that I did not recognize as the person I had treated.  Lung cancer, especially when inoperable or metastatic, is a terrible disease. At the end of my lung cancer rotation, I had a list of 120 names.  At the end of my residency training, 10 were left unchecked.

I learned a lot about those patients by reading those obituaries.  The unassuming elderly woman with her arthritic hands had once been a famous sculptor.  The still dignified but stooped over old man had led a battalion at the Battle of the Bulge. The forty year old man who smoked two packs a day despite the fact that he had watched his own father die of lung cancer left three grieving children behind, and contributions could be sent to his local church.  And I discovered that I wasn’t the only one reading the obituaries.   Years later, my secretary at my new job in California and I were talking about reading those brief little bylines that so neatly summarized lifetimes of love, joy, milestones and tragedy.  She said to me “I thought that I was the only one who reads the obituaries!”  Then she whispered conspiratorially, “and I know this is REALLY bad, but when a day passes that I don’t see someone I know, I feel like I’ve missed seeing an old friend!  I’m a little disappointed.”   It turns out that a LOT of cancer doctors read the obituaries.  The lives imaged, and imagined are the ones we never got to see.

So when asked if it’s worthwhile for my new resident to see my follow ups—patients that he did not treat—I say, no, I don’t think so.  But when it comes to me, many times these follow ups are the highlight of my week.  I get to see the fears gone, the new lives started, the transformation of priorities brought on by conquering a life threatening illness. Sometimes I even get to see the new husbands, the new wives, and the new babies.  Occasionally though, I’ll get a cranky one—someone who says, “You think I look great, but I still have this, and THIS, and THIS….” reciting a litany of side effects.   And then I get to quote one of my old professors, a great man, who when confronted with such a patient would draw himself up to his full height, puff out his chest, and say, “You’re still ALIVE?  I must be better than I thought!”

Miracles Do Happen

Sometimes miracles do happen.

In 1999, I was called for an emergency consultation on a young man in his early 40’s who had come into the emergency room.  He had been involved in an automobile accident, and the police were trying to arrest him for drunk driving since he could not “walk the line”.  His breathalyzer test was negative, and finally it dawned on the police that there was something physically wrong with the man, and they brought him to the emergency room.

An emergency CAT scan revealed that the patient had a solitary brain tumor in the cerebellum, the part of the brain that affects balance.  This was the real cause of the car accident, an undiagnosed cancer growing in his center of equilibrium.  He was taken immediately to the operating room where the neurosurgeon resected a large mass, and got out as much as he could without doing damage.  The pathology returned as “metastatic lung cancer to the brain.”  Lung cancer?  What lung cancer?  But sure enough, a chest X-ray revealed a single large tumor in the man’s left lung.

Suddenly the prognosis was dire.  The patient had gone from a previously healthy human being who was mistaken for a drunk driver, to a man with Stage IV lung cancer, with a median survival (statistics, statistics!) of 6 months.  NO ONE wanted to operate on his lung, since that would be, proverbially speaking, like “closing the barn door after the horse had gone.”  He was referred to me, for radiation to the brain (to clean up any cells that had been left behind) and to the lung, to prevent him from having symptoms of airway obstruction or coughing up blood.

I looked at this man and said to myself, “Well, even though he’s not likely to be cured, let’s give him the best shot possible to live the best quality of life for the longest time possible.”  He was young and healthy and he had children to raise. I prescribed aggressive radiation doses to both the brain and the lung.  The patient made it through the treatment and was able to be tapered off the steroid medication that prevented brain swelling.  He never did have any symptoms from his lung tumor.

He came in regularly for follow up, always asking for a renewal of his Percocet prescription.  I don’t know why–he didn’t take his pain medicine much, if ever, but he always wanted to be prepared, “just in case”.  When I left that job in early 2004, my former staff told me that he came back a couple of times to see the physician who took my place, but then stopped coming.   He just plain dropped out of sight.  For years, like “The Ancient Mariner”,  I recited his case when seeing new lung cancer patients so that they and their families would have hope.  I told every resident and medical student I came across. I championed aggressive approaches in Tumor Board meetings.  I was a believer in the impossible.

Last fall, in October of 2011, I got a call from a colleague.  He was on the medical school admissions committee and had just interviewed a young woman who was applying to our medical school.  He could barely contain his excitement.  He said, “Do you remember a patient named JS?”.  I said, “Of course I remember him—he is my case study in miracles!”  He said, “Well GUESS WHAT!!  I just interviewed JS’s daughter for our medical school class of 2012.  And do you know what she said?  She said you cured her father of lung cancer over ten years ago when she was a kid, and now she wants to go to medical school because of YOU.  She wanted you to know that.”

As I said, miracles DO happen.