Best Dick

In some of my previous entries, I have mentioned how important it is for patients to bring a friend or relative to their first appointment.  Most of the time, we welcome the spouse or best friend who is able to hear and process the information we are giving, especially if the patient herself or himself is still in the “deer in the headlights” phase of cancer awareness. Personally, I don’t mind if you bring a recording device—I realize that there are complex facts to be absorbed and difficult decisions to be made. There are occasions, however, where the addition of extras can be counterproductive. Bringing your mother in law along with your grandchild still in diapers can be distinct distractions to the doctors and nurses involved in your care, especially if the latter leaves stains on the newly upholstered chairs.  There are those “significant others” who are actually adept at alienating the people you most want to make friends with. Those are the personalities that can make your doctor and nurse retire to the back room where they punch holes in the drywall while considering their escape plan.

First there are those I call the pirates.  These are the people who commandeer the ship and make it all about themselves.  Each time I ask the patient a question regarding a symptom, the pirate pipes in about the time he or she had that very same symptom, and what it meant.  If I ask about a family history, I get the story about the time the pirate’s Aunt Nellie had this same kind of cancer, and about all of the terrible awful side effects she had from treatment.  These are the guys and gals who will tell you that your patient can only have an 8:15 appointment; because that is the only time their ship can sail over to radiation therapy to give the friend or spouse a ride.  They are often pleasant but always insistent—they want to make sure that I know how disruptive this disease has been to their sense of self importance and their place in the patient’s universe. By the consultation is over, I have a complete medical history on the pirate, and know their allergies, sexual deviations and food preferences, whether I actually know about the patient or not.

Worse are the pit bulls (and I mean no offense to the breed—you know I speak metaphorically here.)  These significant others come in with the assumption—no, the CONVICTION– that the doctor is negligent, ignorant, and literally out to harm their spouse or friend.  They are prepared to fight to the death.  When I ask the patient a question, the pit bull answers with a snarl.  The pit bull assumes that he must protect the patient at all costs, even if that means literally biting the hand that is offering help.  These are the friends and relatives who are actually dangerous.  They are usually engineers, scientists, professors, and mathematicians who have been on the internet, calculated the risks, and are going to teach you how to do your job so that they can make sure you don’t kill their special person. They are smart and they have done their homework.  They have completely forgotten that I am here trying to help.

We had such a pit bull recently, who accompanied his girlfriend, a lovely patient with cancer of the pancreas.  For the most part, I have stopped giving my email address to patients and families due to their propensity to spam me and my unwillingness to read every internet joke every passed around, and don’t even get me started about those chain emails. In a momentary lapse of judgment, I did however give mine to her significant other. After all, his earnestness was compelling. He wrote to me daily with each incident that his girlfriend experienced, his theories of why she experienced that particular thing, and his antidote for the problem.  And each time I replied with advice, he wrote me back with the reasons that I could not possibly know what I was talking about. Despite our differences, in the end, we tamed him with kindness.  His girlfriend did well through treatment, and four months later she is still in remission.  Our pit bull became a pussycat.

One thing I will never forget is his email signature. Improbably, and without a trace of irony he signed each email, “Best, Dick.”  Really?  I sure hope so, for her sake!

Dammit Janet

There is cancer.  And then there is CANCER.  The first refers to the ones we discover early, excise completely and move on—a tiny rent in the whole fabric of a life, easily mended or patched but never quite forgotten.  But the second, CANCER in capital letters—these are the ones that can never be discovered early enough, the ones that cause gaping holes in the hulls of unsinkable ships and the whole ocean falls in after the vessel goes under.  This kind kills, and kills so quickly that there are very few survivors left to mount the political assault necessary to raise millions for research and a cure.  These are the cancers that have no armies in pink T shirts walking or running for the Holy Grail.  Highest on my list of evil enemies these days is cancer of the pancreas.

In the early spring of 2011, my friend Janet Porter, President of the Scottish Deerhound Club of America, developed abdominal pain that she initially thought was gallstones or an upset stomach from food poisoning.  Her discomfort progressed rapidly and then, almost overnight she became jaundiced, with a yellow cast to the whites of her eyes, tea colored urine and light colored stools, because the blocked bile duct at the head of the pancreas cannot empty into the duodenum as usual, and the bile backs up into the blood stream and leaches into the skin.  She was diagnosed quickly, worked up well, and pronounced a good candidate for a Whipple procedure, one of the most difficult operations that a skilled surgeon can perform, involving removal of most of the pancreas, gall bladder and common bile duct with considerable rearrangement of the indoor plumbing. Janet was “lucky”.  Most patients diagnosed with cancer of the pancreas are inoperable and incurable from the minute they are diagnosed.  Janet was a smart cheerful optimistic person.  She underwent this difficult surgery, and then took months of chemotherapy and radiation, finishing late in 2011.  In the spring of 2012, she was able to attend the National Scottish Deerhound Specialty show which was held in Michigan. A week later she was told that the cancer had recurred in her liver and despite additional treatment she passed away on August 20.  She was 59 years old—we were born the same year. From the time she was diagnosed she lived every minute to the fullest—she saw her family, took care of her friends, and when it became clear that she was not going to survive she did what every good dog person does—she found homes for her beloved hounds.  I wrote something on the Deerhound List to try to describe her courage, and people liked what I wrote, but all I could think of, quite inappropriately, was title of that old song from The Rocky Horror Picture Show where Brad sings to Janet, in front of a cemetery—“Dammit Janet”.

Today in clinic I saw another patient with pancreatic cancer—this time a lovely woman who is 87 years old.  One of the best surgeons in the country had deemed her operable when she was diagnosed in May, but she hesitated, knowing that complications from such radical surgery could abruptly end her life, or at the least, affect the quality of her remaining days.  She was started on chemotherapy and did well initially, at least well enough to be considered for definitive radiation therapy, which is used when surgery is not desired or possible. Last week, a scan done for treatment planning showed that, like my friend Janet, the cancer had already spread to her liver.  Today I explained to her and five of her visibly distraught middle aged children that there would be no point to pursuing radiation therapy to the pancreas.  I said it would be like closing the barn door after the horse had gone.

Is an 87 year old dying of cancer less sad than a 59 year old?  How do you compare the life well lived for all those years which should have ended quietly, rewarded with a peaceful passing with the life that ended early, devastating friends and family?  Sitting in my exam room with that family today, I certainly could not say.  But tonight I am still thinking, damn it.  Janet.