Back at the Ranch

“The sun is riz, the sun is set, and we ain’t outta Texas yet!”

It takes a full day to waltz across Texas.  I’ve been reminded of this twice in the last four years—once in July of 2009 when I drove my daughter from California out to Houston to start medical school, and the second time eighteen months ago when we drove my mother’s barely used Subaru from Colorado to Houston to replace the now ancient Volvo we had bought my daughter for her sixteenth birthday.  A girl’s got to have wheels, you know. Both of these trips reminded me of the long charter bus rides that I used to take as a child competing for the Dad’s Club YMCA swim team at out-of-town meets all across the state.  My favorite ride was through the Hill Country between Austin and San Antonio in the spring, when thousands of bluebonnets carpeted the roadsides, punctuated by red dots of Indian paintbrush.  Back in those days, I would gaze out the window at the Herefords and Black Angus and I would imagine that one day, some day, I would have my own ranch.  Others would complain about the endless stretch of highway between San Antonio and El Paso, but not me.  I could easily imagine myself owning a thousand barren acres in west Texas, where I would have all of the dogs and horses I could ever want, and not have to talk to anybody, nope, never.   How I would make a living out of that ranch never crossed my mind.

That fantasy came to an abrupt end a few years ago as both of my parents faced major health crises.  Twenty five years back, they had retired from Houston to live out their dream in the Aspen/Snowmass area of Colorado. Well, perhaps “retired” is not quite the right word, since my mother never worked outside the home and my father never stopped working—he  likes to call himself “the oldest practicing plastic surgeon in the United States”, to which I rejoin, “Perhaps you shouldn’t brag about that, Dad.” But I am digressing.  They became avid skiers in the winter, and enthusiastic hikers in the summer, and they played golf and tennis and rode horses on the mountain trails.  They did that until my mother became ill in the spring of 2005, gradually losing her ability to walk, and to think clearly, and I discovered that while Aspen is a glorious place to have a cruciate ligament repaired, or to fix a compound fracture fresh off the slopes, it is no place to come down with a lymphoma of the central nervous system requiring chemotherapy to be instilled directly into the ventricles of the brain.  They don’t do that at Aspen Valley Hospital, or likely anywhere in the middle of that stretch of Interstate 10 between El Paso or San Antonio.  My father’s recent bout with pneumonia and a touch of heart failure confirmed my suspicions that, cowardly as it sounds, I want to be near good doctors and good hospitals as I age.

I never did get that ranch in Texas, but fifteen years ago we bought three level acres smartly outfitted with a four stall portable barn and a couple of grass paddocks here in San Diego County, on a street which was originally named Caballo Rojo.  My first Quarter Horse, and the first tenant here was a little red gelding named Lucky, so with a sly smile and tongue firmly in cheek we called our new place Rancho del Caballo Rojo and the name has stuck. And when I fall off my horse, as I have on occasion, I am deeply grateful that some of the best hospitals in the country are less than twenty five minutes away.  Dad, for the meantime, is living with us.  But he held on to a hundred acres or so that he bought years ago in Pleat, Texas, southwest of Houston, with its own working oil well on the property.  On a good day, that old well pumps out five barrels of oil a day.  Sometimes I dream about retiring there, so last time I was in Houston we went out to see the old farmstead.  Say what you will but I was very glad to see that a large and very modern appearing hospital has been built very, very nearby!

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.