November 30, 2010

mistaken identity

A buddy of mine had suggested urology as a potential career choice as it seemed to be a good gig.  I may have to rethink that possibility.  We had our last practice practical tonight in gross anatomy.  On one of the tags, it was some structure that resided in the pelvis.  I thought to myself that it looked a bit like a vagina and was trying to figure out what portion of the female reproductive canal they were after (os or isthmus of cervix).  Turns out it was a prostatic urethra.  That's the part of the urethra that goes through the prostate gland.  Of a male.  Yes, men have prostates and women have vaginas with a uterus.  You'd think that'd be self evident in the training of a physician.  So not only did I get the structure wrong, but I got the entire gender wrong.  In my defense, the cadavers are really disfigured by now so structures are anything but self evident.  And the prostate in question was really, really, really large.  I felt better after I heard a string of students say that they made the same mistake.  I, however, failed to hear anyone say that they mistook the anal sinus for the vaginal vestibule.  I pulled that bonehead, too.  I think I'd have to reconsider the notion of OB, too.  Heck, with those identifications, I'm not sure I'm even qualified to have sex.

November 25, 2010

am I my brother's keeper?

"Tell me, can this radioisotope kill the tumors or is it just to relieve the pain?"

I pause.  What do I say?  I tell the truth, at least as far as I know it to be true.  "It's to alleviate the pain."

"So they can grow back.....What's the point?"

Those conversations are hard, which is to grossly understate the nature of the matter.  I've had people tell me that I don't need to be my brother's doc, so to speak.  I can just be his brother.  And my answer to that?  "Bullshit."  When my brother asks me questions like the one above, how can I walk away from that?  What man could look his brother in the eye and have the brazen cowardice to walk away?  To be honest, I'd rather be hit repeatedly with a 2x4 across my head than to have to answer those types of questions from him.  No....that's not true.  I hate the circumstances that have brought about the necessity of questions like those.  I did not ask to bear the crux of those types of questions.  They hurt to answer.  I answer them as even keeled as I can.  I hold back the emotion and let it out later.  And I've had a lot of those types of conversations lately, and not just with my brother either.  They're emotionally gruelling and they take their toll on me.  But then my brother didn't ask for this disease and his pain.  Bony tumors hurt.  Chemo hurts.  Radiation hurts.  Getting stuck hundreds of times with needles hurts.  Watching him talk to his kids 300 miles away hurts.  And so while my pain is real and sometimes aches so deep as to hurt viscerally, I will honor that connection we share no matter how much it hurts.  Cain, who whined, "am I my brother's keeper?", was a coward and a shell of a man, after all.

November 24, 2010

radioactive piss

It's Thanksgiving eve and we've just finished up another all day experience at MD Anderson.  My brother's van pulls into my driveway to drop me off and he turns around and asks me, "do you mind if I use your bathroom?"

............(My brother's urine is now radioactive.  He was dosed today with Quadramet (samarium 153 SM lexidronam).  It's a radioactive compound that preferentially gets taken up by osteoblastic tumor metastases (translation=tumors that secrete bone-like substance but they don't create healthy bones).  It's a bit of a trojan horse strategy, really.  Once those bony tumors take up the samarium, they get hit with beta particles which knock the tumors back to alleviate bone associated pain.  It doesn't go to any soft tissues so there are infinitely less side effects than standard chemo options.  On the other hand, it doesn't hit the soft tissue tumors like chemo)..........

"Yes, yes, I do," I replied in predictable smart-assed fashion. "You can pee on my lawn and see if you can make a radioactive tracing.....On second thought, the dogs may lick it......but you can pee on my side yard. I don't like those neighbors anyways."

And I laughed a laughter that went straight to my soul.  The image of being 12-years old and writing one's name in the snow while emptying the ol' bladder contrasted starkly with the seriousness of the situation here and now.  Not one of simple mirth, that laughter encompassed all the joy and pain that have been visited upon such occasions during this journey, each with their own costs.  And it felt good to let go of everything, of life, of cancer, of death even if only for the most brief moment of time.  Laughter has been in short supply of late so at that moment, it felt so good to laugh in such a soul reflexive fashion.

My brother opted to use my bathroom over the yard....but I secretly hope that tonight, he sneaks out into his back yard and makes a big J.  The thought brings a smile to my face.

November 21, 2010

random fact

Just learned that wonderful cut of steak by the name of tenderloin actually comes from the psoas major muscle.  The reason it's so tender and juicy is that it's a non-weight bearing muscle.  That alone makes it prized but it's not a terribly large muscle so it's limited in quantity.  Combine the two and you get an expensive but tasty piece of meat.  In humans, it's the major muscle (along with the iliacus) that lifts your thigh up at the hip, aka your hip flexor.

November 20, 2010

learning is fun(ny) sometimes

Your nose has three bones residing within your nasal cavity called conchae, or turbinates.  The reason I know that, besides gross anatomy, is that some years back I had surgery on my nose and my turbinates were shaved down to help breathing.  What I did NOT know was that the tissue covering the turbinates is highly vascularized.  If fact, it's awfully similar to another tissue in the male body.  I am referring to, of course, erectile tissue.  When your nose gets stuffy, your nasal epithelium becomes highly engorged with blood.  And what is a common therapy?  Pseudoephedrine (or phenylephrine since that stupid law that makes sudafed a regulated substance).  It's a sympathetic agonist that constricts your engorged blood vessels.  That allows more air to flow through your nose and you can breath better.  Likewise, when someone takes a cialis and gets an erection that won't go away (priapism), guess what the first therapy to try is?  You guessed it.  Pseudoephedrine (or phenylephrine).  Next time you get a stuffy nose and need a decongestant, I bet you'll think about it in a different way.

November 17, 2010

something to hold to

Through the drizzle and fading twilight, I walked from my school back to MD Anderson where we'd spent the last 4 days.  Up the escalators, a short jaunt to elevator T, and up to the MRI floor.  My brother was still getting his MRI as my parents waited in the chilly waiting room.  As I walked up to receive the rundown on how the visit with the radiation oncologist went, the look on my mother's face portended a grim assessment.  Her only words said through a clenched mouth, "I wish you had been there."

My brother has bony metastases throughout his pelvic area causing him considerable pain.  Option 1 was to knock them back with radiation to alleviate the pain.  From reading the radiation oncologist's summary, it was concluded that beam radiation was off the table.  The pain is diffuse and does not localize to any one met.  To irradiate all of them would be to invite disaster.  There are simply too many of them.  To make it worse, my brother and parents could overhear the telephone conversation between the radiation oncologist and attending oncologist.  (Note to self - never allow yourself to be overheard by the patient having a medical conversation with another doctor).  I think the phrase that stood out to my parents was when the radiation oncologist, whom we had invested hope to be able to alleviate the pain, uttered something to the effect of, "I'm not sure why you sent him to me.  There's nothing I can do."

Option 2 is to pump my brother with something along the lines of strontium or samarium.  Those preferentially will go to bony tumors and hopefully knock them back a bit.  That would then be followed up by enduring another round of chemo.  And so we wait to hear back from the nuclear specialist.  Even that, though, is palliative only.  It's to reduce pain and suffering.  There are no curative or restorative therapies proffered.  So I try to reconcile what I know medically, statistically, clinically with being a brother, a son, a human.  And I guess I'm still ruminating what to do with that.  Yesterday, I took the day off from studying and tried to find some understanding of that.  I meditated, I pondered, I grew angry, I pontificated, I blustered, I grew sad.  All that I can conclude is that I find no absolution in my rational point of view.  And so I tell my brother, I'll be there for him every step of the way to whatever end.

November 14, 2010

sex & death

In the basement of the gross anatomy lab, one professor says to another with a bit of a smirk and shrugging his shoulders, "It's pumped up and I can't find the off button."

Only later does it dawn on me what exactly they were referring to.  We were dissecting the genito-anal region that day and it seems one of the donors had a penis pump implanted.  Somebody decided to see if it worked.  In case you're wondering, Mayo Clinic has a rather informative drawing of what it is and how it works.  It's simple, really.  And I can assure you that it definitely works.  After all, if it works on a cadaver, I'm pretty sure it'd work in a living person.  I guess Freud was on to something when he said life is all about "sex and death". 

November 11, 2010

happy to be wrong

I have a near pathological need to be right.  You can ask my son.  He keeps a running tally of the number of times I've been wrong.  I think I get it from my dad.  If you ask him if he's ever been wrong, he replies, "Once.  I thought I was wrong but it turns out I was right."  As a result, when I start to draw conclusions, I usually have a pretty strong degree of confidence in their accuracy.  So it was with my brother's progression.

My brother has been suffering miserably of late.  He's lost 40 pounds, his pain levels were increasing dramatically and has difficulty even walking.  Not what one wants to see from a cancer patient.  But he was confident that the primary tumors were behaving.  In his words, he said 
"my gut instinct tells me they are stable. Don't ask me why I think that...I just have a feeling. The rest of my body: that's another story."

Pain is usually one of the most reliable prognosticators for progression of cancer.  But visceral sensation in the chest is just not that precise.  Just think of a heart attack.  It often feels like pain in the shoulder or arm, not the chest.  And when my brother's primary tumor shrank upwards of 60ish percent with chemo, he never felt any difference in his chest.  My fear was that he wouldn't be able to discern a 30-40% increase in the primary tumor.  It'd still be smaller than it was originally.  So when he was telling me of his immense and growing pain in his shoulder and hips, I grew troubled.  I figured the primary tumor would fly under his pain radar.  I inferred that if the tumors in his hips were growing, then most likely the ones in his chest were, too.

Today, we got the preliminary results of the PET and CT scans.  It was a mixed bag but I've never been more relieved to have been wrong in my life.  The primary was mostly stable (there was one small ancillary growth near the primary).  The bony metastases in his hip and leg bones, however, were growing.  My brother...well, I'm not sure how he feels about it.  Me?  I breathed a big sigh of relief, which I know sounds odd but here's my reason.  If the primary had grown, because of its location near the lungs and great vessels of the heart, it would be life threatening, plain and simple.  The tumors in his hips and legs, though, are not trivial.  The risk of a fracture is real and dangerous.  A fracture would require major surgery.  The bony tumors have absolutely impaired his quality of life and my heart aches to see him in such pain.  It impairs his mobility and morphine just doesn't work that well on bone pain.  But a tumor invading the hip bone does not carry the risk of a tumor invading the lungs or aorta.  And that's why I am greatly relieved.

November 10, 2010


Roughly half a century ago, the physician Carl Jung wrote about a concept dubbed 'Synchronicity'.  In his words, it was "temporally coincident occurrences of acausal events".  In other words, they are two events that are wholly unrelated by cause and effect, yet nonetheless are still related.  Most people would call it a coincidence.  When subjugated to common sense, it seems absurb.  Coincidences are coincidences.  Nevermind it was developed by one of the forefathers of the modern psyche in conjunction with Wolfgang Pauli (developer of the famous Pauli Exclusion Principle) and Einstein (relativity).  It has, shall we say, a bit of intellectual weight behind it.  And when I think about it, a lot of what he think is absurd.  Gravity, after all, seems ridiculous when analyzed in the same fashion.  I pick something up, let it go, and it drops.  Why?  Gravity.  What's that?  A force.  Huh?  A force.  You mean  like Star Wars?  When it comes down to it, I don't truly comprehend gravity but I can still see it when it happens.

I'm not sure I understand synchronicity either but I do think I experience it from time to time.  I experience moments that seem utterly removed from cause and effect but still quite related.  This morning, while studying lectures about the pelvis, I'm answering questions emailed from my sister-in-law about the excruciating pain my brother is feeling in the.....pelvic area.  A certain sense of intellectual unravelling begins to occur at that point with it being replaced with wonderment and strangeness.

November 6, 2010

trust to your instincts

The last block caught me more than a bit unprepared.  Couple that with all the emotional milieu (we're also now babysitting our nephew overnight a couple nights a week), and it can get a bit unsettling.  Though completely unintentional, my son reminded me of a valuable life lesson by watching his football games.  You see, he plays defensive end in football.  He's not real keen on offense as he just "likes to hit people".  For some reason one game, he got put on kick return.  I could immediately tell that he had absolutely no clue what his assignment was.  He kinda wandered around a bit and wasn't sure exactly where to line up.  But his instincts told him, "don't just stand there, hit somebody and take them out!"
He got knocked down but he made danged sure that the guy he hit wasn't going to make the tackle.  I especially love how A) he cleverly brings the guy down without getting a flag (learned that from his dad), B) the kid he hit has to readjust his helmet and runs off in the wrong direction, and C) my son gets up to go try to find somebody else to hit.

Later on, he had another kickoff return hit. This time, he's out for blood and takes not one but two kids out.  Enough to make a dad right proud.....and good advice back to his dad.  Trust to your instincts.  Don't just stand there, hit the books.

November 3, 2010

they always come in three's

I finished exams and did end up passing but that was soon to be the least of my worries.  I checked my cellphone noting that I had a voicemail from my mother-in-law.  I immediately knew something was off as she never calls me unless something was wrong.  Sure enough, she was asking for my opinion for her sister who was just diagnosed with colorectal cancer.  To make it worse, my wife's aunt had just lost her husband of over three decades to heart failure.  Her uncle, who was 62, had very much been a father figure to her so it was a hard and difficult loss.  And the cherry on top is that my brother has lost over 40 pounds the last few months and is struggling with severe neuropathy in his feet brought on by the chemo.  He only half jokingly said that he could go as a skeleton for Halloween.  Another week like this and I'm going to start buying wine by the cask.