June 4, 2011

     "Y'all need to stop giving me new material to write about," I tell my dad.  The clock reads nearly 11 pm at an IHOP about an hour south of Dallas.  We're on the road out of necessity and he needs to give himself his IV antibiotic so I turn the hanging light into a makeshift IV pole.  The staff are understanding and even helpful.  The day of my brother's memorial service, my dad's arm developed a red swelling along one of his veins.  He showed it first to me about 1 pm at the reception.  Not good.  The odd thing was the swelling was not located where the IV line went in.  It was downstream.  You start running through the differential diagnosis of what it could be.  Most likely it was something relatively benign but included in the list of the differential diagnosis were some potentially serious stuff - bacteremia, lymphatic involvement, cellulitis, necrotizing fascitis, etc.  By that evening, it had grown substantially and we made the call that it was time to leave Dallas and begin the 5+ hour journey down to MD Anderson's ER, again.  Again.  Again.  Again.  It never ends, except when it ends as it did for my brother.  The price of cancer is eternal vigilence.  It's easy to feel trapped sometimes. 
     The day my brother died, we ended up in the ER for an infection in my dad.  The day of his memorial, we are there again.  By 3 am, we are once again drawn into the inescapable gravitational pull of MDACC.  The doc comes in, examines it and is puzzled by the fact that the swelling is discordant from the IV site.  She says to my dad, "most likely, it's nothing terribly serious, probably superficial thrombophlebitis from the Zosyn.  It's known to cause that in some people.  But given your disease we need to be sure.  I'm going to order an ultrasound but just to be on the safe side, we'll continue the IV antibiotics until we have the ultrasound results."
     The ultrasound confirms it.  Present in the vein is a clot that clogs everything up.  Inflammation and swelling follow and my dad is left with a painful but usually relatively benign condition.  He is discharged by lunchtime and in good shape.  That is until he calls me at midnight later that day.  Out with a buddy at a bar, it's the first time I'm having fun since I can't remember when.  I switch to doctor mode instantly, though.  His temperature is starting to creep up to that dangerous cliff of 100.4 degrees.  So far, the closest he got to the edge was 99.8 but that's scary enough.  Fortunately, a fever never materializes.  By noon the next day, he's over at my house and showing me his arm.  His forearm is starting to look like Popeye except red.  I wonder if we're starting to approach one of those rare but deadly serious complications of superficial thrombophlebitis (STP) or did they miss a deep vein thrombophlebitis on top of the STP.  Piecing together my anatomy, I somewhat arbitrarily decide that if the swelling swallows and passes the elbow, it's time to head to the ER post haste.  The forearm has compartments enclosed by strong sheaths.  If the process breaks out of that sheath, that's an uh-oh situation.  I'm not sure what I base that conclusion on.  It sounds right, though.
     My wife has accused me of enjoying these moments in a twisted fashion. Harsh, but partially true if I'm honest with myself.   It's not that I enjoy them.  At these junctions, my life and its purporse seems to resolve into a clarity that I can't quite explain.  I feel a deep fear which goes straight to my bones at having to make decisions that affect those I love.  But, somewhat arrogantly yet true nonetheless, I deep down know that the calls I make are right and there's ironic meaning knowing that someone can benefit from that arrogant self-assertion.  I've told my dad on many occassions, this one no exception, "I love it when the doctor says exactly the same thing I tell him beforehand.  Either we're both idiots or I actually know what I'm doing."  So that fear of being wrong and the heady power of being right lie in opposing juxtaposition.  At these points, I feel more alive and connected to life even when surrounded with the forces of death.  And yet I utterly despise and revile the situations that necessitate me being me.  What a strange manner of a career.
     I make the call.  Instead of heading back down to the ER, we're going to use compression, increase the frequency of heat and elevation and add an NSAID accepting the short term risk of masking a fever.  We'll see how it progresses.  At this point, I don't know if I'm right so all that sits there is the fear of being wrong, the absolution of being correct not yet borne out.  I hope I'm right.

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