sunset



Rocky Mountain National Park

Oh noose, tied myself in, tied myself too tight

Looking kind of anxious in your cross armed stance

Like a bad tempered prom queen at a homecoming dance

And I claim I'm not excited with my life anymore

So I blame this town, this job, these friends

The truth is it's myself.

And I'm trying to understand myself

And pinpoint where I am.

By the time I get things figured out

I've changed the whole damn plan.

Oh noose, tied myself in, tied myself too tight

Talking shit about a pretty sunset

Blanketing opinions that I'll probably regret soon

I've changed my mind so much I can't even trust it

My mind changed me so much I can't even trust myself

- by isaac brock

the selfishness of grief; or, I gave all

Close my eyes for a while
Force from the world a patient smile

But I gave you all
But you rip it from my hands
And you swear it's all gone
And you rip out all I have
Just to say that you've won

Well now you've won

- mumford & sons

     The early phases of grief are dominated by pain surrounded by loss.  A deep visceral, gutteral pain that threatens to cleave the body in two.  It's dominated by a sense of shock, fury, and profound loss.  But then life goes on, as that damnable axiom (under)states.  And therein lies the dilemma of latter grief.  It's selfish.  It's not just about the lost loved one.  It's about me and how I relate to the world.  I want to protect what I have left but the grief still has me its iron clad grasp.  How do I relate to the world while succumbing to grief?  Why won't my grief just leave me alone and let me study?  Why can't I just get past this turn in the road?  How can I remain true to my grief while juggling being a student, a husband, a father, a son, a human being?  Haven't I given enough?  Why can't I just get back to living my life?  
     Clamoring for answers from grief is about as useful as asking my dog to solve a polynomial equation.  She just lies there and wags her tail.  Kinda futile, to say the least.  But life demands that we keep going.  My training is ever ratcheting its pace fasterfasterfasterfaster, my dad still has cancer and (hopefully) is approaching a stem cell transplant soon, my wife still lives her life, my son still needs a father.....But there ever present is the grief that demands utter and complete obeisance.  It's not enough to say, 'yes, I feel the grief' and then move on.  It requires of the soul to relinquish all that brings joy and pleasure.  It thirsts for the very essence of my being.  It's not enough for give part of me.  It wants it all.  And after having it all, it still is not sated.  It demands even more yet.

the loneliness of grief

     "Why didn't you tell me it was this bad?" I asked my wife.  "I'd like to hope that I was at least somewhat supportive, even if I didn't understand at the time."  The time to which I was referring was an incident some years back.  My wife had lost someone incredibly close to her in a very, very tragic way.  And it was far too early in this person's life.  He was about my son's age.  About six months after the death, I remember seeing her very....well, unmotivated for anything in life.  (There's that word anhedonia again.)  At the time, I had no idea what she was going through.  How could anyone know what this is like until they experience it?
     And my wife's answer will stick with me because it's true.  I don't want it to be true and I'm not sure when, or even if, I would've figured this out on my own.  But the longer it sits with me, the truer it gets.  "I didn't tell you because you couldn't understand......and in the end, there's no one to go through the grief with you except yourself."  Tears began to well up in both of our eyes.  "You're there and it's only you and your grief alone.  No one else."
     Don't get me wrong.  I have some wonderfully caring people who wouldn't hesitate one moment to help me out.  And I greatly appreciate it and they do help out in their own ways.  I've leaned on more than a few different shoulders.  But my wife is right.  There is The Path of Grief that you and you alone walk down.  No one else is able to accompany you there.  You can relate to others about the pitfalls and dangerous spots.  You can ask about their own stories on that path.  There even may be similar twists and turns on that journey.  But in the end, on that dark path is you and your grief alone.

finish line

     In the wilds of a Colorado backcountry trail this past summer, the soles of my hiking boots decide to separate from their respective shoe bodies.  Thank goodness for duct tape.  It's MacGyver'ed me out of many a backcountry problem - torn tent on a stormy evening, blister on the feet, burn on the foot, ripped backpack, etc. 

     Upon finishing exams - 6 in 10 days, and successfully, I might add - my particular soul also felt its own separation while coping with newly discovered territories of grief.  Ravines, cliffs, and caves of impenetrable darkness that I never knew even existed.  Existential silver, sticky, tensile stuff is holding me together.  Strong stuff, and that's a good thing because I sure need it.  I sure hope it doesn't give out.  But then, duct tape never does give out, does it?  Because you can always whip out more.

     On my way to yet another exam, the traffic was flowing freely, much like the tears that ran down my face.  As usual, they came out of nowhere.  Before my morning tea had even wet my lips, memories of my brother haunted my waking state.  Not just tears.  Gut wrenching sobs with fists full of destructive anger.  No bones broken.  The bathroom tile is sturdy. 
    Exam?  How am I going to take an exam like this?  Ariving early, I am in no mood to be around other students.  Without any conscious thought, I walk over to MD Anderson.  My feet chose the path for me.  I pass through those familiar doors not as a brother, not as a son, not as a doctor-in-training.  Not as anything other than the most broken parts of myself. 
     Where to go where eyes streaked red with tears (and stress) will not garner attention?  The chapel.  I haven't been in there since my brother was offered the choice of "going down swinging".  I sit one seat over from where I sat on that ruinous day, almost as if that old vestige of me was still sitting in vigil behind the phantom of my brother slumped over in a wheelchair while the memory of our mother is crumpled over him. 
     What do I do now?  I scroll through my brother's iphone.  (It will always be his iphone, no matter how much I use it.  It's become a talisman of sorts.)  I come across a guided meditation on grief.  Seems as good a time as any.  Shortly into it, I'm instructed to imagine a guide.  Someone to help me on this path.  Of course, my brother comes to mind.  Thoughts and emotions stream out of me rapid fire.  'How am I supposed to do this?  Why did you die?  Why the pain?  Why did you have to die like THIS?  And finally, I miss you.' 
     And in return, I receive no big brotherly advice.  No words of encouragement.  No solace.  His response is, 'how do you think I feel?  I lost everything.' 
    'Yeah, I know.  I know."  I dry my eyes, take a deep breath, and wander back over to my school to take an exam.

2 down, 4 to go

75 questions over diagnosing diseases based solely on physical findings.  Unfortunately, "I need to run some tests" was not in any of the answer choices.

1 down, 5 to go

Ugh.  101 questions over psychiatry.  That didn't go well.  And I'm going to go out on a limb that the class average sunk right along with mine.  We'll see.

a not so subtle metaphor

     By all conventional wisdom, this monarch caterpillar shouldn't be.  Frost has lightly blanketed my garden on multiple nights, winter starting the decaying process of the butterfly weed upon which it depends for sustenance.  Surprisingly, I saw at least a dozen cats yesterday and figured last night, the coldest yet, would be the one to send them off gently into that cold dark winter night.  Somehow this one endured.  It shouldn't be.  It should be in Mexico overwintering in warmer climes or it should be dead.  But it's not.  It's stuck here in my garden with the dying butterfly weeds.  It's not where it wants to be, if ever a butterfly could want.  It's certainly not where it's supposed to be based on the migratory patterns.  An existential crisis if ever there was one.  It must struggle to endure its dying source of nourishment.  It must find an enclave protected from the elements in which to create its chrysalis.  It must endure until weather warms and favors growth over decay.  And finally, it must emerge out the other side transformed into something else.  But first, to endure.



bereavement

III. Bereavement
     As death of a loved one is filled with anguish and pain it should come as no surprise that grief is one of the most painful human emotions.  It is not clear how long grief should last (even if the category of 2-6 months is currently popular).

     The final lecture from my Behavioral Science class this block was about grief.  How appropriate.  And the above came from the reading.  The two to six months part is laughable to me, as it was to the psychiatrist who gave the lecture.  "My dad passed away during my residency and it takes a lot longer than 2-6 months.  I'm not sure where they got this number," she informed us.  The lecture then delved into how we as physicians need to try to distinguish appropriate grief from a major depressive disorder in our patients.  A very real and substantial part of me appreciates the contributions of a medical model of looking at the darker aspects of moods.  It has utility and it has value.  I've seen what happens when depression goes untreated and results in suicide.
     But as I read more and more about grief vs. depression, I began to think that there's something lacking in substance to the medical model.  Medicine seeks to treat or event prevent diseases.  If there's a broken bone, we reset the bone, immobilize it and allow it to heal properly.  For viral infections, we administer vaccines to eradicate the scurge of polio.  Antibiotics have made rheumatic heart disease a thing of the past. 
     But how does that work for someone's psyche?  The psyche is broken and we seek to fix it.  There's a certain material logic to it.  If someone is suicidal, we'd certainly like to prevent that.  But taking the "fixit" analogy can cut the journey short when 'fixing' equals 'happy'.  There is something quintessentially dark about the human spirit.  Jung called it the shadow side and the older I get, the more I think there's something to it.  Our society places way too much emphasis on being happy or content as the goal of life.  Pain avoidance, I suppose.  There's even a whole body of medicine trying to link positive moods with life extenstion, nevermind the countless self-help books on being happy or positive.  But life is more than the number of days.  Don't believe me?  Name any great story that has endured the test of time.  The overwhelming majority involve soul wrenching pain and suffering.  Very few are happy-go-lucky stories.  Greek tragedies, anything by Shakespeare, you get the idea.  Yes, there may be hope and triumph involved but at the base is still suffering.  There's a reason for that.  Every single human being will be faced with it at some point in their life.  It is part and parcel of the human condition where literature and philosophy have as much to say, if not more than medicine has to say. 
     So I think about that lecture and how I approach that from my own experiences and how I will (probably) approach that with my patients down the road.  And at the end of the day, I do not choose to differentiate between appropriate bereavement and major depression.  They seem one and the same to me, a part of the human condition with artificial labels.

il faut d'abord durer

     Hemingway was known to sign personal letters with the French phrase il faut d'abord durer.  Idiomatically, it translates as "first, to endure".  It's been my motto ever since my brother died.  And it's a hard axiom for me.  I always enjoyed excelling.  Being above average was fun for me.  In football, I played to win.  And you don't get into med school by being middle of the road.  So it's a hard pill to swallow to set my sights at this point on merely surviving.  It feels like I'm settling.  But with the trifecta of med school, death, and my dad's condition.....I remind myself that it's a lofty and noble goal at this point.  If I can just get through all of this intact, that's no small victory.  So entering into the next round of exams, woefully unprepared, I remind myself, "first, to endure."  Go easy on myself and let go of the notion of honors and be content to endure.

anhedonia

     Lack of desire.  Devoid of pleasure or joy.  In a nutshell, it's not giving a shit.  About anything.  In medicine, we call that anhedonia.  Hedonism is to heedlessly indulge in pleasures.  Throw the negative prefix 'an-' in front of it and you're left with a mental state devoid of joy.  I like that term.  And usually, I'm not one to be partial to fancy medical mumbo-jumbo.  We make up all sorts of ridiculous and pompous sounding terms like using erythematous instead of red.  But anhedonia, I can get behind because it describes my mood perfectly.
     And I'm not sure why it took me awhile to understand that term and be able to apply it to myself.  This summer while studying grief, research suggested that the depression phase of the Kubler-Ross model of grief peaks at around five to six months.  And sure enough, it's been six months since my brother passed away.  When I read that, I envisioned the pain of grief getting worse.  But that's not it.  Not at all.  Tears are mostly gone now.  The everpresent anger is now a memory of the past.  But in many ways, what replaced it is far worse in it's subtlety and devastation.  Gut wrenching anguish is replaced by emptiness.  It's a void that insidiously covers your soul.  It's not caring whether I stare at a wall or have my nose in my books.  It's utter and complete apathy.  It robs you of your desire for anything be it worthy and noble or simple and sweet.  And you don't realize it until you are too far along into that long dark night of the soul.  Anhedonia.

pre giving of thanks

     "Open up and say 'ahhh'."  We're all familiar with that routine at the doctor's office.  But you ever try it with yourself in the mirror trying to see your own tonsils?  Not as easy.  With my pen light and a knife substituting as a tongue depressor I was able to manage it early this morning.  In doing so, I have really good firsthand knowledge of what an overgrowth of Streptococus pyogenes looks like.  It's better known as strep throat and even though my case wasn't a typical presentation, it made me suspicious enough to drag my infirmed body to the doc on a Saturday.  I knew there had to be something more devious at work on my throat than a common cold.  It felt like I was eating shards of glass everytime I swallowed.  Needless to say, studying (and blogging) have been out of the question.  It was so painful I couldn't even sleep.  Heading into Thanksgiving, I'm thankful for the people that developed the rapid strep antigen test, the NP who was willing to run the strep test even though mine was not classical, and whomever made the amoxicillin.  Hopefully, I'll be able to actually study in a day or two in order to make up for all the lost time.  Well, first I'll need to catch up on sleep.

game day

     In my football days, there was always at least one practice a week that was meant to simulate a game situation.  Any coach worth his salt knew that practice and the actual game are very, very different psychologically.  So they'd try to simulate that intensity and unpredictable nature of the real thing.  Same is true with interviewing patients and taking a physical.  We trained on actors who were healthy and mobile.  They did their best to pretend at being ill but even when they were acting sick, it was something simple like a stomache ache from an ulcer.  Acted pain and real pain are worlds apart.  The patients I'm seeing at MD Anderson?  They are hospitalized.  And people aren't hospitalized for no reason.  They are truly sick.  So all that practice I did on the actors, my wife, even my dog, went right out the window when you're trying to interview a patient who's lungs are so full of fluid they have difficulty completing a sentence.  Or, the patient in his twenties on methadone who's eye movements and acute sensitivity to nausea are EXACTLY like what my brother experienced.  And so on.  Nothing much prepares you for that except the real thing.  And as hard as it is, I'm grateful for the opportunity.

first encounter

     "I have a patient for each of you.  One," the doctor pauses here, "I'm not so sure about but we'll see how it goes.  The other is straight forward."
     He knocks on the door and introduces me to the patient as doctor which strains against any humble nature I have because it just feels cool.  I figure I've worked hard enough to get to this point that I can enjoy a bit of brief vanity, even if I'm technically not a doctor yet.  We're given nothing about the patient other than the last name.  That's it.  We're supposed to take a full medical history and give a full physical flying solo.  We then report back to the doctor overseeing us with our findings.  He takes us back to the patient so we can present our findings, shreds (deservedly so) our technique, educates us on a better way, and then we're on our merry way.  Repeat about weekly.
     Given his pregnant pause, I went out on a limb and guessed that I got the "not so sure one".  The daughter is in the room and I wait for her to finish up.  Then an occupational therapist goes in and I move further toward the back of the line.  As a med student, I think we're somewhere above the faucet but below the coffee machine in the hierarchy.  I wait about 45 minutes which is not really any big deal for me at MD Anderson.  I'm quite used to waiting here and I joked with my dad that they even keep their trainees waiting. 
     I finally get the green light and I'm in the room introducing myself to the patient.  One quick glance and I now know that I got the difficult patient.  She has a nasogastric tube emerging from her nose.  I look at the tube and notice the green fluid in it.  It's obviously not to feed her.  The green is the stomach fluid which is being emptied.  Her stomach is swollen to the size of a large watermelon and as hard.  I begin to gently question her and after many long pauses, her eyes focus on the window.  She slowly raises her hand and begins waiving.  I query as to whom she's waving.  "My daughter," as a half smile erupts on her face.  Keep in mind we're on the 10th floor of the hospital wing and absolutely no one is out there.  It's more than a little heart breaking to see a cancer patient in poor condition who is hallucinating but I cordone off that part of me, at least for now.  I do have a job to do.  I recover my senses and conclude the interviewing part isn't going to work so I try to salvage what I can and move to the physical exam.  After a very few quick parts, she says to the entering nurse, "I need to spend more time with you, and less time with him."  And with that, my first patient encounter lasts about 5 minutes and is over.

sick

     As a kid, I got sick a LOT.  I almost didn't graduate high school on time because I missed about a third of my senior year.  Since I didn't like school too much, it was a sort of guilty pleasure to enjoy the missing school part, though not being sick.  Now that I'm in med school, it's a completely different story.  Being sick sucks.  School marches on unabated and the work piles up relentlessly.  Fortunately, I'm back on me feet and ready to start digging out of the hole.

language

    Apparently, the average med student learns about 13,000 new words in the first year alone.  Not sure how many in the second but it definitely keeps increasing.  The words get longer and more complex with their connotations, too.  Try saying 'Membranoproliferative Glomerulonephritis' 10 times.  And not content to leave it alone, pathologists had to identify two different forms so that there is a Type I and a Type II.  And then you have to know the inferred clinical signs because in addition to being nephritic, is also also nephrotic.  I think I'm beginning to forget simple words like 'cat' and 'dog' to be able to remember this gobbledygook.

crazy

General advice from the clinical instructor (an internal medicine doc) of my last group.

     "Anyone entering oncology needs to have a psychotherapist.  No, I'm serious.  Even though you may be normal, the clinical world in which you inhabit is not.  Take care of yourself."

slave

     My uncle recently wrote on my dad's blog what it felt like to try to be the stem cell donor and have it fail.  They spent 35 days down here, flew from Michigan to Houston twice, made multiple 70 mile round trips back and forth between MD Anderson and here, spent numerous hours in the waiting room, been poked and prodded and in all manner of ways..........and came up empty.  He will not be the donor.
     My response?  Welcome to cancer.  You bust your ass, give all you've got and then find a way to give even more, you never stop trying, battle the disease 24/7, hold onto that ridiculous yet enticing word 'hope'............and still come up short.  That's cancer in a nutshell.  Don't get me wrong.  It's not that I'm not appreciative or grateful for his effort.  I am.  But what he experienced in that condensed episode is what my brother fought against for 15 months and what my dad continues to fight against for 10 months day in and day out.  Yeah, cancer sucks and welcome to its world because it owns you.

the problem with hope

     I hate the word 'hope'.  It's a cruel and bitter emotion that won't leave you alone.  In meditation, one is taught to 'let go' of attachments to emotions.  I can often do that with anger and grief and anxiety.  In fact, I've gotten pretty adept at it.  But not hope.  I despise it because even if I let it go, it never lets go of me, along with its cousin of disappointment.  'Hope springs eternal in the human breast' and all that jazz.  A three hundred year poet wrestled with it then as I wrestle with it now.  Some things never change.
     This morning right before class, I get a phone call from my dad.  MDACC has already initiated the search for an unrelated donor.  "They got over 900 potential hits initially.  They want to narrow it down to 3 people and that should take about 2 weeks," my dad tells me.  His voice is filled with hope.  As a consequence, my ears are also filled with hope.  But does it penetrate down and do I allow my heart to dare hope?  Can we find a 10 out of 10 match in just a few short weeks?  Is that possible?  More importantly, is it probable and likely?  Do I dare get my hopes up????

Know then thyself, presume not God to scan
The proper study of Mankind is Man.
Placed on this isthmus of a middle state,
A Being darkly wise, and rudely great:
With too much knowledge for the Sceptic side,
With too much weakness for the Stoic's pride,
He hangs between; in doubt to act, or rest;
In doubt to deem himself a God, or Beast;
In doubt his mind or body to prefer;
Born but to die, and reas'ning but to err;
Alike in ignorance, his reason such,
Whether he thinks too little, or too much;
Chaos of Thought and Passion, all confus'd;
Still by himself, abus'd or disabus'd;
Created half to rise and half to fall;
Great Lord of all things, yet a prey to all,
Sole judge of truth, in endless error hurl'd;
The glory, jest and riddle of the world.

Go, wondrous creature! mount where science guides,
Go, measure earth, weigh air, and state the tides;
Instruct the planets in what orbs to run,
Correct old time, and regulate the sun;
Go, soar with Plato to th’ empyreal sphere,
To the first good, first perfect, and first fair;
Or tread the mazy round his followers trod,
And quitting sense call imitating God;
As Eastern priests in giddy circles run,
And turn their heads to imitate the sun.
Go, teach Eternal Wisdom how to rule—
Then drop into thyself, and be a fool!

 - alexander pope from an essay on man

do this in remembrance of me

     My dreams have been troubled of late.  Often my brother is in them.  Always with cancer, never healthy.  Death is also present, too.  They're not pleasant dreams.  Pot pies have been on my menu a lot lately.  And not just any pot pie.  "They've gotta be the cheap Banquet ones," as my brother would say.  And he was right.  And still is right (can he still be right now that he's dead?).  The banquet ones trump all.  I didn't even realize I was eating them so often because of him until my mom mentioned she and my dad had some one night in honor of him.
     And I think back.  Why pot pies?  They're some cheap frozen meal that can't possibly be real food.  But wh am I addicted to them?  When we first moved to Texas, I was only 9.  Both parents worked and so during that first summer, my brother was forced to baby sit me.  We had this ritual where we'd conjur up our lunch time meals.  Iggy's Grub, we called our kitchen.  Nothing fancy, always frozen or canned but it got the job done.  Three meals, specifically I remember.  Dinty Moore's beef stew.  As we got older, we both considered this on par with dog food.  It fell out of favor.  Chicken Chow Mein, though, I don't remember him liking this one.  How I wish I could shoot him an email and ask him.  "Was that one we ate at Iggy's Grub?"  Nevermore.  And Banquet Chicken Pot Pies.  This one stayed with both of us through our adult lives.  Why, I don't know.  But I remember reminiscing with him at MD Anderson about them.  It's so bizarre how a 69 cent item is the cause of such pain and tears for me now.  As I write this, I've got two in the oven cooking.  And I'm going to eat them and remember both that summer when were kids and the time at MD Anderson.  Memories are all I have of him now.

tally

Grades are finally in and the tally is:

• Epidemiology/Evidence Based Medicine - honors on the one and only exam and honors in the class.
• Genetics - just a pass on the one and only exam and high pass in the class overall.  Both these classes are now done.  Now on to the continuing classes.
• Behavior - high pass on the exam
• Fundamentals of Clinical Medicine - only a pass.  This class is presented very differently than the other classes and I dramatically underestimated the difficulty.  Need to rectify that.
• Pathology - high pass but they set the cutoff of honors at 93% so that's a hard target to hit.
• Pharmacology - ditto for this one.  There were a couple math problems I just couldn't figure which probably kept me at high pass.
• Integrative Clinical Experience/Problem Based Learning - pure clinical based on cases we work through.  Knocked this one out of the park with a straight up 100.  We're also graded by the group facilitator on how we do in the group work.  He told me I could've taught this class (it was mostly cardiovascular so I'd hope I could teach that after my years in industry) so needless to say I've got honors for this one.

Not too shabby for an old dude.

tails

     We called 'heads' on that flip of a coin.  It seems to have come up 'tails'.  My uncle donated his stem cells but the count only hit somewhere in the neighborhood of 200,000.  That number needed to be closer to 1 to 2 million so we're way off.  They're going to try some last ditch efforts to see if there isn't some way to get the cells produced but I'm not holding my breath.  It seems we're headed to the national registry so I will again make this plea. 
     If you feel motivated to impact someone's life (possibly my dad's but more likely someone else's) in a very big way with very little impact on you, I would urge you to register at bethematch.org.  You fill out the request online and they mail you some q-tip types of swabs.  You swab the inside of your cheek and mail it back.  That's all it takes for the initial steps.  They then contact you if you match anyone down the road. 
     And I'm sure my dad wouldn't mind hearing directly from any of y'all to encourage him in his battle.  Fighting day after day after day in the face of continual losses gets more than a bit disheartening.  Cancer sucks, after all.

flip of a coin

     Have you ever had a moment in life where your very survival was distilled down to two very real and very different possibilities?  I can think of one instant in my life.  I had climbed Mt. Kenya and while coming down at the very end of the trip when things are supposed to be safe and triumphant, I came face to face with a cape buffalo.  I was five feet away from him and if the bull charged, there was little chance I'd survive.  My climbing guide had lost his dad to a cape buffalo so it wasn't a trivial thing.  For what seemed like an eternity but in reality only lasted a second or two, my existence was called into question.  Fortunately, the bull didn't feel much like goring me and gave a warning snort and wave of the horns that I promptly honored.  I imagine that's what life must be like for my dad right now.  His brother, the donor, is down at MD Anderson again.  He's in the apheresis unit again.  They've given him shots to stimulate his stem cells again.  And they're collecting his blood again.  All to see if he's able to produce the stem cells.  If he is, then my dad gets a very good chance at life.  If not, and that proverbial bull rushes, who knows what will happen - will we find an unrelated donor, how good of a match will they be, how long will it take, how many complications?  It seems as fickle as the flip of a coin.

pain

     The proctors shuffle sideways through the tight rows and begin to pass out the exams.  The last one, which is actually a two-fer-one test.  A total of four versions for the test, each person gets a random version to lessen the likelihood of cheating off your neighbor.  Even the earplugs are supplied by the school to prevent any earpieces that could allow for cheating.  I thought the school was just being nice. 
     I roll up the earplug and shove it down into my ear canal.  As the spongy material decompresses against my ear canal, it's a bit like walking into a tunnel.  All extraneous sounds, and thoughts, fade away into the background as my mind approaches a zen-like state.  Except one sensation.  There's pain in my left ear radiating up from my jaw.  Right before exams started I had a tooth flare up.  Bad.  No time for dental appointments, I numbed it up with vicodin.  I discovered that while I could NOT study while in pain, I COULD break through the fog of opiates with enough caffeine and enough will power.  So each day, I'd wake up in a haze and start pouring tea into my body by the gallons, hoping that by the time the exam rolled around I'd still have enough pain relief on board while simultaneously having enough caffeine to counteract the mental fog.
     I know, I know.  It was less than ideal but when your back is up against the wall, you do what you gotta do.  All those rules and guidelines about not self medicating go right out the window when it's three am, you have exams, and you're in severe pain that laughs at the notion of ibuprofen controlling it.  The memories of my brother were quick to haunt me, too.  How many times had I watched him wait for the pain meds to kick in...waiting....waiting....waiting....ahhhh, relief.  It always took about 30-40 minutes.  So at three am, I'm frantically digging through our house looking for pain meds.  I got them for my hiking first aid kit.  They must be there.  Nope.  Medicine cabinet?  Nope.  After a half hour finally breaking out in a cold sweat due to the pain, I finally find them, pop them, and then plop myself onto the couch in front of the tv.  It takes two South Park episodes on Netflix for them to kick in.  Waiting....waiting....waiting...ahhh, relief.  44 minutes, just like my brother.
     Blissfully, I can fall back asleep hoping that my brain will begin to function on a higher plane by exam time at 1 pm.  And so I repeat this ritual for 7 exams over 10 days and amazingly, it works.  I am able to study.  I am even able to drive, much to my wife's consternation and worries.  And to top it all, I am able to do well on exams.  I wouldn't recommend it and if I had the chance to do it all over again, well, there wasn't a lot I could do.  But I can say that being visited by the specter of my brother's pain at three am is a powerful teaching moment.  If I didn't already have enough appreciation for patients with pain that is not well controlled, I now have another personal level of empathy and understanding.  Opiates get a bad rap because of some bad people but for the majority of patients who really have pain, they are a life saver.  I don't know what I would've done without them.  They got me through my first round of exams and made me a more caring doctor on top of it.

pause

My third exam is done and in the bag.  100 questions over genetic diseases and all the esoteric minutia that goes along with them.  I'm going to go out on a limb here and say that with a few exceptions, I will not see most of this tested material in my career.  Ever.  Expanding repeats, unbalanced translocations, calculating the risk of birth defects in inbred cajuns.  Ain't gonna happen.  Lots of grumbling about this class throughout my class.  Keep in mind that med students are a bunch of hypercompetitive braniacs so grumbling is the norm.  They're not used to being wrong.  But in this instance, I think there's some legitimacy to the grumbling.  Oh, well.  Don't care.  Exam is done.  And like the class yesterday, this whole class is done.  This was the one and only exam worth ~70% of the grade.  Good riddance.

I did get my score back on my first exam, which was Behavior.  Squeeked by with an honors grade by 0.4 points.  Sweet.  Not expecting honors on the next two.  But as I said, don't care.  Pass is all that matters for those.  They are done and will factor minimally in the board exams.

I'm taking the evening off, instead choosing to spend it with wine, barbeque, and South Park.  Tomorrow begins the studying for the real exams.  The heavy weights are next week.  Monday is Pathology (the 800 pound gorilla), Wednesday is Pharmacology (lots of memorization), and Friday is a tag team of a two class exam that really amounts to assimilating everything from every class and seeing how it applies to imaginary patients.  It's bizarre.  They only had 5 lectures in this class but it's probably the hardest and most expansive class that we have.  The diverse topics range from anemia of chronic disease to fever of unknown origin to heart failure to my personal favorite, EKG interpretation.  The other difference is the test is written by a pure clinician, not a PhD.  I'm hoping that balances in my favor but we'll see.

ruminations & anxieties

     Even though he lives just a few miles away, I've hardly seen my dad lately.  Exams and the lead up to them have been brutal and I've had to compartmentalize.  I still try to call him at least every two or three days but even that has become more difficult.  I typically would call when I'm making that hour long drive to-and-from the med center.  But even that time is now packed with listening to lectures in the car.  Besides, it's hard to gauge over the phone how he's doing with the waiting.  First, the manic rush to stem cell followed by the brick wall of a poor collection.  And now playing the waiting game. 
      So I honestly do not know how he's doing.  But I have a decent imagination.  He hates inactivity and waiting.  I'm sure his mind is running through endless scenarios of "what it, what if, what it?"  I know mine has.  And my mine isn't content to just ask the question.  It has to answer them.  In the back of mind where I still have a bit of reserve brain power, I've begun to wonder, 'what about that new clinical trial with genetically engineering the patient's own T-cells?'  Before, it was a moot point since we had a perfect donor match.  It wasn't necessary.  Hopefully, that still holds true.  But now?  I don't put much stock in hope.  I tend to put my stock in Plan B, just in case.

Second test done.  It was only 56 questions.  It was mostly over stats and who doesn't enjoy being tested over stats?  The only good thing I can say is that this class is over.  It was a short class with only one exam worth 70% of our grade.  Good riddance.

first

104 questions over behavior and my first exam is in the bag.  Not sure how I did other than I passed and that's good enough for now.  Line'em up and knock'em down.

highs

     Tight with strain, my eyes easily glaze over at any chance they get.  Subsisting on fast food, I've abandoned exercise for a bit, and in all likelihood am drinking too much.  Check that.  I told my wife, "yes, I know I'm drinking too much.  If I'm still doing it in 10 days, then you have cause to be concerned." 
     And yet I emailed my wife just the other day, "in some weird, twisted strange way, I'm almost enjoying myself."  I started with real patients last week and this week marks the finish of the first leg of a sprint begun in August.  It's exam time.  The first of four this school year.  And they don't mess around.  Seven exams in ten days, probably in the neighborhood of 600ish questions in total.  I'm not sure I'd ever want to do this whole training gig again but I must admit that I am thrilled at the opportunity.  I do not regret it one bit.  I vary between thoughts of "oh shit, I don't know anything, I'm screwed" to delusions of "meh, it won't be that hard."  It ain't easy.  And nevermind all the obvious emotional associations of what I'm studying being being inextricably wrapped up with my brother and dad.   But despite it all, I love the fact that I'm doing this.  I feel alive.

the lows

     I walk the half mile from my school to MD Anderson.  It could be the 3rd time or the 300th time.  I lost track long ago.  I call my dad to let him know I'm on my way over.  "I'll update you when you get here."  Uh-oh.  That can't be good.  Normally, I get some sense of what is going on.  But nothing this time.  And we haven't even met with the stem cell doc yet.  The donor, my dad's brother, is running into a brick wall from the perspective of a donor.  His platelet counts are too low to donate. 
     But really, that's only half the problem.  It's compounded by the fact that he hasn't been able to muster enough stem cells to even hit 1 million cells after a good week of attempts.  They want 4 million cells.  They can get by with 3 million but even that has some qualifications.  You can imagine that if you collect all 3 million at once, there'd be less stress and handling on the cells.  But if takes 6 collections, well, some of the cells aren't going to be viable so you don't really have 3 million live cells.  It'd be like going to the grocery one item at a time or all at once.
     So they sent him home to recuperate.  The hope, and I mean hope in the philosophical sense of the word as this is anything but a diagnosis, is that his brother battled a cold a couple weeks back and perhaps that's limiting the response of his bone marrow to kick out enough stem cells (and platelet cells).  We shall see in due time.  If that's true, then he should give a good collection in a couple of weeks.  If not, then it's time to hit the national registry to attempt to find a match there.
     If you're like me, then you may be wondering why they don't just go directly into the bone marrow to collect the cells they need.  I asked the stem cell doc that very question.  First, if they can't collect peripherally via the blood, then the collection tends not to be adequate from the bone marrow.  One predicts the other.  But equally important is the fact that stem cells collected from the blood tend to produce better outcomes (at least in MDACC's hands) than stem cells from the bone marrow.  So it'd be better to collect peripherally from an unrelated donor than from the marrow of a related donor.  As to the why, that's complicated and I'm too tired to go into it now (exams start next week for me).  Besides, it'd be esoterically boring to all but the most hard core science geek.  I'm going to go drink some boxed wine and watch South Park before drifting off to sleep.  It's been a long day.

be careful what you ask for

     Checking my email, I notice one in my school account that's from an unfamiliar name.  I open it and it's from the doctor I will be paired up with to start practicing my History & Physical on real patients.  No more actor patients.  Well, we'll still use them for other stuff.  But, at least in part, it's now time to move onto the real deal.  I requested an oncologist.  Normally, they don't like to take requests but the course coordinator knows my story and is more than willing to help me out.  So I get paired up with a breast oncologist at MD Anderson. 
     In the email, he's giving me the time and date of our first excursion.  He asks me to show up at the hospital wing of the complex.  I offer to meet him at his clinic thinking it would save him a trip.  Nope, he informs me that the patients I will be seeing are inpatients.  That means they're hospitalized.  These patients are sick.  Of course, anyone with cancer is sick but they're not hospitalized without reason.  So I'm skipping from playing doctor on actors to real cancer patients in the real hospital.  Couldn't we just start with a patient that has the sniffles or a sore ankle?  Nope.  These are patients grappling with a life and death disease.  I'm terrified while reading the email.  But I asked for this. 
      I immediately flash back to my brother's countless visits to the clinic.  Often, the visit would start off with a resident.  It is a teaching hospital, after all.  And some of the residents inflicted emotional pain on my brother by their ineptitude.  They weren't mean.  They just didn't know what they were doing.  Inexperienced or stupid?  In the end, it doesn't matter to the person on the exam table.  That patient is scared, in pain, confused, and frustrated.  Violating that Hippocratic oath, albeit unintentionally, they inflicted harm upon the patient.  I watched it first hand and it infuriated me.  I even came up with a rule that I'd tell everybody, "don't ask the resident any medical questions.  None.  Ask the nurse, ask the PA, ask the doc, but for the love of Pete, let the resident get out of here with doing as little damage as possible." 
     I'm not a resident.  I'm even further down the hierarchical ladder.  Right above mop bucket is medical student.  That's me.  That will now be me on the side of that doctor-patient dynamic.  It's scary.  Damned scary.  All I can do is trust myself.  Trust that little unconscious part of my brain that takes over during these moments.  It happened when I played football and it seems to happen in medical situations, at least so far.  Something just takes over and does the right things.  That, and practice like hell with my wife to insure I don't inflict a moment of pain on these patients.  I watched it happen on my brother and I'm going to do my damnedest to make sure it never happens to one of my patients on which I'm learning.

waves

     I was sitting in my backyard, the temperatures surprisingly nice given the brutal and record breaking summer we had.  I had spent the Saturday morning studying, had lunch and then mowed the yard.  Nothing to do now but relax with satisfaction of a good day.  Drink a beer, observe the butterflies, and periodically move the sprinkler.  It was good.  But then out of nowhere, unheralded and unanticipated, came the image of my brother.  This was not reminiscing about good memories.  This was the dirty and difficult process of dying.  All the images, all the emotions, all the decisions, all the struggles.  It's like they were yesterday.  The waves keep coming over me again and again.  I'm at a loss of what to do so I write.

thanatos

     That case before?  Yup, it was cancer.  Started out as colon cancer, went into remission, but then she developed Stave IV ovarian cancer.  Turns out her family had a condition running through the gene pool called Lynch Syndrome (or hereditary nonpolyposis colorectal cancer if you really like medicalese).  They get colon cancer along with endometrial or ovarian cancer.  And to be honest, it wasn't that emotionally hard reading all the medical stuff.  It wasn't even that hard to role play giving the bad news.  I've done that with my both my brother's and dad's diseases.  It kinda loses its punch when it's just an academic exercise. 
     But at the end of the case, we all piled into our lecture hall to watch a video interview.  A different patient at MD Anderson who had Stage IV ovarian cancer (translation - terminal) agreed to be interviewed about end of life issues.  It was less than 15 minutes and I counted the number of times I had to physically bite down on my tongue to keep tears from spilling.  So many of the same struggles and issues that were thrown at my dad and brother.  It took three times chomping down on my tongue to create physical pain out of emotional pain.  Then a rather well esteemed chaplain and rabbi at the medical center got up to tell some stories about end of life.  And through them all, he's encouraging us to drop the notion that because there's nothing medically, meaning curatively, that can be done for patients, we still have a role to play.  And perhaps it's a role that only a doctor can play.  Our relationship with the patient is unlike any other.  And if we judge our success solely by restoration of health or not, we're going to be sorely disappointed, not mention at a high risk for burnout.  But if we treat to validate and heal the patient's spirit, that's a different measure of success.  And I'm listening to all his stories about redemption and hope and peace in the face of death and I'm struck at how that wasn't there for my brother, at least from where I sat.  It was a nasty and brutish and above all, painful death.  So if I measure success by peace or healing of the spirit, did I fail him?
     And so, too, did the doctor fail him in that regard?  We all tried to move my brother towards acceptance but there is something about the aura of a doctor.  Their word carries a different weight than a family member.  But I remembered back to a line the doc said to my brother that rings in my head clearly, "so what I'm hearing you say, is that you'd rather go down swinging."  I can picture the doctor saying it, hear his voice, and see his body language like it's on a screen before my eyes.  And my brother nodded his head 'yes'. 
     We're taught to respect the patient's autonomy.  They have the right of self determination that trumps most anything.  But as a physician, at what point are we feeding the patient's mistaken belief of a cure?  There was nothing medically that supported the last couple of treatments my brother engaged in.  And from the doctor's point of view, I guess he thought that it was more important that my brother die fighting as he wished.  There was absolutely no doubt that's what my brother chose.  I don't know that's what he really wanted.  But I don't want to second guess my brother or sit in judgement of his life.  Far from it. 
     I'm torn as to what I'll do when put into that situation.  I can't see myself encouraging someone on when there is no hope medically.  But can I see myself encouraging them to heal their relationships, to do what final things that truly matter, and to heal their soul while there is still time, when they still wish to fight against any hope?  At what point is the specter of the Grim Reaper of Death really the Angel of Mercy?  And did I really go into medicine so that at times I could be the Angel of Death?

update

     I haven't had time to be with my dad much for his MD Anderson visits.  It feels weird but I've busy with school.  Since the ball is now rolling for stem cell transplant, those are becoming more frequent again.  As such, I'm not exactly clear on the protocol they'll be using because it can vary a bit depending on the patient.  But a LOT goes into a stem cell transplant.  You don't just walk up and say, "here, pump some of dem bone marra' cells into me."

• First things first.  The donor.  And first, the donor has to be cleared for takeoff.  My dad's brother underwent a series of tests this week and from what I understand, a LOT of waiting, and waiting, and waiting.  Welcome to MD Anderson.  And the tests came back as a 'go'.  So now, he's receiving multiple daily doses of Neupogen to tell the stem cells in his bone marrow to start replicating.  And replicate they shall, even to the extent that they start to spill out into the blood.  The advantage of that is that he doesn't have to have his actual bone marrow harvested so it's a lot less painful for him.  Just a stick in his arm.  They'll start the collection process next week.  They collect daily and count the number of stem cells they get.  They continue to draw on him like an ATM until they hit somewhere in the neighborhood of 4 million cells.
• Next, the patient.  Like the donor, the patient also has to be cleared for take off.  That means imaging in the forms of a CT, a PET, and x-rays to make sure he doesn't have any hidden solid tumors that we didn't know about (you know that for them to run that test means that happens enough to people to warrant the test).  After that are some various odds and ends stuff that are really quite time consuming.  It's basically a full time job.  Among those, I have to imagine, is putting in a central line.  Usually, that means putting a catheter in the vein that runs right below the collar bone, appropriately named the 'subclavian vein' because it runs below the clavicle (aka collar bone).  That's there to infuse the chemos, the stem cells, the rejection suppression regimen, antibiotics, antifungals, antivirals, and the multitudes of blood transfusions that he'll get.  All those tests and processes start for him next week.
• Then the fun really begins.  First, they'll hit my dad with a dose of Rituxin on the 27th as an outpatient.  He got that with chemo before and other than some flu-like symptoms for a day or two, it's pretty mild with respect to side effects.  I'm not sure if he'll get another dose of Rituxin a week later, again, I haven't seen the full protocol they'll be using for him.  Then after that comes the nasties.  These are the traditional chemos that cause the nausea, chemo brain, thrush, and all-around-feeling-like-shit.  Multiple days with multiple infusions.  At that point, he's in the hospital and he'll get the stem cells from his brother.  That date is not yet set but I anticipate sometime the first or second week of October.

extrusion of pain

     Monday morning.  Brand new week.  I took a jog in the morning sun before the thermometer had a chance to flirt with triple digits.  I don't particularly like running.  In fact, after about the first mile, I pretty much hate it.  But I need to exercise and I need something mindless.  So I go for a Monday morning run.  Exercising means music and I crank it up.  And out of the blue, a line from a song hits me like a blow to the stomach.

Suddenly, you were gone
from all the lives
you left your mark upon...

     The waves of grief and sadness have been flowing over me with greater occurrence of late.  Sometimes, they are triggered by events that warrant anticipation or expectation.  Holidays, birthdays, special occasions.  Those I can handle.  I expect it and brace myself for the emotions.  It's the little ones that creep out of nowhere, like a predator stalking a prey that is unaware of the danger lurking around a corner.  Sometimes elicited by a song, sometimes by a dream, or many times by nothing at all.  Those are the ones that hurt the worst.  And they're becoming worse.  Like running while tears come down your face.  Visions of my brother's final days flash through my mind.  Prognostications of something going horribly wrong with my dad are right behind them.  Crimeny, I'm out there trying to clear my head before going to school.  Apparently 'clearing my head' is permission for something else to take that vacancy.  And then another song shuffles through the iphone of my brother with these lyrics

For my father and my brother
It's too late
But I must help my mother
Stand up straight

     That's it.  Screw this.  I'm done with running and am actually looking forward to school by now.  Exercise has done anything but unwind me.  I drive the 33 miles down to school for my group work where for two hours every Monday, Wednesday and Friday, eight of us, under the tutelage of a doctor, unravel a case and practice how to be doctors.  Pieces of information are fed to us slowly with probing open-ended questions so that we can hone our skills at each stage of the diagnosis and treatment.  This case?  Patient comes in with fatigue and unexplained weight loss.  After identifying the "problem list", we're now free to start compiling our Differential Diagnosis.  There's a bit of a pause becomes symptoms so nondescript as this patient can be damned near anything.  But I say, "anytime there's unexplained weight loss, especially with fatigue, you have to include cancer."  As the scribe today, I write that as the first line on the dry erase board.  C--A--N--C--E--R.  I know damned well where this case is going and I bet it's not going to end well.  I can't run fast enough to escape this one.

two flew over the cuckoo's nest part II

     I came home and in my best Southpark imitation, told my son, "don't do drugs.  Drugs are bad, umkay."

"Yes, dad.  I know," he responded with a sense of exasperation.

"No, you don't know.  I just came from a psych ward where I interviewed some poor guy who's entire future is now going to be spent cycling in between being homeless or institutionalized because he completely fried his brain.  Let me tell you what can happen..."

     It was sad, really.  Which is to say, a drastic understatement.  The interview was subdivided up between the various students.  By chance, I got the part that dealt with developmental history and substance abuse.  Essentially, my questions revolved around, "tell me about your childhood" or "tell me what you drink, smoke, snort or inject."  And given the case, those were the biggies.  A tragic case - a dual diagnosis of schizophrenia and substance abuse.  His demeanor was what is called a 'flat affect', probably from the medication working.  That means he used the same monotone voice to describe the grades he got as the same voice he used to tell about being sexually abused.  It was the same voice he used to tell me about the cocaine he used to make the pain go away.  It was also the same voice that he used to tell me of his plans to "hurt those who hurt me.  I didn't want to kill them.  I just wanted to make them feel the same pain as me."
     Up until the age of 12, he lived a normal suburban existence where he "didn't want for nothing.  I got A's and B's in school."  Then he moved from his caring aunt back to his abusive mother and step father.  Shortly after, substance abuse started as did the schizophrenia.  Which came first?  Chicken or the egg.  I wonder how much research has been done to show what impact substance abuse can have in creating mental illnesses.  And vice versa.  (And homelessness is clearly a mental health problem.  No amount of job training is going to change that fact.)  He still managed to complete high school and was on his way to becoming an engineer.  And I believed him.  He could rattle off dates and hospitals and diagnoses like they were written in front of him.  I couldn't tell you what I did last week but I'm the sane one.  Yet ask him to spell "world" backwards and he couldn't get past "w-o-r???".  It was like his brain worked right up to a certain point in his life and then just stopped.  No new information or thinking.  And when we began to exit the ward, we waited until an orderly could get a key to let us out.  I was at the back of the group and looked out at the ward.  I guess part of me said, 'don't turn your back on a potentially dangerous situation.'  My eyes panned across the room and saw him sitting on the couch.  Despite the lack of any emotion on his face whatsoever, he raised his hand in salute and waived goodbye to me.

too much

     "When I add up all the things I'm supposed to do to fight cancer, and I subtract all the things I can't do because of cancer.....there's not much left in the day for me to do the things in life that I want to do."  I heard this on more then one occassion from my brother.  And now, I read something similar from my dad in his blog about losing his whole rhythm for life.  For myself, I felt some of the same things this past summer went I went deep, deep, deep into my own grief.  We are creatures of habit and when that is stolen from us, it leaves us reeling.  Things that we enjoyed or took pleasure in are now bland and tasteless.  Even the rising of the sun no longer holds any sense of promise.  I have no encouraging words.  I fight my own struggles every day.  Just some lyrics from someone who lost too many people from his life and struggled with maintaining his own will to live.  It's the quintessential struggle to survive in the midst of having your life as you know it stolen from you.

The way out
Is the way in
The way out
Is the way in...

Out of touch
With the weather and the wind direction
With the sunrise
And the phases of the moon

Out of touch
With life in the land of the loving
With the living night
And the darkness at high noon

You can never break the chain
There is never love without pain
A gentle hand, a secret touch on the heart

Out of sync
With the rhythm of my own reactions
With the things that last
And the things that come apart

Out of sync
With love in the land of the living...
A gentle hand, a secret touch on the heart

You can never break the chain
There is never love without pain
A gentle hand, a secret touch on the heart

A healing hand, a secret touch on the heart
Life is a power that remains
- 'secret touch' by neil peart

countdown

T minus 20...
19...
18...
     I park the car, grab my luggage and find the bus to take me over to the airport.  Once there, I submit myself to the rather dehumanizing airport security.  And wait.  Wait, wait, wait.  Eventually, enough seconds tick off the clock to allow me to board the airplane.  There's an almost claustrophobic feel to the closeness.  All the irritating aspects of humanity seem especially exposed.  The overhead luggage never fits right and neither do my broad shoulders fit into the seat.  Inevitably, someone nearby is hacking germs everywhere and I think to myself, "great, now I get to inhale those things and get sick."  And no flight is complete without the crying infant.  I wait, and wait, and wait.
     Behind the scenes, airtraffic controllers are controlling the chaos and the pilots are going through their preflight checklist while we the passengers sit unwittingly at their mercy.  By some seemingly abitrary decision that might as well come from the clouds, we are cleared to go.  And something happens once the pilot comes over the intercom.  Something starts to happen.  The plane begins to move.  Potential energy (waiting) turns into a kinetic energy (one of movement).  The throttle kicks in while my body is forced back into the seat demanded by the laws of physics, and I am simply amazed at the brilliance of those mental giants who made flight possible.  The airplane parts from the ground and rises through the clouds.  There's almost a magical quality to it.  But of course, it's not magic.  It's all vectors.  A million things went into making not just that particular flight, but the general concept of flight possible.  And countless failures.  But we trust that the pilots know what they're doing.  That some mechanic did their job despite having a fight with their spouse.  That some air traffic controller double and triple checked everything despite battling some illness.
17...
16...
15...
     I felt some of that same awe of being propelled down the runway yesterday.  My dad is heading to stem cell transplant.  It really is happening.  Things are beginning to move.  The waiting is nearing an end.  There is a sensation of being forced back into the seat.  Gravitational forces take over.  It's all vectors now.  The way things move are no longer within our control.  But what about....???  Those questions never end.  At some point, they are answered with "MD Anderson is THE best."  Intellectually, we know that to be true.  But still, there is that crushing doubt that exists.  Yet it exists simultaneously in that same space as the awesome notion of replacing someone's stem cells with another human being's.  It's Mary Shelley's Frankenstein writ large.  Or, her alternate title, A Modern Prometheus.  They are truly stealing the knowledge of fire from the gods, or the forbidden fruit from the tree of knowledge.  What religion, or even humanistic philosophy, does not place value on the sanctity of blood?  My dad's blood type?  Gone.  It will soon be his brother's.  All the immunizations that my dad received as a child, as an immigrant, as an adult.  Gone.  They will soon be his brother's.  All the abilities and susceptibilities to the various colds and bugs that afflict some but not others?  All the immunological memory to infections in the past like chickenpox?  Gone.  They will soon be his brother's.  In exchange for eating that fruit, there is another chance at life.
14...
13...
12...

differential diagnosis part II

• 3 eyes of newt
• 3 hairs of a border collie
• 3 dashes of powdered bone
• 3 eggs from a robin
• 3 berries from a holly

Under the light of a full moon, boil the ingredients and stir clockwise precisely 30 times.  Take 3 draughts of the brew and stare into your crystal ball.  Ask the spirits in a slow and steady voice, "wwwhhhaaattt ttthhheee hhheeelll iiisss gggoooiiinnnggg ooonnn???"

     That might as well be what we do for my dad at this point.  Seriously.  To recap.  He finished 5 rounds of chemo, had improved substantially, and right before his six round, his counts plummeted inexplicably.  His neutrophils went to zero.  His total white blood cell count also dropped.  His red cells and platelets dipped ever so slightly.  But a week later both his platelet and red blood cells looked good.  So whatever was happening was specifically hitting the white blood cell population, especially his neutrophils.  His bone marrow confirmed that he did NOT have a new leukemia, a recurrence of his CLL, or myelodysplastic disease.  Besides, in those diseases, his blood counts would've looked differently.  But hey, everyone is different and you're never certain how a patient is going to present.  So to be sure, you look at the bone marrow and that confirmed it.  So that left the possibility of an autoimmune reaction where his body attacked his white blood cells for some reason or a virus.  They just posted his virus results online and they were negative.  And there's no real definitive test for an autoimmune reaction of this nature.  There's one suggestive test and my dad's results weren't even close to suggesting that it was that. 
     So for everything on his differential diagnosis, we came up with nothing.  It's possible it was a virus that we are unaware of having this effect.  It's still possible it was some sort of acute autoimmune reaction.  It's possible that it was the phase of the moon.  But we're certain of nothing.  Medicine is like that a lot of the times.  At our current level of ignorance, the disease processes are just too complex and too numerous for us to be able to understand it all.  So, you take a step back and ask, "how is the patient doing?"  Well, he's a bit more fatigued than usual and in a bit more pain.  But who knows why.  We have a match and there's no point sitting around hoping his neutrophil counts return.  The cancer will come back and some point.  It's only a matter of time.  And besides, the goal of stem cell transplant is to first obliterate the patient's bone marrow anyway.  File this little episode under "$*#($%)*" and put it behind you.  So you move forward.  There's not the luxury to sit and ponder what might be happening.  The donor, my dad's brother will be down here in a few days to begin his part of the process of donating his stem cells.  We're not sure when my dad begins.  He has a visit with his leukemia doc on Wednesday and then the stem cell doctor in three weeks.  I suspect things will start to happen pretty quickly after that.

differential diagnosis - part I

     When encountering a disease like cancer, there are so many possibilities that can be encountered, that it can be mind boggling to the patient.  When the course changes paths, it can leave the patient saying, "what just happened here.  I thought we were doing A.  Now you're telling me we're doing D.  What happened to A, B and C?"
     And perhaps physicians don't do as good a job as they could at educating the patient about all that is going on.  But to be fair, the situation can be so complex, that there isn't any real good way to reduce it to layman's terms without grossly oversimplifying.  It's a tough balancing act but let me try to explain where my dad is at and why he's left in the lurch, so to speak.  It all involves the concept of a 'differential diagnosis'.  So first, I need to explain that conceptually.  I'll go into the specifics with my dad next.
     Whenever any patient presents, the first thing we're trained to do is to begin composing a differential diagnosis.  That's really just a list of all the possibilities specific to the situation.  For example, say little Johnny comes to the pediatrician with chest pain, a nasty cough, and all around just feeling poorly.  At the top of the differential diagnosis would be some type of respiratory infection, maybe pneumonia if it's really severe.  Down the list would be all sorts of other potential problems that are less likely but still possible.  We treat and rule out the most common and obvious causes first.  Tuberculosis is possible but not at the top of the list.  Now let's say that a 60-year old Johnny who's been smoking for 40 years presents with the same symptoms.  Given the patient, our differential diagnosis just changed.  Yes, we'll still include respiratory infections but now our suspicion has to include some potentially cancerous lung mass.  Or, possibly, there's an infection there on top of some other disease that has weakened the patient and made him more susceptible to the infection.
     So how does the doc even begin to communicate possibilities as wide and divergent as cancer and a simple viral infection?  One could lead to death and the other could mean being home sick for a few days.  Kind of a big difference there.  So as physicians, we're trained to keep our poker face on.  We run tests, tests, and more tests and begin to tick things off the differential diagnosis list.  And because some diseases require treatment quicker than others, we don't have the luxury of waiting until we're 100% sure.  The threshold of certainty is much lower in the real world.  Someone with acute appendicitis needs an answer pretty danged quickly.  They don't have weeks to figure it out.  But sometimes those tests can indeed take a lot of time.  And to be honest, when a medical team is chasing a viral infection and then cancer, it can appear as if they have no clue what they're doing.  It'd be a bit like going to an auto mechanic for a flat tire and coming out needing a new transmission.  And sometimes, that probably is the case.  The doc missed something critical and really is clueless.  (I doubt that to be the case with my dad.)  I won't pretend that doesn't happen.  I've seen it first hand.  But even when the team is incredibly competent, it can leave the patient feeling frustrated, confused and filled with uncertainty as to what is going on.  You kinda throw your hands up in the air and frustratedly ask, "is anyone in charge here?"  In the second part, I'll do my level best to read the tea leaves and guess at what my dad's doc had on his differential diagnosis list and what all that means.

one flew over the cuckoo's nest - part I

     We followed the signs to our assigned room.  To enter through the doors, you had to push a button.  To go back out the door, you needed a key.  These weren't designed to keep people out.  These doors were designed to keep people in.  The final door had a sign that said,

CAUTION - HIGH RISK OF ELOPEMENT

     Ooookkkaayyyyy.  They escorted us into a room and a psychologist came in and briefed us.  We were in one of the county psychiatric hospitals.  They had a volunteer patient that was going to come in.  The psychologist would interview the individual to demonstrate what our lecture taught us - how to interview a psych patient.  Unlike our actor patients, these were the real deal.  And unlike our actor patients, there's no set script you can follow.  They're psych patients.  Who knows how they'll present.  As one of our lecturers told us, "I don't consider that my day has started until I've had a patient storm out of the room and slam the door on me."  It's a bit of a mystery as to why our first patient encounters are with hospitalized psych patients but, oh well.  Sink or swim time.

     We hear a key in the door (wait, are we locked in this room?) and it opens.  A woman takes a half step in the room and her eyes quickly pan the conference room.  There are 14, count'em 14 doctors-in-training in white coats sitting around a table.  Not exactly a welcome sight for anybody.  I know that I wouldn't want 14 people assessing me, especially inexperienced students.  In less than a second, she shakes her head sideways, utters, "no way" and scurries out of the room.  That's encouraging.

     The psychologist leaves the room and catches the patient.  We wait a few minutes.  We hear the key in the door again (this door really does lock automatically to keep people out of this room) and the psychologist brings in the patient.  She nervously sits down and proceeds to be intereviewed.  About every two minutes, she puts her hand over her mouth and mutters under her breath, "I need to get out of here."  After the psychologist concludes the interview, she turns to us students and asks us if we have any questions we'd like to ask the patient.  While her words still hung in the air and certainly before anyone could even begin to formulate a question, the patient said quite adamantly, "Uh-uh.  I'm gone."  And she stormed out of the room.  I guess our day had officially started by the criteria above.

     The psychologist without missing a beat turns to us and we start discussing our clinical observations.  After the discussion, the psychologist says to us, "Oh, and her diagnosis?  She's paranoid schizophrenic.  I did not know that until after the fact since she's not my patient."  Why in the world would anyone pick a paranoid schizophrenic to volunteer to be assessed by 14 students???  I got the impression that someone was playing a very cruel joke.

tradition

     Traditions are usually thought of as being good.  In fact, I'm not even aware of a word that implies a bad tradition.  If you break the word down, it has a long history.  Coming from the now dead language of latin, the original word is 'traditio'.  Not too different from our modern word.  And if you look at the roots of 'traditio', it's actually a combination of two words.  The first is 'trans' which means 'over'.  Pretty straight forward, like in 'transcontinental' or 'transport'.  It implies a moving from one place to another.  The second part is the verb 'dare' which means 'to give'.  So literally, it means 'to give something over' which has now come to mean 'to hand down from one generation to the next'.
     I think for my mom today, the literal meaning of 'to hand over' is much more appropriate.  Today is her birthday.  Last year, she spent it down at MDACC with my brother while he was getting his tonsils removed.  There was still some element of hope in the eyes of those around me then.  Today, she's down there with her husband so he can get the second infusion of immunoglobulins (basically, he's getting the antibodies pooled together from numerous donors in an effort to provide some reinforcements for his compromised immune system).  So for two consecutive birthdays, she has handed over with hope something quite precious to the entrusted care of MDACC.

My dad has entered the blogosphere giving his own thoughts on this journey.  You can read him here.

http://abe-conversationsbymyself.blogspot.com/
    

tower of babel

     So what exactly does a freshman year of med school look like in hindsight?  There could be lots of ways to measure it - hours studying, amount of decreased sleep, number of beers imbibed.  But the best way, it seemed to me, was recommended by my family doc.  Stack up the books.  

     Lest you think I'm playing with forced perspective on the camera, that's an 80 pound pit bull next to it.  She ain't exactly a dainty dog.  While she can chomp through steel, not even her mandibulas del muerte could go through this much material.  And to be honest, this isn't all inclusive either.  There's no cadaver (HUGE amount of learning and memorization there) and after the first block, I rarely bought the books anymore in the interest of saving time and money.  And to be fair, I did split the first year into two, though in retrospect it was definitely not a 50/50 split.  For the fall semester, it was probably a 40:60 split and the spring semester was probably near 20:80.  So this past spring, I was doing 80% of what the rest of the students were doing with respect to class load.  Add to that my brother and my dad, and I was more than carrying a full load so I'm not scared of the second year carrying a full load.  What I am afraid of is that I have to remember that pile for the Step I exams next summer.  That's in addition to what I'm going to learn this year.  Drinkin' from a fire hydrant, eatin' an elephant, insert your own insane analogy here.

moving target

     As we left yesterday's appointment with the leukemia doc, I turned and looked at my dad.  There was an expression to him that was not content to be confined to his face.  No, this feeling of utter and complete perplexion was so vast in encompassed his entire being - his gaze not focusing on much, his shoulders slumped and his back bent over.  He had been doing so well.  His energy had begun to return indicative of him making his own blood.  The sixth and final round of chemo was his "victory lap".  There was then to be a break of a few months, at least enough to allow my mom and dad to spend Christmas together without any distractions of chemo fatigue or nausea.
     But then in a moment, last Friday we found out his neutrophil counts had plummeted.  No sixth round of chemo until we have a better idea of what was going on.  His overall white blood cell count had decreased substantially, as well.  And the red blood cell count had dipped ever so slightly.  Just enough to make the picture extra confusing.  The PA asked my dad, "you didn't already have chemo, did you?"  Because this is what his numbers would look like immediately after chemo.  Only he hadn't had chemo.  The numbers were supposed to be going up.  Cancer didn't read the chart.  His numbers went down.
     More bloodwork and a bone marrow biopsy and wait until yesterday.  I'm not going to go into all the details right here and now (my studies are beckoning) and it's where medicine becomes art.  Things are very subtle, very nuanced.  Lots of shades of gray.  I'll explain a bit later.  For one reason or another (or yet another or another), my dad is no longer making any neutrophils.  I don't mean they're low.  I mean zero, zip, nada.  He's never had neutrophil counts this low at any time in the process.  And even the couple of times he did get really low, those are the times we ended up at the ER for neutropenic infections.  The good news is - and yes, there is good news - we know that his CLL is not acting up because all the other counts look good and the bone marrow confirmed it.  Likewise, we know that he didn't develop a different type of leukemia (not that common but it does happen).  We also know that it's not a game changing addition of a disease called Myelodysplastic Syndrome (MDS).  Adding that to the mix would have greatly complicated things, and I mean greatly. 
     So the ship changes course for the hundredth time.  Or, the thousandth time.  I lost count.  No victory lap of a sixth round of chemo (it would have the potential of doing more harm than good given where he's at now).  No break of six months.  And a greatly reduced ability to fight infections in the interim.  It's stem cell transplant time.  Fortunately, one of his brothers is a FULL match.  That's a very, very, very big deal.  FULL as in 10 out of 10 markers match perfectly.  That lessens the chance of rejection substantially.  He's already booked a flight down to Houston so they can begin to assess him.  They need to perform a pretty comprehensive physical exam and make sure he's fit enough to donate.  I would say I don't anticipate any problems but nothing has gone as planned with this disease.....
     As to when my dad starts his end of the deal, that's not clear yet.  We need to wait on the results of a few more tests.  And to be honest, there won't be definitive answers then either.  Possibilities, maybes, kinda sorta, like I said, it's where medicine becomes an art.  Depending on those, we're talking potentially sometime in September or probably October.  So as my dad likes to say, "we wait, and we wait, and we wait...."

professionalism

     This year, we have an entire course called Behavior.  Taught by psychiatrists, it's part psychiatry and part how to interact and deal with patients.  We just had one lecture on the doctor-patient relationship and so of course professionalism came to the forefront.  About one fourth of the lecture was dedicated to the rather obvious dictum, but apparently difficult to follow based on all the anecdotes we heard, "DO NOT SLEEP WITH YOUR PATIENTS.  EVER.  Even if you have to say to yourself before you go into every room, 'don't sleep with this patient', do that because it's never a good idea to sleep with your patients."  And the instructor would then proceed to tell us yet another anecdote about when one of her colleagues violated that rule.

in pursuit of purpose

     The conversation is always the same, only the names and minor details change.  It goes something along the lines of "Your brother is in a better place.  God had a purpose for his death.  He was needed up in heaven.  Blah, blah, blah."  I always quietly bite my tongue and don't reply.  I really want to rip those empty platitudes to shreds.  But in the end, that wouldn't really change the way I feel.
     I thought more and more about this very common response to loss.  I think it reflects an innate human need to find meaning and purpose in an event that disrupts our world view to its very core.  Things we clung to no longer seem true so we try to erect the same house of cards, hoping this time it will withstand the winds.  Our psyche and society has difficulty with accepting it on the terms of "shit happens."  So we need to turn it into something good and full of purpose.  Then we can get back to the business of living in our still intact world view. 
     Only that doesn't work so well.  At least for me.  I believe it cuts our internal journey short and closes too many doors into our soul.  "My brother is happy and in a happy place now so I can now go back to my life.  Pain over."  That would be temptingly easy to adopt.  But I don't believe it.  Not even for a second.  In it's place, I adopt a different strategy.  We cannot change the circumstances of a tragic loss.  Buildings fall, diseases happen, cars collide, and people die.  That cannot change.  The only possibility is what I do with that tragedy.  Do I become jaded and embittered?  Do I push it down and pretend it didn't happen?  Or, do I befriend the notion that pain comes in all manners and different forms?  To find a purpose, I know which choice will make me a more caring and empathetic doctor, nevermind a more soulful person. 
     So instead of assigning purpose that absolves us of any choice, responsibility or duty (he's in a better place, God had a purpose, etc), I decide to create purpose from my actions after the fact.  That's a much, much more difficult proposition.  Suddenly, I'm now responsible for growing out of a tragedy.  There is no getting over it, moving on, or getting back to a normal life.  The choice is a downward spiral, stagnation of a status quo, or a painful growth by befriending pain.  I must create my purpose and recovery or risk falling.  Scary stuff.  Studying for school would seem easier at this point but my brain just won't let that happen. 

summer

     My summer is done.  School has started, my lack of class attendance notwithstanding.  I began to look back over my summer with my wife.  "Wow, I didn't do anything."
     "Sure you did.  You went on your hiking trip, you....." my wife tried to reassure me.  But no, compared to last summer, I did very little by conventional measures.  To an outsider's eyes, it would appear that I sat and watched the grass grow all the while drinking a beer or three.  My wife became a little concerned at times.  There's a very fine, thin line between working through grief and wallowing in it.  And indeed, I did watch the grass grow.  I watched the bees buzz, the butterflies flutter by, and the birds sing, all the while drinking a beer or three.  And all the while, I pondered much about life and it's counterpart death.  I now truly understand what it means to 'work through grief.' 
      Knowing my time was short, I now intimately know what intense grief work requires.  I read deeply and richly about the process of dying and living.  Psychology, religion, medicine, classic literature, personal narrative - not content with any one viewpoint, I asked the meaning of dying and living from a number of authors and thinkers and doctors.  I thought and thunk and wrote and pondered and meditated and cried and lashed out in anger.  Dissecting a tornado, really.  My own son commented the other day to my wife only half jokingly, "well I can't believe dad's memory, you know his brain ain't all here lately."  So did it help?  At first, I was not sure.  After all, I often still feel like shit.  But grief work isn't necessarily about feeling better.  And so after sorting through some more issues surrounding the impending struggle of my dad, I can now say it absolutely helped.  Will I have more emotions to sort through during school?  Absolutely.  I am not so naive to thinking my grieving process done, nevermind the stresses of my dad's battle and my own school (med school is a wee bit stressful in its own right, even if I don't portray that).  Far from it.  It's not even been three months yet since my brother died.  A minimum of two years for a major loss like this sayeth every single book I read, be it from a layperson or grief counselor.  But I feel like I am better prepared and armed to process those feelings as they come. 
     So today, even though school has started, I trust my soul's intuition and extract one extra day of summer - to sit and watch the grass grow while drinking a beer or three and pondering the meaning of life.  I've earned the right to do that.  And even if I haven't, oh well, experience has taught me that I will do just fine with school anyways.

storm clouds

     The heat is oppressive, even for a Houston August.  Concrete under the rays of the sun could cook an egg on an afternoon such as today.  No hope of even a drop of rain is in the forecast.  Yet my soul has been overcast with dark and sullen storm clouds.  About what, I do not know.  Perhaps the loss of my brother?  Common sense would say, yes.  That would seem rational and so I thought but deep down I should've known that it had nothing specifically to do with the loss of my brother.  Deep down, the next storm is about the possible loss of my dad.  My dad has remained stoically optimistic about his prospects.  It's in his nature to believe that things will work out.  But that optimism just wouldn't line up with my gut feeling, though.  Deep in the recesses of my bowels, I knew that 10-15% mortality couldn't be the whole story.  Something was missing.  My gut was telling me that storm clouds were brewing on the horizon.  How many and how big?
     Recently in the news, there has been much hype about a therapy for my dad's disease, CLL.  My dad had seen it on tv so I was obligated to track it down and research it.  Pretty remarkable stuff and very intriguing.  And as I read more, I came across this quote about CLL and stem cell transplant from WebMd.com, "Cure is possible, but it requires a risky bone marrow transplant. About 20% of patients don't survive this treatment -- and even when they do, there's only a 50-50 chance of a cure."  Wait, what?  If no cure, then my dad is dead.  50-50?!?!?  What's the real survival rate for this procedure?  From what we were told by the stem cell doctor, I thought it was 85-90%?
     Into the early morning hours I combed the literature and from what I could gather, the odds of being alive 3 to 5 years after a stem cell transplant for refractory CLL is roughly 50-60%.  Only slightly better than the flip of a coin.  As I searched my memory, I did recall that the 10-15% referred to the initial procedure, the first 100 days, most likely.  I never thought to ask long term outcomes.  Why the doctor did not volunteer them isn't clear to me.  Maybe he didn't want to hit us over the head on the first visit.  To give him the benefit of the doubt, we had another appointment with the stem cell doctor but had to cancel due to the dying of my brother.  But still, an informed patient is a better armed patient.  False hope and sugar coating things does NOT help.  Note to self, ALWAYS be honest with the patient.
     So, we are faced with the looming questions, what exactly are the odds for my dad?  Is what I gleaned from the literature correct, or am I misreading the situation?  Has the procedure dramatically improved over the past few years?  Surely, it must vary according to disease and health status, but how does that relate to my dad?  On the flip of a coin, could I lose both my brother and my dad in just a few years?