sprint

9:30 pm on a Friday night and I've covered 38 lectures in the past 5 days.  Good grief I hope I retained some of that information covered in nearly 400 pages for the last round of block tests that start on Monday.  Then right after that are the finals which of course are cumulative and account for anywhere from 20-30% of the overall grade.

thou mayest

When it comes to things creative - food, music, art - I tend to be exceptionally picky.  So whenever I find a musical artist that appeals to me, it's no small feat.  And then to find one that appeals to my wife, too, well that's just plain rare to find one we agree upon.  That happened recently in the group Mumford & Sons.  I downloaded the album from iTunes and sure enough, my wife and I both liked what songs we heard so far.  Then one day driving home, I ventured into parts of the album I had not heard yet.  And one song in particular contained in it lyrics so painful and yet so beautiful that my eyes welled up and I felt as if my heart would burst.  I had to pull the car over to keep from wrecking it.

Cold is the water
It freezes your already cold mind
Already cold, cold mind

And death is at your doorstep
And it will steal your innocence
But it will not steal your substance

But you are not alone in this
And you are not alone in this
As brothers we will stand and we'll hold your hand
Hold your hand

And you are the mother
The mother of your baby child
The one to whom you gave life

And you have your choices
And these are what make man great
His ladder to the stars

But you are not alone in this
And you are not alone in this
As brothers we will stand and we'll hold your hand
Hold your hand

And I will tell the night
Whisper, "Lose your sight"
But I can't move the mountains for you.

It's basically taken from Steinbeck's East of Eden.  Timshel is a Hebrew word that is difficult to translate into English.  Here's Steinbeck's version of what it means.  Somehow, I fell like Cain in this story.

my brother

We all present different personas to different people.  I am at different times a dad, a son, a husband, an etc.  You get the picture.  Consequently, we don't always get to see certain sides of people.  One side of my brother that always seems to come out, though, is his concern for other people.  Just the other day, I was sitting on the couch next to his bed.  It's an emotional weekend with the house full of family for Easter and I can tell he's in pain.  Surprisingly, it's just he and I alone together and there's a pause in the conversation when he asks, "how are you dealing with all this?"

Despite his own pain and struggles, he automatically asks how I'm coping.  That's just the kind of guy that he is.

terrain of the soul - part I

I spent three days and two nights down with my brother in his hotel while he finished up his radiation therapy last week.  I'd like to say that we had some good talks but I will not use the word 'good'.  Nobody in their right mind would use an adjective such as that to describe the topics of our verbal wrestling.  Meaningful.  Heartfelt.  Soulful.  And unfortunately, Necessary.  I think those come closer to the truth, at least from the lenses of my eyes.  We spoke at length of the concept of burden which I wrote about earlier.  In my desire to assure him that he was not a burden to me, I probably missed what he felt.  So I apologize to him and I thought long and hard about what he said.  As I feel and taste it, burden may not be a big enough word to encompass it all.  (These are just my reflections of what I see.  They are not my brother's words).  Is there a sense of loss from the disappearance of freedom?  Perhaps feelings of weakness at being dependent on others?  Maybe sadness at not being able to fully participate in life?  Elements of sacrifice at difficult choices made?  For me, it's a labor of love but perhaps burden is not such a poor choice of words to describe what he feels.

eyes to see

It's Easter Sunday and from across the room, I notice the choir director's arm.  The doctor part of me never shuts off.  It's now become a fully integrated part of who I am.  I lean over and whisper to my wife, "she has something wrong with her lymphatics."  Since she was a female, my mind automatically went to breast cancer.  The lymphatics of the arm drain through nodes in the armpit.  They also drain the breast.  It's not uncommon to remove the lymph nodes in the armpit.

After the service, everyone from the church swoops down upon my brother with tears in their eyes.  It's been a bit since he's been able to go to church and they wish to express their emotions and prayers to him.  It costs him immensely both physically and emotionally to make it in today but his will is iron in its resolution to go.  Shunning the introductions, I sit quietly in the pew content to hide in the background.  I do not trust my voice to keep its tenor if I am called upon to talk.  The choir director finds me and begins to express her heartfelt sympathy for our family.  With tears and kindness in her eyes, she tells me of her battle with breast cancer.  I sense an unspoken bond with people who battle these diseases.

the air

Fox, get out of there.  Fox, no.  Fox, stay.  Fox, out.  It's Easter weekend and my brother's house is full of 4 generations worth of family members.  Included in that mix is our dog Fox.  The antithesis of everything that is a pit bull, she is an incredibly sensitive dog with a kind heart.  She keeps trying to go into the room in which my brother resides.  He's set up in their tv room with what he calls his 'princess and the pea' arrangement.  The cushions and pillows are stacked in such a way as to render the pain as minimal as possible, to the extent that's even possible.  It's not.  The air in my brother's room is thick and heavy with emotions.  Searing pain, smoldering anger, profound sadness, unrequited questions....all are emitted from the various family members who enter to simply be with my brother.  And Fox can smell them all.  She wants to be near them.  All the complex and subtle emotions that are wrapped up together and she can sense them.  She just wants to be present in the mix.  A pretty wise dog.

burden

I once had a lecture from an ENT (ear, nose, throat doc) who told the story of a patient with esophageal cancer.  The cancer got into the vocal cords and they had to be removed.  The doc told the patient, "I didn't take your voice, the cancer did.  I removed the cancer."  The doc was in essence telling the patient, "if you're looking for something to blame, don't blame me for loss of your voice.  Blame the cancer."  It seems an important distinction.  I thought it a relevant and interesting way to look at things so I filed it away in the back of my mind.

It seems relevant now.  I get the sense that both my dad and brother think of themselves as a burden.  We were all raised to be independent and self-sufficient, so for them to have to rely constantly on other people must be a hard pill to swallow.  So I now say to them, "You are not the burden.  The cancer is the burden."

what's in a question?

I am often asked, "how is your brother?"  On the surface, such a simple question really.  But it has become increasingly puzzling for me to answer.  I truly wonder what people mean by it.  Do they want to know everything?  Do they want the truth as seen through my eyes or my brother's?  Are they just being polite?  Do they want a simple summation?  Or, are some, as I strongly suspect, wanting me to answer how they wish him to be?

• How - the adverb meaning "in what manner or way"
• is - the intransitive verb meaning "to have an objective existence."  Think Hamlet's 'to be or not to be' soliloquy and all the philosophical baggage with that.
• your - the adjective meaning "of or relating to you"
• brother - the noun meaning "a male with a common parent"

 

So, in the fragile confines of my mind, this question has come to mean to me, "in what manner is the one whom you shared your childhood with existing at this point in time?"  Ah, it becomes a bit clearer to me now, though a bit less savory to answer.  Do I show how his daily life is filled with trips to MD Anderson like this?

 

Or, do I perhaps give the most recent medical finding that he's struggling with such as this?  "Patient presents with bilateral parasthesia of the maxillary branch of the trigeminal nerve, demonstrates no gag reflex, unmitigated weight loss, a "foggy head", severe fatigue and poorly controlled diffuse bony pain.  As cranial nerves V, IX, and X are becoming increasingly impaired, evaluate for potential brain mets or intracranial pressure through bony involvement of the skull/leptomeningeal disease.  Proceed with radiation to the base of the skull and systemic Tarceva.  Followup in 1 month."

 

Or, maybe do I reveal how people across all different backgrounds, united by their own desire to provide any comfort possible to those in pain have come to help in their own ways?

 

(picture by our mom taken at the hotel my brother's staying at near MD Anderson.  Includes my brother and his wife sandwhiched by two of our cousins from the Great White North, eh)

All are equally true in their own fashion.

 

courage

This is in the end the only kind of courage that is required of us:

the courage to face the strangest, most unusual,

most inexplicable experiences that can meet us.

- Rainer Maria Rilke

the healer's art

     It's the final session of my Healer's Art class.  Three hours on a Tuesday night when I should probably be at home studying.  Overcoming the urge to head home, I stroll on over to the other medical school.  It turns out to be well worth it.  The theme of the evening is Service and Calling.  Blank sheets of paper are handed out and we are instructed to close our eyes and clear our mind.  "Now imagine that all practical considerations of practice are removed - financial, logistic, time constraints, etc.  What kind of patient would you like treat?  What kind of doctor-patient relationship do you envision?"
     A bit of resistance goes up inside of me.  A ruthless pragmatist, I don't like wishing upon a star, so to speak.  But I suspend my disbelief and give the instructor the benefit of the doubt that this exercise has utility.  I ponder.  I envision.  I ruminate.  Now we are told to distill the thoughts down to 2 or 3 sentences.  And to be fair, I am more than a bit surprised and enlightened at what comes out on the paper.

Allow me the ability to help bring out the patient's own desire to get better.

Allow me the ability to help guide the patient down their walk through life and experiences, regardless of what end may come.

These two statements have a lot of personal baggage for me.  Within the past year, my 39-year old brother has been diagnosed with Stage IV thymic cancer and my dad with a high risk Chronic Lymphocytic Leukemia.  As a physician in training, I began to experience and truly understand one of the biggest hurdles to modern medicine - compliance.  Obviously, most patients want to get better, right?  Who wouldn't want to be rid of cancer?  But it's never that cut and dry.  I tell you that line becomes damned blurry when it comes to staring down that needle which holds the next round of chemo and all the horrific side effects which will follow.  Or, spending the umpteenth day at the hospital in a row.  Or, the simple challenge of trying to eat intellectually knowing full well that the calories are necessary but the person simply just can't get the food down.
     I don't have the answers to this problem.  But I do know that simply writing a prescription or suggesting a course of treatment is only half the battle.  Trying to bring out the best in the patient, trying to engage their inner will to live, and probably the most difficult of all, realizing that not all sufferings can be assuaged, these are the subtle yet infinitely difficult challenges that came out for me during this exercise.  The pharmacological repertoire is limited here, as is the standard medical training.  Philosophy, humanity, and empathy are much better tools.

applied technology

My dad has pretty bad neuropathy in his feet.  So when he's confined to a bed for chemo or such, his feet feel like ice cubes.  One sheet and two blankets covering a pair of socks weren't enough to halt it.  Hey, I know what to do.  Back in the day, we'd need to keep animals warm post surgery.  Normally, we'd use fancy water circulating pads.  But at times, I'd be doing procedures off-site at various academic labs that didn't have fancy equipment.  I'd use a glove filled with warm tap water.  So long as you tie the knot properly, it works pretty well.  You never know when mice technology might apply to humans.

philos

my balding brothers

random stories

"I know what the MD in MD Anderson stands for," my dad says out of the blue.  "Most of the Day."

"How about Most of the Days, plural."  Just look at my dad's and brother's schedule for MD Anderson during the month of March.  And this actually incomplete because it was before my dad spent another 5 days in the hospital and the follow up visits afterwards.  April actually looks fuller.

loss of a myth

Sherman made the terrible discovery that men make about their fathers sooner or later... that the man before him was not an aging father but a boy, a boy much like himself, a boy who grew up and had a child of his own and, as best he could, out of a sense of duty and, perhaps love, adopted a role called Being a Father so that his child would have something mythical and infinitely important: a Protector, who would keep a lid on all the chaotic and catastrophic possibilities of life.

The Bonfire of the Vanities

infallible

It felt weird being away from md anderson for my brother.  I kinda felt like I was letting him down but I had exams.  He was down there to meet with his attending oncologist as well as a radiation oncologist to go over the plan as to what to do next.  I'm not sure I completely understand the results in their entirety but the plan is two-fold.  Regarding the numbness of the facial skin, the plan is to irradiate the cervical spine.  The radiation oncologist put the odds at 50:50 at being able to restore sensation to the face.  The radiation is done daily Monday through Friday for two weeks.  He'll be staying at a hotel down here and starts on Monday.  The second aspect is to begin taking the newer chemotherapy Tarceva.  It's an oral pill so he's already begun that one.  He then has a follow up in about a month to check in to see how he's doing.

My dad is making up for me missing my missing my brother's appointment.  In a stupor, I bubbled in answers on my scantron, hopefully the right ones.  Afterwards, I skipped on over to MD Anderson for my dad's appointment.  Several hours later, he's starting his second round of chemo. 

Here is before the chemo.  And once again, the antibody Rituximab is giving him problems. (I won't show the picture from that since he looks ugly.)  Last time, he had a typical allergic reaction by itching as one would with hives. This time, his body decided to shake things up by presenting as chills. It's amazing how quickly it progresses. He mentioned that he was really cold. I went to go another blanket and by the time I got back, his whole body was shivering. Stop the rituximab. Give a benadryl and hydrocortisone push. Wait. Slowly bump it back up.  Only his blood pressure is very low.  So that can slow the restart, too.  Only he's on a beta blocker and the chemo nurse is having time understanding his blood pressure was low before he started this chemo round.  That's what beta blockers do.  Physiology 101 and all that jazz.  Oh, and he's received 100 mg of benadryl so just maybe that cns depressant effect might just be adding to that.  Doesn't he know not to argue with doctors?  That courtesy should obviously extend to know-it-all med students.  Well, at least to me, because as my wife and son can attest, I'm never wrong.  It's going to be a llllooonnnggg night.  But it's all for a good purpose.

anguish?

This beer was a gift from some very caring people who know what it is to watch a loved one struggle with cancer.  I was saving the last one for something to celebrate.  I kept waiting and waiting but it seems to me that joy has left my life.  There's nothing left to celebrate.  My brother received word today that the cancer may have spread to the brain/neck (we're still waiting on the final results of the MRI).  His chemo slot this week has been cancelled and he's on schedule to meet with a brain/spine oncologist next Tuesday.  With nothing to celebrate I figured I'd honor the pain.  Life is all too short - what a ridiculously appropriate cliche - so I took the beer outside and drank it while watching the purple martins fly overhead.  My parents have headed up to Dallas to be with my brother.  I wish I could go with them but exams loom in front of me.  How am I going to take exams in the midst of this?  The exams start tomorrow but the pain is right here and right now.  I'm not sure how one recovers from this pain.

Later in the day, my brother calls back.  I'm not sure I understand all the results since I haven't seen the pathology report yet but it sounds like the brain is clear.  So I guess there was some small victory to celebrate after all.  There is something, however, on his cervical spine (neck) that may or may not involve the cebrospinal fluid.  He has apppointments on Thursday and Tuesday to get the full story and decide in which direction (surgery vs radiation) to take.

love

you can never break the chain

there is never love without pain

a gentle hand

a secret touch on the heart

- secret touch by peart

hope vs fatalism

"What does 'H' mean when it's next to a number?" my mom asked.  She was reading the printout of my brother's bloodwork.  In my mind, my reply is 'ask me no questions, I'll tell you no lies.'  But she asked, so I respond in as short as an answer as possible hoping to derail the conversation. 
"It means 'high'...."

My brother chimes in, concern in his voice, "which value of mine is high?"

"One of the markers of cancer.  It's been high for a long, long time."

I need no bloodmarkers to discern the ailing status of my brother.  They merely confirm what mine own two eyes can readily discern.  He is in pain.  Badly.  His voice quivers, not with emotion, but with the effort of trying to master words.  His platelet count did not recover anywhere near enough to receive the next dose of Gemzar.  To further complicate matters, he started having numbness on one side of his face.  It follows a very distinct nerve pattern (the V2 part of the trigeminal nerve, it's the reddish color in the picture below).  That can be due to one of two things.  It could be due to inflammation of the nerve root in the form of a viral infection, or a tumor which is compressing the nerve.  He's also experiencing some pressure behind the eyes and decreased taste sensation on the same side of the tongue.  So my brother will receive an MRI of the head and neck to determine the cause.

The results of that scan will determine the future course (we will probably know by Tuesday).  If it's a tumor(s) in the brain and/or neck, they can attempt to irradiate it.  Radiation is really the only option because most chemotherapies do not cross into the brain very well.  That would then potentially be followed up with chemotherapy.  If neuritis (inflammation of the nerve), then he will attempt to receive a different chemotherapy from Gemzar next Thursday.  And you may notice that I qualify that with 'attempt' because nothing is definitive at this point.  What that chemotherapy would be and how it would be given  is not entirely clear to me but that's because it's not entirely clear to the doctor.  We're off in the hinterlands for which modern medicine has no good guidelines.

Which leads me back to the question my mom asked.  What does that high number mean?  I struggle to not be the thief of hope because it's all my family has going for it right now.  But I also wish to remain honest and the medical model has very little hope left to offer at this point.  That question may be better put to a spiritual counselor.  So in reality, I have no good answer.