27 September 2015
23 February 2009
Yes, I thought that would get your attention!
As the temporary owner of a half dozen of the word's noisier and rambunctious children (or so it seems to my eardrums anyway), the achievement of a Christmas day without an argument is monumental. And now I suppose you want to know how I achieved it?
The day started normally with the youngsters arising at about 6:30am, and heading off to the present pile (under the pathetic plastic thing that passes for a tree!). The presents were all catalogued, shaken, smelled and guessed well before anyone else showed up.
The mid-morning flurry of preparation for going to Christmas Day service was undertaken with good nature and a resignation that today and Easter Sunday are days when there is really no excuse for not going - especially in this household! So we all tramped off to watch mother blow (across?) the flute and father advance the electronic slides during carols and sermon.
So we returned home for lunch, which of course had to be spread ... but then no-one who is hungry is going to complain about putting the food out and getting it ready. And then a minor hiccup while we waited for our invited guest to arrive, before finally sitting to eat.
Conversations degenerated into the normal rough and tumble of a meal with 8 people around the table, 7 of whom have a whole life time of experience together. Dinner over, and now .... SCUM!
This is the secret weapon! As soon as the dishes are cleared, out came 3 packs of cards and we started to play SCUM! The most important part of this game is that the last one out gets ragged by the others, and so long as its not the same person, the psychological distress levels are held in check. And as the youngest are getting better through practice its usually the eldest who play irregularly who suffer. Fortunately, the guest had never played so she was easy pickings!!
Sorry ... what's SCUM? Its a card game where one gets rid of cards by throwing out multiples in numerical order, with the aim being to have no cards left. First finished is "El Presidente", although others call him "emporer". I suppose it depends on your Republican aspirations! Next out, "Vice Presidente". Second last out "Vice Scum" and last out "SCUM". I say this in capitals advisedly because it is not a pleasant position and all other players are keen to see that you know this.
But it is fun and my lot can ... and did! ... play for hours. Until early evening. So that's the trick - SCUM!
What a terrible time of the year! Well, that's what I find anyway. Christmas seems to bring out some rather unfortunate trends in the populace.
Firstly its the 'OVER' season. Over-eat, over-spend, over-drink, over-theorize, "I'm over it"! Now I guess that you can all understand the first three, but what is that next one all about? My sister and I have this ongoing Christmas joke that starts with one of us saying "So that's TTMOC!", like we are surprised and enlightened.
Not familiar with TTMOC? Oh. "The True Meaning Of Christmas". Yes, the theories on what constitutes the true meaning abound. And if you came to the conclusion that it is actually Santamas or Clausmas, we you could be forgiven!
I should introduce here my story about my muslim (to keep things even, I'll use small letters for all references from here on) acquaintance from university when I was doing my medical degree. He is now a well-known medical and literary figure but I will nevertheless refrain from name dropping! It was coming up to christmas and he was talking about celebrating christmas. This puzzled me because while I would not call myself an expert on the muslim faith, I had the small suspicion that muslims do not celebrate christmas, mainly because there is a disagreement over the status of Jesus (sorry proper name!) and therefore it remains a christian festival. And as a reasonable premise one can say that muslims don't celebrate christian festivals, and christians don't celebrate muslim festivals.
Anyway, I remarked, "I am curious as the reasons why a muslim would celebrate christmas". He answered "Oh, I think it is a wonderful economic feast!" A few TV clips on christmas in China seems to support this, as does more than AUD$14 billion spending at DJ's. I'll bet you've never heard that one put forward for the true meaning of christmas! But there in lies the dilemma. Is this "meaning of christmas" anything to anybody?
Historically it is a christian festival, and those who are of that practice, are quick to state that the birth of a certain first-born about 2000 years ago is the reason for the celebration because of the later significance of the individual. Unfortunately I don't recall that any of his contributions were economic or really family-oriented in that get-together-once-a-year-and-have-a-bloody-good-argument-and-spend-more-than-we-can-afford-on-presents way.
Now I do think that family get-togethers are good, but what ties them to Christmas? Just the holidays perhaps, certainly not the christianity any more. What would happen to christmas if we moved the family holiday period to start with the New Year, and let workers have 2 religious holidays per year to match their faith?
Perhaps we could then see the true meaning of christmas?
11 October 2008
He had had a life threatening illness a long time before, having suffered an intracranial hemorrhage from a berry aneurysm of the cerebral artery. Yes, I know, stop with the big words and tell us what it means!
One of the blood vessels running into the brain has a weak spot. Weak spots in vessels under pressure form a bleb - like the bike tyres. Because the area is weak, it swells and then can burst or leak. When that bleeding happens the blood will track into the brain and cause a stroke, or it will flow into the space around the brain. This 'space' is a layer filled with fluid called cerebrospinal fluid (I know big words again, it's not my fault! Really, that's what it's called! We will call it CSF!) that provides a cushion for the brain. So the blood can flow into the CSF area and coat the brain.
When this happens, the brain gets really irritated! The patient gets sudden severe headache and can pass out, become brain damaged, a 'vegetable' (horrible name but more horrible condition) or even die.
So that's what happened to him, but he recovered with some changes in the way his brain worked. Where you and I might think a thought and keep it to ourselves, he did not. He was 'dis-inhibited'. It's a little hard to take because it's so confronting? Questions like "are you married?", "got any kids?", "where did you spend your holidays?", "who gave you the tie?", "where did you go to school?". No questions were taboo. No questions were malicious. No answer was unacceptable!
But after the initial gasp, I just packed away the discomfort and settled in to enjoy the ride!
He had a real bad disease and he came back pretty often for more treatment, so I was subject to a lot of questions. To make matters worse he had developed brain secondaries and was on a steroid tablet. Happy pills! So you can imagine the combination of the dis-inhibited being uninhibited! I took my medical students to see him - they get that 'kangaroo in the headlights' look when they are out of their comfort zone, and I thought he would rattle them (that allows me to then make some points to further their education). I thought they needed to meet some one like him.
During the teaching session I got a call and wandered off for two minutes before returning. On return I heard him address the blond petite medical student as "Barbie Girl". They were all laughing. Before leaving he wanted to know if he was going to see me next week and I told him I would be at a course. Before long he had all the details! Seattle, needles, prostates and finally the big question - "what are you going to get me?"
I hesitated momentarily and as that happened, I saw what lay ahead of him and how we had become more than usually involved. "I'll bring you something back" I said, wondering just what would be the right thing.
In Seattle, I visited the Space Needle and traveled to the top. Glorious! You have to do it one day! Of course like all good tourist destinations, you exit through the gift shop and there it was! A baseball cap from the Space Needle. This was it - he was going to lose his hair soon!
I arrived back at work on Monday and there outside the department he was. Not waiting, just good timing. He was heading in for his treatment. I called out "Hey, come here, I promised you something!" He stopped and looked startled as I thrust the cap into his hand. "See, the Space Needle! I told you I'd get you something!" More quiet than usual he said thanks. I ushered him towards the machine for treatment.
That was the last I saw of him.
Until last week .... the nurse collared me in passing to say, his wife called in to say that he died and to say thanks for looking after him .... oh and by the way, guess what he is wearing in his coffin?
2 April 2008
The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the administration had a lot of nerve, and the Obstetricians felt they were all labouring under a misconception.
The Ophthalmologists considered the idea short sighted; the Pathologists yelled, 'Over my dead body', while the Paediatricians said, 'Oh, Grow up!'
The Psychiatrists thought the whole idea was madness, the Radiologists could see right through it, and the Surgeons decided to wash their hands of the whole thing.
The Internists thought it was a bitter pill to swallow, and the Plastic Surgeons said, 'This puts a whole new face on the matter.'
The Podiatrists thought it was a step forward, but the Urologists felt the scheme wouldn't hold water.
The Anaesthesiologists thought the whole idea was a gas and the Cardiologists didn't have the heart to say no.
In the end, the Proctologists left the decision up to some a_s_s hole in administration.
30 March 2008
James Baldwin, US author (1924 - 1987)
Her name was something like Thea Tribes. She died last week.
Thea came to me over two years ago with a cervix cancer. Big thing - the cancer that is. She was a pretty petite girl with a young family. It was not surprising that the cancer was big when you consider the the preceding 12 months. Thea had seen her family doctor with vaginal bleeding. She was sent to see a obgyn. He said it was 'dysfunctional uterine bleeding' - a common enough hormone-related problem of the womb lining which results in episodic, non-period bleeding - and she needed a D&C (a scrap out of the womb lining). She was booked for theatre and got a start some 7 months later. But the obgyn got sick ... so no D&C. Thea saw the obgyn again and was re-booked. And she saw the obgyn a third time.
Finally 12 months after the first visit, Thea made it to the OR with the obgyn. As is normal, the patient is put to sleep and the obgyn begins with a pelvic examination. Now according to Thea, and she was believable ...... THIS WAS THE FIRST TIME A PELVIC EXAMINATION WAS UNDERTAKEN BY ANY OF HER DOCTORS.
Of course with that one simple examination, the penny dropped and the diagnosis was made. After a year left untouched, now it wasn't small. Other tests including MRI and PET scans showed the big cervix cancer as well as lymph nodes halfway up the tummy. Probably incurable. Almost certainly incurable.
Then it was my turn to try to turn this mess into something positive. But not surprisingly, I wasn't up to the task. She managed about 2 years of pretty reasonable quality of life while her little girl grew up, but the last 6 months have not been any walk in the park with increasingly difficult problems. Life had become no fun. She needed more medications - steroids for swelling, anticlotting agents for clots, platelet infusions for lack of platelets. And then the day before yesterday, it became too much.
She died with her family.
At our first consultation she asked me why these other doctors hadn't examined her and whether they were incompetent. I know the examination wasn't done, but I don't know if they are incompetent. I told her that she needed to concentrate on her treatment and her family then, and that she had my support if she wanted to do something later.
Competence is a strange concept. The media thinks that it means being perfect and never making a mistake. Obviously no doctor will be competent if that is the definition - certainly I wouldn't be competent.
The competent doctor tries to be better when they are shown to be deficient, and they try not to make a mistake again. Certainly if you have made such a grave mistake as not doing a standard examination in this case, what does the competent doctor do? Apologize? Say sorry? (the patient may have died anyway but her cure rate was reduced) Alter their practice?
24 November 2007
When the Patient Is a Googler
By Scott Haig
We had never met, but as we talked on the phone I knew she was Googling me. The way she drew out her conjunctions, just a little, that was the tip off — stalling for time as new pages loaded. It was barely audible, but the soft click-click of the keyboard in the background confirmed it. Oh, well, it's the information age. Normally, she'd have to go through my staff first, but I gave her an appointment.
Susan was well spoken and in good shape, an attractive woman in her mid-40s. She had brought her three-year-old to my office, but was ignoring the little monster as he ripped up magazines, threw fish crackers and Cheerios, and stomped them into my rug. I tried to ignore him too, which was hard as he dribbled chocolate milk from his sippy cup all over my upholstered chairs. Eventually his screeching made conversation impossible.
"This is not an acceptable form of behavior, not acceptable at all," was Susan's excruciatingly well-enunciated and perfunctory response to Junior's screaming. The toddler's defiant delight signaled that he understood just enough to ignore her back. Meanwhile, Mom launched into me with a barrage of excruciatingly well-informed questions. I soon felt like throwing Cheerios at her too.
Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.
Every doctor knows patients like this. They're called "brainsuckers." By the time they come in, they've visited many other docs already — somehow unable to stick with any of them. They have many complaints, which rarely translate to hard findings on any objective tests. They talk a lot. I often wonder, while waiting for them to pause, if there are patients like this in poor, war-torn countries where the need for doctors is more dire.
Susan got me thinking about patients. Nurses are my favorites — they know our language and they're used to putting their trust in doctors. And they laugh at my jokes. But engineers, as a class, are possibly the best patients. They're logical and they're accustomed to the concept of consultation — they're interested in how the doctor thinks about their problem. They know how to use experts. If your orthopedist thinks about arthritis, for instance, in terms of friction between roughened joint surfaces, you should try to think about it, generally, in the same way. There is little use coming to him or her for help if you insist your arthritis is due to an imbalance between yin and yang, an interruption of some imaginary force field or a dietary deficiency of molybdenum. There's so much information (as well as misinformation) in medicine — and, yes, a lot of it can be Googled — that one major responsibility of an expert is to know what to ignore.
Susan had neither the trust of a nurse nor the teachability of an engineer. She would ignore no theory of any culture or any quack, regarding her very common brand of knee pain. On and on she went as I retreated further within. I marveled, sitting there silenced by her diatribe. Hers was such a fully orbed and vigorous self-concern that it possessed virtue in its own right. Her complete and utter selfishness was nearly a thing of beauty.
When to punt is not a topic taught in medical school. There is but one observation that I can offer: Patients like Susan, as self-absorbed as they are, know it immediately. They can tell when you're about to punt.
I knew full well what was wrong with this woman, and I could treat her, probably as well as anyone. But treating her condition, which was chronic patellofemoral pain, would test the mettle of patient and surgeon. What we have doesn't work very well nor very quickly. The swelling takes months to go down, the muscles take even longer to strengthen. Good patients often complain, "It was better before we started," in desperation or anger, before they see improvement. But with plenty of therapy, braces, exercises and one or two operations, this knee does improve. It's often tough going, though, and patients have to stick with you. I like to be straight — "It gets worse before it gets better" is what I tell them. Susan's style, her history and, somehow, most telling, the way she treated her son said she was not going to make it through this. Not with me, anyway.
A seasoned doc gets good at sizing up what kind of patient he's got and how to adjust his communicative style accordingly. Some patients are non-compliant Bozos who won't read anything longer than a headline. They don't want to know what's wrong with them, they don't know what medicines they're taking, they don't even seem to care what kind of operation you're planning to do on them. "Just get me better, doc," is all they say.
At the other end of our spectrum are patients like Susan: They're often suspicious and distrustful, their pressured sentences burst with misused, mispronounced words and half-baked ideas. Unfortunately, both types of patients get sick with roughly the same frequency.
I knew Susan was a Googler — queen, perhaps, of all Googlers. But I couldn't dance with this one. I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help. A certain Dr. Brown, whom I'd known as a resident, had been particularly interested in her type of knee problem.
Disappointed and annoyed, Susan stopped for a beat.
"You mean Larry Brown on Central Avenue?"
"Uh, yes —" I started.
"I have an appointment with him on Friday. And, Dr. Haig?" she said, pulling Junior by the arm out my office door, "Watch out on your drive home tonight. There was an accident near your exit."
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.
5 November 2007
This story is about one of my favourite patients. Other doctors can't stand her. She misinterprets, jumps to conclusions, is irrational, over-excitable, accusatory and demands to know things. She also has a sorry background.
She was married to a local medical figure. They had a very acrimonious divorce that was compounded by her depression. She ended up as the 'mad ex-wife'. The worst thing that can happen to such a woman is to also get sick! But she did.
Her initial outlook was excellent; "95% chance of cure" said the cancer specialist, "What are you worried about?" Perhaps being one of the 5%? And sure enough it came to pass that the cancer came back. Her specialist was away and I was on call.
The notes described a very disturbed woman with unreasonable expectations and noisy conflicts. As the next doctor, I felt apprehensive to say the least. I decided to take a low-key approach. I said hello and then let her talk.
Forty minutes later she finished. Then we returned to the beginning of her story. Everything that happened was addressed. I apologised for my colleagues when she appeared to have been fobbed off. I chided her for being unreasonable when her expectations were excessive. I reassured her when she had received standard treatment. When she jumped to conclusions, I forced the conversation back to re-explain. When she misunderstood, I used different analogies. When she became accusatory, I explained the other viewpoint. I just wanted to put the past behind us. Forty minutes later I was finished!
When the old patterns had been cleared away and we had arrived at a common purpose, she turned out to be just like other patients. What common purpose was that? I promised that I would not lie or hold anything back from her ('no crap' was the phrase used), that I would treat her problems seriously and present to her the available options with my opinion and support her with whatever she chose.
Unfortunately the option that she chose made her worse. But still our relationship remains on the same footing. Physically she is worse, and she still jumps to conclusions, but the understanding forged at that first meeting remains. We speak as doctor and patient should, with a common purpose. No crap!
Who is the better doctor? If my medical knowledge is not balanced with humanity then I become useful only while a patient is treated as a curable lump of meat. Patients are more than this. Healing for all patients results from and produces proper relationships. Patch Adams said (and I paraphrase) "Doctors shouldn't just prevent death, they should improve life".
I want to be involved in that!
The sound from a motorcycle exhaust is not supposed to exceed 75 decibels. Well, strictly speaking, a Harley-Davidson is not a motorcycle, it’s a Harley-Davidson!
You will all be familiar with the machines – deep, loud bellow from a two wheeled projectile which looks to have a pot belly. To some it is the sound of heaven, to others it spells trouble. To our cancer patients from all over the island, it is the sound of the Lone Ranger. Hi Ho Silver! To the rescue!
Yesterday, I had the pleasure to meet with the local HOG (that’s Harley Owners Group) at the headquarters of the local Cancer Society where the members presented a cheque for more than $25,000 to the Cancer Society for purchase of software to assist the Department.
The software to be purchased is used for image fusion. In modern medicine, much of the information used is carried in the form of pictures. Different scans give different information. Until recently, the images were presented to doctors on paper or film. Taking the information from one scan to the other was inaccurate and awkward. Sometimes the films have different sizes, sometimes the orientation of the films is different, sometimes one scan shows the problem clearly but another shows nothing at all.
For a long time, doctors have wanted a way to put the images on top of each other, to change their sizes and orientation so that they match. In this way the information from all the available images can be combined.
The radiotherapy department likes CT scans because the CT data is used to predict the performance of radiation beams in the patient. Yet the MRI scan is much better for defining the extent of a brain or muscle tumour, or the position of a prostate containing cancer. “Fusing” the two images so that the MRI image accurately overlies the CT image means that the MRI data can be reliably transferred for more accurate planning. And better imaging means better definition of the area needing treatment. Better definition means more cancer and less normal tissue, leading to better cure and less side effects.
I would like to repay our HOGs with a promise from me and three requests to you.
I promise that we will put their donation to good use. And now my three requests. Firstly, if you see a HOG member (you’ll know them when you see them, they stand out!) say thanks. You have a 1 in 4 chance of benefiting from their generosity one day. Secondly, listen to that wonderful noise! Thirdly, look at that shine!
HOGs are fine by me.
Father bashing has become quite a hobby in the last 15 years. Many people credit their fathers with their later success or failure.
My father was a victim of his own health. As a healthy 25 year-old final-year accountancy student, he was taking his elder sister to a dance in the nearby town of Digby (it's not on your maps because it's in Australia!). In the twilight their motorcycle sideswiped a truck. The siblings both suffered severe injuries to their right shins. But bones heal.
Dad was placed in hospital to heal, but the man in the next bed had TB. Dad ended up with TB. Before the bacterium was known, TB was called 'consumption' for good reason. Dad was sent to a sanitorium to recover. Unfortunately his immune system was not geared to fight the bug. His left lung was a mess. He was labelled as 'incurable' and expected to die soon. That's a heavy burden before your 30th birthday.
An American Army colonel, Dr Gebauer, came to demonstrate his successful operation to control TB. He called for volunteers. With 50% chance of surviving the operation but some prospect of cure, Dad thought that it was the better option! Five others undertook the same risk.
All six were successful. Five died in car accidents, none died of TB.
But accountancy was now a thing of the past and life was more difficult. Marriage and four children meant that his first holiday with Mum occurred after 19 years of marriage.
Finally at the age of 59, life was settling down. While visiting the rented family home, Dad and his best friend took his new Volvo for a drive. The only eyewitness said that the car was up on two wheels as it went around a bend and into a very large gum tree. Death was quick.
I was not there and couldn't be found. The local priest looked for me in church but couldn't see me. He informed the congregation of the need for their prayers. Discovery was quick, but not painless. Mum never forgave the priest, but I didn't mind so much. You can dress the news up, but when you come to say "Your father is dead", the suffering is the same. The news that that lump is cancer is very similar, I think. But I think that suspecting the truth beforehand actually makes the shock less.
I regret that I did not know my father better. I cleaned out his desk after his death. I was struck by the similar way that we both thought. And now I regret not knowing him better. Mind you, the fault is all mine. Brash youth who knew everything better his parents - every child repeats the mistake. Mike and the Mechanics had a song called "The Living Years". The chorus goes:
"Sing it loud, sing it clear, You can listen as well as you hear, It's too late when we die, to admit we don't see eye-to-eye".
Need I say more?
Have you got any? I don't really have one. I've dabbled in a number but none have stuck with me through the years. Black & white photography, pottery, screen printing, the list goes on.
What happened? I went to medical school! Until that point I had the time to devote to hobby. Up to that point I had a life!
Medical school is very similar to other university courses, except for one thing. The breadth of work to be covered is much greater. The corollary is lack of time - it takes a lot and most of that is spent reading.
So you spend 5 years (didn't do my medical degree in NZ!) reading Anatomy, reading Pathology, reading Physiology, and just when you decide to do something for a change - you read Pharmacology or Oncology or Psychiatry or Surgery or Obstetrics or Clinical Endocrinology …. get the picture? As my old Dad used to say, there are more subjects than you can poke a forked stick at! And each topic has its own remnant of the Latin language and characteristic names to be learnt. You pick up useful titbits of information such as the fact that Hansen's disease is tuberculosis and is caused by a nasty bacterium called Mycobacterium tuberculi - great for a trivia contest??!!
This is a pleasant walk down memory lane, but what does this have to do with hobbies? Medical school is the start of a lifestyle. Internship, residency and specialist training all require lots of reading. And then one day you are finished and have successfully passed your examinations. What most of us fail to realise is that by this stage we have a hobby. A major hobby.
Its called reading medical literature. And it gets in the way of life and other hobbies. This is one of the problems with a doctor's view and experience of the world.
After exiting from the training situation, I have made a conscious effort to find some hobbies for myself that will carry me to and through retirement. I haven't been very successful yet.
I have been thinking about some hobbies. When younger, I derived a lot of enjoyment from motorcycle riding. Thoughts about finding a similar machine to restore have been creeping in. I can just imagine what my wife will say when she finds out. I know what my boys will say!
'The House of God' is a book about the first year doctor. The author writes about the American experience. My first year wasn't all that different.
The author, Samuel Shem, meets his mentor at the start of the year. The Fat Man, as his mentor is called, has a series of rules that cover almost every situation. I apply one of the rules is my practice. The rule says "Remember it’s the patient with the problem". This rule has a positive and negative aspect.
On the positive side the rule pushes me to tell the patient what is happening. This takes time. It is also quite difficult because each patient is so different in learning, approach, experience and readiness. I would be kidding myself if I believed that I did better than a poor job. Communication between similar people is so error prone, that adding cultural and professional difference along with the anxiety of a cancer diagnosis can only make it worse. Nevertheless I try!
The negative aspect of the rule is that it removes me from patient's experience. I don't have cancer. I'm not getting treatment. There is no comparison between my hope that treatment will work and their hope that treatment will work. There is most definitely no similarity between our reactions when the cancer returns.
That brings me to John. He was young. He was an asset to his family. He was a righteous man involved in seeing that people were treated right. He impressed me as a man who knew where he fitted in his world. Communication was easy because he wanted to know what was happening. But it was also difficult because he didn't really think in a medical way. He taught me about New Zealand history as much as I taught him about his cancer. That's the positive side.
Then we entered the negative side. The cancer came back. Did I do anything wrong? No. Was I slack? No. Would I do it the same next time? No. I just didn't recognise the rogue cancer early enough. I felt uneasy during the whole treatment but I didn't recognise why. So in the end, John and his family paid the price of this failure. To say that I felt bad rates as an irrelevancy. I understand how his kids feel because I have been in the same situation.
There are no winners. Him, me, his wife, his kids, your country - we have all lost. This disease is a wanton beast. So what do I do differently? I am more suspicious, I'm on my guard looking for the rogue cancer that needs special handling. I also have to work harder not to withdraw from the next patient. The next patient still requires their doctor. I have to start over.
Shame John can't.
All doctors have a favourite patient. I haven't seen mine for 4 years. I can't even remember what he looks like. I just remember his approach to life. Why do I remember? Because I want to be like him.
Imagine that! Wanting to be like a cancer patient.
This man was a patient when I was a 'young' doctor. Actually this is untrue for I was never a 'young' doctor. I reached the status of a junior doctor when I was 'old'. If the truth be known, at least half of the consultant that I worked for were younger than me. This is the result of a first career in teaching (another story!).
I looked after him in hospital during radiation therapy. He had had a small lung cancer removed 6 months before. The operation had gone well. Unfortunately he developed headaches and difficulty with his arm, similar to the problems of a stroke. His general practitioner was very good and he had the diagnosis made quickly after a CT scan (previously known as a CAT scan, and the brunt of many animal jokes!). He had a cerebral metastasis … sorry, a small piece of the lung cancer had entered the blood stream and lodged in the brain.
The immediate but temporary solution is steroid tablets to reduce the associated brain swelling. Pleasingly he recovered with these tablets. The longer lasting solution lies in radiation therapy to the brain. Depending on the circumstance, surgery to remove the brain lump might be also undertaken. It wasn't in his case.
He lived some distance from the radiation unit (Nelson Bay, NSW that beautiful summer destination in Australia) and so was staying in the hospital during the radiation therapy. We spent some time talking, as his medical needs were very minor.
Later I saw him regularly as a senior training doctor (also older by this time!) in the clinics. He was always on a high from living! Why is life so good? I asked. He replied that when he was in hospital some one said to him that no matter what happened with his cancer, he still received his remaining days one at a time. I was told to make sure that each one was a good one, he said. I have, and guess what? What? Each day is better that the last one - I wish some one had told me this when I was 21!
He didn't say it, but he was glad I had told him at 61 also.
It shouldn't happen this way. Kids are not supposed to die before their parents. Parents are supposed to die first.
The death of a child causes many problems. I remember reading that the separation rate among parents in this circumstance is extremely high. The death of a child is seen as a waste of life - decades of lost potential. Someone must be responsible. Parents play the 'what if' game.
What if we hadn't hurried him to get to school on time? What if I had checked the baby before I went to bed? What if I had been a better parent and recognised her bad health earlier? The sad thing is that there is always at least one aspect of a child's death that can be used for self-blame by the parents.
Our third child had fits when a few months old. Because Mrs Ocker Doc is actually a Dr Mrs Ocker Doc, the 'what if' game had a whole new aspect! The self-blame was substituted with a litany of medical conditions that cause fitting in infants. Many of these rare conditions start with fitting but end with degeneration and death. Fortunately it turned out to be Benign Epilepsy of Childhood, and child #3 is normal … or at least has no major problems!
One of the hardest things for modern First World people to grasp is that we do not have control over every detail of our lives. Things just happen. When the people of the First World find that life is beyond their control, guess who gets the blame? "How could a loving God do this?" Now this attitude is not fair. We think that the Almighty has total control over bad things while we are solely responsible for the good things. The Almighty is on a hiding to nothing!
What is the benefit of a child who dies early? Is the life wasted? To answer 'yes' means that there must be a point after which that life has not been wasted. Is that point conception, birth, 21 or 'three score and ten'?
Literature is made up of short stories and 'War and Peace' epics. And the whole range in between - suspense, travels, sagas, cheap thrills, reflections. People's lives are the same. I don't believe that anyone's life is wasted. Some are short stories, some are long stories. What makes the story worth knowing is the quality of the love and relationship that they have been involved in and responsible for. Very short lives can be very sweet short stories.
Why am I writing all this? Friends of ours from the West Island discovered their baby daughter dead in bed yesterday. She was 2 months old. I'm about to ring them. What do I say to them?
I played a small part in Jeannie's life
I first met her when caring for her father with poor lungs. The next week I changed terms and found her at another bedside. Her husband was hospitalised for prostate cancer treatment at the same time.
They were a good couple. They had faced a large share of adversity. Their children had left, but they fit together and still loved each other. Her husband was in and out of hospital.
I had so much medical work to do that each day at 5pm I would stop being a doctor and sit with each patient "chewing the fat" about the day. She was always around when I did my socialising rounds. They lived within a block or two of the hospital.
I learnt that Jeannie had had cancer also. And not once. Twice. Believe me, this is nothing like winning Lotto twice.
She just wanted him at home, and managed to do this with the help of the Palliative Care team who visited her regularly. Eventually he died. Jeannie was lonely but thankful for the good time that they had had together.
I didn't see Jeannie for 2 years or more.
Then a friend mentioned that she was in hospital. That day I did all my socialising with Jeannie! One of her cancers had not been cured. It had seeded her liver and was making her sick. She battled through several courses of chemotherapy. Initially there was a marked reduction in the liver masses and she felt better.
Later the liver masses resumed their march. Jeannie was in a bad way. She said that she was finished with her life. She felt that she had completed writing the last chapter. Despite the hardships, she liked the story of her life with her husband and children living beside the hospital in the working class suburb. She had no reasons left to continue living. Life wasn't any fun and she had no wish to have extra time for its own sake. She wanted to close the book.
I visited her everyday to sit, hold her hand and talk. As she deteriorated it became obvious that despite stating that she had nothing left to live for, she was fighting. I don't mean that she was fighting with a positive mental attitude. She was appeared to be forcing herself to continue breathing. For 5 days I watched this. Finally I said to her "Jeannie, why are you doing this? It's all right, we are here with you and we are happy for you to go. You're not alone."
She seemed to take a break from her task of breathing. “I've fought all my life, Doc. I just don't know how to give up.”
We didn't give up either. We nursed her body and spirit until will power was no longer sufficient. I felt privileged to help her close the book. I hope that this page honours the book of her life.
Few patients ask to pray with their doctor. Godfrey was an exception. He had spent most of his life in the Christian missionary service, or rather his life was a missionary service. He had founded a Bible College.
I heard about him at church. He replaced the regular minister one Sunday night. The congregation was very impressed with the 'old missionary'.
Two weeks later he came to clinic in pain. He had prostate cancer that had spread to his bones. Radiation therapy to the sore spots was very successful in relieving the pain - as it usually is. He agreed that the aim of treatment was his comfort. He was very matter-of-fact that his lifespan was firmly in the hands of his God. At the very end of the consultation he asked, "Will you pray with me?" I did.
Between follow-up visits a medical friend working at a nearby hospital called one night. Godfrey had broken his leg. An orthopaedic surgeon had fixed the unstable bone. Although this solved the immediate problem, he did not recover well. He was not walking, and was nauseated. Now doctors have a saying "to a hammer, everything looks like a nail"! Which means that the care of an orthopaedic surgeon is focused, not unexpectedly, on bones and he wasn't getting good care. I'm the same with non-cancer bone conditions, by the way.
I stopped in on a social visit. As much to support my medical friend who was floundering, as to see that Godfrey was getting appropriate treatment.
It turned out that he had liver secondaries and kidney failure. Liver secondaries in prostate cancer usually signify impending death in the next few weeks, while kidney failure usually causes death in a few days. The kidney problem is treatable but the liver secondaries are not. I discussed these things with him. He decided that treating the kidneys would only prolong the inevitable. And he thought that the kidney death sounded easier.
The next day he was very agitated and despondent. We talked about the agitation. He couldn't put a finger on it. On a hunch, I said to him "Are you worried that your Christian commitment may have been misplaced all these decades?" He felt ashamed, he doubted his commitment and his God.
Fortunately he was wrong. "Godfrey, go back over your life. What does you life's story tell you? Were you wrong?" No, I wasn't. "This is the anxiety that everyone suffers at the end - did I do it right? Could I have done it better?" He nodded his head. I quoted him a verse from Matthew's epistle 'Well done, you good and faithful servant'. "That's what He will say to you".
Godfrey relaxed. He nodded in agreement. The next day he was calm and serene. His entire family came to see him and was happy that he was settled. It tired him out but he said goodbye to each one. Then, after they had left, he closed his eyes and went to meet his God. He was ready to go home.
My first patient as a 'real' doctor was a very rare bird. All through my training I had read about the rare diseases - and had seen a few. But I wasn't prepared for the first!
This lady has a cancer that is associated with a skin condition. My very large cancer text (over 2500 pages would you believe and bigger each edition!) said that the skin condition was found in 2 families from Liverpool. I remember these 'Trivial Pursuit' facts - which infuriated those training with me! The treatment elsewhere was standard. She came to settle near her family with her three children.
She had a bigger problem that cancer though. She couldn't swallow. Not food, not water, not saliva. A small tube connected her stomach to a liquid food pump. If you like medical acronyms it's a PEG or percutaneous endo… gastrotomy tube. There, another trivia fact! That diverted the food and water but not the saliva.
A call from 300km away said that she had become ill with pneumonia after repeatedly breathing in the saliva, and could they send her back.
From here on the story switches to the children. Their mum arrived in a very sorry state. She was crook. Barring a miracle, she looked like she was going to die… soon.
I introduced myself to the kids, their cousin, uncle and aunt. "So tell me, what have you been told about your Mum's condition?" Their answer was 'nothing'. As a parent and ex-teacher, I am suspicious of 'nothing' for it usually means something. The aunt and uncle confirmed their ignorance. NOTHING!!
So what do I do now? "I would have called a social worker and handed the family over to them" was the serious suggestion of one of my senior colleagues. Standing there I had a mental picture of three kids on train tracks about to be hit by a train and their world shattered. They had little time to learn the truth, absorb it and then act.
Unfortunately I have been in that position. My father died in a car accident and I discovered this in church with a priest's announcement from the pulpit. It is not pleasant. It makes saying good-bye hard. It leads to unfulfilled regrets.
They wanted to look at her chest x-ray first. So that was where we started. Every question was answered. Can Mum hear me? Is she in pain? Will she die? Every one answered. We talked for over 2 hours. I didn't think that I had really done enough. Time was too short. Isn't it always?
I arrived home late and my wife was angry. I explained and she forgave me.
"People in glass houses shouldn't throw stones". One day I hope that my family will be treated the same and have their grief eased by a doctor who stays back to do the job that needs to be done. All the more I hope for doctors who will tell us earlier about the train that's obviously going to hit us.
The next question to follow goes along the lines of “don’t you know what causes it?” Well, of course I do! My third son was mortified one day to find out that after six children his mother wasn’t a virgin. Obviously we have some work to do there!
So what sort of a woman marries the Ocker Doc? I have wondered about this frequently. Those of you who are acquainted with the Ocker Doc know most definitely that on the physical attraction scale he rates about 1 out of 10. The stocks of good looks were decidedly depleted when it came to my turn. I know it wasn’t the money!
Anyway the important thing is what I think of her!
I often tell patients that life is assessed in the answers to four questions – Where do you go when you die? What sort of a mother are you? What sort of a wife are you? What sort of a friend are you?
I have the answer to one of those questions. She is the wife of Proverbs (last chapter, look it up). I have never doubted that she would be or is my partner, my other half. From the start we have been friend and friend.
Every so often we fall back in love with those urgent compelling feelings, but in the other times there is the decision of love. Whether in the same house or in different countries, the bond holds strong. When separate the separation creates longing. I believe her instinct. She is the expert in the relationship, she knows what we are missing and need.
You see the kids are sourced from this wide and deep pool of respect and affection. The pool was always been full no matter how much we take out!
Those of you who have had the misfortune to meet the Ocker Doc at dinnertime will know that you shouldn't get your hands in the way! The Doc and food see eye-to-eye. It's not the way to his heart - it just maintains guard duty! Dieting is not the Doc's favourite pastime.
Lois is a Sydney-sider (or a "Sudknee"-sider in the local NZ lingo). A pleasant and cheerful woman from the southern suburbs, Lois' only problem was a long-term investment that had paid off. No, she wasn't working the stock market - she was a smoker.
Smoking is a strange activity. Placing your head over a fire and breathing in - can you see the sense in that? Fortunately there is a nicotine kick in it or no one would bother, and then where would the habit be?
Anyway, Lois was a good woman who happened to smoke. She was feeling unwell one day and noticed some blood on coughing. Now I tell you there are few things in the world to get your heart racing better than coughing up blood! We doctors call it 'haemoptysis' but apart from 'haem' meaning blood, I can't tell you what a "ptysis' is. Probably the sound a Roman makes when coughing! Lois entered the medical system quickly.
To cut a long diagnostic story short, Lois had lung cancer - and it had spread to the lymph nodes in the chest. Unfortunately it was inoperable. So she was sent into the clutches of the radiation oncologist. (In the pantomimes, this is where the crowd hisses and the villain appears dressed in black!)
What can you say about lung cancer? Nasty piece of work! In any one year, for every 100 people who develop lung cancer about 97 will die of lung cancer. Now if you were a betting person, you would hate those odds. OK with your money, but not your life.
The oncologist offered her radiation treatment. It wasn't fun - feeling tired, difficult to swallow and going backwards and forwards to the radiation unit every day for 6 long weeks. Not that getting the treatment took long, but the waiting time was longer than the treatment. The staff looked after her well but she still felt bad. After 2 months all the side effects abated and Lois was back to her normal self.
I saw Lois while on holidays. She had put on about 15 kilos! Are you on steroid tablets? I asked. "Oh no, I just have a good appetite. Anyway you told me to enjoy myself! And I just love the taste of food; it's my favourite thing!"
Ah, a kindred spirit!
In medical school I wanted to be an Intensive Care specialist. Long way from a cancer specialist!
To be a specialist, you have to have a personality 'defect', well more of a particular personality profile. Surgeons are men of action, physicians are men of thought and learning, anaesthetists are outdoors people. This doesn't prevent them from being different, but often they run to stereotype.
What are cancer doctors' defects? There certainly is the 'cancer saviour' type. But that is, most definitely, not me.
I looked after my first cancer patients in my second year as a doctor. It was one of the horror terms - rarely less than 30 inpatients and topping out at 45. I found that I was occupied for 8 hours of the days just serving their medical needs.
I got no satisfaction from that job. So each day at 5pm I switched my pager off, finished the remaining work and then walked in to spend time with the patients. Basically I socialised after hours!
I discovered that they were all common folk with big problems. They weren't all the same. They covered the whole range of humans - married, single, divorced, professional, labourers, old, young, male, female, catholics, protestants, whites, blacks, asians, etc. Their differences were fascinating. And yet their reactions to cancer were remarkably similar.
Most people will say that they couldn't cope if they had cancer. But almost every patient seemed to cope. And not only cope, but also to find that life was getting better as a result! That is what attracted me to cancer – sorry, the people with cancer.
Of course it is one thing to find that you like working with a group of patients, you also have to think that you have something to offer them. I thought that I had two advantages. Firstly my mother had died of cancer and my father of a car accident, so I understood something of survivor guilt. Secondly I had another career before medicine that gave me a different perspective on people and their needs.
The first advantage forced me to accept that death is inevitable. The only questions are how and when. Cancer gives you just one advantage. The how and when are much more predictable. And because its CANCER, everyone knows you're going to die soon (good thing that often they are wrong). So you can prepare. But to gain this advantage the doctor must tell you what's happening early.
The second advantage gave me the skills to talk to all patients and to understand that they are all capable of understanding this cancer problem. When I wanted to know, I asked the patient. I discovered that they all want to know about their cancer problem. I say 'all' but of course there are the once-a-year patients who don't!
So here I am in cancer medicine. I still like the people I meet in work time. I still work very hard to gain their understanding.
And I still spend too long talking with them!
1 October 2007
[Many thanks to Carol, who being unable to drown me in the Bay of Fundy now seeks to make me a better person]
I've learned.... That the best classroom in the world is at the feet of an elderly person.
I've learned.... That when you're in love, it shows.
I've learned.... That just one person saying to me, 'You've made my day!' makes my day.
I've learned.... That having a child fall asleep in your arms is one of the most peaceful feelings in the world.
I've learned.... That being kind is more important than being right.
I've learned.... That you should never say no to a gift from a child.
I've learned.... That I can always pray for someone when I don't have the strength to help him in some other way.
I've learned.... That no matter how serious your life requires you to be, everyone needs a friend to act goofy with.
I've learned.... That sometimes all a person needs is a hand to hold and a heart to understand.
I've learned.... That simple walks with my father around the block on summer nights when I was a child did wonders for me as an adult.
I've learned.... That life is like a roll of toilet paper. The closer it gets to the end, the faster it goes.
I've learned.... That we should be glad God doesn't give us everything we ask for.
I've learned.... That money doesn't buy class.
I've learned.... That it's those small daily happenings that make life so spectacular.
I've learned... That under everyone's hard shell is someone who wants to be appreciated and loved.
I've learned.... That to ignore the facts does not change the facts.
I've learned.... That when you plan to get even with someone, you are only letting that person continue to hurt you.
I've learned.... That love, not time, heals all wounds.
I've learned.... That the easiest way for me to grow as a person is to surround myself with people smarter than I am.
I've learned.... That everyone you meet deserves to be greeted with a smile.
I've learned.... That no one is perfect until you fall in love with them.
I've learned... That life is tough, but I'm tougher.
I've learned.... That opportunities are never lost; someone will take the ones you miss.
I've learned.... That when you harbor bitterness, happiness will dock elsewhere.
I've learned.... That I wish I could have told my Mom that I love her one more time before she passed away.
I've learned.... That one should keep his words both soft and tender, because tomorrow he may have to eat them.
I've learned.... That a smile is an inexpensive way to improve your looks.
I've learned.... That when your newly born grandchild holds your little finger in his little fist, that you're hooked for life.
I've learned.... That everyone wants to live on top of the mountain, but all the happiness and growth occurs while you're climbing it.
I've learned.... That the less time I have to work with, the more things I get done.
At a fundraising dinner for a school that serves learning-disabled children, the father of one of the students delivered a speech that would never be forgotten by all who attended. After extolling the school and its dedicated staff, he offered a question: "When not interfered with by outside influences, everything nature does is done with perfection. Yet my son, Shay, cannot learn things as other children do. He cannot understand things as other children do. Where is the natural order of things in my son?"
The audience was stilled by the query.
The father continued. "I believe that when a child like Shay, physically and mentally handicapped comes into the world, an opportunity to realize true human nature presents itself, and it comes in the way other people treat that child."
Then he told the following story:
Shay and his father had walked past a park where some boys Shay knew were playing baseball. Shay asked, "Do you think they'll let me play?" Shay's father knew that most of the boys would not want someone like Shay on their team, but the father also understood that if his son were allowed to play, it would give him a much-needed sense of belonging and some confidence to be accepted by others in spite of his handicaps.
Shay's father approached one of the boys on the field and asked (not expecting much) if Shay could play. The boy looked around for guidance and said, "We're losing by six runs and the game is in the eighth inning. I guess he can be on our team and we'll try to put him in to bat in the ninth inning."
Shay struggled over to the team's bench and, with a broad smile, put on a team shirt. His Father watched with a small tear in his eye and warmth in his heart. The boys saw the father's joy at his son being accepted. In the bottom of the eighth inning, Shay's team scored a few runs but was still behind by three. In the top of the ninth inning, Shay put on a glove and played in the right field. Even though no hits came his way, he was obviously ecstatic just to be in the game and on the field, grinning from ear to ear as his father waved to him from the stands. In the bottom of the ninth inning, Shay's team scored again. Now, with two outs and the bases loaded, the potential winning run was on base and Shay was scheduled to be next at bat.
At this juncture, do they let Shay bat and give away their chance to win the game? Surprisingly, Shay was given the bat. Everyone knew that a hit was all but impossible because Shay didn't even know how to hold the bat properly, much less connect with the ball.
However, as Shay stepped up to the plate, the pitcher, recognizing that the other team was putting winning aside for this moment in Shay's life, moved in a few steps to lob the ball in softly so Shay could at least make contact. The first pitch came and Shay swung clumsily and missed. The pitcher again took a few steps forward to toss the ball softly towards Shay. As the pitch came in, Shay swung at the ball and hit a slow ground ball right back to the pitcher.
The game would now be over. The pitcher picked up the soft grounder and could have easily thrown the ball to the first baseman. Shay would have been out and that would have been the end of the game.
Instead, the pitcher threw the ball right over the first baseman's head, out of reach of all team mates. Everyone from the stands and both teams started yelling, "Shay, run to first! Run to first!" Never in his life had Shay ever run that far, but he made it to first base. He scampered down the baseline, wide-eyed and startled.
Everyone yelled, "Run to second, run to second!" Catching his breath, Shay awkwardly ran towards second, gleaming and struggling to make it to the base. By the time Shay rounded towards second base, the right fielder had the ball ... the smallest guy on their team who now had his first chance to be the hero for his team. He could have thrown the ball to the second-baseman for the tag, but he understood the pitcher's intentions so he, too, intentionally threw the ball high and far over the third-baseman's head. Shay ran toward third base deliriously as the runners ahead of him circled the bases toward home.
All were screaming, "Shay, Shay, Shay, all the Way Shay"
Shay reached third base because the opposing shortstop ran to help him by turning him in the direction of third base, and shouted, "Run to third! Shay, run to third!"
As Shay rounded third, the boys from both teams, and the spectators, were on their feet screaming, "Shay, run home! Run home!" Shay ran to home, stepped on the plate, and was cheered as the hero who hit the grand slam and won the game for his team.
"That day", said the father softly with tears now rolling down his face, "the boys from both teams helped bring a piece of true love and humanity into this world".
Shay didn't make it to another summer. He died that winter, having never forgotten being the hero and making his father so happy, and coming home and seeing his Mother tearfully embrace her little hero of the day!
Footnote: A wise man once said "... every society is judged by how it treats it's least fortunate amongst them". Good News travels slowly. It doesn't make the front page. Humanists say that we are basically good - yet we glorify in the bad, actually we build an industry on the bad!
It has been a long time since the last posting. Many things have changed over the last 2 years. It is time that I started writing again, and perhaps inviting people to visit and list also.
I saw a favoured patient last week. Another brain tumour patient - most of my memorable ones are! - who is still alive and doing well nearly 2 years after original treatment. The last 2-4 years has seen the use of drug called temazolomide in combination with radiotherapy that is extending the duration of survival of patients. J is obviously one of them.
When I saw her originally I discussed some 'end of life' issues with her and said that she needed to answer the question "Where do you go when you die?".
She perkily jumped up and said, "I know the answer to that one!". Her husband also assured me that this issue was well settled. As I had just moved to this new city, my family were church-hunting and attended the first church on the list (there were only 3, all local). I came across J and her husband there. Warm and welcoming and explaining that they had placed their personal trust in Jesus long ago and this illness was just another turn in the road heading towards home. No big problem.
What good news! Cancer doesn't have to rule the patient's life, but so refreshing to find one so accepting and yet almost oblivious to the problems because there are bigger issues. Her daughter is pregnant and going to deliver in 2-3 months - what a joy for her to see her granddaughter!
12 June 2005
All cancer patients do die, but only a proportion under my care. The cured ones go on to forget me! Not many people measure success by how forgotten they are!
Still, whether forgetting me or not, I am influenced by them, their stories and their lives. Writing helps to keep perspective on what's important.
I apologise if you can identify me from this blog. It is my intention to be anonymous. You don't need to know who the patients are, even if it's you.