Saturday, July 19, 2008

It's done

Henry completed his 29th radiation treatment yesterday. It's officially the end of his treatment for the tumor.

We're thrilled for him. We feel so lucky that he's come through such difficult treatments without major side effects or complications.

As I've said many times, we're far from out of the woods, and will now learn how to live with fear and uncertainty. But this is exactly where we wanted to be, and I am deeply grateful for that.

Saturday, July 12, 2008

Could he have been...?

Could I have been a parking lot attendant?
Could I have been a millionaire in Bel Air?
Could I have been lost somewhere in Paris?
Could I have been your little brother?
Could I have been anyone other than me?

--Dave Matthews Band

The night we first met our oncologist, and got the horrible news regarding his tumor, prognosis, and impending treatment, I asked him a question.

"Is he already gone?"

"No," he answered, "He's not. Your son is still here."

I'm not sure he understood my question. I'm not sure that I fully did, or maybe that I could admit to myself what my question implied.

For many many months I've mourned Henry. Not my son, the three year old who has managed all of this horrific treatment fabulously, who makes me laugh, who has taught me so much about life. I've mourned who he was going to be, that he will no longer be. Future Henry. 8 year old Henry beating his dad at video games. 15 year old Henry breaking girls' hearts. 20 year old Henry coming home from college and eating me out of house and home, 6 foot 5 and dashingly handsome.


Ten years ago this summer my father was in a devastating car accident. He suffered severe head trauma, including a basilar skull fracture, subdural and epidural bleeds. He was unresponsive and in a coma for weeks, and rehabbed for years. He's now living independently, remarried, and quite happy. He's truly a product of the miracles of modern medicine, and had his accident not been quite close to Baltimore's Shock Trauma, he likely wouldn't have made it.

But the man who lives today, who looks and sounds like my father, isn't my father. My father is gone. Head trauma, especially to the frontal cortex, changes a person, both from a life skills and personality standpoint. He retains some preferences, some mannerisms that my father had, but he's a totally different person. Same building, new occupant. He's a nice enough guy, and I have affection for him, the way I would expect to feel about a long lost uncle, now found. But my father is gone.

I was angry for a very long time at Dad's doctors. It took me over a year to understand that he was gone. And they didn't tell us that, but they knew. The extended yet somehow unfinished mourning was difficult. It would have helped for someone to have told me.

Talked about screwed in the head. My feelings about my dad definitely were near the surface after Henry's diagnosis. And this is why I asked if he was gone. What I didn't specify to our oncologist was who I was asking about. Because Future Henry really was gone, already. And if I'd asked clearly, I think he would have told me.

Except, Future Henry had never been there. It was different than Dad, a much more static being than a three year old. How much of your child's life can you predict when they are three?

There's a saying in Buddhism: The glass is already broken. You can hold a glass, look at it, admire it, drink from it...but one day it will break, and be gone. Why be attached to something that isn't there?

I'm not mourning future Henry anymore. Maybe I will again, maybe not. I know I'll be sad at the trials he will face that he wouldn't have without cancer and treatment. But I'm more and more ready to see him for who he is. Who he always was.

Saturday, July 5, 2008

Yummity yum yum

I'm no TBTAM, but I like cooking. For those who haven't already made her green beans, you really ought to try them. Fabulous.

This is my new favorite summer recipe, so I thought I'd share. It originally called for chicken breasts to be cooked with the orzo, but I'm trying to eat less meat, and besides, the chicken added nothing. Still, if you like a little more protein, brown them lightly in a frying pan before lying them on top of the orzo as it simmers.

Orzo with Mediterranean Tomatoes and Feta

10 oz grape tomatoes, halved
12 pitted kalamata olives, quartered
1/4 cup snipped fresh flat parsley
2 T capers, rinsed
2 T red wine vinegar
2 t extra virgin olive oil
1 t dried basil

1 can chicken broth
1 c dried orzo

crumbled feta cheese

1. Mix first 7 ingredients together. They're best if they marinate a little while (I try to make this part in the early afternoon and refrigerate), and keep for a few days without looking old.

2. When you're ready to eat, boil the chicken broth, and add the orzo. Simmer covered 10-12 minutes.

3. Dinner is served! Make a bed of orzo on your plate, spoon the tomato mixture over, and sprinkle liberally with feta.

Easy, simple, delicious. Just how I like to cook. Hey, and it has the word "mediterranean" in the title. Must be good for you too!

Word of warning, recipe as written makes smallish servings. I usually double for a family sized meal.

If you try it, let me know how you like it!

Thursday, July 3, 2008

Just One Thing

My residency program participated in a program called Balint group. It's commonly used in family practice residencies, based on the efforts of Dr. Balint, who recognized that difficult patients bring up difficult emotional issues in medicine, and it helps to process them with other doctors. I found it to be useful as a resident, often because it was a much needed break from constant clinical information. And compared to the other hundreds of noon conferences, I think I remember more of my Balint sessions than anything else.

I had a patient in residency that I discussed in our Balint group one day. Kevin was 44 years old, and was working the system like a pro. He was morbidly obese at 450 pounds, on disability for a moderate orthopedic injury that he had suffered in his thirties, and utterly lacking in executive function. He whined, begged, cajoled, and pestered me and other providers until he got what he wanted.

My discussion was regarding my depth and breadth of negative feelings toward him. I didn't like his voice, his appearance, his smell, his lifestyle, his choices, his demands. I disliked every interaction that I had with him. I had intended to discuss some more sophisticated emotional response, but the more I talked the more it was obvious that the man disgusted me.

Our Balint leader stopped the conversation. "You are this man's doctor," he said, "and you need to find one thing, just one thing, that you can like about him, or you'll never get past this."

He was right.

I've thought of that advice often over the years, and it's been very helpful to me. So many of my patients are delightful and wonderful people, but alas, some are not.

Still, all of them are people, and if I look long and hard enough, I can find one thing that I can hold on to and feel positively about.

I am ashamed of how I felt about Kevin, as I look back on things. In my defense, he was my first real and long-term exposure to his lifestyle, and I've come to realize that it's neither unique nor particularly satisfying. I also see now that part of my disgust was due to my inexperience in dealing with difficult patients; I let him direct my care, and allowed behaviors that I would never allow at this stage in my career.

He taught me a valuable lesson, and I wish only the best for him.

Wednesday, July 2, 2008

Merck? Schering?

I tried to give Pfizer a tip several months ago, but I haven't heard from them yet.

Here's my next big idea: Advantage for people.

This is my fourth summer in practice. It's clear that my practice sees more and more Lyme disease every year. Last summer I started catching some in kids too. Reported cases to the CDC have increased from 600 to over 1200 in my state. Likely some of this is increasing awareness, therefore increasing testing and increasing reporting, but the general sense is that the real disease burden is on the rise as well.

Lyme disease is carried by deer ticks. Generally, they need to be attached for at least 24-48 hours in order to infect the host. Unfortunately, they are so darned tiny that it's often very unclear how long they've been attached.

What scares me is not the disease that we catch, but the disease that we miss. I'm certain there are huge numbers of subclinical infections that never come to the attention of patients. Then there is a lot of mild disease that is interpreted as viral infection and allowed to resolve spontaneously. Full blown primary Lyme is pretty uncomfortable and most people seek medical attention, but even with that, presentations can be atypical and difficult to diagnose.

To boot, the testing for Lyme is far from ideal. False positives and false negatives abound. And trust me, no one wants to mess with secondary or tertiary Lyme, manifestations that can come up years and years later.

So, let's go for prevention. How about a monthly pill, a la Advantage for pets? Maybe they could even make it taste good so that we could apply it directly to patients' noses to be licked off.