Monthly Archives: February 2015

It was as if her soul had cruelly been branded “Kick Here” at birth. It was not that she was dealt bad cards so much as she never had much of a prayer to be in the game of life. Alcoholic and abusive parents spawned this only child almost three decades ago and rendered havoc on her congenitally frail spirit and teetering health. Not surprisingly, she was cursed from the beginning as a severe diabetic. This had withered away her adolescence in angry diabetic comas and multiple illnesses as her family rambled helter-skelter across the country, lashed to the whims of a drunken, oft – unemployed father.

Now a mother herself, Maria was at most a trembling waif of a young woman. She had been murderously robbed of childhood innocence, weaned on despair, suckled on disappointment. Against the odds for severe diabetics, she had amazingly survived pregnancy with very healthy twins.

She had escaped her hell of a family only to find herself in a ramshackle marriage to a pestilence, not a man. A wife beater and child abuser, her enlisted military husband was a belligerent, brooding hulk for which fatherhood was a grave inconvenience and a blot on his life.

I have come to believe that it was not by chance that one of our sage senior physicians happened to pull ER duty the day she walked the miles to our hospital carrying her precious cargo shivering in her arms. Both of her babies had fevers, and to the discerning eye, it was clear that evil had pitched its tent in their home. Incessant apologies from a terrified, tearful mother, as well as classic fractures and scarred, blistered skin from burning cigarettes having been pressed into innocent skin, wailed as a wounded plaintiff cry for a savior, for justice. Clearly both she and her children had been abused. She collapsed out of catharsis and experienced at least a momentary reprieve from fear and overwhelming grief when the emergency-room team were marshaled to gather them all into our protective bosom. Simultaneously, the search was set for her stain of a husband.

In short order, it became painfully clear that the tragedy had no bounds. It was soon obvious that Maria was ill. Evaluation in the emergency room showed that she had rapidly worsening kidney failure from what was soon learned to be malignant masses in her abdomen that were choking off her kidneys and eating voraciously through her pelvis.

I was drawn to this wounded pup. The ache of seeing such unfairness from a world that offers no guarantee of freedom from suffering was a constant companion for many of us tending to her care. Our clinical bond and trust falteringly evolved. Leveraging the lifeboat of her children, I painstakingly strained to encourage in her a glimmer of hope, and perhaps flame, the fading flicker of her fight for her life, for her children.

We all have bucket lists of dreams unfulfilled and longed for. Her dream was common enough. She longed to simply play with her children, to frolic with fantasy, unburdened by dread. Now she was resigned to a painful death; it was all she expected. Only the irrepressible devotion to her babies and the possibility of their future being so uncertain carried her on. However, it quickly became clear that the cancer would agonizingly strain the last beats of life from her.

We raced through the diagnostic evaluation and made a hurried dash to save her kidneys and numb what had to be blinding pain. There was never the slightest whimper, the faintest fl inch from her. Through wounded eyes, she watched, disaffected, rallying only when her babies were safe and near. It was for them that she allowed the tubes to be inserted into her kidneys; for them she tolerated the invasion of her belly to knit together her perforated, strangulated bowels; for them she bloodlessly whispered a vacant yes to chemotherapy. If only she could have had just a moment’s peace.

A few years ago, I suffered through the disaster of a rental condominium in Orlando that only Erma Bombeck could rightly do justice. It was absolute architectural anarchy. If water should have passed through it, it did not, if designed to support weight, it would not, if it had been controlled the environment, it could not. It was simply a massive disappoint and grand inconvenience.

Therefore, one day the stuff of fairy tales landed in my mind. I fashioned a story and made the calls. Perhaps I was serving my need to somehow save her, perhaps not. By the time the smoke cleared, it was all arranged, clearly by the hand of a force far greater than mine: airfare, a rental car, lodging, and Disney World admission was waiting, free of charge for Maria and her babes.

Yet she was giving up and dying. I eagerly told her of the scheme to whisk her away to fantasy land. I was stupefied by her visceral response. Life beamed in her eyes, and for the first time of what was to become an adorable habit, Maria smiled. I could almost hear her soul snap into action, barking orders to finally fight the beast eating her body. Her husband safely spirited away, a battered and bruised young, very alive mommy made it home for a long weekend for the first time. Irrespective of my personal faith, I was ill prepared for what lay ahead for Maria and her children.

A few Mondays later, my nurse hovered in my doorway, seemingly buoyed by joy, wet-eyed, and spiritually transfigured. Stammering, she said, “It is Maria … Maria, she … ah …she is so alive.” I am sure I fumbled out something only to have my nurse say, “No, it’s Maria; you don’t understand what’s happened.” In an instant, she was gone and I was confused.

Then I saw the glow of life as never I have seen before. Guided by grace, this beautiful woman glided into my office and sett led into the chair. I was steeped in the warmth issuing from this vision. It looked like the Maria God would have fashioned were he to meddle mercifully in her miseries. She spoke serenely. “I stopped taking the narcotics; they made me sleepy. And I have no more pain. I am eating everything in sight, and my sugars seem okay. Doctor? Doctor? Are you okay?” Aghast and afraid that I might burst the bubble, I beckoned her in to the exam room. It was normal, unbelievably normal.

A lump was growing in my throat, and my voice grew strangely hushed. I vaguely remember calling the chief of radiology for the urgent CAT scan, but I do remember his return call after it was done He was incredulous, questioning me. “I do not know what you pulled, but the scan I have here—well, it’s normal. No tumor, and healing bone.” Gone, too, was the bowel obstruction, the blocked kidneys—all of it, gone. The physical exams, CAT scan, blood tests—all were normal. Softly, before I could gather myself, she spoke as if the hand of God were gently stroking my disbelief. “I know,” she said. And then she was silent. I was in the presence of grace.

I had no problem getting through on the phone to make all the arrangements final, and in moments, it was done. She would leave for Orlando that weekend. The sweat of my soul slid down my face as my nurse handed me a tissue and floated out with our miracle.

On a Monday, some weeks after the joy of a lifetime with her children in Orlando, Maria appeared in my office. She was gaunt, wasted, and desperately pleading. “Tell me my babies will be okay,” she said. “Tell me what will happen to them. Tell me.” We spoke until the ache lifted from her spirit and she reached some manner of closure with the cancer that had so quickly returned to ravage her body. Abruptly, she stopped, rose to face me, and gently put her arms around my neck without a word. I saw that she knew it was over and her children would be safe.

There was no sorrow that Friday in the hospital. Her babies lay besides her in her arms, sleeping, as God called his angel home.

Read more

As I made rounds, lilting laughter punctuated a ragtag vocal ensemble’s singing of “Danny Boy.” It ebbed and flowed from the oncology ward lounge, warmly filling a sterile hallway, but not my heart. It was the twentieth St. Patrick’s Day since small-cell lung cancer had riddled and devoured my tough, son-of–Hell’s Kitchen, World War II–veteran Irish dad. Although he died during the dreary, wet, frozen rains of a New England fall, he was etched into my heart’s memory owing to one very\ magical St. Patrick’s Day.

As I have done on every St Patrick’s Day since his death, I was reminiscing about a time when I, a newly minted, wet-behind-everything medical student and a second lieutenant in the US Air Force in the Health Professions Scholarship Program, visited my dad at work as General Electric’s chief labour relations negotiator in Manhattan. The day ended at a midtown Irish bar with me accompanying him on the tavern’s beer soaked upright as he crooned “Danny Boy.” You could feel the century old pub wood weep as a sonorous tenor voice I had never before known he had lifted hearts, minds, and glasses. Mutually uninhibited, but not inebriated, father and son were in tune.

So here I was, decades later, on another St Patrick’s Day, rounding on the oncology ward, tired and tied to a bittersweet memory. Regaining focus for the duties of the day, I began to thumb through the chart rack. Suddenly, intruding through the funk was the unmistakable sound of a Buck Rogers ray gun. It was right behind my left ear, magically mixing with leprechaun-like chortling and giggles.

I spun on my heels and was bowled over by the impish grin and theatrical posturing of my toy-toting assailant. Hopping and toe-dancing as lightly as a shamrock blown by faerie breath, and half naked in hospital regalia with toy cosmic carbine in hand, retired USAF Chief Master Sergeant O’Reilly squealed, “Ah-eee! Gotcha, doc”!

O’Reilly had whistled and skipped to an easy truce with his sleepy follicular non-Hodgkin’s lymphoma for sixteen years prior to this admission. His blarney charmed the beast called anxiety. His acceptance of the capriciousness of a life filled with the Damocles sword of a strong probability of an aggressive transformation of his disease was like a therapeutic balm of Gilead for not only himself but also the many patients he befriended and bolstered.

His checkups were always happy routines rife with fabulous tale spinning, unabashed limerick-singing, and other sound medical practices. Clinic visits from the sage retired chief leprechaun of the USAF always ended with a pat on my head, a wink at the nurses, and his trademark squeezing off of a couple laser beams of magic from the now infamous toy gun at whomever he thought needed it most. It never hurt, it often helped, and, more than once, it seemed more powerful than my prescription pad. An emeritus professor of mirth and mentorship, O’Reilly was one of the wisest men I knew.

Shortly before this final admission, the limber leprechaun interrupted plans to visit family in Ireland because, as he said, “Me shillelagh’s telling me something ain’t right.” A thorough history and physical revealed nothing. The complete blood count showed a slight drop in his usually robust hemoglobin, and his platelet count had fallen considerably. So did my heart when review of the peripheral blood smear suggested what an immediate bone marrow examination confirmed—myelopthisis.

His lymphoma had transformed aggressively and was exploding in banshee like furor. It was replacing his bone marrow. Further staging showed broad lymph node, boney, spleen, and meningeal dissemination. An incredibly bright man, he fully understood the limits of therapy and the grave prognosis. Typically unafraid and more concerned for his family, he was annoyed at the change in travel plans. He sprightly assured me, “I have a few things yet to do, so let’s have a go at it.”

We did. After a rocky course consisting of intensive systemic and intrathecal brain chemotherapy, massive transfusions, considerable assistance from colony-stimulating factors to support his white blood cell count and fight infection, and the use of erythropoietin to help him make blood, this knobby-kneed leprechaun of a man was zapping my dour spirits. Bald and beaming and headed toward a major clinical response, he was working his magic on this very special St Patrick’s Day.

It was his family in the lounge warming the ward with lilts of laughter. Spying my doleful drudge as I began ward rounds, he had left the comfort of family and friends to fire a laser beam of life my way. Clearly unfazed by the enormous odds of a rapid and refractory-to- treatment recurrence of his cancer, he oft en grandly showcased his plastic phaser, quipping something to the effect of, “If it comes back, we’ll zap me cancer with this thing; it’s better than those poisons, eh?”

O’Reilly was one of the gift s clinical oncologists can garner in decades of clinical practice if they are open to receive them. He was one of those wonderful “doctor-patients” put in our path to minister magical wisdoms just when we oncologists need them most. Being touched by such patients’ special zest, zeal, and wisdom is one of those easy medicines to swallow. Souls such as these are precious jewels in the growing treasure chest of a clinician’s experience, and the luster of the clinical pearls they impart are often both illuminating and transformative. So it was with O’Reilly.

Unbeknownst to me, he had more things than fighting his cancer on his agenda. He had taken particular notice of one of my young clinic nurses. She was a seemingly emotionally cold and somewhat intense second lieutenant nurse that was “too young to act such a tough nut and too talented not to try and crack,” according to O’Reilly. She had requested transfer to the inpatient oncology service. This coincidentally put her on the ward—and in O’Reilly’s service and sights—when the aggressive transformation of O’Reilly’s lymphoma occurred. Both I and the senior nursing staff were concerned for her, believing her far more fragile than her implacable demeanor might suggest, but our “tough nut” showed no signs of trouble and, sadly, few signs of warmth, even when O’Reilly’s improbable clinical remission occurred.

Shortly after that St Patrick’s Day, the probable occurred. O’Reilly was readmitted with signs and symptoms of a rapid recurrence. He was quick to grasp his situation, calmly and confidently summarizing my lengthy delivery of sad news to a family unwilling to believe the unacceptable, saying gently to all, “It’s been a great run, so now, soon, I’ll be with sod and saints.” In his final days of a rapidly progressing malignancy that would not be denied, he had three simple requests: some intimate uninterrupted time with the missus, a steady supply of Guinness Stout, and “one last shot at some unfinished business.” Curiously, and without any explanation offered, he decreed that the “tough nut” young nurse be assigned to his care, and furthermore she was to be the only medical staff he wanted in his room—no one else, no exceptions. Somewhat bewildered, but always admiring of his wisdom, the charge nurse and I warily agreed. On hearing his request, the young lieutenant almost condescendingly agreed, seemingly fashioning it as some sort of dramatic last wish. After all, she thoughtlessly quipped, it was “probably [her] turn anyway.” She would be in his service, having no idea how true that would prove.

I was shaken upon news of his passing the next morning. However, deeply appreciative of O’Reilly’s gifts, I was both concerned and curious as to the impact, if any, his passing had made on the young “tough nut” nurse. No worries. I no sooner strode onto the ward than she ran up to me glowing, seemingly transformed and weightless, her eyes brimming with tears of joy. She reached into her pocket and produced our leprechaun’s little laser gun. Smiling, she told me that he had called her to his room, eschewing all others. She bubbled joyously about how they had chatted for hours about secret things—special things about love and the rich life. She was bursting with the pride and surprise of one who had been picked above all others as something special and lovable. Tugging at my white coat like the impatient, exuberant child she then was, she announced triumphantly that she was the last target he aimed a final salvo of saving love at. He then bequeathed his otherworldly potion in a pistol to her, saying, “I can go now. You’ll know when to use it and when it’s time to pass it on.”

Death is not always so kind or so graceful in its gift s. When we healers and helpers are absorbed in our sorrows, perhaps lost in the fog of sadness over the limits of our skills or other concerns, we may also be most vulnerable to the laser beams of life from those who by all rights should be sorrowful and yet are not.

Read more

It snowed in my clinic today. How strange. The forecast for the oncology clinic was once again for increasing periods of foggy depression with precipitation sure to follow. These “bad weather” days in the oncology clinic can blanket one in disappointment and squelch the slightest iota of joy.

This was not so for Jake, a twentysomething US Air Force sergeant whose initial journey into the world of cancer brought good humors to the clinic. Despite his initial diagnosis of what was initially thought to be early-stage testicular cancer, life was in full bloom in Jake, and when first diagnosed, he excelled at engaging it.

However, today’s clinic visit was a big one—the big one. His cancer was not early stage, and today we would decide if our last assault in the war against the worst testicular cancer anyone could remember had met with any permanent measure of success. Th e bad news meant it was time for raping his bone marrow, nuking his cancer with a bone marrow transplant, and running to the rescue with harvested bone marrow stem cells—the Adams and Eves of his blood. A full year had passed since the last of the intensive chemotherapy had coursed in Jake’s veins. His chest wall had been partially removed, and his spine had weakened. My “robo-patient” sported space-age alloy mesh for his right chest wall, and two titanium rods strained to support his spine. He had started all this as a strapping six-footer. Although he stood tall in our eyes, we had mercilessly beaten him down to about 5’8”, as if shrunken by a giant press of malignancy.

A little over two years before, Jake’s saga that became legend was born. There was nothing typical about it. His traitorous testicular cancer cells had set up shop throughout the back of his abdomen, his pelvis, his brain, and his lungs. Markers of the cancer’s activity in his blood were ascending like a ballistic missile. He probably had twenty pounds of the beast in him. The prognosis, even with the chemotherapy, aggressive surgery and radiation treatment, was poor, although not impossible to cure—but with a huge price and a reasonable chance treatment might not be survived.

Weaned in the rough-and-tumble barrios, Jake always had mountains to climb. He saw his initial diagnosis of the cancer as no greater peak than he had faced before. He embraced it with maturity beyond his years. In the beginning, he handled his chemotherapy with bravery and grace as he spent that initial hospital time socializing with other patients; he was a regular poster child for just how well intensive treatment could go. Then the dam broke and all manner of havoc let loose. The chemotherapy had exacted a toll of relentless nausea and vomiting so severe it ripped his esophagus. It had also caused both kidney failure and near-crippling lung disease. His diet, which he called “high-octane intravenous go juice,” was administered via tubes and transfusions. The chemotherapy’s assault on his bone marrow required many transfusions of red blood cells owing to profound anemia, as well as platelets to prevent him from spontaneously bleeding.

Masses still clung to his chest wall and spine aft er chemotherapy. Although markers in his blood of cancer activity were negative, it was likely that these masses, benign or not, would become locally invasive and result in a catastrophic outcome. All this left Jake simply too gaunt to even cast a shadow. Any more insults against this walloped warrior and he would be gone.

Yes, Jake loved to climb mountains. His dream was to conquer Half Dome in Yosemite before he “checked out.” It became his quest, his daily obsession, and his reason to fight. We would talk of manly things: athletic escapades and the heroic exploits he would have when well. He loved our talks, hanging on each imagined adventure, wringing them for every precious drop of hope. When it first was clear that we might lose the battle, his initially engaging and courageous demeanor smote me. It was the right stuff of heady inspiration. In time, however, this demeanor gave way to one of simply surviving each moment, scratching out some modicum of feeble hope that one day he could really put one foot in front of the other and leave the hospital alive and well. The time came when Jake was pondering whether he should even try. He was tired and had had enough. He thought it was time to seal the contract and acknowledge defeat.

Rarely had I launched so fervently into supporting a patient with wavering will. All the stops were taken out. Every manner of cajoling, admonishing, preaching, challenging, cheerleading, and commiseration was thrown at him. In shameless desperation, I offered a contract for life: I would deliver him from his travail, and he would climb one last mountain.

I did the wrong thing. I promised he would live. I just knew a nasty exit was not yet in the cards. Jake did not. Yet somehow, agonizing in every moment, he plodded on. His recovery from the removal of his chest and spine tumors was bloody trench warfare, gargantuan suffering to gain a shot at cure. Nevertheless, gain he did. I thought we would lose him, but there was the promise—our contract. He fumbled on until now it had been a year since the last of all the therapy—a crucial time at which, if he was cancerfree, it would portend well that he might remain so. We were in the clinic. This was the day.

I had seen him twelve weeks previously, and we hoped then that we would declare him cancer-free at the one-year mark. He was indeed cancer-free at that time, but he was a cane-assisted, barely walking testimonial to the melee and carnage of his journey. There may have been the faintest, almost imperceptible spark of life.

Today was different, very different. There was something impish, something teasingly spry this time. There was a lilt in his banter and swagger in his walk. An engaging hint of a wry smile flirted across his face. Crazy sprouts of curly black hair seemed to almost dance merrily on his once bald head. Something was up, and so was Jake. He was impatient for me to get on with the checkup routine, almost as if I were his dad making speeches rather than passing out the presents on Christmas morning.

That was when he produced his prize. Unbeknownst to me, he had gathered all manner of folk who had shared his saga over the past two years just outside the exam room. I think he even waved down passersby. Beaming and bouncing, he produced his treasure trove. It was a small, dirty, banged-up, seen-better-days cooler. With all the pomp and circumstance of a five-star hotel concierge, he bade me to open it. There, placed on a bed of mountain laurels and glistening, as were both our eyes, was a wet, weeping ball of ice—a snowball. Before I could connect the dots, he produced the prize—a photograph. Plain in God’s sight, shirtless, with a deformed chest and rods in his back like bionic harpoons, was Jake, high atop Half Dome in Yosemite, his fists in the heavens, the snowball in his hand.

It snowed in my clinic today. I think I will go out and play.

Read more

In The Merchant of Venice by William Shakespeare, Portia, a brilliant Shakespearean heroine, impersonates a lawyer and pleads that mercy be granted a debtor in default to an abused moneylender who is demanding a rather gruesome repayment. Portia pleads that the quality of mercy is greatest when given freely and that mercy must have some weight on the scales of justice.

Leaving Martin Luther King Day and headed into Presidents’ Day, my thoughts returned to a decades-old episode in my life in which similar words and sentiments of Shakespeare, Dr. King, and President Lincoln resounded.

Tom was a new air force sergeant with a mass in his chest. Almost everyone was convinced of the diagnosis. However, as I had oft en preached, “Although tumor is the rumor, tissue is the issue.” Thus, a surgical biopsy was scheduled.

Garrison Keillor, of Prairie Home Companion fame, would be proud of this young Minnesotan sergeant. How Tom got to be noble and gracious at such a young age, I do not know, but this kid was something special. The surgery went well. The biopsy looked extremely bizarre under the microscope, but our best pathologist was enormously confident about Tom’s rare diagnosis. Something about that pathologist gnawed at me. Nonetheless, as we had a direction, I sat with the gracious sergeant and explained the intense therapy that lay ahead, the consequences of certain sterility and the high risk of permanent organ damage and possible death.

The therapy almost killed the patient. Many organ systems were severely damaged, perhaps permanently. Yet this young man’s spirit only strengthened. When he was strong enough to speak in his many trips to the intensive care unit, his first words were always questions about how the other “older patients with families” were doing!

After Tom’s final treatment, I received a hysterical call from our best pathologist. Between sobs, he told me how confident he had been about Tom’s diagnosis. Because of his confidence, he hadn’t checked on the all the special studies I requested. My colleague was wrong. Tom’s tumor was an unusual variant of a highly treatable type of cancer. Although the mass was apparently gone, the drugs he received had never been tried before, and Tom would not survive more therapy. The pathologist’s wife had suddenly shown severe mental health problems. His family was falling apart. His desire to “save somebody” had clouded his judgment.

I had to talk to Tom. I told him everything.

Tom understood and solemnly said, “We have to fix this.” Moist-eyed yet resolute, he searched my face and asked, “Is he going to be all right?” He grabbed his IV poles like the arms of a helping comrade. He lifted himself out of bed and said he had to see the hospital commander “to tell him to forgive the pathologist and to remember all the good he has done and will do.” I thought Tom could not walk; perhaps grace carried him to the commander—I could no longer see clearly through my own tears.

After over a decade of research, the previously untried treatment given by mistake was shown to be highly effective. The hospital commander, who was merciful in helping the pathologist recover, became surgeon general of the US Air Force and personally saved lives and commanded rescue efforts on 9/11 when a hijacked plane crashed into the Pentagon near his office. Tom survived. He is home in Minnesota, working as a union steward with his three children adopted from Ethiopia.

Portia was right. Mercy is not forced; “it droppeth as the gentle rain from heaven … it is twice blest … it blesses him that gives and him that takes.”

Read more