Kevin Foley, 1971-2009*

If I have a quibble with this blog it’s the pseudonym “Sick Guy,” never the way this brilliant, strong, beautiful man lived. Cancer silenced Kevin’s voice on November 19. Those who have followed his travels through illness have a sense of how eloquent and artful his writing was, of his gifted mind, incredible wit, spirit, and his courageous self-exploration.  He could also cook and curse with great flair, give the most surprising and intuitive gifts, tell you anything about politics or Cal bear football. And he loved me, to my great fortune. His family and closet friends (and new Springer Spaniel puppy, Berkeley) were his life. Missing Kevin will now be a large part of ours.

To the people who have come to this site again and again, the strangers who are now friends, the people who have left comments of such heartfelt encouragement, the silent but loyal readers, your support has meant so much to Kevin and to me.

Thank you for sharing this experience with us. It’s a road no one should have to take. I wish I could write a different ending.

L.

*A memorial service in celebration of Kevin’s life will be held at the Unitarian Universalist Society of Burlington, Vermont, on December 5 at 4 p.m.

Burlington Free Press obituary: http://bit.ly/6DlMLn

Los Angeles Times obituary: http://bit.ly/7E3wAe

Zoo York

I shocked myself, but I am going to New York tomorrow for a brivanib nursing visit.

I was supposed to go last week -- two days after the chest tube was out. The idea of doing that was so appalling, so paralyzing, so beyond my mental and physical capabilities, that I didn't consider it. What I did consider, long and hard, was dropping out of the trial. When I think about quitting, when I think about staying home tomorrow and for my as-yet uncertain CT scan, which could happen as early as next week, I feel this pulse of relief and life. So what the hell am I doing? Part of it is my compulsive need to finish things. Part of it is that I had my best scan in terms of measurables the last time around. (Obviously, other stuff didn't work out so well, but I don't blame brivanib for that.)

As you'd expect from the lack of posting, I've been feeling terrible and concentrating on pain management, which has taken a huge toll on my alertness. Things have improved enough that I'm hoping I can get through the next 40 hours -- and even have a little fun doing so.

Another brick in the wall...

B., like me, loves Legos.

But his pleasure is mixed with pain.

Most of his sets are themed, one-way efforts -- build a particular helicopter or construct some specific diorama. He prizes these; more so if they involve Star Wars. They make him miserable; most are still just slightly out of his reach, so he's left with a half-dozen sets in various phases of constructions, most of which with some missing pieces from the orgasmic initial few moments when he tore open the box. The Legos he has fun with are the generic unbranded, unplanned bricks. I bring all this up because I'm really feeling his pain. I want his room clean, yet his idea of room cleaning involves beginning to assemble a lego kit. He fails, leaves it on the floor or the table, and the room is messier than other. I also bring this up because it's something of global problem, one that says something about how kids live today:

In the United States, Lego’s biggest market and the biggest toy market in the world, games with themes like “Star Wars” and “Indiana Jones” were among the reasons Lego sales jumped 32 percent last year, well above the global pace. But experts like Dr. Jonathan Sinowitz, a New York psychologist who also runs a psychological services company, Diagnostics, wonders at what price these sales come.

“What Lego loses is what makes it so special,” he says. “When you have a less structured, less themed set, kids have the ability to start from scratch. When you have kids playing out Indiana Jones, they’re playing out Hollywood’s imagination, not their own.”

Even toy analysts who admire the company and its recent success acknowledge a broad shift. “I would like to see more open-ended play like when we were kids,” says Gerrick Johnson, a toy analyst at BMO Capital Markets in New York. “The vast majority is theme-based, and when you go into Toys “R” Us, you’d really be challenged to find a simple box of bricks.”

(via Kottke)

Weak as a kitten

The post title is a lie since most kittens have more spunk than I do at the moment, and possibly more strength.

I was released from the hospital on Aug. 29, and the weekend passed in a bit of a daze, but not completely. I was pleased that merely being at home made many, many, many times more active than in the hospital, even when I was deliberately conserving energy.

The fact that I have atrophied so much of my physical strength over the last three years means that it only takes 15 very sedentary days to decimate that meager base. So I'm trying to walk around more as part of a de-kittenifying effort. I'm thinking about setting a few activity quotas for myself and consciously trying to make myself get in, say, 10 stair climbs a day, 15 walks across the house, 5 minutes spent doing some of my stretches for my back leg and thigh. I once worked for several fitness magazines, and one thing I remember from the exercise physiology literature is that the less strength you have, the faster you can gain more. Put another way: The nice thing about starting from nowhere, even if you have cancer, is that you can make at least a little progress very quickly (that is, of course, if your health isn't in some kind of crisis).

Meanwhile, I still have the odd sensation of walking down stairs and feeling my legs get progressively weaker until the end when they become, essentially, numb dead weight. After eleven stairs. Eleven. I'm watching out for myself because there is no way I am going to blow all the fighting I've done with a household accident. (On another note, so many of our friends are runners and cyclists and skiers. It's not that I spend a lot of time actively envying them, but it's painful for me to imagine having access to all that strength and endurance and grace. It's a beautiful thing; and easy to take for granted. At this point, I would be so happy to walk to the corner store. Or sprint across a grass field with a kid and a dog. Our bodies are gifts.

We're still negotiating my return to the brivanib study. The doctor's original suggestion -- come to New York tomorrow -- was a non-starter and is now withdrawn. I'm not sure what kind of arrangements we are going to make for the next two visits, but I do know that I am going to make my point as clearly and firmly as possible (up to the point of withdrawing from the study), hoping they will stretch the rules at as much as possible. I feel peaceful about whatever happens.

More for archival purposes than anything else, a quick rundown of what happened medically: I left the hospital with a full-sized surgical chest tube and followed up as an outpatient with the surgeon three days later, on Monday. The valve attached to the tube (a Pneumostat) makes it easy to check for an air leak; when the surgeon did so, my lung appeared sealed. So he pulled out the tube. (Ow.) I had a couple of awful days where I was taking lots of pain killers and lying around semi-responsive for most of the day. The chest tube actually hurt more out than in -- no idea how that works. Today I woke up feeling much better in terms of pain, breathing and energy.

Sweet ice cream

Nobody's asked the question, so I haven't tested my answer, but if someone asked me what they should read after a cancer diagnosis, I would be strongly tempted to reply, "Atul Gawande."

Gawande is a surgeon and not an oncologist, and he is animated by health policy and procedure, which aren't usually the first concerns after diagnosis. But, as his editor at The New Yorker says, his pieces open like umbrellas, and the click of understanding that comes along with them has, for me at least, made the culture of physicians and hospitals more comprehensible. Understanding more about how doctors think (and how yours might frame crucial medical decisions for you) is a practical example of why Gawande is so useful to patients. But Gawande is a literary writer, and reducing his work into some sort of tool (even a tool so useful as an umbrella) cheapens it. The understanding and the pleasure he offers are the real rewards.

This month's Harvard Magazine has a profile of Gawande's life and work I wish I had written.

When Gawande began writing for the New Yorker, the Brigham’s public affairs department wanted to see each piece before it was submitted. “No way was the New Yorker going to allow that,” he says. “[Michael Zinner, Brighman and Women's chief of surgery] stepped in and said, ‘I’ll take responsibility.’ Then he said, ‘You don’t have to show it to me.’ ”

The two men share a fervent belief that pulling back the veil on medicine will do more good than harm, even if it means pushing transparency’s limits right up to the edge of lawsuit territory. “What is the alternative to understanding the complexity of the world?” Gawande asks. “It’s denying it. There’s no way that’s a successful strategy.”

Released

I've let it get too late to say much of anything, but I can say that I left the hospital earlier today and it feels great. My legs are groaning from underuse -- I knew it would have been a good idea to walk some laps along the ward at some point instead of pitching myself to my knees with the utmost dignity trying to negotiate one step here -- but everything else is purring. I'm feeling like we did a really great thing for me by getting this tune-up, and I'm ready to start back getting into life. Part of re-entry included pizza from a nearby farm's wood-burning oven, eaten upstairs on a floor picnic with the kids. I highly recommend this for both therapeutic and gustatory reasons.

It probably seems implausible, but I'll have you know that I'm refraining (for now) from commenting on what I thought was a pretty juicy Kennedy article in today's Times. A good piece in the sense that it raises some interesting policy issues while offering some Doctors Behaving Badly-style color. For those who have read it, doesn't that guy from Duke sound bizarre? I also enjoyed the sniffy M.D. Anderson dude. Physician, heal thy ego.

That squirrelly placebo effect

via Marginal Revolution, a short piece drawing a distinction between two forms of placebo effect, a lesser-known statistical type, and the other, more familiar form involving psychological beliefs and expectations. It's a subject that's been kicked around a little bit lately because there are some reports that the placebo effect in drug trials is getting stronger.

Placebo has strength in numbers (Mind Hacks):

Because the statistical concept of placebo is drawn from the study data, the study itself has an effect.

For example, the strength of the placebo effect is measured relative to the active treatment. The Wired article says that placebo is getting stronger, which is another way of saying that the difference between placebo and the drug is getting smaller.

It turns out that the more rigorous the study the less strong the drug effect is, or, in other words, the stronger the placebo effect.

For example, we know that better designed and higher quality studies show smaller drug effects. This includes things as simple as randomisation. If your method for randomly allocating people to groups is more susceptible to bias, it's more likely to produced biased results. Better randomisation improves the placebo effect, again, nothing to do with expectancy or belief.

So one reason why the placebo effect might be increasing is that studies are just more rigorous these days.

 A bit of a long clip, but there's more there if this subject interests you.

'After Diagnosis, Determined to Make a Good Ending'

Edward Kennedy's approach to the end of his life:

“I’m still here,” Mr. Kennedy would call colleagues out of the blue to say, as if to refute suggestions to the contrary. “Every day is a gift,” was his mantra to begin conversations, said Peter Meade, a friend who met Mr. Kennedy as a 14-year-old volunteer on Mr. Kennedy’s first Senate campaign. 

Some patients given a fatal diagnosis succumb to bitterness and self-pity; others try to cram in everything they have always wanted to do (sky-diving, a trip to China). Mr. Kennedy wanted to project vigor and a determination to keep on going. He chose what he called “prudently aggressive” treatments.

Goodbye, Sen. Kennedy

Senator Kennedy died Tuesday night, a victim of a malignant glioma, the terrible brain tumor which had kept him away from the health-care bill where so many of us has hoped he would conjure his legislative magic one last time.

He was 77.

To say the least, he was a complex man -- for me, growing up either in or on the fringes of conservative Orange County, California, his name was a joke, a sure laugh line, a sort of argument-ender that more confident kids would throw at me. For much of his life, his personal life was worthy of that opprobrium; his alcoholism and moral failures are well known. It's fair, I think, to remember Mary Jo Kopechne today. But looking at the Senate now, and following the careers of legislators like Chuck Grassley, Max Baucus, Harry Reid, Kent Conrad and so many others, Kennedy's political genius and goodwill is ever more apparent. His list of legislative accomplishments, many bipartisan, is long.

And he gave us Obama. I'm truly convinced of that.

Richard Nixon, who earned himself far graver disgrace than Kennedy's in the decade I became aware of politics, did no similar work toward redemption, and yet he received it anyway. I personally don't believe that Kennedy needs redemption at this point. But perhaps his example can still help redeem our politics? I hope now that his life -- his scandals, his strength, his privilege, his tragedy, his inspirational and even ridiculous qualities -- will inspire us to do better.
*
August 28 update: I'm less sure than I was when I wrote this that Kennedy needed no redemption at the end of his life. In any event, it was crass to just throw the idea out there unsupported. Joyce Carol Oates, who wrote a novel inspired by Chappaquiddick, gives the idea the complexity it deserves in a Guardian essay.
*
Card Blue on Edward Kennedy:

Teddy

Ezra Klein gathered a nice collection of links to Kennedy material:

Some Ted Kennedy Links

August 25 hospital post

Still waiting on release. I broke this out from the the main hospital update post to increase my post count make it more legible. Today's question: Heimlich or Pneumostat... Heimlich or Pneumostat? Super-medical-student W., who apparently risks a testicle if he even discusses medical recommendations to be made by the surgeon, suggests doing research on this crucial pre-release question myself. So I do. After perusing a "helpful guide to mobile chest tube drains," I find myself cold to the whole subject. The Pneumostat sounds better to me, but who knows. At least this time I will know how to use the thing, which I didn't the first first time I left the hospital. Making the plan will involve having an X-ray tomorrow morning and discussing things with the surgeon. Residents have opened hope of going home tomorrow, but I'm too smart to be fooled. Right? Riiiight??

In other news, my formerly shy son B. practically mauled departing guest G. in hopes of convincing her to stay longer. (At least that's what I hope he was doing.) Little T. just cried a little. They are so out there with their emotions, and I spend so much time bollixed up.

Haunted

I told L. the other day that I wasn't scared of dying.

It must have sounded like total B.S.

I have cried to her about dying, after all. I have clutched her about dying. She has watched mortality get into me mercilessly at 3 a.m. She has listened as I have tried to isolate the worst parts -- is it the absence, missing the end of the story I so lovingly and hopefully commissioned? Is it the process, the pain that seems to increase until you're trading lucidity for every last bit of control and wakefulness that you fought so long for? And yeah: Before that point, I will certainly fear whatever nasty medical procedures I opt for in the name of comfort or buying time.

But categorically "scared of dying?" I don't know. Our porch steps, when sufficiently icy, may be more threatening than epithelioid sarcoma. Some horrors do not move me. I know is that I'm not going to hell for my petty crimes and misdemeanors (I'm not making fun of this idea in the slightest; I'm just not scared of how I've lived my life.) It agonizes me to think of not being with my family any more, but I know they will be OK without me. Even the scary pain -- at that point, lucidity is overrated. You get the shots.

But then there's the pain of my loved ones: my wife, the little precious ones. Yes, they'll be all right. They may well do better. But there's no morphine for them. It haunts me.

And there's the Zadie Smith problem -- the story you'd like to tell most, the big finale, is the one that, by definition, you cannot share, probably cannot even experience. Sometimes I feel like I don't exist if I can't tell L. something. It haunts me. (So I imagine haunting her.)

*

It haunts me--

I feel crushed beneath the awful weight of wasted time.

With this hospitalization, I feel a sudden burst of energy and purpose, much like the one that burst upon me when I first found out I had a life-threatening illness, but redoubled now because I feel a new urgency about the work I can do for my kids. I'll never finish those efforts -- so I'm not scared there -- but I'm a world-class time fritterer, and there's so much I want to say and do. My parents will be spending a lot of time here over the next several months. I want to spend real time with them; record our voices talking together both for the experience of it and, later, for B. and T. Can I manage.... wisely? Can I fill the right photo album and write the right letter and let go of what's superfluous and, in the midst of it all, leave time for a life for myself?

The challenges go on and on...

L. and I have a lot to talk about.

For complicated, lovely reasons, I never did finish the last Harry Potter, but I remain determined to do so.

My friends are crucial.

I want to invest more in this blog -- and in a new writing project I have hardly begun.

Selfishly, ridiculously, I'd really like one last time at Lucques or Chez Panisse. Or even Frontera.

Last (for now), but not least: This year, damn it, I am going to plant some bulbs.

*

I'm haunted, yes. But it's not all bad.

Hospital report the second (omnibus edition)

Ow. Ow. Ow.

I don't think I will update this much until I get better.

Why did the truck run over me?

*

Aug. 21 update: I'm still sore, but the lung has fully or almost fully expanded with air. It's also leaking air, which the chest tube is allowing to escape, keeping everything expanded. Everyone expected that it might take a while to get the lung fully sealed; the surgeon spent close to an hour scraping off the scar tissue that the previous pleurodesis left behind. I'm honestly not focused on a departure date -- I want this to last, darn it -- but early next week seems plausible. In the meantime, I'm sitting up in a chair, which seemed impossible even yesterday.

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Aug 22 update: I'm a little disappointed about how today has gone medically. Still leaky, so X-rays tomorrow. (Say "CXR" if you want to have a cool way to refer to a chest X-ray.) I've spent some time on my feet, which is good, less time in the chair, which is not so good. I don't feel like I made the jump ahead I did yesterday, but I certainly haven't regressed. I'm comfortable in terms of pain if I remember to keep up on the button, and my breathing is good. I felt more wide-open during the magical first days after getting my very first little pigtail catheter, when I could just effortlessly bring in these great flows of oxygen, but I'm not straining for breath at all. It's more that my lungs are more efficient and I can oxygenate fully without taking a full-on, ultra-deep breath. I have been enjoying a nice stream of visits from well-wishers, which feels great: T., newly cast as Daddy's Girl; L., my rock and stalwart; B., who said, "I haven't gotten to kiss you in five days!"; G., who flew in from California and didn't even get see me with my hair combed, apparently scandalizing the nursing assistant (at least that's what I thought the woman thought; she was confusing me); Scary-smart G.K. who preaches at church and whom I have some questions for (none of which I managed to ask or get answered in today's crowds); and LG., who is hooking me up with books. Damn you, friends and family! You are making me feel so lucky even when I'm... sort of not.

But then again... I sort of am.

*

Aug. 23: I spent a lot of time with W., the super medical student, talking New York restaurants. Habits linger, they truly do. The news in SG medical world is that my posterior chest tube has stopped bubbling and will be removed tomorrow. (The procedure: Morphine + groaning, football-player-like exhale combined with brisk yank. Reduce drama by adding the phrase "remove suture" somewhere around morphine if it is relevant.) The leaky anterior tube will stick around for a day or so on water seal (to get an idea of how it will behave at home). Eventually it will get a one-way drain, probably a much discussed Heimlich, and I will go home. I'm sure there will be some CXR action happening to make sure that the posterior bubble isn't reforming and to make sure the anterior bubble is also behaving nicely. I didn't ask for a revised release date. Wednesday seems plausible, though. Maybe even Tuesday if I'm lucky.

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Aug. 24: One tube is gone. Apparently there are studies on what a patient should do during chest tube removal -- hum, hold breath, release breath, etc. -- and none of it matters all that much, so we opted for me to hold my breath and the silence worked fine. A quick tug followed by a steady pull, a weird internal slither as the tube jerked and spun its way up, and it was gone. I think I'll be in less pain generally and find it easier to get comfortable for sleep, so that's positive. I'm now more confused about what was going on medically, however. I'm not sure that either tube ever "sealed" based on what I'm hearing now, but I was sure that one had based what I was told before. Who knows? Something is bubbling maniacally down there at the moment. If I understand correctly, removing the tube will allow me to start using a Heimlich valve when I go home. The aspirational date for that, I now gather, is Thursday. I'm disappointed but thinking positively.

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Originally published Aug. 20 or so, approximately 6 a.m. Updated as indicated.

'No other'

My goal is to write about palliative care from the perspective of my very limited experience of the phrase. The vein of material isn't exactly rich yet. So far, I haven't gone much beyond accepting more intensive home-nursing services and letting myself articulate palliative care for me personally as a possibly beneficial idea. Going even that far has been hard.

But I'm still upset about the political death panel distortions, and Pauline Chen has a nice column about some of the difficulties and shyness on the physician's side of the conversation, so I thought I would link to that briefly and save my own chaotic views for later. My thought is that here, again, is a place where carelessly applied cancer metaphors can cause so much unnecessary pain. It's easy to think about ending curative treatment of tumors as "giving up" -- but isn't shifting your approach to an illness that isn't getting substantially better more akin to letting go? Or a dozen other phrases that any person or family in the midst of this situation could dream up?

Talking Often, and Calmly, about Dying:

As someone who has written an entire book about the difficulties of caring well for the dying, I find all the fury aimed at halting support of end-of-life care discussions more than a little ironic. Why? Because the truth is that most of us need all the help we can get to start these difficult conversations. The truth is that we never talk or even want to think about talking about dying because we are afraid of dashing our loved one’s or our patient’s hopes. The truth is that we fear — even abhor — these discussions because we believe that by talking about dying we are giving up.

Chen also describes some research findings alluded to here that I still find shocking: Only about one-third of terminally ill patients have discussed end-of-life care with their doctors.

*

This is a narrative that works well with Chen's Web essay. It's tough, but very smart and and informative. My pullquote doesn't really do it justice:

His coolness is his armor. “I do not feel obligated to be sort of eternally involved with the experience of death,” Dr. O’Mahony said. “It’s not healthy to be there all the time.”

But the danger is that “death gets to be banal,” he said.

“Do you know that poem by Dylan Thomas?” Dr. O’Mahony asked with a faint smile. “After the first death, there is no other.”

THE OBLIGATORY DISCLAIMER: Let me reiterate that I'm absolutely not sick like the people in these articles yet, and my doctors agree. I am not using "palliative" as a euphemism for "hospice," "terminal," etc. While I am obviously not a well dude, the fact that I had a decent scan recently and that some things are going pretty well for me at the moment are giving me the strength to look hard at things that scare me.

A touch

My local oncologist, Dr. S, will never be my friend, but I respect her deeply. She's prim and organized, qualities mysterious to me. She laughs at my jokes, which I appreciate. Beyond this, though, she maintains scrupulous personal distance. She's not unfriendly, just aloof.

And yet, when I fell into crisis at the end of June, it was her I was desperate to see.

I throw around a lot of scary, chewy words and ideas here. Cancer has hyped up my emotional expressiveness in ways very good and very bad. But I think this truly was a crisis. I had an almost nonexistent appetite, and eating was a painful chore because my mouth was peppered with little sores and sensitivities. Pounds were sluicing off my too-thin frame. I couldn't sleep at appropriate times. My pain felt uncontrollable.

My breathing, which hadn't been easy for more than a year, had deteriorated slowly but relentlessly. I took the problem for granted even though I was dimly aware that it was neither normal nor acceptable, even for a cancer patient, to be unable to walk from the living room into the kitchen without hunkering down to pant some place along the way.

Some evenings, as pain seemed to drip from the tumor in my hip like poisoned rain and pool in my lower leg and foot, I would just sit and sob as L. tried everything she could think of to help until she, too, was sobbing. My physical problems were formidable, my mental issues insidious. The constant strain either put me into a major situational depression or, more likely, converted a longstanding chronic depression into something fiercer and more debilitating.

I somehow knew I needed Dr. S, and L. somehow got us an appointment almost instantly. As I slumped in a chair and mumbled, Dr. S grasped the essentials and quickly made a sensible and comprehensive plan. The appointment ended with two profundities and a pile of prescriptions. The first profound thing was a referral to the palliative care unit of the Visiting Nurse Association, which I am going to be talking a lot about.

The second was that she touched me. I couldn't recall Dr. S ever doing that outside an exam or handshake.

For some reason, as she talked plainly and kindly about how long and hard my illness had been (thoughts I try not to let into my mind), she felt moved to conclude by reaching out awkwardly and patting my shoulder. I was out of it, but engaged enough to be surprised.

Her hand, I felt at the time, almost burned with portent.

Good or bad I could not say.

*

I'm hoping to write about a half-dozen posts about the experience of starting palliative care while still pursuing a curative option, brivanib. Even though changing focus to palliative efforts is nothing like entering hospice, I found the decision fraught and worth writing about. Posts in the series will be tagged "palliativecare" at the bottom. And need I even say that L. was way smarter about this long before I was?

Hospital report

The latest news from the hospital is that they have scheduled a VATS for me tomorrow at a time to be determined. Since I won't be eating or drinking after midnight in the event that they can somehow squeeze me in as the day's very first case, I'm hoping someone's battery gives them trouble and they get here a scooch late. Otherwise, it could be a very long day.

This will be an actual surgery (albeit laproscopic) with real anesthesia, not that friendly sedative stuff. They will basically work the lung over in a variety of ways, including using talc and what sounds suspiciously like sandpaper to create scarring that will fuse the two layers of pleura that contain the lung together, theoretically making it impossible to collapse. More on that soon. They will remove the two tubes I got this week and insert a big surgical chest tube rather than the little 12 french "pigtails" we've been striking out with this month. Some combination of this work, we hope, will help the lung rise and stop leaking, at which point I will go home.

I don't remember clearly enough to have total confidence, but I'd say my expected stay here after the operation is about four days if all goes well. I've recovered well from this in the past, but it's no fun. It will be more difficult this time because the big, painful new tube is going into an area that is already banged up by the two tubes currently in place and the two-week old one they just removed. I plan to moan, whine and abuse any patient-controlled analgesia they provide. I will also sleep a lot.

That's the news. Here's a little noodling: In a display of good old fashioned surgical arrogance that I've only seen on TV, the doctor here seemed to feel that it would be literally impossible for the lung to collapse after he got through it. Given that I've had a pleurodesis three times and the lung has collapsed partially or mostly after every single one, sometimes disquietingly quickly, I sort of wish we had put down a bet on it. Fortunately, I liked the man and I think he has the chops to back up his confidence, even if he understandably isn't up-to-speed on just how intractable and infiltrative epithelioid sarcoma lung mets are. And, of course, I might of misunderstood what he was trying to say to me.

Let's stipulate I understood him correctly just for fun and think about the first two times I had VATS. (We won't count my first bedside pleurodesis.) I don't know anything about the guy here who did my first VATS other than he specializes in hearts (why don't they tell you that at the time?), but I feel strongly that Dr. Unpronounceable A at Sloan-Kettering was an exceptionally careful and competent physician. Everything from his big, prestigious job to his calm demeanor to his deliberate approach to my case to the incredible expertise, bedside manner and smoothness his chief intern showed when he put in a chest tube at my bedside convinced me. The chest tube I got in the emergency room here at home was like a scene from Saw; the work the young man did in NY was about as traumatic as Miles Davis, plus I got free instructions into how and where to flood the lidocaine for optimum pain control which will no doubt be useful as my career in thoracic surgery progresses. You can trust someone who teaches like that.

My miraculous little boy

LA put together a great day for the kids Saturday despite the difficult circumstance of not knowing when the pulmonologist she desperately wanted to talk with would come in -- 8:30 in the morning? Or 8 at night? (Night.) As she woke this morning, she heard some chinks and giggles and was greeted by a peanut butter sandwich and a glass of milk. ("We don't know how to make coffee," B explained.) They wanted, he explained, to make "your life easier since Daddy is in the hospital."

On one level, I just wanted to cry and cry. You're supposed to get to be a child, not make mom (or dad's) "life easier." But what sensitivity and perception he shows. This is far from the only incident. He truly is a small miracle of gentleness, and I like to think we've had no small part in helping him get to be that way.

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Part what impresses me about this is that it represented a real sacrifice for him. For B., seeing peanut butter, handling peanut butter, SMELLING peanut butter, anything peanut butter is viscerally disgusting. He reacts like he's inhaling deeply from the breath of a javelina.

I also enjoyed how he took the lead in redirecting a compliment, a story familiar to LA/Lee Ann's burgeoning group of Twitter followers:

LA, to the kids: "You guys are sweet."

B: "Our mommy is so sweet!"

T: "...and Daddy is so sweet."

B: "Obviously, we inherited the sweetness gene."

Take that, Craig Venter! Millions (tens of millions?) of dollars spent, and I bet my eight-year-old is closer to deciphering the "sweetness gene" than you.

(Edited Aug. 18 for coherence.)

A sad thing

The matter is basically resolved, so it's silly to post here, but I wanted to say something about the "government death panels" that have been around the news.

First, just how stupid do they think we are? A couple G7's in suits weighing granny's value to society and cutting off or reducing her medical care on that basis. Yeah, right.

What the provision would have done was allow Medicare to pay for end-of-life counseling, including things like the development of advance directives, which help your chosen representatives make choices in accordance to your wishes when you are too sick to make them yourself.

I have been thinking about palliative care a lot -- in part because I have signed up for the home-nursing service's palliative care unit even as I continue chemotherapy -- and advance directives are a key part of that process. I actually did mine quite some time ago, as did L.; in my case it may be time to revise some of my answers, but something is most definitely better than nothing.

It would be great, of course, if everyone were cognizant of the necessity of planning for not being immortal, but since most folks are highly resistant to the simple fact that they too will die one day, a few bucks spent helping folks to make their choices and preferences legally enforceable (hopefully) seems worthwhile. Note that there really isn't anything in the bill for the doctor or social worker here; removing the cost, as I see it, almost exclusively helps the patient, who may feel reluctant to pay to enter a difficult conversation. (The time we spent with a social worker going over the forms was covered without discussion by our cancer center; we paid for legal documents like powers of attorney when we had our lawyer draft our will.)

As I said, though, this is moot: No advance directives in the bill. But I still find myself dispirited by the crude, fear-mongering language used by opponents of the provision, as well as my sense that it was picked as a target purely as a matter of opportunity, not on any rational policy grounds. Even worse, this is an expensive target; expensive (as documented by studies) in terms of end-of-life spending, but, even worse, expensive in terms of human suffering.

It's been a quite while since I did my advance directive, so I may not have much to say about that, but over the next couple weeks, I am going to document MY experiences with opting to use some palliative care services long before they are strictly necessary. Summarizing my responses with some writerly tough love, my feelings are good, bad, intrusive and emotionally charged. Of course, I wouldn't feel right if I didn't expand upon that quite a bit.

On the inside

We went to see the pulmonologist on Friday -- always a mistake! -- and my lungs were even worse than the last time she had seen me two weeks before.

I had some clues beforehand: a slight constriction in my breathing and an increase in fatigue. The advance warning helped me make some preparations for the visits. I washed thoroughly (I'm not supposed to shower at the moment) and gave myself a shampoo in the sink. This will delay my descent into looking bizarre by a day or two. I brought a good book (thanks, Lee!). I even kind of sort of tipped B. by talking to him about how much my doctors are working to help me even when they make choices I don't like, for example keeping me in the hospital. I also skipped lunch, though this was more lack of appetite than premonition. The end result, though, was that we were able to get admitted and get my procedure done (removal of an old tube; insertion of a new one) at a reasonable hour.

Of course, the nurses, billing reps, IV nurses, nursing assistant, residents and the rest of the hospital's manifold "teams" kept me up most of the night; but that's just the way the place works. My room is quiet and, at the moment, I share it with no one.

The plan now? Get a CT scan and form a plan. Everyone's memory is shaky but it seems we've done VATS twice on the right side, but only a bedside pleurodesis on the left. So perhaps a pleurodesis is in order. Troublingly, and unlike every other procedure of this type that I have had, my lung didn't immediately reinflate with air and return to its proper position. I have no idea why. The recent removal of the other tube, or something more sinister?

Wit and wisdom of a naughty girl (part 5 of a 586-part series)

The Naughty Girl is in such an amazing, glorious phase that it seems churlish to keep joking about her naughtiness. (Here's a paraphrase from an e-mail she dictated to me while she was away: "Daddy! I love you so much my head is going to fall off!") However, she retains a certain amount of... let's say, sass. Her pre-school teacher babysat last night and reported the following two vignettes:

1) T. and B. about to have a pillowfight. The equipment is set, the ground rules established, and the bell is about to go off, when T. pauses proceedings to crack and re-crack her knuckles with a sort of exaggerated theatricality and relish you'd expect from a professional wrestling match, not a little girl's bedtime. (If she had a long, waxed mustache, she would have twirled that for good measure.) We didn't even know she knew how to crack her knuckles.

2) It's the last few days of pre-school, and all the rules are relaxed, so two little boys who love to wrestle are given special dispensation to mix it up during a field trip to a nearby farm. T., intrigued by what's going on, sort of strolls up as things are breaking up and says, "I might like to wrestle." One boy, the hockey player, immediately runs away. The other is more game -- sadly, though, my silky-haired, blue-eyed little cherub improvises some sort of deadly hammerlock and has him on the ground in seconds. The match is promptly, and mercifully, called.

Reunited

I had other things to say, but then it seemed easier -- and more eloquent -- to post this image of T., B. and me from yesterday. I'm hoping L. would like to post an image, also.

We're all back together, and it's nice.