Home. As I stare out of my window at the office, looking at the people try to navigate the snows here in Maryland, milling about, hats on heads, gloves, wool coats flapping in the wind, I think about the concept of "home".
I grew up in Los Angeles. Well, part of the time there. Bronx, to Westchester County, to Oklahoma, then California. But, West L.A. was my home from middle school to high school and was formative. Sunny, wealthy, diverse. There were 10-20% Iranians in my high school. It was predominantly Jewish otherwise. 99% of the people went on to college. Every Ivy League school was represented on my block, both in the parents and in their children.
It was privileged to say the least.
But, strangely, it never felt like home to me. There was an artificial quality to it. Maybe it was because I wasn't born there and came as an observer. Maybe I just romanticize my supposed individuality from the materialism.
So, here I am in Baltimore, Maryland.
10 years now and running.
Not a whole lot of Asians, few Iranians. Mainly Christians, white and black.
Most of my patients have a very different background than I do. I practice at one hospital that borders the city and another amidst pure suburbia.
Remnants of blue-collar industrial Baltimore inform my existence. Bethlehem Steel. Sparrows Point. The Aberdeen Proving Grounds military base. Domino Sugar.
Smoking. Heavy metal exposure. Lead paint. Heroin.
When friends from elsewhere ask me if HBO's "The Wire" is really true about its depiction of Baltimore... they are a bit stunned when I say that it is 100% accurate and real.
I've been spit on by patients. Stuck myself with an HIV needle a couple times. Learned more about drug terminology than I ever thought possible. Seen very creative hand tattoos that I never thought could be done in the confines of a person's home.
We travel in life. Sometimes it's tourism to some cruise through the Mediterranean. Camping. Going to a museum or a monument.
Sometimes, though, the traveling is mental. We move somewhere in our minds, we transform as we accumulate each new experience. Our ethics, our worldview change as we grow, age, fall in love, feel loss.
Why the hell do I live here? They always ask me. My friends from home.
Why do I live here?
Because it's my home.
Wednesday, December 23, 2009
What Does A Cure Mean?
"I'm cured, right?"
"Yes."
"So, why can't I walk?"
"Well, it's not as simple as that."
"The cancer was in my back, right? You said it was in my back? Now, it's not. Now, it's CURED..."
It's been 2 months since K.S. finished her chemotherapy for lymphoma. She had had some low back pain for a couple months. She saw her primary doc who had ordered an initial set of spine films and started some physical therapy.
I mean, she's only 40-something, busy in life with kids, family, etc.
Moving boxes, bending to get a casserole, having sex... there are a million reasons why a woman her age can get a little back ache.
Who would have thought it was an aggressive lymphoma eating into her vertebra and eventually compressing her spinal cord?
Well, that is until she one day just started urinating on herself, slipped and a big CRACK let out in her lower back... boom, no feeling and little movement below the belly button.
A spine MRI showed a massive lesion eroding one of her lumbar vertebrae and causing the dreaded "cord compression" and "pathologic fracture".
She had an emergent spine operation, then radiation and chemotherapy... steroids, pain meds, rehab, physical therapy, months of treatment.
A repeat PET/CT scan showed no cancer. A complete remission. Maybe even a cure.
But, she can barely wiggle her toes, has no control over her bowels, has a chronic indwelling catheter in her bladder and has a bed sore.
Is that a cure?
She likely will never make a neurological recovery. Her cord was partially transected during the fracture and it's been months now with little functional improvement.
The prognosis, as we say, is poor.
But, she's alive.
"Maybe I should have just died."
"Don't say that. You are alive. Don't give up."
"Do you ever really think I will walk again?"
"Maybe."
"Tell me the truth."
"Maybe. Don't lose hope."
"Please don't lie to me. Be honest with me."
"No, K.S., I don't think you will ever walk again."
What does it mean to be cured? The cancer is gone, but the patient is destroyed. The life that was once known is no longer and will never come again. No matter what, she can never be made whole again.
Entropy. The 2nd law of thermodynamics says that entropy can never decrease. It can only increase. We all decay. It is the natural order of things.
We age, we wrinkle. Our joints hurt, our minds falter. Our bodies fail us.
I try to think of this as the natural cycle of life. To meditate. To think of the teachings of the Buddha and Taoism to guide me.
But, it's hard. K.S. will never have the moments of joy that she once had before her illness. She will always be a paraplegic. Broken, even if repaired. Always broken.
But... CURED.
Whatever that means.
"Yes."
"So, why can't I walk?"
"Well, it's not as simple as that."
"The cancer was in my back, right? You said it was in my back? Now, it's not. Now, it's CURED..."
It's been 2 months since K.S. finished her chemotherapy for lymphoma. She had had some low back pain for a couple months. She saw her primary doc who had ordered an initial set of spine films and started some physical therapy.
I mean, she's only 40-something, busy in life with kids, family, etc.
Moving boxes, bending to get a casserole, having sex... there are a million reasons why a woman her age can get a little back ache.
Who would have thought it was an aggressive lymphoma eating into her vertebra and eventually compressing her spinal cord?
Well, that is until she one day just started urinating on herself, slipped and a big CRACK let out in her lower back... boom, no feeling and little movement below the belly button.
A spine MRI showed a massive lesion eroding one of her lumbar vertebrae and causing the dreaded "cord compression" and "pathologic fracture".
She had an emergent spine operation, then radiation and chemotherapy... steroids, pain meds, rehab, physical therapy, months of treatment.
A repeat PET/CT scan showed no cancer. A complete remission. Maybe even a cure.
But, she can barely wiggle her toes, has no control over her bowels, has a chronic indwelling catheter in her bladder and has a bed sore.
Is that a cure?
She likely will never make a neurological recovery. Her cord was partially transected during the fracture and it's been months now with little functional improvement.
The prognosis, as we say, is poor.
But, she's alive.
"Maybe I should have just died."
"Don't say that. You are alive. Don't give up."
"Do you ever really think I will walk again?"
"Maybe."
"Tell me the truth."
"Maybe. Don't lose hope."
"Please don't lie to me. Be honest with me."
"No, K.S., I don't think you will ever walk again."
What does it mean to be cured? The cancer is gone, but the patient is destroyed. The life that was once known is no longer and will never come again. No matter what, she can never be made whole again.
Entropy. The 2nd law of thermodynamics says that entropy can never decrease. It can only increase. We all decay. It is the natural order of things.
We age, we wrinkle. Our joints hurt, our minds falter. Our bodies fail us.
I try to think of this as the natural cycle of life. To meditate. To think of the teachings of the Buddha and Taoism to guide me.
But, it's hard. K.S. will never have the moments of joy that she once had before her illness. She will always be a paraplegic. Broken, even if repaired. Always broken.
But... CURED.
Whatever that means.
Monday, December 21, 2009
I'm Focused On Living
"I'm focused on living right now, ON THIS...", she said, pointing to her maimed left breast, as I asked her about loneliness and dating. Then she smiled... "but next year, when my reconstruction is done, watch out."
I'm focused on you, S.G. It's hard to see someone sick at any age. I don't deal with pediatrics so that is often abstract to me.
Honestly, for the patients that are 70 years old and older, part of me thinks that their suffering is a tragedy, but that this is part of the cycle of aging and life. Maybe I'll feel differently when I'm that age.
But, for the 30 and 40 year olds like S.G., struck down with the lymphomas and leukemias and breast cancers and testicular cancers... it's different. They are "young", my age and can articulate their loss and their potential loss so well. They are often smack-dab in the middle of marriage and child rearing and career, so the losses are, some ways, if you can even quantify them, more.
S.G. is in her late 30s. Unmarried. Very sweet. She was diagnosed with node positive breast cancer, stage IIIA a year ago. After surgery and chemo and radiation, a year of Herceptin monoclonal antibody treatment and now anticipating a TRAM reconstruction, she has four more years of hormone treatment, at least.
She's gone into early menopause, can no longer have children, has a disfigured left breast and a distorted body image. Her libido, if there even is such a thing after all of that, is gone. Oh, and her hair thinned prematurely as a result, so she still has to wear a wig.
And, yet she has time to joke with me about all the "action" she's gonna get in 2010. Hell, I can't even think about that.
I hope to face my own death and the death of loved ones with courage and humor and dignity.
There was a massive snowstorm this weekend. As I struggled to get from hospital to hospital amidst the blizzard, I cursed my fate at drawing this crappy weekend call.
But, like all things, today, the sun came out, the streets were cleared and there is a freshness to the air.
Taking care of cancer patients is the same. It's chilling, lonely, fraught with fear and despair. But, there is an end to it. And a beginning again.
What you lose and what you gain is sometimes largely dependent on your mind and spirit.
Like S.G., I'm hoping for a good 2010.
I'm focused on you, S.G. It's hard to see someone sick at any age. I don't deal with pediatrics so that is often abstract to me.
Honestly, for the patients that are 70 years old and older, part of me thinks that their suffering is a tragedy, but that this is part of the cycle of aging and life. Maybe I'll feel differently when I'm that age.
But, for the 30 and 40 year olds like S.G., struck down with the lymphomas and leukemias and breast cancers and testicular cancers... it's different. They are "young", my age and can articulate their loss and their potential loss so well. They are often smack-dab in the middle of marriage and child rearing and career, so the losses are, some ways, if you can even quantify them, more.
S.G. is in her late 30s. Unmarried. Very sweet. She was diagnosed with node positive breast cancer, stage IIIA a year ago. After surgery and chemo and radiation, a year of Herceptin monoclonal antibody treatment and now anticipating a TRAM reconstruction, she has four more years of hormone treatment, at least.
She's gone into early menopause, can no longer have children, has a disfigured left breast and a distorted body image. Her libido, if there even is such a thing after all of that, is gone. Oh, and her hair thinned prematurely as a result, so she still has to wear a wig.
And, yet she has time to joke with me about all the "action" she's gonna get in 2010. Hell, I can't even think about that.
I hope to face my own death and the death of loved ones with courage and humor and dignity.
There was a massive snowstorm this weekend. As I struggled to get from hospital to hospital amidst the blizzard, I cursed my fate at drawing this crappy weekend call.
But, like all things, today, the sun came out, the streets were cleared and there is a freshness to the air.
Taking care of cancer patients is the same. It's chilling, lonely, fraught with fear and despair. But, there is an end to it. And a beginning again.
What you lose and what you gain is sometimes largely dependent on your mind and spirit.
Like S.G., I'm hoping for a good 2010.
Thursday, December 17, 2009
Ode To The Gas Passer
I just heard that a colleague of mine killed himself two days ago. An anesthesiologist. Trained at the same hospital that I came from. Wife. Family. The whole shebang. I don't know the whole story, but apparently, he had been depressed for some time. He had tried once before.
All of this was triggered a year ago by a complication involving a pregnant young woman. First child. 27 years old. Supposed to go well.
It didn't.
She died.
He was involved. He thought he did it. An epidural gone wrong or some crap like that. Just some horrible unforeseen shit went down and he happened to be involved.
So, it ate at him.
Maybe there was some prior depression. But, this doesn't help. So, he finally killed himself.
I never even suspected a thing.
I would talk with him about common patients in the hallway, about his new position coming up, about our time at Hopkins, blah, blah.
I just saw him two fucking weeks ago...
2 weeks.
Two weeks.
When I was in med school at UCLA, 4 classmates killed themselves by the time I graduated.
Four!!!
Problems with boyfriends, with parents, with drugs, with grades, with self-esteem...
We would have some crap lecture every year about the "impaired physician"... something so abstract when you are just trying to use the stethoscope from the right direction or trying to get laid with some nursing student that you met in the library.
Who the hell knows about life and sadness and all that B.S.?
We all carry such pain inside of us. From our lives, our jobs, our families... maybe just from the despair of living on this blue dot, circling this crazy galaxy in this infinite universe.
But, we feel it. It. Sadness? Blah? Something. Despair. Sometimes, we don't even know the unsettled feeling that we feel.
Underneath the veneer of perfection and the titles and the money and the house and the 2.5 kids and the dog, there is a real feeling inside of us that sometimes remains hidden...
I'm sorry for you and your family, C.G. I can't imagine what you felt to think that you caused that young woman's death. I'm so, so sorry that you had to die to make yourself feel less pain.
If there is a heaven, I hope you are in it.
P
All of this was triggered a year ago by a complication involving a pregnant young woman. First child. 27 years old. Supposed to go well.
It didn't.
She died.
He was involved. He thought he did it. An epidural gone wrong or some crap like that. Just some horrible unforeseen shit went down and he happened to be involved.
So, it ate at him.
Maybe there was some prior depression. But, this doesn't help. So, he finally killed himself.
I never even suspected a thing.
I would talk with him about common patients in the hallway, about his new position coming up, about our time at Hopkins, blah, blah.
I just saw him two fucking weeks ago...
2 weeks.
Two weeks.
When I was in med school at UCLA, 4 classmates killed themselves by the time I graduated.
Four!!!
Problems with boyfriends, with parents, with drugs, with grades, with self-esteem...
We would have some crap lecture every year about the "impaired physician"... something so abstract when you are just trying to use the stethoscope from the right direction or trying to get laid with some nursing student that you met in the library.
Who the hell knows about life and sadness and all that B.S.?
We all carry such pain inside of us. From our lives, our jobs, our families... maybe just from the despair of living on this blue dot, circling this crazy galaxy in this infinite universe.
But, we feel it. It. Sadness? Blah? Something. Despair. Sometimes, we don't even know the unsettled feeling that we feel.
Underneath the veneer of perfection and the titles and the money and the house and the 2.5 kids and the dog, there is a real feeling inside of us that sometimes remains hidden...
I'm sorry for you and your family, C.G. I can't imagine what you felt to think that you caused that young woman's death. I'm so, so sorry that you had to die to make yourself feel less pain.
If there is a heaven, I hope you are in it.
P
Monday, December 14, 2009
Christmas
Another holiday approaches. I am not Christian, as anyone who reads my blog would surmise. But, the message of Jesus is one that resonates strongly with me. I suppose it is universal in its appeal.
I try to think of Jesus as a historical figure. An itinerant preacher amongst the Jewish poor, preaching a message of faith, charity and love. This, despite Roman oppression. Despite poverty and sickness and despair. Despite venality and sensuality.
How this message of hope for a better, more just afterlife must have provided such comfort for those who were the most downtrodden in life.
I would hope that we all would reflect some time, amidst the crass materialism of the "holidays" and think of how we can, in our own way, in this singular life of ours, strive for more justice and generosity in our day to day existence. How we can provide hope and help for others less fortunate. How we can lift ourselves up from despair.
The new year approaches. Renewal in the middle of wintertime. Turning towards the spring to come.
Physician, go forward and heal others.
Most of all, heal thyself.
I try to think of Jesus as a historical figure. An itinerant preacher amongst the Jewish poor, preaching a message of faith, charity and love. This, despite Roman oppression. Despite poverty and sickness and despair. Despite venality and sensuality.
How this message of hope for a better, more just afterlife must have provided such comfort for those who were the most downtrodden in life.
I would hope that we all would reflect some time, amidst the crass materialism of the "holidays" and think of how we can, in our own way, in this singular life of ours, strive for more justice and generosity in our day to day existence. How we can provide hope and help for others less fortunate. How we can lift ourselves up from despair.
The new year approaches. Renewal in the middle of wintertime. Turning towards the spring to come.
Physician, go forward and heal others.
Most of all, heal thyself.
Sunday, December 13, 2009
Camus
I've been listening to my books on tape quite a bit recently. Actually, more of a lectures on tape. Albert Camus. That is the latest fascination. I've finished the piece on "The Stranger" and they've moved to the "Myth of Sisyphus". It's not light reading, to say the least. A bedrock of Existential thought, Camus provided some core principles that later philosophers such as Sartre expanded and modified.
The nutshell of his thinking is that life is fundamentally absurd. Devoid of intrinsic meaning. That there is no God. And that we are deluding ourselves by thinking that there is a rhyme or reason to the nature of the universe. There is only life and then death. Nothing more. And that simple fact makes each of our finite lives difficult and ultimately doomed. One solution is suicide. Terminate as soon as possible, since you will one day die anyway. Why wait? The other solution is to delude yourself with fixation on the supernatural. God, mysticism, the unexplainable. To dream or hope or even truly believe that there is a Watchmaker behind all of this, blind or otherwise. The third is to actively embrace your life and its absurdities. To accept the inevitable decline and destruction of life and to revel in it.
I think a lot about Camus lately. The holidays. Cancer. Getting older. My brother turned 40 this year. Our lives are AT LEAST half over. It's ironic that I'm only just starting to really enjoy life and find meaning in it, but it is speeding ever more quickly by. I guess that is the very nature of life.
I wonder sometimes if I would ponder all of this as much if I didn't deal with death on a daily basis. I wonder sometimes if people NEVER think about this. If they blissfully pass through life without much worry or useless thinking. At least until the end.
But, this is my lot. My job makes me think endlessly about death. Even as I relax with a girlfriend or vacation with parents or have drinks with friends. As I exercise. Or read. Or sleep.
And I think of Camus.
Can I embrace life?
The nutshell of his thinking is that life is fundamentally absurd. Devoid of intrinsic meaning. That there is no God. And that we are deluding ourselves by thinking that there is a rhyme or reason to the nature of the universe. There is only life and then death. Nothing more. And that simple fact makes each of our finite lives difficult and ultimately doomed. One solution is suicide. Terminate as soon as possible, since you will one day die anyway. Why wait? The other solution is to delude yourself with fixation on the supernatural. God, mysticism, the unexplainable. To dream or hope or even truly believe that there is a Watchmaker behind all of this, blind or otherwise. The third is to actively embrace your life and its absurdities. To accept the inevitable decline and destruction of life and to revel in it.
I think a lot about Camus lately. The holidays. Cancer. Getting older. My brother turned 40 this year. Our lives are AT LEAST half over. It's ironic that I'm only just starting to really enjoy life and find meaning in it, but it is speeding ever more quickly by. I guess that is the very nature of life.
I wonder sometimes if I would ponder all of this as much if I didn't deal with death on a daily basis. I wonder sometimes if people NEVER think about this. If they blissfully pass through life without much worry or useless thinking. At least until the end.
But, this is my lot. My job makes me think endlessly about death. Even as I relax with a girlfriend or vacation with parents or have drinks with friends. As I exercise. Or read. Or sleep.
And I think of Camus.
Can I embrace life?
Saturday, December 12, 2009
The Holidays
I find the holidays somewhat depressing. Maybe it's the juxtaposition of cancer opposite the Hallmark messages that surround me. Maybe I'm just a curmudgeon. I saw four people yesterday with new cancer diagnoses. All under the age of 50. Young. I'd like to think that I've become more toughened to the nature of suffering, but I'm not sure that is the case. If anything, I feel more sensitive as I get older. I'm not sure why. Maybe it's my own mortality. Maybe I've just come to recognize that there is no judgment of the value of a life. That it is essentially absurd and intrinsically meaningless. But, to each of us, there is some existential meaning that we construct for ourselves. And, after being a doctor now for more than a decade, I accept that our lives are precious, if only for the fact that they are OURS. But, seeing these four kinda got me down.
I am grateful for my job, my occupation, my calling, if you will. It is unique to step outside of our own sphere and see how other lives unfold. To see the movie that plays for each person's hopes and dreams, loves and losses. I reminisce of people that have come and gone. Patients, colleagues. Friends, lovers. Family. And, I feel blessed to have experienced so much in my life.
It's just that cancer sucks a lot. Especially during this time of year.
I am grateful for my job, my occupation, my calling, if you will. It is unique to step outside of our own sphere and see how other lives unfold. To see the movie that plays for each person's hopes and dreams, loves and losses. I reminisce of people that have come and gone. Patients, colleagues. Friends, lovers. Family. And, I feel blessed to have experienced so much in my life.
It's just that cancer sucks a lot. Especially during this time of year.
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