Archive for the ‘Uncategorized’ Category

Health choices could obviate doctors. Mostly.

April 16, 2019

The winter left gravel and sand

On the roads all over the land

Back home the snow’s pelting

In the north, here, it’s melting.

I’d call the Alaska spring grand.

 Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

I ran into a patient last week not much different in age than myself, who gave me permission to write more about his case than I have.

Every doctor should tell every patient 8 things (not necessarily at every visit): nicotine, caffeine, alcohol, diet, exercise, sleep, seatbelts, and marijuana.  Most of that advice goes unheeded; docs work with people living in the real world making real decisions.  If people did what they know they should, 3 out of 4 physicians would be out of a job. 

This patient, however, has lived his life as an example of a healthy life style.  He loves his wife, he loves  his work.

The medical part of the visit did not last long, dealing mostly with the inevitable consequences of living a half-dozen decades on a planet with gravity.  We had the chance to chat.

He manages dozens of workers in a handful of departments.  I made the comment that I love my work and I don’t have leadership skills.  He told me that’s exactly that kind of person he wants as a department head: the ones who don’t think they’re leaders can make the best leaders.

As the conversation progressed I could tell that I’d love having him as a boss.  Though I aim now at a place on the organizational chart at the same level as the janitor, I could see that with his kind of encouragement I could rise in an organization, and probably love it. 

I have to consider the possibility that lots of people have happy, healthy lives, and thus do not need to see the doctor often.

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Snow melt left all the local paved surfaces covered with sand.  Cars kicked up dust till the street sweepers swept away winter’s detritus, which made the town dusty for about 10 days. 

Two weeks ago, coming back from fishing, a machine on the highway raised a column of dust that could have guided the Children of Israel.

Now most paved surfaces, including sidewalks, have been swept.  Parking lots have lost tons of sand and pea gravel, but almost all have a shrinking snow pile at the edge leaving a thin trickle of melt water draining to the gutter.  When gone, they leave behind more sand and gravel, and the flotsam of winter: hats, gloves, and socks.  It’s spring in Alaska, daytime temps don’t go over 45, freezing nights leave a coat of ice on vehicular windows. 

And back home, in Iowa, they’re still waiting for the last snow fall. 

 

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Literature, gold, and fishing: building rapport with patients.

April 3, 2019

We agree that fishing is fine

What a joy to have one on a line

On a fish charter fling

The salmon are king

But they get away, some of the time.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

I arrived here 2 weeks ago.  Yesterday, I saw 3 patients, my peak day until today, when I saw 5.  With one exception, every patient I’ve seen so far has been male.

The youngest patient to date used to teach English.  Of course I gave my undivided attention, and in short order recommended Beryl Marham’s West With the Night, along with Ernest Hemingway’s posthumously published True At First Light.  We had an excellent discussion about the joys of traveling and working, and exchanged tips on slowing down.

I try to get advice from my retired patients about successful retirement.  All so far have recommended the local senior center and lots of fishing.  One had retired from full-time fishing guide to fishing when he wanted to.

Another of today’s patients mines gold by panning.  It gives him a good deal of exercise (which I always advise), he loves it, it challenges him intellectually, and provides him with an income.  But he wouldn’t say how much.

Most of the time, I ask the patients if they fish (they all say yes here), but today some I treated beat me to the question.  At which I dug my phone out of my pocket and showed off some salmon pictures from the weekend.

king salmon x 4 march 19 Homer Alaska

Friday, Bethany and I,  off on a fishing charter, caught 4 king salmon, and we got another on Sunday.

salmon winter king 2019 March

The king are the  largest of the salmon species, those caught outside of the summer breeding season have the most fat.  Salmon have the healthiest fat of any animal on the planet.

Of the five, our skipper estimated four would come in between 20 and 24 pounds, and the smallest about 16.   My patient admired the photos but in short order admitted he holds a record for one of the nearby rivers at over 60 pounds.

A fish that big, once hooked, does not go quietly into the boat.  The fight that ensues can wear out a person’s grip; the successful catch requires constant line tension.  The fish that charges, making the line go slack, has a good chance of getting away.

Over the weekend we also caught rock fish (sometimes called sea bass or rock cod), ling cod, and kelp greenling.  The captain referred to them as trash fish and threw them back.  None of them weighed more than 4 pounds.  Each one brought its own thrill to the day.

Underworked and overpaid: my 800th post

March 27, 2019

I figured on low patient flow,

At least till the thawing of snow

The warming of spring

The break up will bring

As the snowbirds go to and fro.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

I anticipated low patient flow, but not this low.  So far in the course of three clinic days I’ve attended three patients, average age 70, two of them male.

I asked for and received permission from a patient to write more about his medical problems than I  have.  After extensive investigation and several therapeutic trials with continued deterioration, he came to see me.

One of the previous physicians on the case thinks a lot like I do, and in his thorough work up I found some of the more esoteric tests I enjoy.

The larger the number of doctors you see before you get to me, the smaller the chance that I’ll have anything constructive to add.  Everything reasonable has been investigated up to now, I said, and anything treatable I find relates more to me thinking unreasonably than it does to deficiencies on the part of the other doctors.  Still I ordered a dozen more blood tests, added three new items to the problem list, and recommended a lot of lifestyle modification.  Which, as always, came down to 8 things: nicotine, caffeine, alcohol, diet, exercise, sleep, seatbelts, and marijuana.

I had to explain that my tenure here is very time limited and that further follow-up would be elsewhere.  We discussed the relative merits of the Mayo Clinic and the VA.

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The sun shone brightly today.  The snow, pushed to the edges of the parking lots to form glacier seedlings, is melting steadily, keeping the heat from the days.

Back when rivers served as highways in Alaska, dogs hauled freight on ice, but boats could move more goods faster.  Thus the spring thaw assumed great economic importance during the Gold Rush, which brought non-Natives here in large numbers for the first time.  Alaskans call this season “break up.”

We have had enough trips to Alaska that we can talk about the long Arctic summer day and the weeks of the Arctic night.  We recall when we landed in the rain and flew out after the ocean froze.  But this is the first time we’ve been here for break up.

While fishing on Sunday we noted large floating white chunks, ice come down the rivers and into the sea with the snow melt, along with trees and other debris.

Break up also brings the snowbirds back from the lower 48.  Those folks, on average older than those who rode the winter out here, should bring an increase in patient flow.  Until then, I’m overpaid and underworked.  Not many would complain.

Back in Alaska

March 19, 2019

To come back we both felt the push

To Alaska, this time, not the bush

We see cars, we see trucks,

But never mukluks

You could say that life’s rather cush.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

 

We have now flown so many times to the 49th State that we managed to arrive at our destination the same day we left.  Still, we traveled for 17 hours.

We got here shortly after the “spring forward” time change, which sends the entire country one time zone east.  We dealt with that problem by going three time zones west.

Coming to Alaska till now has meant “the bush” to me: places accessible only by air or water.  High prices, consistent foot traffic, ATVs and snow machines on the streets at all hours.  Life in those places resembles life on islands, with a close sense of geographic identity and an almost  complete lack of theft.  You don’t need driver’s licenses or license plates if you have a vehicle there.  And most people don’t.

The majority of the patients I’ve cared for in the bush have been, well, Alaska Native.  Specialist care means flying into Anchorage (in one place it meant a boat ride to Ketchikan), with all the implied hazards, not to be undertaken lightly.

And now we find ourselves in a metropolitan area with a couple of movie theaters and a really great selection of grocery stores.  The main thoroughfares have traffic lights (that work).  We haven’t seen a single ATV on the streets yet.

The hospital architecture resembles that of the hospitals of western Iowa where I’ve worked, but the directory here lists dozens of doctors, including at least one surgeon.

It’s still Alaska.  Restaurant prices and portions befit the largest state in the Union.  We found a pile of moose droppings five steps from where we parked the car.  The sidewalks show the ravages of multiple, radical freeze-thaw cycles.  The Walmart parking lot pavement consists mostly of chuck holes.  Ravens dominate the skies, eagles come a close second, and the drone of small aircraft continues throughout daylight hours.  When clouds clear, you can see breath-taking mountains in more than one direction.

A moral dwarf amongst real veterans

March 14, 2019

Technically, you can call me a vet

Though I never faced much of a threat

And now the VA,

Making up for bad pay,

Is paying off Uncle Sam’s debt. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada.  Any identifiable patient information has been used with permission.

Bethany and I drove up to the Sioux Falls VA hospital for my annual rheumatology appointment.

I have ankylosing spondylitis, a close cousin of rheumatoid arthritis which primarily affecting the spine.  It hurt me since before I turned 18 until my first injection of Enbrel in 2000.  It kept me out of Viet Nam, but not out of the Public Health Service.

So that I now qualify for Veterans’ Benefits, including health care.  The VA pays for an injectable medication which would retail at over $60,000 per year.  When I need a refill, I make a call and it appears on my doorstep in a Styrofoam insulated box in 2 or 3 days.

By comparison to the price, one 2-hour drive and 4 lab appointments yearly rates as a Best Buy.

Because I hurt for so many decades, by the time the pain stopped my body had gotten really good at generating and recognizing endorphins.  All in all, I feel better than I did when I was 18.

And when I sit in public places, I never stop my physician observations, even when I’m a patient.

I watched and listened to the Real Veterans in the waiting rooms today, and I made diagnoses.  The swollen knuckles of rheumatoid arthritis.  The blotchy facial redness and bags under the eyes of alcoholism.  The bug eyes of hyperthyroidism.  The slowness, shuffle and tremor of Parkinson’s.  Way too many “thousand-yard stares” of PTSD.  The scalp scars, cane, and abnormal gait of a traumatic brain injury.  Too many missing limbs to count.  Behind me, the conversation’s speed and volume (loud enough to hear, too fast to understand) of bipolar mania.  The hopeless faces of depression.   And attentive spouses steering veterans in wheelchairs.

While the lab tech (who gave me permission to write this) drew my blood, I noticed swelling in the front lower part of her neck.  I told her to get her thyroid checked, specifying thyroid stimulating hormone (TSH), and anti-thyroid peroxidase (TPO); and an ultrasound if those tests come up normal.

It doesn’t take much historical knowledge to be able to recognize the conflict that modified the hero.  Although, with two fronts ongoing for the last 25 years, I can’t tell the Iraq vets from their Afghanistan contemporaries.  Some served in both theatres.  Some Korean vets served in Viet Nam.

I don’t feel myself a veteran in the presence of the real ones, I feel a moral dwarf.  I never faced a greater danger than a drunk’s slow punch in the ER.  I put up with bad pay and bad management for 5 years.  I lost income, my fellow beneficiaries lost things that cannot be replaced.

Still, the VA treats me the same as they treat the Real Veterans.  Part of the culture of VA employees involves a lot of caring and warmth that people bring from their hearts but the Federal Government does not pay them for.

For my time in the Public Health Service I got 5 years of cross-cultural experiences that could never be purchased.  And now I get benefits equal in value to a good full-time job.

 

 

March 10, 2019

I had me a weekend on call

With patients good-looking and tall

As the assignment will end

A free day I’ll spend

And perhaps I’ll return in the fall

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

I had call for this locum assignment’s last weekend. Things started abruptly with three complicated patients already in Emergency.

Over the course of the weekend I hospitalized one patient overnight.

Winter sports generate their fair share of injuries. Despite good protective equipment I took care of hockey players who encountered a basic truth of the universe: two objects cannot occupy the same space at the same time.

I have not seen nor heard of a curling-related injury. That sport has limited following in the US, perhaps because of its lack of violence.

Newton’s 3 laws (a body in motion remains in motion unless acted on by an external force, a body at rest remains at rest unless acted on by an external force, and every action has an equal and opposite reaction) applies to skiers and snowboarders, no matter how good-looking they are.

Canada legalized marijuana less than a year ago. The legal stuff carries high potency, and comes at an affordable price.  I cannot for the life of me figure out why anyone would run the risk of illegal adulterated weed in the face of accessibility of a relatively pure product.  But some people do.

In other places, at other times, I’ve taken care of people who consumed so much alcohol that they lost consciousness during winter snow falls. Brought to the ER, the ambulance crews could estimate the length of time they had been exposed to the cold by the depth of the snow that had accumulated.  Not one of them developed frostbite.

Which does not mean I don’t see an occasional case. The most memorable one came one summer in New Mexico, when the patient, bitten by a rattle snake and ignoring instructions to keep a layer of cloth between skin and ice pack, froze the top layer of skin.

When the sun came up Monday morning I could account for a decent 6 hours of sleep.

The weekend call doctor here gets Monday off. After a leisurely breakfast, I came in about 9:00AM and started working on clearing up administrative odds and ends.

The office manager found me after lunch, hard at work rewriting a referral letter that I’d sent to the wrong specialist, not realizing two had the same distinctive, 4-syllable name.

The government covers rural physicians for 43 days of yearly locum tenens, running from April 1 to March 31. She explained that my Sunday call exhausted that particular account.  Tuesday, this assignment’s last day, could not be paid for.

I grinned.

A day off.

Part of the adventure.

 

 

 

Teaching 3 things I didn’t learn in med school

February 26, 2019

The student might have thought I was mad

When I lit up an alcohol pad

And then used that fire

To heat up a wire

But then I made happy the sad.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

Some of the docs here have decided to split weekend call so as to avoid working 72 continuous hours, a step I regard as so healthy that I volunteered for Saturday call last weekend. I had the chance to teach a medical student, Dyon, who intends to do a Family Practice residency.

All patients mentioned gave permission to write about their cases.

The first patient came in with a subungual hematoma, or blood clot under the finger or toe nail. A very painful problem, but one easy to cure by putting a hole into the nail.

The nurses couldn’t find the usual tool, an electrocautery, which looks like a disposable electric soldering iron.

I taped an unfolded paper clip to a tongue depressor with 3cm of wired extending past the end. In the absence of a Bunsen burner, I turned an alcohol pad into an alcohol lamp by tearing a corner from the foil packet and lighting it with the patient’s cigarette lighter.  The student, in his capacity as fireman, held the flame close at hand.  I kept the paper clip tip in the hottest part of the flame till it glowed, and applied it to the nail.  It sizzled nicely but cooled too quickly to go all the way through.  The first “alcohol lamp” burnt out before resolving the problem.  Then the patient volunteered to keep his lighter burning.  On the 3rd try, the glowing metal melted the nail, and close to half a teaspoon of dark red blood spurted free.  The patient, like most in his situation, had such relief that he started to chuckle, probably from endorphin rebound.

In short order we faced an 11-month-old, and another chance to teach. When babies, about 10 months old, distinguish family from non-family, they fear strangers.  While humans can see from birth, it takes till age 9 to fully organize the information coming from our eyes.  Thus, if you don’t make eye contact with a 10-month-old patient, you can examine the ears without force or trauma; they think if they can’t see you, then you can’t see them.  The trick worked on the 11-month-old.

About an hour after, an adolescent arrived with a toothache. Standard treatment consists of pills for pain and infection; in addition I showed the student, the patient, and the parent how to find the acupuncture point that the Chinese call Ho-Ku and that Western anatomists call the branching point of the superficial radial nerve.

For all three patients I got to show off knowledge acquired outside of medical school.

Taking Call: the best reality show

February 24, 2019

I volunteered to take call

And it wasn’t a wonder at all

For no Valentine’s date,

I’m missing my mate

And hanging out in the hospital’s hall.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

The US had President’s day while Canada celebrated Family Day. I took call Sunday.

In truth, I don’t like call. But while Bethany visits her sisters in Arizona, hospital duty beats sitting and watching TV.

Over the course of 24 hours I cared for 12 people, half before noon. I called in x-ray twice and lab once.

I told two patients that I couldn’t possibly give better advice than their 12-step programs.

Several people required prescriptions, but the pharmacies here would stay closed 2 days running. Like most Emergency Departments, ours houses a limited number of drugs that can be dispensed until the drugstores open up.  For three of those patients, I wrote standing orders: they could receive, for example, injected or inhaled medications till Tuesday

One patient needed an x-ray, but, as the problem had been present for 2 weeks, I gave a splint and a requisition for the study on Wednesday.

One person’s repeated denials of domestic violence failed to convince me, and the spouse’s behavior raised further suspicions.

But like my patients who drink to excess and smoke things they shouldn’t, my good advice only goes so far, and if I try to push good advice, I risk alienating the person. I get more patients to change by building rapport.

I had attended 4 people before, and they greeted me warmly.

Half the patients came in before noon. For the rest of the day, they arrived singly or in pairs.  I never fell too far behind in my documentation.

The last patient arrived by ambulance an hour and a half before midnight. Over the course of the day the mercury had gone from -12C to -20C (single digits to 0 Fahrenheit).  I kept driving back and forth rather than walking, not so much because of the cold but because the air is so dry the windshield didn’t need scraping.

That last patient proved quite complex, needing IV treatments and both lab and x-ray evaluation.

I left the hospital about 1:00AM, reasonably tired.

A long day working, certainly. But right now, with Bethany visiting her sisters in Arizona, hanging out with patients and nurses at the Hospital constitutes a better reality show than anything on TV.

A fast 3 weeks vacation

February 14, 2019

In Denver we sat down for a meal,

To talk of how people heal.

We were shooting the breeze

Speaking medicalese

It’s just our typical spiel.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. I took three weeks’ vacation between assignments.

Three weeks’ vacation went fast. We had enough time for laundry and almost enough time for mail before we visited our (physician) daughter, her (physician) husband and their two children in Texas.  Not surprisingly, dinner conversation included medical topics as common as B12 deficiency and as esoteric as clivochordoma (a ridiculously rare sort of brain tumor).  But we also talked about normal stuff like the grandchildren developing, the political situation, physician career development (for all 3 of us doctors) and the progress of my Texas medical license , which I started back in May.

Some states make licensing easier than others, and I wondered out loud who oversees licensing authorities to make sure they act in the State’s best interests.

Bethany and I stayed 2 days with the 2 grandchildren (who between them don’t have 4 calendar years) listening to the pounding of the Galveston surf and watching squadrons of pelicans fishing in knee-deep water.

We flew directly from Houston to Denver. Our youngest daughter and her husband came to Colorado to touch base with family and friends before a planned move to Israel.  Three of my 6 sib, along with spouses and children, live in Denver.

We met in a Persian restaurant for supper.

Medicine has warped our conversations and vocabularies, starting with our internist/cardiologist/Emergency physician father who dropped the words “myocardial infarction” (heart attack) at least six times a meal.

When I had young children, and even after, I literally brought my work home with me, sometimes attending patients in the basement and usually dictating office notes after supper. When I had call, I took the kids with me to the hospital starting, before the first one could walk to when the youngest one hit puberty.  Of course family meals included discussions of the drama and irony my work.

Our youngest daughter married the youngest son of my former medical partner. One of my Denver sisters, an interpreter for the deaf, has been through veterinary school 3 times, and she does a lot of ER interpreting.  Her son, just done with premed, is in the process of studying for the MCAT (Medical College Aptitude Test).  My Denver brother, a paramedic for decades, will apply to PA school within the year.

My other Denver sister has a PhD, arguably the more normal sort of doctor.

The family’s way-off-the-wall sense of humor dominated the evening. At the end of the meal we had a short hands-on colloquium on OMT, or, in common English, back cracking.

 

Saxophone and life lessons

February 3, 2019

In Memoriam

Diane G.

March 28, 1960- January 24, 2019

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. Just back from my 4th Canadian assignment, I’m taking some time off in the States

After a miraculous, 15 year fight with cancer, Diane, my friend and saxophone teacher, died last week. I was with her when she passed, not as her physician but as her friend.  Bethany was there as a friend as well, and to support me.

She died surrounded by the love of her friends and her family.

Diane had to see other physicians while I went locum tenens, but I never found another music teacher. Thursdays when in town meant life lessons along with music.  She would not accept money, so I brought chicken soup.

At her urging, and with her permission, I wrote about her in 2011. I have included the post word-for-word below.

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog.

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant.

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her.

“Well,” I said, “Just lay back on the exam table while I check your tummy.”

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart.

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post https://walkaboutdoc.wordpress.com/2010/05/23/can-a-soprano-beat-a-naked-lady/)

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.