Oasis

Albuquerque almost always suffers draught, and in the summer of 2008, strict water use rules were once again in place to help maintain the dwindling aquifer supporting the desert city.  The city's public education approach for diminishing personal water use was multi-pronged.  The most entertaining, and perhaps the most effective, occurred on the Albuquerque evening news.  Each day the public water utility would calculate which Albuquerque residence used the most water in the preceding 24 hours.  This information was then delivered to the local news station who dispatched a newscaster to the residence and reported live on how many gallons that greedy household consumed.  We called it the water report of shame.  Inevitably the reporter would be standing in front of a lavish mansion surrounded by a lush manicured lawn and sometimes even, gasp, a fountain or koi pond.  For a brief moment, Albuquerque's proletariat paused to chuckle at the follies of the rich, a very small population in an otherwise very poor, hard working state. 

The Albuquerque Water Report of Shame is what I contemplated on the afternoon of July 26, 2012 amidst the longest shower of my life.  Jenny had come to two days before to gently bathe me in the tub avoiding the drain tubes protruding from my right armpit, the large incision on my chest and a smaller incision in my armpit from the lymph node dissection.  The bath was a success and Jenny and I planned to tackle my hair the next day. But I got lazy and then the day after, bold.  I was going to shower myself, upright and one armed.  My Mom helped me roll up a wash cloth, wrap it around my neck, and safety pin a drain bulb to each end like a yoke. 

I examined the shower terrain.  The shampoo and soap were on a shoulder height platform on the left, this would work well because that side was my good arm. I double checked the drain bulb yoke and safety pinned the washcloth tails together to ensure the contraption wouldn't slide off my neck altogether dislodging the drains with the fall.  I stepped in the shower stall. 

The warmth ran over my tangles of dirty hair.  The wash cloth yoke absored water and became heavy around my neck, feeling more secure. It takes a long time to shower using only your non-dominant arm.  To not drop the soap because you don't have a way to pick it up.  To gently wash around the incisions and drain sites when you can't see them.  But for once in a long time, I was in no hurry. 

Why did I attempt my first post-op shower solo?  I was not embarrassed to ask for help or be helped naked.  Jenny would have gladly come to my assistance as she had the day before.  I showered by myself really just to see if I could do it.  And I did.  If I had been in Albuquerque, 413 Benton Street, surely would have been showcased on the evening's water report of shame.  But at least it would have been for an unconventional reason.  A sense of self-efficacy.

Under the Influence

At the end of medical school I still viewed benzodiazepines and opiates as miracle medications that we are lucky to have access to. Midazolam allows people to relax before and during a procedure with no memory of the events.  Morphine and its family members take acute pain away after surgery or while healing from a fracture.  And both benzodiazepines and opiates have had tremendous impact in improving comfort in end of life care.

Three short years of residency training later when I read Vicodin, or Ativan, or Percocet, or worse yet MSContin, on a patient's medication list, I shudder.  I scan the patient's problem list, hoping to see  'fracture,' 'metastatic cancer,' or 'recent surgery' but that only happens 1 out of 100 patients that I see.  Instead, like so many other patients, this next patient has 'chronic pain syndrome.'  The commonly used western medicine diagnosis that explains the use of opiate medication for the long term.

I brace myself before I enter the examining room reviewing the scenarios:  is the woman actually taking the medications or selling them? I have been fooled several times.  If she is taking the medication, is she fully informed about the risks (messes up hormone levels, causes depression, can't drive safely, efficacy wanes overtime as our body gains tolerance)?  Has she tried other things to live with her pain with fewer side effects (acupuncture, meditation, writing, gentle yoga, swimming)?  Where is her pain?  Often time the answer is 'all over.' I remind myself that Dr. Flinders wisely responds "unfortunately these medicines don't help with psychic pain" in such a situation.  I consider the threats I may confront before I enter the exam room with a patient.  "Well, doc, if you don't give me more (fill in the blank benzo or opiate) I will just have to go back to drinking alcohol. I don't want to go back to the booze but I will if I have too."  This happened to me more times than I can count during my residency training.

Now I look at the orange plastic pill bottles with childproof white lids lined up on my dresser. Ibuprofen, Bactrim, Ondasetron.  These words do not bring back distressful patient stories.  The remaining two, oxycodone/acetaminophen (Percocet) or lorazepam (Ativan), brought back the proceeding paragraphs.  Now after having those bottles in my possession for 2 days, those two bottles stare back at me almost as a friendly joke.  My full name in bold printed on each. Several pills already missing from the total count.  I think how much I enjoyed each pill, what comfort it afforded me.  Two more hours of sleep with tolerable pain, a slow walk around the block with David with both dogs to get some fresh air.  Less muscle spasm so I could dress myself more easily.  All the misuse associated with those medications, the deep sorrow my patients carried, my involvement in propagating their use with grave misgivings.  All that darkness slid away.  And again I was thankful.

Nitty Gritty:

1. I am home from the hospital and doing well.

2. I took two short walks today.  Slow walks while David wrangled Luna and Olive himself.

3. I am very sore but it is manageable.

4. I am not nauseous!

5. I have two drains coming out of my arm pit. They will be in for awhile.

6. My surgeon removed two sentinel lymph nodes.  Neither showed cancer during the quick testing they can do during the surgery.  Final results will be ready in about two weeks along with the rest of the tumor results that will help determine what further treatment I need.

7. Friends are taking turns making delicious dinners for my parents, David and I. 

8.  A hummingbird flew into the dining room during dinner tonight.  It left some tiny,tiny feathers then flew back out the door.

Surgery Update

Jessica is out of surgery!  She has been moved to the recovery room and is doing great!  The surgeons said that both the mastectomy and the expander placement went very smooth, no complications, completely straight forward.  Now we wait for Jess to recover.  More updates to come!

*** UPDATE ***
Jessica is out of the recovery room, has zero nausea (is actually drinking a lot, and eating crackers and jello), and is doing great.  she is even feeling up to updating her own blog.  The following is Jessica (slightly drugged) updating her blog (David acting as stenographer):

Hi everybody! that was the best saltine cracker I have ever eaten in my entire life!  We have a view of the city, and I hope to get the oxygen nose prongs out soon.  I'm doing well, and I have been getting wonderful care.  David is staying over night with me in the hospital, and my parents are staying in Oakland with Marc and Lynne(one block from Obama).  Thanks for all the LOVE, good energy, and support. I felt totally surrounded by goodness and healing. 

Non-literary, purely informative

Good morning!  I slept like a rock last night without any medication!


To simplify things, here is more information about this week's lineup:

Monday July 23rd
9am: Lymphoscintigraphy at UCSF China Basin.  More radioactive stuff to localize my sentinel lymph nodes.  This will help Dr. Ewing, my breast cancer surgeon, take out the correct lymph nodes during the surgery using a Geiger counter type device.  Amazing.
2pm:  Mastectomy (just the right breast with cancer) at 2pm at UCSF Mt. Zion.  The surgery is 3-4 hours.  The waiting room is A325. Then I go to the PACU (recovery area). When I am awake enough I will go to the surgical floor of Mt. Zion hospital (4 East).

Tuesday July 24th
I will likely go home Tuesday afternoon.  It is not mastectomy-related problems that would keep me another night but rather full recovery from all the medications used in anesthesia. I will come home with one to two drains.  I refused to get post-mastectomy garments from the medical supply store.  Instead Ellen and I went to TJMaxx and blew $100 bucks on four hip outfits that have holes in the right places for the drains and either pockets or a good match for a hipster fanny pack accessory to hold the drain bulbs. 

Onward
I will be doing my successful healing at my parents' house
413 Benton Street
Santa Rosa, CA 95401

Visitors
You are welcome to visit at my parents house anytime.  If I am asleep, I will stay asleep. Then you can hang out with my parents, David, Luna and Olive who would also benefit from your visit.  As for the hospital, I think visitors bring great energy and I welcome them, however I don't know the UCSF rules. 

Surgery Update
David or Betty will hijack my blog and post an update on how my surgery went.  It will have gone wonderfully (whoa, that was a complicated verb tense), but check back here for confirmation of this.

Help
My parents, David and I will need help with things but we don't know what those things are just yet. My parents, David or Kamin will contact you directly for help with things if needed.  Also, David and I will be moving into Christoph and Brooke's place at some point later this week or next.  We will need lots of help with that since I won't be able to use my right arm for awhile. 

Mariah, thanks for setting up the meal train. The first meal delivery last week from Margo and Jerry was SO WONDERFUL.

Gratitude
Thank you for your love, concern and well wishes.  I feel it and it feels good.  Keep the goodness coming.

Magic Wand

In addition to obtaining a rainbow mohawk wig and two pairs of nerd glasses at Scandia Arcade from our collective skee-ball winnings, I cashed in for a magic wand to commemorate the magic that happened earlier that day. 


The surgery date initially offered by UCSF was August 21st. Then miraculously, twenty-four hours later, I got a phone call stating that they can take me on Monday, July 23rd at 2:15pm.  Amazing!  I don't like that tumor sitting there, just waiting to spread or grow. This will also greatly expedite answers about my long term treatment since it depends on tests that will be repeated on the tumor removed in the surgery. Hooray! I am so grateful. 

Zebra

I had three appointments at UCSF on Friday.  I viewed them as information gathering appointments that I thought would reconfirm my decision to have my mastectomy and treatment here in Santa Rosa.  But surprisingly just the opposite happened. 

Kamin drove me north in the early morning hours from the vacation home my classmates had rented between Carmel and Big Sur to meet my parents at the Mt. Zion campus of UCSF.  Over the next 5 hours worth of consults I had a glimpse back into the world of medical academia.  I met three new attending doctors but also many fellows, residents and a very quiet, smiling medical student with a smart phone harnessed to her blue scrubs. 

The whole experience brought me back not to residency, but to medical school at Stanford.  Santa Rosa is a special place to train.  Residents have significant autonomy.  After intern year, our supervision occurs more discreetly in the clinic workrooms and little comes between each resident and her patient when providing clinical care.  At major academic medical centers, there are many layers of trainees.  Although it had been three years since I had been in this setting, and certainly longer since I had a been a patient in this setting, I slid right back in. The parade of student, resident, fellow, attending did not seem odd to me.  I was not surprised when they made errors or contradicted each other.  It was only after glancing over at my semi-horrified Mother's face during the third consult that I realized this indeed was a circus.   

There is a slang term "medical zebra" for a rare diagnosis or unusual medical situation. "If you hear hoof beats behind you, don't expect to see a zebra."  It is a common medical trainee mistake to jump to the rare diagnosis rather than the more likely, common one.
 
Breast cancer is common.  But what hit me half way through my appointments at UCSF was that I am a medical zebra because of my age, because there is something funky with my breast tumor biology, because likely I have a mutation that has not yet been discovered.  And when you are a zebra, it feels safer to be in the circus because other zebras have flocked there too and you are not alone in the herd. 

Nitty Gritty:
What we do know:
1. I will be have my mastectomy at UCSF, date to be determined.
2. The results of my MRI could not have been better. No other tumors on the cancer side.  No disease on the non-cancer side which means I am still going for a unilateral mastectomy as I had hoped.
3. Her2 status is still up in the air.  My biopsy is on its way to UCSF to be re-checked.

Uncontrolled Crossing

Last night David and I saw Wes Anderson's 'Moonrise Kingdom.'  The movie reminded me all of the different worlds each one of us inhabits simultaneously whether or not we are aware. Yesterday I completed a paperwork extravaganza that made my different roles file in and make themselves obvious.  First I completed the California State Disability blue booklet. I have filled this out countless times for my own patients, but never imagined I would ever fill out the patient section.  Then the medical leave paperwork that must require a PhD to correctly complete since my Master's and M.D. was insufficient.  Next the bohemith online physician credentialing packet for my first job as a full fledged Family Medicine Physician that was due by the end of the day.  And lastly, a rental application for Christoph's place where David, Olive, Luna and I will likely make our home together. 

Last time I had cancer I fought these simultaneously roles.  I was a medical student being treated by my prominent Stanford professors.  I tried to be brilliant rather than vulnerable.  They tried to teach me rather than be saddened by my diagnosis.  I broke up with my boyfriend because I loved him less than he loved me.  I struggled with my parents who desperately tried to protect me from something overwhich they had no control, my own renegade cancer cells.

This time I realize I can be all of these things at once. Because if there is one thing I learned from my first cancer and then confirmed from caring for my patients in residency, is that life is exceedingly messy.  Not just fingerpainting preschooler messy.  An eight year old girl hula-hooping on the back of a lame horse navigating a mine field in order to save a kitten from a burning house kind of messy.  You just got to hula-hoop and move towards the kitten.  Life is an uncontrolled crossing.

D-day

I have traveled this road before. Five years ago I had breast cancer while in medical school. A week before my graduation from family medicine residency, my breast biopsy revealed invasive breast cancer once again. 

 

 

When I saw the new snowy nodule on my routine mammogram, and then on my ultrasound later that evening, I knew what was coming. The biopsy was swift and the results would arrive the next day. I arranged to receive them over the phone to avoid the nauseating silence and clock-watching in the clinic waiting room.  Instead, my family, David and Lynne joined Christoph and his family at Toad in the Hole Pub to watch the Eurocup Germany v. Greece game.  A decent collective distractor.  I was more saavy this time.  My doctor called just as Greece scored a goal. The Germany fans clammered with disapproval as I shimmed out of the pub to recieve the news I already knew.  We filed home quietly and sat in my parents living room. Cancer happens, and it feels unlucky. People cry and swoop in. When cancer happens again, there is less to say. You think, this is not something that should feel familiar.

Last time I wrote privately. In my mind, on the backs of bills, on my laptop in my sundrenched living room in New Mexico with Katie and Boots.  This time I will write here.



The Nitty Gritty
What we know: 
1. The cancer appears small and low grade (slower growing).
2. My surgery date is July 19th in Santa Rosa.
3. The tumor is highly estrogen receptor positive so I will need aggressive anti-estrogen treatment for five years (ovarian suppression and an aromatase inhibitor).

What we don't know:
1. if this is a recurrence or a new cancer.
2. if it has spread to my lymph nodes.  I am hopeful it has not because the tumor is small.
3. if I will have chemotherapy.
4. if this cancer is Her2 positive or negative (first test says yes, a second says no, the third test and several others are in the pipeline).  This result matters because if positive I would have herceptin + chemotherapy.