Daniel Menaker

Onconversations XVIII–Part Two

Wednesday, November 30, 2011

PULMONOLOGIST’S NURSE (in the examination room, checking my history just before the thoracentesis procedure starts): So you developed a slight fever and chills and had some pain in your chest and shoulder after the biopsy.
ME (grouchy): Yes, and because of the biopsy, if you ask me. Even Dr. ______  seems to think so.
NURSE. Ah-ah-ah! Now we know that correlation isn’t the same as causation. Heh heh.
ME: Well, there’s no point in arguing about this, but that has never stopped me before, so why should it now? So you think it’s possible that I had this biopsy done and immediately afterward started developing symptoms just as a coincidence?
NURSE: I’m just saying we don’t know that the one thing led to the other
ME: I know.

——

DOCTOR (at the beginning of the thoracentesis, with me sitting with my back to the doctor, gown open, back draped, about to be numbed and then punctured): Oh, we have the warm gel.
ME: That’s a new amenity.
DOCTOR: Try to breathe normally.
ME: Easy for you to say.
DOCTOR (laughs): Do you want to see the fluid–what’s going on here–in the ultrasound image?
ME: Sure.
DOCTOR: OK, you can turn around for a minute. (He points to various areas.)  This is the fluid–it’s even less than I thought it would be.  This is scar tissue, no doubt from the needle biopsy.
ME (to myself): Are you listening, Nurse Correlation Is Not Causation–he is in the room with us. (Out loud): What’s are the white lines?
DOCTOR: Probably small adhesions from the biopsy. Unfortunate but not serious.
ME (to myself):  QED. But you know you are angry only really because you are scared, right? Nothing to be done about that biopsy now, except to keep mis-typing it, perhaps wishfully, as “biposy.”
DOCTOR: You’re going to feel a pinch [translation: pain] and then some pressure [more pain].
ME: Wonch!
DOCTOR: That’s the little vacuum, probably sucking at the inner pleura and the lung.  I just want to make sure I get everything. We’re almost done…..  (a few minutes later) OK. all finished. Do you want to see this stuff?
ME: Yes.
DOCTOR (Showing me  a vial of bright-red liquid): About two hundred cc’s. Chump change.
ME:  I get it–cc’s–chump change.
DOCTOR (not laughing): It’s red because there’s some blood, as I expected. But nothing to worry about.
NURSE (happily): Sometimes we get a liter, or even two liters!

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Onconversations XVIII–Part One

Monday, November 28, 2011

(After the second needle biopsy I had, a few weeks ago, to determine if the lower, unclustered tiny nodule was malignant–it was; I knew it would be–I developed a pleural effusion: some fluid between the pleura of my halved and benighted left lung. This was in my opinion the result of a bungled procedure–it sort of felt bungled while it was going on, even though I was sedated and imagined that extraterrestrials were in the room. In order to treat the nodules, they have to be stable and in the same place, so the deformative fluid outside the lung had to be reabsorbed or taken out. The wait for the radiation was growing longer, so I went to see the interventional pulmonologist yesterday (late, on the day before Thanksgiving). He is a handsome, confident man, and evidently a leader in his fairly new field.)

DOCTOR:  Doctor _______ wants to start SBRT as soon as possible. There have already been some delays, and we can’t count on the nodules remaining indolent forever. So our suggestion is that I perform a thoracentesis [needle draining of the fluid] right now.
ME (gulping invisibly; more needles!): Um, OK, I guess.
DOCTOR: OK, so there are some things we need to do first–get an X-ray, take your vitals, go over your history with the nurse. Then we’ll do the procedure, numb the skin area on your back, and use an ultrasound device to guide the needle and insert the tiny catheter to drain the fluid.  Then we can analyze it and see what it actually is and hope it doesn’t come back
ME: Er, OK. Actually is?
DOCTOR: My guess is that there is some blood, a lot of protein, this and that. If it’s all blood, which is extremely unlikely, well that would be a problem, for various reasons that it’s pointless to go into, especially since I really don’t think it is. So let’s proceed.

——

VITALS NURSE (about 65, jolly, daffy lipstick, with a Caribbean lilt): So sit down right here and let me check your blood pressure.
ME: I don’t know–I’m worried it will be high with you looking so beautiful in that uniform.
NURSE: (laughing): Oh, a funny one! Thank goodness–it’s now so late in the day.
ME: Do you have  a date tonight?
NURSE: Of course!
ME: How about your friend sitting over there?
OTHER NURSE: I do, too.
ME: With different guys, I hope.
NURSE: (laughs): Get up on that scale now…. Let’s see 75.3–that’s about 175 pounds.
ME: The shoes are pretty heavy, and my wallet is really loaded. It’s really more like 170, I think.
NURSE:  OK, now let me take the blood-oxygen level. (Puts one of those gentle alligator clips on my forefinger, and for the hundredth time I wonder how they work). 98–very good!
ME: Well, thanks. I told you–
NURSE (interrupting, very serious, leans forward): You are glorified and sacred. Do you know that?
ME:  Well thank you.
NURSE: I mean what I say–gloriFIED and saCRED.  Now you can roll your sleeve down and go back to the examination room.
ME:  Thank you for your help. I hope you have a wonderful Thanksgiving.
NURSE (leaning forward seriously again): Also do not forget this: You are fiercely and perfectly made. Hear me–fiercely and perfectly made.

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Onconversations XVII

Monday, November 21, 2011

(Phone at home rings)
ASSISTANT: Is this Mr. Robert?
ME: Well, this is Robert Menaker [MEN-ah-ker].
ASST: Oh, yes, Mr. Menaker [men-A-ker]. Are you Mr. Robert Menaker?
ME: Yes.
ASST:  This is ________, from Dr. ______’s office.
ME: Oh, yes–hi. I bet you’re calling to confirm next Wednesday’s appointment.
ASST: Let me see.
ME: It’s only Friday–this is an early confirmation, if that’s what it is. Very conscientious.
ASST: I’m calling to confirm that you have an appointment with Dr. _____ next Wednesday.
ME: Right.  Well you know, it’s only a tentative appointment.
ASST: Next Wednesday, at 4 P.M.
ME: Right, but it’s only tentative.
ASST: But you can confirm it?
ME: Well, it depends on what the X-ray that I’m having on Monday indicates. If the fluid under my left lung is gone, as I hope and think it will be, then I won’t have to see Dr. ______ for the thoracentesis on Wednesday. But if it’s not gone, then yes, I’ll see Dr. _____ at 4 PM on Wednesday.
ASST:  Please hold on for moment.
……………………………………………………………………………………..
ASST (back on the line. Obviously): Depending on what an X-ray on Monday shows, you will have an appointment with Dr. _________ on Wednesday at 4 P.M.
ME: Right.
ASST: Your appointment for the X-ray is at 1 P.M. on Monday, at the main campus.
ME: All correct, except the X-ray is on East __th Street.
ASST: Hold on just one second…. The  X-ray will be taken on East __th Street.
ME: Right.
ASST: We will call Dr. ______ on Monday or Tuesday to find out the results of the X-ray.
ME: Good.
ASST: And then we’ll call you to confirm or cancel your appointment with with Dr. _______ on Wednesday.
ME: Of course.

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Onconversations XVI–Part Two

Monday, November 14, 2011

Before they did the PET scan mentioned in Part One, they made a body mold. Of me. Of my back from the waist up. You lie down on the granite-hard PET table on a big, long plastic bag filled with what feels like warm oatmeal. You lie perfectly still for fifteen or twenty minutes. (There is a lot of lying perfectly still in this business.) The oatmeal hardens around you and, voila!–or as I used to say when I was nine and just [mis]reading the word, “viola!”–there is a cast of your back which will be used to keep you in place when the lung-nodule stereotactic body radiation therapy begins.

PET TECHNICIAN: This looks very good.
ME: I did my best not to move.
TECHNICIAN: Some people can’t seem to help twitching and shifting. But you make a good impression. (We both laugh.)
ME: I bet you never made or heard that joke ever before.
TECHNICIAN: You know, I think that’s only the second time in all the time I’ve been doing this.
ME: I’m impressed

I go back to sit in the recliner and let the stoplight-red contrast continue to circulate.

NURSE (from a desk near the recliner row to someone I can’t see): I’m going to inject Menaker!

She comes in and adds some radioisotopes to my already tinctured vascular system by means of the IV she started what seems like three weeks ago but is actually only about two and a half hours ago. Then they take me back into the PET room (where I had the impression made) for the PET itself.  The PET consists of once again lying perfectly still on the very hard table but this time with my arms stretched out over my head and being ferried to the far end of  a tube and then being slowly drawn back through it. Did I say “slowly”? The entire Pleistocene could have taken place. Somewhat worried about creating a “hot spot,” I nevertheless try to think about and remember things that I am certainly not going to mention here. But like the Pleistocene Era, the scan did in fact come to an end. Bringing my right shoulder down out of that position afterward  reminded me of trying to loosen a rusty bolt on a tire. Only with pain.

DOCTOR (radiologist): Well, the good news first.
ME (to myself) : Oh, fuck.
DOCTOR: The nodules are exactly the same, very small, and there is no evidence of any other hot spot anywhere in your body or in the pleural effusion outside your lung. That’s the not-so-good news–the effusion.
ME:The what?
DOCTOR: The pleural effusion.  You see, there is a buildup of fluid around the base of your left lung, probably as a result of the needle biopsy that was done a couple of weeks ago. It happens in about five per cent of those procedures.
ME: Oh. Well, that explains why I was sick, right? Slight fever, night sweats.
DOCTOR: Almost certainly
ME: I knew something went wrong during that test.
DOCTOR: What?
ME: Do you really want to know?
DOCTOR: I asked.
ME: Well, believe it or not, I don’t like to complain.   But I thought the procedure was disorganized in general and when they put the needle into my lung, even though I was sedated, I felt something–well, “pop” is too strong a word, but something seemed to just feel wrong.
DOCTOR: I see. It’s going to be hard to figure out cause and effect here. But in any case, imagine a balloon filled with Jello with three or four beans in it.
ME: Why?
DOCTOR: Bear with me. Now imagine you push the outside of that balloon, even if only a little. What happens to the beans?
ME: Oh, I get it–they move.
DOCTOR: Right. So if the beans represent the nodules we want to treat they are slightly out of place right now. And they have to be in exactly the right pace for us to target them when we do the radiation. So we will give the fluid time to re-adsorb and then proceed with the treatment.
ME: When?
DOCTOR:  Come back in two weeks and we’ll take a quick CT scan and I hope we’ll be able to proceed very quickly after that.
ME: And if there’s still some fluid there.
DOCTOR:  We’ll do a thoracentesis. It’s–
ME: I sort of know what it is. Somebody takes the fluid out with yet another needle.
DOCTOR: But I hope it won’t be necessary.

He leaves. Leaves me alone with the radiology fellow who is his assistant.

ME: It was probably a bacterial infection, right?
FELLOW: Almost certainly.
ME: Why didn’t someone give me some antibiotics when I got a fever, just in case.
FELLOW: That’s a good question. I’ll ask.
ME: So if the rate is five per cent, that pretty clearly indicates that the effusion is iatrogenic. Do you know that that means?
(Here I would immediately like to kill myself on the spot and spare lung cancer the trouble–for asking such a condescending question.) I’m so sorry–that was patronizing.
FELLOW: It’s OK. Yes, it has to be almost always iatrogenic.
ME: I mean, you’re an iatros yourself. I can’t believe I said that.
FELLOW: It’s really OK.  You’re in a very anxious situation. Probably trying to regain control.

We smile and shake hands. She leaves. The PET technician comes back in, whistling a tune.

ME: I recognize that–it’s Ralph Vaughan Williams or something, right?
TECHNICIAN: Uh, no. It’s The Who. “Tommy.”
ME (suicidal again): Oh. Right.

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Onconversations XVI–Part One

Friday, November 11, 2011

At 3 AM  on the day of my second PET-scan–the first having been cancelled because I had breakfast and some Oreos because no one told me not to eat for at least six hours before the procedure–I get up and have a peanut-butter-and-jelly sandwich with a side of half an Ambien–exactly six hours before my rescheduled PET-scan appointment.  They refer to the building I go to–the one where, owing to renovations you have to go up an extra floor to get to a place where you can walk an endless corridor to get to an elevator to take you back down a floor–the “main campus.” It’s 8:45, and my appointment is at 9:30.  I wanted to avoid High Rush Hour going across town and also figure maybe I can jump the PET line. I am taken to a small cubicle to undress from the waist up and put on one of those open-in-the-back gowns whose resistance to being tied in any sort of modest and comfortable fashion was taken care of, comically speaking, long ago.

NURSE (starting an IV, for the radioisotopes that will be plungered into my vascular apparatus later): How are your veins?
ME: I’ve been told they’re very good.
NURSE (tying beige, junkie-style rubber tubing around my upper right arm): Let’s see. (She taps  veins on my wrist, in the middle of my forearm, and in the crook of my elbow.) I’ll put the IV here [mid-forearm] to let you read your newspaper without crimping the line.
ME: Thanks. (I look at her ID tag.)  Is your name Irish?
NURSE:  Scottish, but I’m a little bit of everything–you know: Scottish, Irish, Hungarian, some Greek.
ME: And how long have you been here, at _______?
NURSE: Twenty-five years.
ME: Wow! A long time.
NURSE: Aiming for thirty because then I get to have this special health insurance that —  (She goes to explain a complex group of benefits that she’ll get with five more years’  employment.) A lot of us are just waiting for that thirty-year mark.  I’ll be sixty when it happens. Imagine! Sixty!
ME:    Chicken feed.

I wait and wait and read the newspaper without crimping the line. The nurse comes back and says, “You’re second this morning” and takes me to another curtained-off cubicle down the hall, next to the PET-scan room itself, where I wait some more. I guess I didn’t jump the line. The peanut-butter-and-jelly sandwich could have been at 4 or even 5. There’s a guy already there, bald, gowned, coughing, waiting in the curtained-off recliner next to me. When I’m seated, I lean forward and can see only the deeply-crevassed soles of his running shoes.  Then the nurse come back and weighs and measures him–“Five-eight, one-eighty,” she reads out.  Six feet, one-seventy, in case you’re interested.  Like a blade, a melancholy 19th-Century chevalier home from the Prussian Front.

NURSE (coming into my cubicle with two Styrofoam cups filled with brake-light-red liquid): You should drink these, for contrast.
ME: They look like Gatorade for Venusians. (I take a sip. I have done this before–I had to drink four of these cups for my first PET scan, three years ago or so, but it was an incandescent celery-green in color and tasted the way I imagined WD-40 would taste with five packets of Equal added to it.  Then, to the nurse): Hey! This isn’t so bad. But do I have to guzzle it?
NURSE: No–you have to wait maybe another hour for this to circulate.
ME (to myself): Maybe even 6 A.M.

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Onconversations XV

Tuesday, November 08, 2011

On the radiology floor, which is being loudly renovated, adding to the general Kafka-esque or “Brazil” feeling of the whole place, they call me into a small dark curtained-off room where various tests are performed by a tiny, young subcontinental-looking woman. From the adjacent curtained-off room, I hear the sound of a cripple’s boots sloshing through very wet mud. What is going on? I look up at a monitor and there seems to be an ultra-sound of a fetus only it’s all wrong. Oh, it’s a heart. Oh, it’s my heart. The subcontinental turns a dial and suddenly the cripple is in my cubicle and I realize it’s the sound of blood being fa-LUMPed around in my very own heart. This is the sound of my life. It will be stilled someday.  Very strange.
When I go back to this floor a few days later–up this elevator, not that one, because of the renovation, then turn left, check in with reception and they’ll send you down the hall where you can take another elevator back down to 3, I wait for a PET scan and then preparation (it’s called “simulation”)  for  SBRT.  The preparation consists of making a body mold, of me, so that I will be still when they bombard my lung nodules with high-powered radiation, and tattooing my chest, indelibly, to help aim the rays, and other mapping and positioning procedures.

SON: Permanent tattoos, Dad?
ME: Yes.
SON: Cool!

I am walking toward the dressing room to get ready for the simulation. I have been waiting for an hour or so as people in various stages of health and deterioration–a wig, a cane, portable oxygen, shiny pate–come and go.

RECEPTIONIST: Did you drop this, sir? (I turn around. She is holding a small round brown object.)
ME (recognizing the object): Oh, yes. I guess so. It’s an Oreo. It must have fallen out of this tote bag. Ya caught me. Oreos.
RECEPTIONIST: (laughs, but a cloud crosses her face): Oh, OK. Um, tell Dr. _____ about this, if you’ve been eating Oreos, OK?
ME: Uh, sure. Well, I’ll just throw this one out. (I do so.) If I were home I’d probably eat it. Shh. But here it might not be such a good idea.
RECEPTIONIST: (laughs feebly)

In the changing room, I change. Dr. _______, pretty young “Fellow” with a lovely smile whom I’ve met before, comes in.

ME: The receptionist told me I should tell you I’ve eaten a few Oreos. Are they carcinogenic or something?
DOCTOR: No, but wait. You’ve had something to eat?
ME: Yes–a couple of Oreos. A little embarrassing, I guess. Comfort food, or something.
DOCTOR: Did you eat breakfast?
ME: Yes–was I not supposed to?
DOCTOR: No, not when you’re going to have a PET scan. Didn’t Dr. _______ [thoracic oncologist] tell you?
ME: No. Neither did Dr. _________ [radiologist, and her supervisor].
DOCTOR: Well, they both probably thought the other was going to tell you.
ME: Well, neither did.
DOCTOR:  I have to talk to Dr. ______. But he’s in a meeting.

I wait another half hour. The supervisor Dr. _______ finally enters.

DOCTOR: Well, we can do the simulation but you’ll have to come back for the PET. You’re not supposed to eat anything for six hours before the PET. Dr. _______ wants the PET because you’ve had a fever and some night sweats.
ME: Yes, I know. I mean, of course I know. I have burned a hole through the Internet looking up lymphoma symptoms.
DOCTOR: We don’t think you have lymphoma. But we do need the PET. I’m sorry no one told you not to eat. But, see, your body has to be as at rest as possible–no digestion, no exercise, and so on–so that there won’t be any false hot spots.
ME: Hot spots?
DOCTOR: Places where the metabolism is going fast, which might show up looking like neoplasms.
ME: Cancer.
DOCTOR: Yes.
ME: In my case more cancer.
DOCTOR: Yes. We don’t want to start this SBRT treatment before we make sure nothing else is going on. I don’t think there is.
ME: I hope the fuck not.
DOCTOR (laughs): Me too. But we want to make sure. We can do it all at once if you will come back. Or we can do the simulation today and you can come back for the PET. But that doesn’t really make much sense. I’m very, very sorry.

I am now remembering that I had a PET scan a few years ago. You don’t eat anything and they put contrast in your vein and then you rest quietly for forty-five minutes and then they send you through the tube and then pull you back through it. I could have remembered that myself. But I didn’t. I remember it clearly now because I was in a recliner chair in a dim room and I reclined it all the way back and then when I needed to go to the bathroom I couldn’t figure out how to sit back up again and struggled and flailed about to get out of the chair as peacefully as I could but fearing that the scan would light up like a Christmas tree. What I had a hard time with I always have a hard time with–the largely modern principle of You Do the Same Thing To Get Something To Do The Opposite Of What You Made It Do In The First Place. If you have a foot rest on a plane, you can press it down and in with your heels until it doesn’t stick out anymore, but then if you want it to stick out again you don’t in any way pull it up but press it down even farther and sproing!, it sticks out again. Many devices now use this double and triple repeat action to achieve different results. When I want to turn my cell phone on, for Christ’s sake, I press “END.” What is that? Anyway, the point was that all I had to do to get the recliner to sit back up again was keep doing what I did to make it recline. I swear there used to be more different buttons and dials and levers which had separate and distinct functions, and didn’t double and triple up on top of each other, like layers of filo.

ME:  I’ll come back and do it all at once.
DOCTOR:  I think that’s wisest. We’ll see you on Tuesday.

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