Wednesday, May 28, 2008

Access (Part II)

Just a quick note to provide an update regarding our trip to UVA and the problem with the Port-a-Cath. I met with the interventional radiologist and determined that the current device had to be removed, since it was now partially exposed through a small defect in the skin. Fortunately, there was no sign of infection. The removal under local anesthesia proceeded without difficulty.

After discussion with my oncologist it was decided to delay placement of a new access port until after I have the repeat imaging studies scheduled for June 5. Based on that information we will have a better idea of which type of venous access device will be most appropriate.

Our trip to Charlottesville and back was speedy and pleasant. Thanks once more for your prayers and expressions of encouragement.


Tuesday, May 27, 2008

Access is Everything

It was 2:00 AM when the call came in to the emergency room alerting us to the arrival of a young male patient with an apparent drug overdose. Paramedics were already performing assisted ventilation as they wheeled him into the available trauma bay. The patient was poorly responsive, with a ghastly gray complexion, pinpoint pupils, a barely palpable blood pressure and a purple hue to the fingers and lips. As a second year resident on my ER rotation, his care fell to me.

We needed to gain immediate access to a vein in order to administer life-saving drugs and intravenous fluids. Several attempts to access a peripheral vein were frustrated by severe scarring at every available site – the result of years of self-injections of heroin. Even leg veins and groins were impenetrable. A hematoma under the tongue suggested that this patient had even tried to use the sublingual veins to get a desperately needed fix.

With no time to spare, I prepped the area just beneath the right clavicle to perform a subclavian catheterization with a large-bore catheter: “Check the landmarks, penetrate the skin just beneath the clavicle at the junction of the middle and lateral thirds, and aim for the opposite shoulder…” Success! Venous access established and within minutes the patient was awake, thrashing about, and breathing on his own.

I have vivid memories of similar heart-racing moments to gain access to critical bodily compartments: from delicate scalp-vein venipunctures on premature newborns, to emergency chest tube insertions in patients with an acute lung collapse, to difficult spinal taps in patients suspected of acute meningitis. Until we had established a reliable port of access, any attempt to reverse the patient’s deteriorating condition was compromised at best and sometimes impossible. (Watching "ER" on TV has often caused a visceral reaction as I relive some of those moments.)

Reliable central venous access is also essential for the administration of Interleukin-2 and, to facilitate that access, I had earlier undergone the placement of a semi-permanent device called a Port-a-Cath. This device consists of a titanium reservoir which was surgically implanted beneath the skin just below my right clavicle. The reservoir is connected to a catheter which is inserted into the major vein that empties into the right upper chamber of the heart. Unfortunately in the last two days, persistent tension on the overlying skin has compromised the capillary circulation resulting in the development of a pressure ulcer at one edge of the reservoir. As a result, I will now require revision of the implant. We leave tomorrow for Charlottesville to have this done. If not attended to, I will not be able to receive the planned second round of the Interleukin-2 therapy, scheduled for mid-June.

Access is essential in many arenas. It was to improve my patient’s access to timely and personalized medical care that I established Personalized Family Medicine a little over two years ago. The result (in my humble estimation) was a dramatic improvement in the quality of each patient encounter, in patient satisfaction, and hopefully in clinical outcomes.

Throughout this personal encounter with cancer the one thing that I have grown to appreciate more than ever is the direct access I have to the Great Physician. Because of what Christ has done, I have an open line to an all-powerful, loving God who is anxious to infuse me with spiritual health and strength that enables me to face any challenge (Ephesians 2:17-18, Hebrews 10:19-22). I am grateful that the One who is on call 24 hours a day, seven days a week, lovingly resuscitated me when I was near death (Ephesians 2:4-5).

It is also because so many of you have gained access to that same source of power through prayers of faith that I am witness to His awesome mercy and grace. Please continue to do so as we return to UVA to take care of this complication.

I will keep you updated,

Tuesday, May 20, 2008

Medicine or Miracle?

I love the story of Scrooge as portrayed by George C. Scott in the 1984 TV adaptation of Charles Dickens’ classic A Christmas Carol. Do you remember the scene when Scrooge awakens to discover he has not missed Christmas? He is giddy with gladness, and every human encounter becomes an opportunity to share his new-found joy in living. That is precisely how I feel lately.

Appreciating like never before both the frailty and preciousness of life, I cherish even the most casual relationships and look for opportunities to tell my story. In the past I would assume there was plenty of time to catch up with neighbors, family and friends, to nurture those relationships over time – now I am tempted to hug total strangers! In conversations I now quickly dispense with superficiality, look for opportunities to express in kind the genuine love that I have received, and attempt to direct the dialogue to subjects of consequence.

In the process of sharing my story, I will mention my rapid decline, the delay in starting Interleukin-2 therapy, the remarkable outpouring of concern and prayer by hundreds of people, the awesome goodness and grace of God, and the miraculous and rapid regression of the cancer. I love to watch the response. Some immediately light up, offer praise to the Almighty, and become animated in their expression of joy. Others seem to need more time to process the information, offering their congratulations after a brief (and less animated) pause.

Of course as I ascribe my remarkable recovery to divine intervention, I recognize that some may not draw the same conclusion and need time to process their own ideas about cause and effect. Is it a miracle or simply the medicine? As a physician I have often wrestled with this question.

I like the definition of a miracle found in Wikipedia: “A miracle, derived from the old Latin word miraculum meaning ‘something wonderful’, is a striking interposition of divine intervention by a supernatural being in the universe by which the ordinary course and operation of nature is overruled, suspended, or modified.”

While trained in the scientific method, I am quite comfortable acknowledging a supreme being who is able to overrule, suspend or modify the rules of nature which He created in order to accomplish His purposes, to accomplish something wonderful. In my case, and in many similar cases I have helped manage, the miraculous and the medicine are not mutually exclusive operations – rather I see them as complementary.

If high-dose Inter-leukin 2 were the sole cause of my recovery, then why is it NOT effective in over 94% of patients with stage IV melanoma? Clearly there are additional forces that influence response and outcome. I believe in my case it has been the thousands of prayers that have gone up on my behalf – and a living, loving, all-powerful, transcendant God who has responded to those prayers.

Science aims to explain observable phenomenon, to answer the “how”, not the “why”. It is possible, even probable, that as our understanding of the “how” becomes ever more refined, we may actually peer into ways in which God accomplishes the miraculous. For example, as string theory predicts that within the same space many alternate universes may co-exist, it is not difficult to contemplate how Christ may have manipulated these alternate realities to convert water to wine. A personal, imminent, and good God may intervene in His own creation to accomplish His purposes – to answer the “why”.

I am grateful for Inter-leukin 2 and for the skilled physician who has supervised its administration, fully convinced that God has used this naturally-occuring agent to accomplish a miracle in my body. He is ultimately the author of it all and I celebrate Him!

It’s Christmas morning and I see the day in a whole new light!

Thursday, May 8, 2008

In Remembrance

Last Sunday I was privileged, as an elder of our church, to help serve communion. It was an emotional experience for many reasons, not the least of which was because I had not been able to participate in the Lord’s Table since my rapid decline three months earlier. By most reasonable predictions, I would most likely be receiving the elements on my death bed by now, if I had not already passed all need for bread or drink. And here I was, standing before the congregation who has so faithfully prayed for me, able to give thanks and to sing with them “By His stripes we are healed!”

I once heard a definition of the Eucharist (Holy Communion, Lord’s Table) that I love: it is a Greek term that means literally “good gift” or, more fully, “hilarious thanksgiving”. For me this last Sunday was indeed a day for hilarious thanksgiving. And I have the tear stains of many friends on the shoulders of my sport coat to prove it!

It is a tradition during the course of administering the elements to quote Jesus’ words at the Last Supper when He said, “Take, eat. This is my body which is broken for you. This do in remembrance of Me.” I have often wondered what He meant by those words. Did He really think we might forget Him or the sacrifice He endured?

Then I studied the meaning of “remembrance” in the original language. In this context it means much more than simply not forgetting. Over and over in Scripture we are told that God “remembers” His covenant (Gen 9:15, Ex 2:24, Ps 98:3, 106:45). Clearly an omniscient God does not require the jogging of His mind to recall His previous commitment. Rather, these passages demonstrate how He takes heed to what He has already promised and is moved to action on behalf of His people.

We read that He remembered Noah to rescue him from the flood (Gen 8:1); He remembered Abraham when He spared Lot from the destruction of Sodom and Gomorrah (Gen 19:29); He remembered Rachel to grant her a child (Gen 30:22); He “takes thought” of man (Ps 8:4) – i.e., He is keenly aware with a comprehensive understanding (“mindful” Ps 103:14). Even the plea of the thief on the cross “Remember me when you come into your kingdom” (Luke 23:42) is not an entreaty to avoid divine amnesia, but an appeal to God’s mercy (His character), and His covenant of grace.

So what does it mean for me to “remember” Him? I am to acknowledge His covenant, to honor His name, to celebrate (1Chron 16:4), to boast (Ps 20:7), to contemplate (Ps 63:6, 143:5), and to announce to others with audible praise (Ps 71:16) what He has accomplished through His victory over sin and death. And to add a crescendo to my praise, I am reminded that, because of what He has done, God does NOT remember my sins! (Is 43:25, Jer 31:34) I am to be moved to action, to love as I have been loved.

At a time when I might have been planning my own memorial service, I will rejoice in remembering Him and revel in His goodness!

Sunday, May 4, 2008


On the day before I underwent the thorough assessment at UVA and discovered the remarkable regression of my cancer, an event took place that I delight to relate to you.

Anticipating the need to be available for the first appointment in Charlottesville at 8:00 on Monday morning (and to save some money from the repeated motel stays), we decided to enjoy the outdoors and camp in the nearby mountains during the prior weekend. (See Linda’s blog entry “Mountain Momma”.)

As we were preparing to break camp at Seneca Rocks, WV, I came across two little furry objects lying in the roadway. I leaned over to investigate and beheld two bright orange and black downy chicks lying on their backs, legs clawing the air wildly. Looking around I saw no nest nor even an overhanging branch from which they may have fallen. A monsoon rain had kept us awake most of the night before and I assumed that somehow they had been transported here in the downpour.

Absent the means to nurse two little birds to independence, I said a little prayer for them and went on to pack up our nearby campsite. When I checked the roadway ten minutes later, the chicks were gone. I hoped that their mother may have found them and ushered them to safety.

Then I heard a beseeching little chirp at my feet. It was one of the chicks who had somehow found his footing and apparently followed me the thirty yards to our campsite. I introduced Linda to the little guy, alerting her to beware of this critter underfoot. But he took no interest in Linda whatsoever. As I went about carting supplies from the camper to the car and scouting the campsite for other items, my new-found friend was at my heels, yipping and yawning its beak as if to receive a tasty morsel from this surrogate mother.

One of my strides easily required a dozen little hops by my fuzzy friend, but every time I turned around he was there. At one point the insistent creature hopped up on my shoe as I was packing the trunk. Amusement turned to irritation and I decided to confine the little guy to a bucket while we completed the task of hitching the camper to the car. Just then the kindly old manager of the campground drove up in his golf cart and we offered him the gift of this little bird who had so quickly and freely adopted me as his sole provider and protector.

The manager laughed as he explained that the chick was a woodcock hatchling, one of what was likely a large brood often found hiding in the grasses (without a real nest). A game bird that spends most of its time in the brush, the chicks are left to fend for themselves at a very early age. Apparently, this particular chick got lost in the crowd and “imprinted” on me as his mother when I eyeballed him on the roadway. He assured us that the bird would be fine as he gently lifted him from the bucket and deposited him in some nearby brush.

As I have thought about that little bird, I now believe ours was no chance encounter. On the eve of learning of the remarkable regression of my cancer, I think he was sent to remind me of some important truths.

Like that little creature, at one point helpless and vulnerable, I am to find my footing and follow my Creator – wherever He goes. Whenever He moves, I am to follow at His heels, acknowledging my utter dependence on Him. The strength of my attraction to Him is to be no less than the powerful instinct that little chick displayed when he imprinted on me. I want never to be far from Him and always “underfoot”.

More than that, I am reminded of God's promise to His people as He instructed them “Open your mouth wide and I will fill it.” (Psalm 81:10) The picture He is portraying is that of a mother hen eager to feed her chicks, whose scrawny necks and gaping beaks are craned upward to receive whatever morsel she may have to offer. Our covenant God is more than willing to fill us with good things. He is not a reticent benefactor or reluctant healer. Rather He takes joy in blessing us. He is, above all else, a giving God. (Psalm 37:23-26, Micah 7:18) I am glad!

My part is to become as humble and helpless as that baby bird.