Thursday, June 25, 2009

The Purpose of Pain

"God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains: it is His megaphone to rouse a deaf world." C.S. Lewis, The Problem of Pain

We just returned from UVA where I underwent an ultrasound-guided needle biopsy to assess whether or not the three small areas of increased metabolic activity in the neck and right arm pit that lit up on a recent PET/CT scan actually represent recurrent melanoma. The experience served as a helpful reminder to me that pain has a purpose.

None of these lesions was palpable on exam and the ones in the neck were too tiny to even attempt to biopsy. The interventional radiologist therefore directed his attention to the right arm pit. The aim was to visualize the exact location of the suspicious nodule with high-frequency sound waves, impale it with a large bore hypodermic needle passed through the skin into the center of the lesion, and aspirate tiny bits of tissue into the shaft of the needle and attached syringe.

He began by pressing the ultrasound transducer firmly into my right axilla and in short order identified an abnormal lymph node deep in the recess. After prepping the area and providing a local anesthetic, he made a tiny incision in the skin and guided the needle toward its mark. Because of the relatively small size of the target lesion, the difficulty visualizing the needle on the ultrasound image, and the typical reluctance of lymph nodes to hold still while being attacked by a sharp instrument, repeated thrusts with the needle failed to produce any tissue. These maneuvers did produce considerable pain, however.

The radiologist offered additional local anesthetic to the deep space in my arm pit, but I declined. “It looks like we have a tough guy here,” he quipped to the technician. “Not really,” I replied, “But by the nature and location of the pain, I can tell when your needle is pressing against the involved node.” So I turned from passive subject to active participant in the procedure.

As the physician made repeated attempts to skewer the elusive mass from different angles, my grimaces and muffled yelps served as confirmation that his stiletto-like probe was zeroing in on the intended target. This game of thrust and parry continued for a full hour. Then with an “Arghhhh… Ohhhh, yeah… That’s it!” the hard little mass could resist no longer: a delft stab through its midsection finally yielded adequate tissue for pathologic examination.* The cheers arising from the gallery were deafening :-)

I’m really not a glutton for punishment, and now that the procedure is over, I’d say the level of pain was really quite tolerable. It certainly cannot be compared to the still-vivid memories of excruciating torment that attended a complicated liver biopsy eighteen months ago. Nor am I averse to taking pain meds when needed – More than once has Dilaudid brought me from the brink of unconsciousness triggered by unbearable pain to a state of complete relief and relaxation.

But this most recent encounter with pain has underscored the positive role that noxious stimuli and their physiologic response play in our lives. Indeed, pain produces a reaction in us that is both protective and life-affirming. Repeated admonitions to a toddler to avoid the hot stove or the flame of a candle are seldom heeded until that first misadventure. It took the painful experience of a dislocated toe to teach me not to descend our slick hardwood stairway in stocking feet!

This beneficial role of pain is dramatically and tragically revealed in those medical conditions in which the normal pain mechanism is impaired, such as the peripheral neuropathy that often accompanies advanced diabetes. I recall one diabetic patient of mine who suffered third degree burns to her feet by exposing them to excess heat without any awareness of pain or injury. She ultimately lost both feet.

Of course there are those conditions which produce chronic debilitating pain that seemingly has no positive protective purpose (e.g., fibromyalgia, reflex sympathetic dystrophy, primary neuralgias, etc.) And many suffer unbearable emotional pain from the loss of a loved one, repeated rejection, or other adversity. To be honest, it is in these circumstances that pain seems to mock us rather than preserve us.

As one who has experienced the destructive side of pain, the intractable bone-wracking pain that accompanies the rampages of disseminated cancer, I can sympathize with those for whom this type of suffering is a daily experience. My entire professional career (and that of my colleagues) was devoted to preventing and/or alleviating this kind of misery.

Nevertheless, even here I have found that pain has a purpose. I can say with honesty that, as strange as it sounds, I never felt more alive than during those long nights when I was immobilized with pain from head to toe caused by the rapidly advancing malignancy. In the midst of what was clearly “the valley of the shadow of death”, my head and heart were compelled to confront whether life consisted solely of this biologic existence or indeed encompassed eternity.

As C.S. Lewis suggests, it was in the midst of this kind of pain, that God used a megaphone to reassure me of His promise: “I came that they may have life and have it abundantly.” (John 10:10b) He came. He lived as one of us. He knew rejection. He suffered a measure of pain I will never know. And He did it all that I might know what it is to truly live. My personal experience with pain stripped me of any pretense of self-sufficiency. It taught me to celebrate His presence and His promise, secured by trusting Him fully. It continues to be a remarkable journey.

Dr. (Pincushion) Dan

*As expected, the microscopic analysis of the needle biopsy specimen demonstrated the typical pigment-laden, distorted cellular architecture of malignant melanoma. We return to UVA next week to discuss treatment options with Dr Grosh.

Sunday, June 14, 2009

Sufficient Grace

Is the glass half empty or half full?

The way I answer that often depends on what is in the glass! I recall gagging down two very full glasses of liquid chalk (unsuccessfully disguised as a peppermint shake) in preparation for a contrast-enhanced CT of the abdomen... ugh! Examining the small amount that remained in the Styrofoam container, the technician chided me with a malicious smile: "Ah, but Dr Crabtree, you know you must drink it all." Chugging the last remnant of this awful concoction seemed an impossible task.

When Jesus faced the unimaginable horrors of the crucifixion (and the imminent separation from the Father) He implored "My Father, if it is possible, let this cup pass from Me... if this cannot pass away unless I drink it, Your will be done." (Matt 26:39, 42) Fortunately for us He found the strength to drink the full cup to the dregs.

Then there is the apostle Paul who speaks of a "thorn in the flesh". (1Cor 12:7-8) While Bible scholars debate precisely what physical disability Paul suffered, it is clear that in this regard he was running on empty and he desired to be full -- i.e., to be whole once more. Three times he asked the Lord to remove this ailment. (Hmmm, only three times?) What really intrigues me is the Lord's response...

Whether faced with a bitter cup of suffering that must be drunk to the full, or drained of strength and longing for a full cup of refreshment, our Lord assures us "My grace is sufficient for you." (2Cor 12:9) Nice words, but what help are they really? I am learning the liberating reality of what these words reveal about the life of faith.

Regardless of my circumstances (no matter what is in the glass), God's grace (those gifts that attend an intimate relationship with Him, Eph 1:7-14) will literally fill up or overwhelm whatever the need is so that I can declare "I am satisfied" -- it will be sufficient for me. The Father sent an angel to minister to Jesus in the garden and He was strengthened. (Luke 22:43) Paul was able to conclude: "Therefore I am well content with weaknesses, with insults, with distresses, with persecutions, with difficulties, for Christ's sake; for when I am weak, then I am strong." (2Cor 12:10)

I am happy to report that my glass is more than half full! On June 11 we returned to UVA for a repeat PET/CT scan and MRI of the brain. As of yesterday we learned the results: Of the 18 brain tumors that were treated with the gamma knife procedures in April, all but 3 have regressed and there does not appear to be any new intracranial lesions. The 3 remaining lesions are only slightly larger and display some surrounding edema, suggesting positive effects of the radiation. The PET/CT, on the other hand, reveals three tiny new areas of increased metabolic activity, two in the posterior neck region and one in the right arm pit. These may represent newly developed metastases outside the brain. None of them was detectable on physical exam. Aside from some degree of increased fatigue, I am doing well with no pain and no apparent neurologic impairment. My doctors agree, compared to the devastating disease noted when first diagnosed one and a half years ago, I am doing remarkably well.

Dr Sheehan, the neurosurgeon, recommends simply observing the brain lesions for now and repeating the MRI of the brain in two months. Dr Grosh plans to pursue a needle biopsy of the lesions of the neck and/or right axilla, if the interventional radiologist determines this is feasible. Should the results of the biopsies prove positive for melanoma, I may face a repeat course of high-dose Interleukin-2. I will keep you posted.

Although I had hoped for a complete remission by now, I am truly "well content". Filled up by His grace, my glass is brimming with goodness, knowing His faithfulness, refreshed by evidences of His love (powerfully displayed in the love of family and friends), and constantly satisfied with the rewards of walking this journey with Him. Thanks for your continued prayers.

Dr Dan

PS -- Please pray for my sister-in-law, Genelle. For years she has suffered a progressive neurologic condition that has left her with extreme weakness so that she is now hardly able to speak and has difficulty breathing at times. Initially thought to have MS, a subspecialist has confirmed that she actually has Lou Gehrig's disease (ALS). Her husband, my brother, Paul has been a tower of strength, but I suspect his glass also could use a refill.