A Time (not) to Die

My patient record of June 25, 2014, entered by my medical

oncologist, states:
Assessment:
- Squamous cancer of the tonsil,
treated, with disease in clinical
remission.
- Our plans are for continued systematic
followup. We will be conferring with Mr.
Terry's surgeon today.
- Continued analgesic taper schedule is
anticipated and the patient counseled
accordingly.
- Mr. Terry will be returning to our
center in 2 months.
Yippee! After noticing a lump in my jaw in November of 2012,
three mis-diagnosesover the course of the following year, and
brutal rounds of chemotherapy and radiation from through March
2014, I am finally out of the woods. Of course, it didn't at the
time seem that out of the woods might be exiting the forest
and entering another less hospitable space, for example
downtown Al-Raqqah, or at least some where less painful, like
the Syrian Desert, a nasty little place which although larger than
California, is still smaller than Texas. But still probably less
burning than a radiation table in Houston.
The patient notes of the same date indicate:
Mr. Terry is 67 years old and he returns for
evaluation, now 3 months following
completion of a sequential treatment program
with induction chemotherapy then
chemoradiation, administered for squamous
cell carcinoma of the left tonsil with baseline

staging T2 N2b M0. This patient's clinical

course has been difficult, complicated by
severe grade mucositis for which previously
he required G-tube feedings. Since last here
in late May there has been slow recovery.
If you are at all familiar with how doctors construct their
notes, you'll know that they are masters of understatement . . .
or non-statement. If businessmen wrote like physicians,
nothing would ever get done.1 In defense of the terse and
seeming brevity of patient notes, what doctor wants to risk
saying anything that could be misconstrued, lest they write
something that might either be wrong and, especially,
misinterpreted by the patient . . . or his lawyer? That's why I
cheered at disease is in clinical remission, though I don't know
what other kind of remission - other than clinical might at all
be important to me or anyone else.
In clinical remission is another way of saying no evident
disease or alternatively NED. No Evident Cancer, NEC, is the
term du jour, I learned. While my earlier tests and scans during
the course of treatment had indicated that the tumors were
shrinking or dying, I suppose at the time of those scans my
throat had been so scarred that CT scan images were iffy.
There might have been no cancer evident from my CT scan
review, but there was so much noise' - poor or obscure images
from tissue scarring and burning from radiation that none of
my treating physicians nor any radiologist or radio-pathologist
wanted indeed professionally could not render any
unconditional2 opinion. But here it was yea - in remission.
1 In medicine, little enough does get done. One study of nursing skills and practices showed that
recommendations for change took an average of sixteen years to implement. The subject of snails
pace implementation of new practices in medicine is a complex one. Doctors, like everyone else,
like doing what they know how to do, what they were trained to do. On top of that, the risk of
downside legal and clinical both is great for doctors. That's one reason why many advances in
medicine, especially in surgery, emerge from developing nations, where there is much disease and
often little downside at least for the practitioner - for bad outcomes and malpractice.
2 But as for that every medical opinion is conditional anyway, so what the hell, render away.

And how about the observation patient's clinical course has

been difficult? I guess so. As nearly every cancer patient can
tell you, it's not the cancer that kills you, it's the treatment. A
difficult clinical course is one of the myriad understatements of
my medical life, short as it may be at this point, only sixty-eight
years.
We used to use the therm space cadet for someone who
was totally out of it . . . out of touch with reality, zoned out.
After a few sessions of chemotherapy followed by a dollop of
radiation, I would have been a walking zombie3, to mix a little
metaphor stew, if I'd been walking, but most of the time I was
sitting or lying down . . . and most of that asleep from the posttreatment pain and fatigue.
There is a time for everything and a
season for every purpose under
heaven.
A time to be born and a time to die.
I just sort of figured that this was my time to die. The author of
the Book of Ecclesiastes remains anonymous and I might remain
anonymous too if I consistently referred to life as hevel, Hebrew
for a vapor or a wisp, or better put, vain, futile and empty.
Yikes. Well, Ecclesiastes can be awfully contradictory, but
eventually it proves to be a pessimistic take on life: "The dead
are better off than the living" (4:2). I mean, how much more
pessimistic can you get than that? But, as a retort to itself, the
Book offers, "A living dog is better off than a dead lion." Well,
that's surely true if you are a Westminister Kennel Club Best in
Show Pekingese. But not if you're one of those pooches in the
PETA and SCPA ads on TV. I don't think Ecclesiastes is very clear
on that. But that was two thousand years before the invention
of the candy cane or Champagne, those great societal leaps not
3 All of the zombies I see on TV and in the movies are walking. Do they ever sit down and
talk?

coming until the late 1600s.

If life is meaningless, like Ecclesiastes purports, then why
do we cling so tenaciously to it, no matter what happens you
eventually die? Heaven. Hell. Consigned, one way or the
other, to a fiery furnace of a tight little box under a half ton of
dirt.
The unlikeable Jim Morrison had at least one thing right:
No one gets out of here alive. Surely he didn't. Twenty-seven
years marked his dog's life, though if you visit his Parisian grave,
you would not be chastised for concluding that in death he is a
lion. Dead lions however do not roar. Even Basenjis bark.
________________________________
As for me, someone who's spent a lifetime looking for the words
of others that can be spun into a quick one-liners, I stepped into
the maw of dumb statements when I was told in August 2014
that my cancer had elected to return after a brief ten-week
hiatus.4 Here's what happened:
When I was told that my cancer was back, all my treating
physicians were, predictably, out of town or in a meeting or
doing some sort of radical surgery on a person less fortunate, at
least at that moment, than I. So, after all the scans and screens
and tests had been read and interpreted, I was channeled to
Jennifer A., Dr. Erich Sturgis' assistant.5 After repeating to Joan
and me the bad news that had been previously offered by a kind
radiologist, Jennifer immersed herself in a laptop computer as
we all sat in the exam room waiting for her head to rise. She
was apparently with great haste, if not frantically - looking for
a date to put me on the surgical calendar.
We sat in silence, as Jennifer typed and scrolled looking for
4 Well, it wasn't a hiatus in the strictest of senses. The cancer was surely plotting its return, little
diseased squamous cells circling their tiny wagons and reloading their guns in preparation for
the next, one way or the other last, battle.
5 A couple of weeks later, Dr. Sturbis would spend nearly five hours - with electrocautery and a
sharp scalpel exorcizing cancer demons from my neck.

a good date for an immediate radical neck, a surgery where, as

it turned out, Dr. Sturgis would remove a hunk of flesh. At that
time, as throughout much of my waltz with cancer, I was
clueless. I was to learn, obviously first hand the hard way
what radical means. As later offered by one wag, the tissue
removed from my neck was about the size of a small pony,
redundant as that description seems.
I am not easily shocked, but I admit to perhaps having
been in shock when I finally asked Jennifer, Am I going to die?
She lifted her head from the laptop, turned slowly on the exam
room swivel stool where she was perched, looked straight at me
and offered the merest of grins, saying only Yes.
Duh. I had fallen into one of my own verbal traps, the
sort of which I delight in catching others. Out of some kindness
for the idiocy of my question, after a pause, she slowly added,
We all are.
____________________________
Now, of course, it's presumably not the ultimate purpose of
Ecclesiastes to depress us. But, on the other hand, it is Old
Testament, right? There ought to be meaning to life without any
final judgment or final, ethereal, resting place. But, the thought
of something better there's GOT to be something better, right?
- renders peace or at least is supposed to - while we're
tethered here.
Here is the conclusion to the whole matter
after all has been heard. Fear God and keep
His commandments, this is the whole duty
of man because God will bring everything
that has been done into judgment.
______________________________
You'd better not pout,
You better not cry,
Better look out,

I'm telling you why,

Yahweh he's a coming to town.6
My great friend and trucking company CEO, Mike S., used
to say in confidence that he thought that fear could be a pretty
damned good employee motivator, if wielded deftly. While this is
hardly textbook leadership dogma, Mike was as correct as he
was honest. One business strategy consultant told me, When
you think your term in office is near the end, then start doing
what you think your successor is going to do when you get fired.
Life is a series of final judgments, though you don't actually
figure that out until youre near the biggest final judgment. It
would be so much easier if God did not give us the freedom to
gain our wisdom over a lifetime. George Bernard Shaw said that
youth is wasted on the young. Boy (and girl), was he right!
And wisdom may largely be wasted on the old.
___________________________________
There are no atheists in foxholes. That's an aphorism
that today's neo-secular society abhors. But, like all aphorisms,
it is resoundingly true. Put another way, There are no atheists in
the doctors' waiting rooms after they've undergone their most
recent cancer CT scan and left the testing room having
experienced the techs' blank stares and hollow 'thank yous', but
worse, Good luck.
What the hell? Good luck? Bon chance? Buena Sera? Viel
Gluck? ?
The God-foxhole observation is attributed variously to
chaplains and other officers at the Pacific theater Battle of
Bataan in 1942. If there was ever a time to invoke the mercy of
God, that surely would have been be the time. The folks that
bring you Lexus indicated that they could be unimaginably
intense in seeking to achieve their objectives, whatever those
might be.
6 With apologies to Haven Gillespie and John Frederick Coots.

______________________
It's been written that Ecclesiastes is an eloquent call for us to
live our lives in a manner consistent with God's ideals for us.
Fear of the Lord might be the first step to becoming wise, as
fear of Mike S. might be the first step toward keeping your job.
Fear of death from cancer, it is said, clarifies the mind, brings
into focus one's life and one's goals and one's loves.
What? That's surely eloquent enough, but it's just not
true. It sounds lofty and purposeful, but it's b.s. Cancer and the
fear of death are actually mind-numbing and mind-muddling.
Cancer is more confusing than it is clarifying. Cancer does not
bring peace, it steals whatever peace you might have had . . .
steals it from the cancer victim and steals it from his friends,
family and, especially, from his or her caretaker. There's nothing
lofty about cancer.
When I got the bad news that my cancer had returned, I was
more befuddled than sad, more curious than depressed.
Certainly, there was no enlightenment, no clarity, no great life
lessons in the re-diagnosis. If I was in shock, I surely don't
remember. But maybe not remembering is the sign of shock.