Sunday, January 15, 2017

Indian Summer

“Make the diagnosis!” – as my medical journals would challenge the reader on page 39 or so. Shouldn't be too hard, for most doctors. First noticed last Friday on the flank of a 75 year old man, about three inches below the left axilla, the patient discovered the lesion by inadvertently touching it when toweling off after a shower, indicating that it was raised enough to be palpable. The pigmentation was variegated within the lesion with a deeply pigmented, almost blue section, and the border was irregular. On very close inspection, there was possibly a small halo of depigmentation, perhaps slightly bluish.

Meanwhile, although the cold and wet weather has come this year in the real weather, in our septuagenarian lives, it seems like Indian summer. “Indian Summer.” Why it's “Indian,” no one seems to know, not even the internet. But everyone agrees on how sweet it is. As a teenager growing up in Philadelphia, I thought that autumn was the best season, sunny and not too hot and not with the Atlantic seaboard humidity of spring and summer. I lived a 15 or 20 minute walk away from my high school, and I remember thinking as I walked across the empty, treed lot at the corner of Montgomery Avenue and North Wynnewood Avenue, that fall would be my favorite season if it weren't for the fact that winter impended, when the cold and winds make you pull your jacket closer around your neck as you walked along the long curve of Montgomery Avenue in the early dark on the way home. That's where the fall weather is headed, but “Not yet!” proclaims Indian Summer. “You got more, man!” And you enjoy it, you take off your jacket, you eat outside, you throw a ball around and take a walk and say how warm and clear it is, and tell each other how lucky you are. You know it will recede, and you hope it stays longer, just a little longer before you have to cover up. That was the way it was in Lower Merion in the 1950's, and that's the way it is for us today in our 70's. Indian Summer is to be relished.

Here in Berkeley it's now January and the weather is cold and rainy, but thankfully not windy, but we are covered up. We know we need the rain, so it's good and welcome and we don't feel oppressed, at least not yet. We've had our health challenges (see, of course), but when I'm asked how I am, I answer: “Vertical!” Verticality is as sweet as Indian Summer, and you never know when your own personal clouds and wind will come.

Nowadays we know a lot more about our health than we used to know, just as the weather-people on TV and even our smartphones have satellites to consult. It wasn't Mark Twain, but Charles Dudley Warner who said that “Everybody talks about the weather but nobody does anything about it.” That's probably still true of weather. A storm appears up in the Arctic and we follow its course down the coast, and maybe it will weaken and maybe it will continue on down, but we can't do much about it except prepare for the effects. That's where the weather and health differ; in health, we detect and then we act. Maybe there's something we can do about it, sometimes not, but more and more, there's something. Still, sometimes things just come out of the blue and there you are, you're never completely sure what will come and when.

So when I was toweling off and my hand strayed to an area I don't generally look at – you could say I'm not vain so I don't look at myself, or you could say, given my excess mass, that vanity is the motive force for not looking – and I took the picture you see above to Make The Diagnosis, I wondered if an arctic storm had just appeared. I know enough about skin lesion that I wasn' just worried, but alarmed.

Fortunately, four years ago I had been responsible enough to have switched dermatologists from a contemporary to a younger doc. Jason Fung was a new derm in town and had been, humblingly, a schoolmate of my kids at Head Royce School. Good guy, active, extroverted, chatty, efficient, forward looking with a scribe at his side. His survey of my skin had revealed nothing troubling, but he now had the visual record on me. When I called his office with “ a suspicious mole,” they offered me a spot that very afternoon. I couldn't take it because I had to take Ann to the doctor, but as it happened she had a routine appointment at his office four days later so I was lucky enough to get a spot ten minutes after hers. Ann thought my prompt appointment was evidence of special treatment, but I said “suspicious mole” was code for “get me in NOW.” Not only good patient care, but malpractice avoidance dictates some actions in practice. Like, for pediatricians, “he has excruciating testicular pain.” A ball can die if it is twisted on its stalk, and you'd rather not have that, and neither would your insurance carrier.

I told my friend Stu when I saw him at the gym that I was going in to be checked for a suspicious mole and he said, “It's probably nothing.” Which is what Ann had said, although she had said to be sure to get it checked right away. I hesitated to take solace from their opinions because I know wishful when I hear it, and I had seen it close enough to know it was a problem. But you never know. I can be alarmist.

So on Tuesday Ann went to her exam room to have her stitches out and I went into my exam room and took off my shirt, joined by young lady scribe asking the questions on her script. Then Jason burst in asking about Allie and Nick and Brian and Sara and even Peter and … whoa! “That looks funky!” said Jason as he caught sight of the lesion. No more small talk. I was surprised that it had been four years since I had been in for a survey; hadn't felt that long at all. And I don't know when my last physical was and if Jim had looked carefully at my body when I saw him – there's enough to talk about without something you don't know is there. So how long the lesion had been there was unknown, just less than four years, and probably much more recent.

It's at least making a neoplastic transition, he said. It might not have made it to melanoma yet, but it's pending. In less than five minutes it was out and in a prep jar on the way to pathology. I thought that the speed of extraction reflected his efficiency, but neither of us wants that thing in my body one more minute than necessary. It was Tuesday and he would call me Friday on my cellphone. He gave me a roadmap – either local excision in his office, or over to UC for tracing drainage to the nodes and wider excision, no more talk, let's see. Let's not prejudge, he said. But I heard his voice and I knew it was scary. He said that he knows it wasn't there four years ago because he had checked everything before he had come in to the exam room. It wouldn't have been his fault. I do the same thing, look back to what I could have done, etc. Was I culpable, is always my question of myself. Guilt is always alive in the mental workings of the Budd. But how long had it been there? We couldn't tell. Sometimes it takes time, and sometimes they just explode. Path would tell us how deep it went – less than 1 millimeter is the best – whether the excision had gotten it all with a good margin, and how the cells looked, aggressive or not so much. In any case, we'll be seeing each other more in the coming days, said Jason. I like Jason, so I told him I would enjoy seeing him.

I was curiously calm. Fatalistic, or in denial? I know I'm really good at denial. Or, you could say I'm really good at being in the moment. Nah … I deny. Ann didn't understand that it was dangerous until later; I think she was in denial, too, but maybe not. But anyway, I figured, say it's really malignant. What would happen? Scan the whole body for metastases? Where does melanoma go? Brain, for sure. Maybe liver, everything goes to liver. Bone? I dunno; lung goes to bone. I would rather not have brain metastases, with seizures and seizure meds, etc. Rather not. Hard way to go.

But what I thought was, then I would know how I would die, unless something else came up. I've never known how I'll die – my heart's always been pretty good. My mother died of breast cancer. Maybe cancer. Who knows how Indian Summer ends and when? I've always figured, somehow, that I would go to my 80's; maybe that was wrong. I've said for some time now that I had taken care of my major responsibilities. Kids up and out. I've got enough money so that it will be a great help to them. Ann needs me. We're in Indian Summer together, walking together. I thought about my funeral. My book club would come, my poker game, my medical friends, Bob and Adele, my sibs and their kids, Larry and Michael and Marjorie. Stephen. Stu. David and Joanna. SOAPM would send flowers. I had always wondered if any patients would want to come. Maybe some, but how would they hear? Some of them love me, that's what I need to know. As they say, it should be a good time, I'll be sorry to miss it. What would Nick do, my estranged but still loved son who works for the FBI?

My financial affairs – I'm pretty simplified, which is good. If it looks touchy, I'll sell the condos and make it simpler. Everyone should be OK. Need to make final adjustments.

It will be a different life from now on, if the melanoma is a threatening one, knowing more and having the blanks filled out. Shorten the time line. I've been getting into really good shape and made a new lower weight target. Keep that up? What about the French? Continue with that? Do the paper on healthcare I'm working on, or give it up? I had lunch with my friend Richard, with whom I'm working on a project, and I found less enthusiasm if I would have to devote the final days. Would hang back on that. Maybe watch more movies, which I am already doing somewhat. Somehow, less pressure. Not much reason to do anything except enjoy yourself. While waiting for the curtain.

I knew it was a melanoma. Jason said let's not prejudge, but I knew. “Funky lesion” doesn't make it into the diagnosis books, but then, it's taken until this year for Northern California (actually Berkeley-Oakland) “hella” as in “that's hella good!” to make it into Merriam-Webster. And medicine is even more conservative. I never want to be an “interesting case,” and I'd rather not have a “funky lesion.” I was already thinking about immunotherapy, hoping I wasn't going that way. But prepared to do it, too. Making sure that others don't get too upset. At least my parents have died, so they won't get upset. No one's indispensable, and everyone thinks when someone gets sick and dies, at least it wasn't me. Checking the ages in obits. A diagnosis takes the curtain back a bit, knowing from what and closer to knowing when.

What if it was in brain already and very aggressive and I hear, “maybe six months.” What would happen then? Well, it's coming sometime. Get the kids straight,make sure no one gets too upset. Provide for Ann, that will be hardest. Have to work with Sara.

We'll just have to see. I told Jason, yes, we're planning to go to Maui for two weeks starting next Friday, but forget that, we go all the time. The medicine comes first. Maybe I'll have to ….

On Thursday morning Ann had just finished with her yearly physical and we were walkingdown 30th Street past Summit to the car when the phone rang. It wasn't Friday yet, but I saw on the phone that it was Jason. He hemmed and hawed for a minute, and I thought, Oh, shit. But then he got to the point. Yes, melanoma. OK, Jason, not great, but that's not the crucial info. Why was he hesitant. Waiting. But … good news! He should have started out saying “Good news,” but I guess he was still hung up on the “melanoma” part. But, only 0.9 mm deep – hoping to be less than 1 mm, and there it is! Just ducked in under the limit! Excision margins – clear! State of cells – not aggressive yet! So, if you had to have a melanoma, this is the one to have, he said. You bet! He said that he would schedule me for a wider excision by the lady who does them at his office. OK by me! In fact, how about tomorrow, Friday? You bet! 1 PM in Lafayette office? Sure! Get this done.

No need to change any plans – go to Maui, go on cruise, Indian Summer continues! Yessir! Worry dispelled. Looked it up on internet finally, and stage 1a, 97% chance of non-recurrence. I'll take that with gratitude.

So, what people say sometimes after they have been seriously ill and they have refocused on their lives is, I won't say I'm grateful for this, but it did me a lot of good. I'm wondering now, I can't say I'm grateful for this scare, but it was only a scare, but scary enough so that I started traveling in the shady land instead of just imagining it, and I know I'll be there someday, so can I say hey, maybe this was the best of the worlds, that I can change my life for the better and still didn't have to be sick. Can I do that? Or maybe I can just realize that my Indian Summer is going just fine. We'll see what I think.

Carpe diem, man, carpe diem. Do as much good as I can and enjoy every single day, even the cold, rainy ones. I just have to wonder, will this rain ever stop? They say we're mostly out of the drought. Hope so. 

BTW -- here's what it looked like ex post facto.  A lot better out than in....

Budd Shenkin

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