Posts Tagged ‘Active surveillance’

I pictured you walking backwards and that you were coming back home...I pictured you walking away from me and hoping you were not leaving me alone...

I pictured you walking backwards and that you were coming back home…I pictured you walking away from me and hoping you were not leaving me alone…

Chapter Two-A dog shows up at the lake
John and Karen had two other dogs, Oscar and Tootsie, both of whom they loved dearly, but there was an emptiness around their home without Meg. The couple felt her memory and presence everywhere in and about the house. The couch, the trampoline, the backyard, the bedroom, the children’s rooms, the porch, and years and years of pictures with members of the family framed throughout the house, served as a constant reminder of Meg. The two remaining dogs were dachshunds; Oscar was the grouchy father, and Tootsie, a high maintenance daughter. The female dachshund next door had been Oscar’s wife and Tootsie’s mother. It had been an “arranged” marriage.

“I miss having a big dog around here John,” Karen said.

“I miss having a dog that likes being in water,” John replied. He thought, “Dachshunds are like cats, they do not like water and don’t swim.”

John and Karen had a small piece of property on the lake near their home. They rarely spent the night at the small cabin on the site, but very much enjoyed going there for “day trips” and always got home before the time the street lights came on.

John and Meg could easily consume a Saturday at the lake with cutting grass, fishing, and working in their small garden there. They often visited the big box stores for stuff needed for whatever they would be doing that day. Meg loved riding in John’s truck, ambling around the property, and dipping into the lake for a swim from time to time as John worked.

“John, what on earth do you and Meg do all day out there?” Karen often asked.

John and Meg looked at Karen in unison and agreed that Karen just did not “get it.”
“Well Karen, Meg and me don’t have nothing to do out there, we got all day to do it, and we may not get but half of it done,” John answered. He wasn’t sharing any of their secrets.

With Meg gone there was a void on Saturdays, not only at home for the couple, but also for John at the lake. John attempted to make the dachshunds his “lake dogs,” but they did not like water and just made a mess out of his Saturdays. Oscar hated it at the lake preferring the warm and known confines of their home and being a lovable grouch on his turf. Tootsie loved riding in the truck to the lake and she loved to cuddle in the warmth of John’s jacket during the ride however, Tootsie was always doing something meddlesome. She explored to the extent that John spent the majority of his time looking for her or keeping Tootsie out of trouble.
On one occasion John lost Tootsie for about two hours though it seemed like an eternity. During the time she was missing, he frantically searched the shore of the lake, the cabin, and the surrounding area. He envisioned Karen chastising him for not “taking better care of Tootsie.” All of his worst fears as to her safety ran through his mind only to find her on top of the boat dock. Tootsie had no problem climbing the steps to the top of the deck, but once there, she would not come back down. He found her accidentally because he saw the silhouette of her small head on the horizon of the dock flooring. His fear of finding the more worrisome silhouette of her body floating in water hence relinquished, John commenced to chastise her under his breath. (Tootsie’s head is small for her body. John’s head is small and Karen often made fun of him for it. John’s mother said her first memory of John as a baby was that he could, “cover his whole face with his hand.” On his high school football team in LaGrange, Georgia, he wore the smallest helmet. It was a size 6 and 7/8, and was specially ordered for him. Karen told John, when she perceived he was gaining weight, “John, you need to be careful about gaining too much weight or you’ll start looking like Tootsie. Your head won’t match your body.”)
On another fateful day at the lake, Tootsie chased a mouse or some other rodent under the cabin, which had only a six-inch crawl space, and it took several hours to determine where she was. Once found, she would not come out and there was no obvious way to get to her or to get her out. Complicating the situation and intensifying the anxiety for John, it was not clear if Tootsie was trapped or just would not come out. Exasperated and about to give up, John found a neighbor with a skill saw to cut a hole in the cabin’s kitchen floor to “rescue” her. The sawed out square of flooring replaced the hole in a patch-like fashion serving as a constant reminder of that day’s three-hour ordeal to free Tootsie from the confines of the cabin crawlspace.
“Karen, I am not taking Tootsie out to the lake anymore. She is a good truck dog and likes to ride, but she is way too much trouble for me out there. I can’t get anything done with her. She gets into stuff. “Dachshunds have a Napoleon complex and that’s her problem,” John thought. He, however, did take her again. It would be a mistake to do so, and it would be the last trip to the lake for Tootsie.
The “last” time Tootsie went to the lake with John, she played the “Napoleon role” that only a foot-long dachshund can do with the great dane puppy which lived next door. She barked and taunted the dog until it grabbed her like a pillow, shook her, and then threw her about thirty feet. All of this transpired in a matter of seconds right in front of John to his amazement and chagrin while he was raking leaves and listening to a Georgia football game. Tootsie’s run in with the great dane resulted in a trip to the vet, a V-neck T-shirt soaked with Tootsie’s blood, ten holes in Tootsie’s abdomen (but no damage to her intestine), two hours of surgery in which John assisted the vet, fifty stitches, and another ruined Saturday at the lake. No Tootsie was not to be another Meg and she would not be going to the lake anymore, period. To make matters worse, on the day Tootsie came home from the hospital, John was holding her in his arms, and was about to give her cheek a kiss when she snapped up and bit him on the tip of his nose. He dropped her to the floor out of shock and a bit of anger, only to find her running to Karen. Karen now became the “good-guy” and Tootsie’s savior in this unprovoked attack, which further aggravated John. Karen then laughed uncontrollably at the situation and particularly at John clutching his nose. John’s nose was now bleeding profusely and when he checked it out in the mirror there was an inch long scratch which was deep and devoid of skin. The area subsequently scabbed over and for two weeks was a painful and visual reminder of the little ungrateful troublemaker that was Tootsie.
“Dr. McHugh, what happened to your nose?” John was asked a thousand times over the ensuing weeks.
“My dog bit me,” he answered. Having to respond to that question in light of the history of the event was “salt on the wound” to John. He did, however, forgive Tootsie.

Several months later after blowing leaves at the lake, John alone and without a lake dog, was resting on an old spring swing left at the lake by the original owner of the property Jessie Jewell. He saw a small puppy walking up the gravel driveway. The lake property is at the end of a road that has a cul de sac. His first thought was that someone had dropped off the dog and left it. As the puppy approached her gait and color made John think that the visitor was a golden retriever puppy and probably one of a neighbor’s dogs. She walked nonchalantly to where he was sitting and sat down right next to him. It was as if she was already his dog and that what she was doing now was what she was accustomed to doing naturally and often.

“Well, what’s your name, cutie pie?” John asked somewhat taken aback by the level of the “make yourself right at home” nature of this stranger.

The dog’s tail began wagging as it looked up at John contentedly. John confirmed that the dog was a female, and as best he could tell, she was a thoroughbred. He figured that someone was probably missing her pretty bad about now. She had no collar. It was unknown to John at the time that this was a foreboding sign. He picked her up, held her in his lap with her belly up, legs open and apart, and began to rub her. To John, a dog that will let you rub its belly is an “at peace” dog and a prerequisite characteristic of one you’d want to have. Oscar would not let you do that, but Tootsie would. This dog was as laid back as you please to be on her back and be rubbed, particularly behind her ears.

“I think I’ll keep you my little friend. Do you like the water?”

When John and the new dog arrived home that evening, he said as he entered the house, “Karen, guess what showed up at the lake today?”

Karen immediately said, “She’s pretty. Look at her tongue; it’s got a black spot on it. That means she has chow in her.”

“You don’t know that Karen. A black spot on the tongue? Are you kidding?”

“It means she has Chow in her. I bet she is a Golden-Chow.”
Karen was right about the puppy having Chow in her as evidenced by the way her bushy tail always was curled up over her back. None of the neighbors near the lake cabin reported losing a dog and so the family adopted the golden retriever looking puppy with the bushy tail and black spotted tongue as their own.

Bess, their middle child who was in sixth grade at the time, named the new pet Chloe. The new dog was the same color as Meg and since Meg was named after the spice, nutmeg, Bess wanted to name her after another brownish colored spice. She thought chloe was a spice as well. That chloe was not a spice was something that John and Karen did not note, but would not have corrected it even if they had noticed the error. John, a poor speller, the next day went to PetSmart to make a tag for her collar, but spelled her name “Clohe” much to the sarcastic delight of his family who never let him forget that he spelled her name incorrectly. Named for a spice that wasn’t, and having to wear a tag with the wrong name on it may have very well been a glimpse into Chloe’s unpredictable future.
The couple and their family fell instantly in love with the gentle intruder. As John’s mother would say, “One man’s loss is another one’s gain.”
The “gift” and the coming saga that was Chloe then commenced; the extent and complexity of which was unknown to John or Karen at the time. Chloe on the other hand, knew exactly what was to come and the role she’d play in the lives of John, Karen, their family, and more importantly, other lives.

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Putting it all together-Factors in "The Decision."

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Second opinions may limit not eliminate poor decision making.

The Real Prostate Cancer Second Opinion Site

Prostate diaries

An angry man is again angry with himself when he returns to reason. ~Publilius Syrus

In my book I mention that a second opinion is a good idea once the urologist tells you that you have prostate cancer. I add that it is probably best to get a second opinion with a radiation therapist, i.e you already have spoken with a urologist.

Well…one of the things that happens now on a routine basis is that folks present to my office for a second opinion about what to do about their newly diagnosed prostate cancer. What happens is the patient searches for information about prostate cancer and invariably they find my book on Amazon or by virtue of Prostate Diaries (which surprisingly has a very large internet footprint)and  then make an appointment for the second opinion. I have seen folks from all over and it has been very rewarding. It is…

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"Mr. Churchill you are drunk..." "And you my lady are ugly." "And tomorrow morning I will be sober and you will still be ugly!"

“Mr. Churchill you are drunk…”
“And you my lady are ugly.
And tomorrow morning I will be sober and you will still be ugly!”

A previous blog post about the “art of getting away with it” prostate cancer and those nasty mean ole urologists.

Vince Flynn dies of prostate cancer at age 47.

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Search this site for ” Robert Frost- The road less traveled.”

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An angry man is again angry with himself when he returns to reason. ~Publilius Syrus

In my book I mention that a second opinion is a good idea once the urologist tells you that you have prostate cancer. I add that it is probably best to get a second opinion with a radiation therapist, i.e you already have spoken with a urologist.

Well…one of the things that happens now on a routine basis is that folks present to my office for a second opinion about what to do about their newly diagnosed prostate cancer. What happens is the patient searches for information about prostate cancer and invariably they find my book on Amazon or by virtue of Prostate Diaries (which surprisingly has a very large internet footprint)and  then make an appointment for the second opinion. I have seen folks from all over and it has been very rewarding. It is less stressful for me as well as I am not making a recommendation, I am only laying out the options as well as the risks/benefits scenarios. I have actually enjoyed this new role that is occurring more and more frequently, In time I plan to promote it.  For  it is a “I ain’t got a dog in this fight” thing.  I can without any attachment to this new patient or his biopsy history offer insight from someone who has removed hundreds of prostates and also “been there done that.” If they are contemplating surgery I can give them the “inside skinny” on that as well. My social media experimentation comes into play as I am much more aware of online sites that offer valuable advise and also I am familiar with the message boards and how they work.

It has been shown that all specialists are biased toward whatever the treatment of their specialty is. For urology and radiation therapy this is no different. Well that is what it is. They have done their job as the doctor and now the onus is on the patient to do his part, i.e. read and talk and do what he feels is best for him and his family.

I am often surprised during second opinion consultations that no mention, or very little mention, of active surveillance had taken place. I am an advocate of active surveillance in the right patient. There is now volumes of follow-up in these patients. I’d refer the reader to Johns Hopkins Active Surveillance program which is easily found by Googling that phrase.

So the little story below is just for your entertainment and enlightenment. What occurs to this patient cannot be avoided always but with the right research, work-up, appropriate second opinions, attention to the preoperative voiding situation, untoward side effects of any of the treatment can be minimized. Minimized not eliminated and that is why the decision about what to do about prostate cancer is so more difficult and tricky than is first imagined by the newly diagnosed prostate cancer patient.

“It is better to cure at the beginning than at the end.”

From “The Decision”

I have good news. I have prostate cancer.   

I am including this story here because it ties into my prostate cancer journey. I have been sued twice (I won both) and have been an expert witness once. I have told my wife for years that I was an expert in this and that, and she always says, “You are not an expert.” I say, “I am if I want to be.” When I was asked to be an “expert” for another urologist in a malpractice lawsuit, it was official. I was an expert. The plaintiff in the case had had prostate cancer. I was asked to be the expert witness in 2006, which was before I knew I had prostate cancer. It is not uncommon for medical lawsuits to take years to develop, so by the time this case came around for court, I was about a year beyond having my prostate removed. When the lawyer called to tell me the date of my deposition (a fact-finding, pre-trial questioning of the major players in a lawsuit), I told him, “I have good news. I have prostate cancer. Feel free to use the knowledge of this if you think it will help the case.” I then asked, “Should I mention that I have prostate cancer to the lawyer at the deposition?” The lawyer said, “Only if he asks.” The deposition was done at my office, the plaintiff’s attorney never asked, and I did not mention the fact that I had prostate cancer. I felt that a jury would value my testimony much more given the fact that I had been through a little of what the patient who was suing had experienced. The date of the trial was finally set, and I began to review all the depositions in earnest. I then began to worry that if I messed up with anything I said, it could hurt the urologist I was supposed to be helping. A friend of mine, who is an attorney, had come to hear my testimony several years ago at the first of my two lawsuits. At lunch following the testimony I had asked him how he thought I did. “You talk too damn much, McHugh.” I had a fear that in this case I would “talk too much,” and I told the attorney that. He arranged for me to meet and be advised by a “Jury consultant”, not to be told what to say, but to learn how to say it and what to emphasize in my testimony. We talked about the case in general, and I asked some questions about how he might use my prostate cancer history.  “I can get pretty graphic with what I’ve been through if you think it would help.” “Dr. McHugh, we basically have two types of expert witness: the professorial type and the type that has passion. You are the passionate type.” He then adds, turning to look at the attorney, “Bill, he’s good; he’ll do well for you.”

Something I had learned from my having been sued was that the attorneys try to make out the expert witness to be a “hired gun” who is only there to say what he is told for money. I remember my attorney asking the expert witness testifying against me how much he made an hour and how much he was paid to fly to Gainesville and back from St.Louis. The questioning went on and on so that the point was not lost on the jury. I remember my attorney leaning on the jury box as “their” expert witness explained all the money he was to make coming to our “small southern town to testify against one of our doctors.” It was beautifully executed by the attorney, I remember this vividly, and I did not want that to happen to me. I told the attorney who asked me to be the expert that I planned to give the money I make to my church and I asked, “In general how much money do I make for doing this?” He gives me a broad range of a per-hour fee for the time spent reviewing the medical history and the depositions. I was not told nor did I request specifics of how much I would be paid, and I purposely did not want to receive any funds for my services before the case.

On the day of the trial, I was supposed to be “called” in the morning but it was changed at the last minute to the afternoon. “The plaintiff’s attorney is going painstakingly slow,” I was told. The significance of this delay was huge. I was able to review almost all of the depositions a second time, particularly the plaintiff’s deposition. I found some very revealing quotes in my second review that I had not seen initially. As I had been formulating my strategy over the last few weeks before the trial, re-reviewing his deposition was invaluable. The quotes he had used in his deposition fit in nicely with what I had intended to use as an argument. I had seen them before, but seeing them after I had time to digest all the information about the case allowed me to use them in their rightful and most powerful perspective.

My heart is pounding away outside the courtroom, and I was thinking that I didn’t want to mess up. I kept reminding myself: I know urology, I know prostate cancer, and I know the specifics of this case. As I waited, I began to look again at their expert witness’s deposition, and I saw where he was quizzed about how much he charged for his expert services: “$250 an hour for reviewing depositions, $350 for my office deposition, and $5000 for my in-court testimony.” Of course the attorney asked the questions several times in different ways in order for it to hit home with the jury, just like I remember him doing it years ago. He then asked, “Portal to portal?” The expert witness said, “Yes.” Then the attorney asked, again for the benefit of the jury, “Portal to portal meaning that you are reimbursed separately for airfare, food, and accommodations, is that right?” The expert said, “Yes.” I could see it in my mind’s eye the attorney leaning on the jury box rail and looking back and forth between the expert and the jury as if to say, “That’s a bunch of money, makes you wonder if he is an expert just for the pay.” I was really getting into this particular deposition and enjoying the gamesmanship of the attorney when I heard someone announce, “Dr. McHugh, they are ready for you now.”

No sooner did I sit down and do the pledge stuff, worrying that I’d use the wrong hand, the plaintiff’s attorney wants to know if I had been paid anything and how much was I going to charge. “I don’t know what I will be charging.” He says, “You mean to tell me you don’t know what you will charge?” “Yes, sir, I don’t know, I have never done this before.” Once I got over the dry mouth (and I mean parched dry) and the nervousness that preceded my testimony, I was fine. It so happened that I saw the bailiff as a patient several weeks later and he commented,”Doc, I filled up your water pitcher more times than I ever had before! Man you were one thirsty doctor  that day!”  In fact, I enjoyed testifying, particularly when he asked me a question in which the urologic premise was wrong. On several occasions he asked a question in which the details were incorrect. I would answer but only after telling the attorney that the number of days he referred to was wrong or that “that’s not the appropriate terminology for what you are wanting to express.” He kept using “urinary retention,” which implies that a patient cannot void at all, when what he needed to say was “obstructive voiding symptoms.” I was impressed, and it gave me confidence, that he had a very bad working knowledge of urology; I may have been in “his territory” by being in a courtroom, but he was clearly in my territory regarding the subject matter of the questioning. I toyed with him from that point on, correcting his questions and then answering them in a favorable fashion for my side by using the exact quotes from the plaintiff that I had read in his deposition just minutes before. I was disappointed that it came to an end. Things would have gone on longer had it not been for the plaintiff’s lawyer acknowledging that Thursdays was the night the judge went out to eat. The judge agreed and said “Why don’t we wrap things up counselor.”

Reflecting later that evening, although initially I thought I did alright, I began to think that maybe I had been “clever by half.” What if the jury thought I was too cocky or that I talked too much? Then it dawned on me that I had not played the “prostate cancer card.” I just forgot about it. I began to go over the whole testimony in my mind, answering the questions much better and throwing in something about “I wore a catheter too; I know how he feels.” About this time, and with me beating myself up and telling my wife that I probably did talk too much, the phone rings. It is the urologist calling to tell me that the trial would conclude tomorrow, and he’d call me with the results. He then added, “John you were great, the way you used your hands and those quotes, where did you come up with those things?” I asked, “You don’t think I talked too much? I can’t believe I did not mention the fact that I have prostate cancer.” “No you did fine, thanks for agreeing to do what you did; I’ll call you tomorrow with the verdict.” The next day he called and told me that the jury found in his favor. About a week later I received a letter from the attorney telling me that my testimony played a large role in the favorable verdict and for me to submit my bill. I email the attorney’s legal assistant and again asked her for advice as to what to charge. She responded that most doctors bill around $250-$350 per hour for the time they spend on a case.

Around about this time, I had another legal issue come up regarding a business matter, and I had sent a contract to a lawyer in Atlanta to review. What the lawyer did was review the contract I sent him and then send me a bill for three hours of reviewing the contract, but he did not advise me about the contract. In other words, I guess, if I want to know what he thinks about his review, I would have to ask him about that and then get another bill for him to tell me. Then it dawned on me how I should handle my bill for being an expert witness. I needed to think like an attorney, not a doctor. After about a month of “pondering” my charges, I decided submit a bill that was the same as the other expert witness. When I sent it in I prefaced the itemized expenses with, “I have decided to charge what the guy that lost charged.” I got my check a few days later, my wife and I added a little to it, and it covered my commitment to my church for that year. As my mother would say, “God works in funny ways.”

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