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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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If you are young and making career decisions you have got to do as my mother advised, ” Choose long-term gain over short-term gratification John.”

Eugene, Oregon Prostate Cancer Survivor Story

For about 15 or so years in late August I’d go out west to hike and fish with the fellows pictured above. The above picture is from the Golden Trout Wilderness in California but I want to tell you a bit our trip to Eugene, Oregon home of the Umpqua River and not far from Crater Lake.

I’m telling you these trips were something else. They have formed a very vital part of my life and who I am. Silly you say. In the picture above we are camped by the Kern River (Google the Merle Haggard song) and rode pack horses for 8 hrs to get there and did it on the side of a steep mountain all the way into the gorge to camp, hike and fish.Seven days of hiking and fishing miles of it alone. City slickers of sorts.  The guy above on the first row and holding what looks like a Red Solo Cup is the guy that planned the trips. We went everywhere and if you could pick the most beautiful places in the world and at the same time was known for fly-fishing…well that is where he’d have us go. But today my story is not about the Kern, but the Umpqua in Eugene. I’ll come back to the Kern another day.

This time our planner did not quite get the full picture of how our trip would be until we got there.  Yes the Umpqua was a renowned Steelhead river, and yes Zane Grey fished there and it is close to the most beautiful sightseeing  area in America,Crater Lake and also home to the Umpqua Fishing Lure Company and on the surface yet another perfect place to hike and fish. Hell it was on the other side of the continent from Gainesville, Ga. My son Clay immediately requested a Oregon Duck Hat. I ‘d never heard of that school and who would name a mascot a duck anyway.

Well we do the usual and fly into Eugene and then rent a van and then off to our trailhead along the Umpqua River. Our plan was like so many trips we’d done before, fish and hike and camp along the river for a week in the solitude we all had paid for both in money and the time and effort it took to be away from our families and jobs.

I remember passing a small drive-in type restaurant in Eugene (in which I bought a T-shirt for my sons that had a funny name making the shirt a favorite of theirs for years), the “Umpqua National Forrest” and the obligatory group picture there, The Steamboat Inn and then all the signs pointing the way to Crater Lake which was on the same road as the supposed “trailhead.”

Well…as we go along we see the river to our right and what one notices quite blatantly are wide areas for cars to park called ” turnouts.” People are parking along the river and then going down the bank to fish. Beautiful water, beautiful large rocks and beautiful holes, but all so “public.” As we drive along taking all this in someone asks, ” Where’s the trail going to be?” In other words how in the hell can we hike on this river in a section not easily accessed by everybody in cars. You see that was our deal, our manifesto, our modus operandi we go where they ain’t. We fish what ain’t fished, we fish where it is hard to get to and then we camp tens of miles from anyone and we get further away as the week progresses.

We see a forest service road that matches what we have on our itinerary and we all sigh a sigh of relief. Okay, this is looking familiar a dirt road and it is heading away from the highway and into green. After about 30 seconds we come to a bridge over the river and then the sign connoting the trail and parking area for hikers. We park. We get out and look around. To this day and as I write what comes mind is the sounds of cars. Swooshing cars going hither and dither back and forth over the sounds of the water of the Umpqua.

“Is this it?” we ask of our planner.

“I think so,” he says. “The trail looks a lot further from the river on the maps.”

We all look at the maps wishing we’d looked at the maps in Gainesville months before. Small dotted red lines along the Umpqua river and … a road on the other side of the river. The road we were just on and a major thoroughfare to one of the most visited attractions in Oregon, Crater Lake.

To be continued…..

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its not that opportunity doesn't knock...folks just don't answer the door

The above picture was taken last year almost to the day in Orange Beach, Alabama. I remember the day vividly. My wife and I went to the beach and for almost every minute of the day construction vehicles were working and making noise just outside our condominium. It was comical how loud and persistent the noise and activity was. BP was paying money for the clean up and Orange Beach was using every penny of it looking for tar balls. We would see workers shift sand all day and from what we could tell from our balcony and on our walks very little was being found. It looked very “governmental to me.”

Anyway, just before I had left Gainesville a patient who had been diagnosed with prostate cancer with a high Gleason score had had a bone scan. I was concerned about it. The patient and his wife became “office friends” of mine and in fact the wife was so kind to drop off  several excellent cakes to my office as a thank-you for our help in his case. The cakes were so good that my wife, who loves to cook, said ” I’ll never cook another cake again. I’ll just get these.”

While at the beach I call on several occasions to get the report of the bone scan. My nurse read me the report as I watched the heavy equipment move sand in front of the beach.

“Wide-spread metastatic bone disease consistent with known history of prostate cancer.”

“Damn it!” I was sick with the news. I called the wife and gave the news and arranged for the couple to come to the office to discuss the findings, the significance and our plan going forward. I arranged for the patient to go by the office and get a LHRH shot and called in Casodex.

That was one year ago. He passed away this week. I loved him and you would have too. Man the man loved to work. He went to work with crutches toward the end. His wife came by almost weekly for a prescription for Oxycontin, the only thing that allowed him to go on.  I never heard him complain. His wife was absolutely beautiful through the whole thing. I am sorry Bess (my daughter says I mention Frank Zappa too often) but it was Frank Zappa, Dan Folgelber, Ablin’s father all over again.

How is it in today’s world, the internet, prostate cancer month, Movember that someone presents too late to cure of prostate cancer?

If this patient had had a PSA several years ago would that have made a difference? Or stated differently…at what point would a PSA and knowing that this patient had prostate cancer would it have made a difference? What do the epidemiologists of the world have to say about this class of patient?

A frequent commenter to this blog I bet has some thoughts on this and we should listen to him.

Keith…are you there?

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an inch of time cannot be bought with an of gold

Now the pepster wants to do podcasts…no way shomcheppie….

 

Today I informed a patient that his prostate biopsy showed cancer and he began, as often patients do, telling me about advice various friends had given him.

“My friend down the street told me not to have the regular surgery, I should have the one with the little holes in stead. My buddy in Tennessee said he had radiation and that for about a year it was rough, but that now he’s fine.”

Do the one with the little holes…okay?

After a year, (of frequency to void, urgency and getting up at night) I am fine?

Now that was good advice. Wonder what his urologist thinks. I don’t know. I elected to just listen to what all his friends and relatives recommended. I learned something.

As my mother would say, “landed on deaf ears John.”

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Jennie C. Davis: Hall of Fame Senior Year of High School Because of her ability to do as she pleases.

The ability to do as she pleases and “calm as a hurricane”…they got that right!

Mother’s Day circa 1994:

You were born in the Depression years.  You were named after your fathers’ mother – Jennie Cooper.  As a child, you could skate faster and ride a bike better than any boy in LaGrange, Georgia.  You loved your mother but were much closer to your father.  You are a diehard Georgia Bulldog fan and it goes without saying that you hate Georgia Tech but you always respected a “Tech Man.”  You were in the Coast Guard and loved the Big Band era of the war years.  Frank Sinatra was your favorite.  You are an encyclopedia of Southern sayings like, “If you misbehave again, it’s gonna be too wet to plow.”  You feel like there is a difference between which side of the Mason-Dixon Line you’re from.  A twist of fate determined that you would raise your five boys without a husband.  You worked at night and went to school in the day and got your college degree at the age of 51 (you commuted 150 miles a day to do it).  You nursed your mother until she passed away, at home and gracefully, and then you battled cancer and are winning the fight.  You often said, “you don’t know what love is until you have children.”  All this you did with enthusiasm, optimism and vigor – always with vigor.  You are an inextinguishable spirit that is contagious to those around you.  You’re tough.  But most importantly, to your children through all the varied times, you imparted unyielding love.  The formula for a good mother is complex; mixing consistency, discipline, example and material needs to mold a child’s character.  In all these things you may not have been perfect.  But one thing was never in question, one thing was never lacking, one thing you had limitless quantities of, and that was love.  We always received love and felt loved and that was your greatest gift as a mother and a part of you we hope to pass on to our children. 

We love you  Jennie Cooper

LaGrange High School Annual Circa 1938

 

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Decisions…decisions….

Sounds very straight forward to me. How about you? Not to pick on the American Cancer Society, but what if the discussion about whether to consider the PSA was the status quo in the diagnosis of breast cancer and mamograms? “Mrs. Smith. Before you consider a mamogram, it may be positive and that may require a biopsy and that biopsy may or may not be positive. If negative you may still have an undiagnosed breast cancer. If positive you may elect a treatment that is not necessary or cause disfiguring side effects. So, Mrs. Smith, what are you thoughts on being checked for breast cancer? Mrs. Smith, Mrs. Smith…?”

Mrs. Smith: ” I am sorry you lost me with the first part. I just want to know if I have breast cancer or not.”

Should prostate cancer be treated any different from breast cancer?

Purpose

The Prostate CAncer gene 3 (PCA3) assay may guide prostate
biopsy decisions and predict prostate cancer (PCa) aggressiveness. This study
explored the appropriateness of (1) PCA3 testing; (2) biopsy; (3) active
surveillance (AS) and the value of the PCA3 Score for biopsy and AS decisions.

Methods

Using the RAND/UCLA appropriateness method, 12 urologists
assessed the appropriateness of PCA3, biopsy and AS for theoretical patient
profiles, constructed by combining clinical variables. They individually scored
the appropriateness for all profiles using a 9-point scale. Based on the median
score and extent of agreement, the appropriateness for each profile was
calculated.

Results

The PCA3 Assay was mainly considered appropriate in men with
≥1 negative biopsy, PSA ≥ 3 ng/mL and life expectancy (LE) ≥10 years. A
 LE < 10 years, ≥2 negative biopsies and PCA3 Score <20 decreased biopsy
 appropriateness, while PSA ≥ 3 ng/mL and PCA3 Score >50 increased it. In men
 without a prior biopsy, LE ≥ 10 years and a suspicious DRE, PCA3 did not affect
 biopsy appropriateness. In other men, a PCA3 Score <20 discouraged biopsy,
while a value ≥35 supported biopsy. AS was mainly considered appropriate if
 LE < 10 years, T1c PCa, ≤20% positive cores and PSA < 3 ng/mL. A PCA3
Score <20 pleads for and higher scores (particularly >50) against AS.

Conclusions

These findings illustrate in which men PCA3 can be of
additional value when taking biopsy and treatment decisions in clinical
practice.

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the devil has a future and the saint a past...

 Happy Fourth From Prostatediaries

 

After having had total incontinence for three months and wearing a condom catheter for that time…when one day I retained some urine I began to consider my incontinence future. When I got to where one diaper a day did the trick, I honestly felt that if it never improved anymore, that I was fine with it. I believe that is what you are seeing in this article. If the incontinence is mild, men accept that much better than you would think, I did. I am surprised even as I think back on how I felt at the time. Many women few men, as do I, as bad patients and don’t deal with problems well. There is some truth to this, however if you consider both the radiation and prostatectomy patient have to go through beside the cancer, i.e. the insult of leaking urine and erection issues has on the male ego…I think men step up and deal with it. I have seen this and this is what I feel is reflected in the remarks below regarding incontinence.

By Kerry Grens

NEW YORK (Reuters Health) – Nearly half of men who undergo surgery for prostate cancer find themselves with greater incontinence problems and less sexual function than they anticipated, according to a new poll.

Before the surgery, some men in the study had expected to have better urinary and sexual function a year after the procedure than before it — a misbelief the researchers say is out of step with reality.

As part of the new survey, 152 men undergoing radical prostatectomy filled out a questionnaire before they had surgery but after they had received counseling on the risks of the procedure. The questions asked about their expectations of urinary, bowel and sexual function a year after the surgery.

About half of men expected the same function after surgery as before, but 17% anticipated better sexual function after the surgery.

On a follow-up survey one year later, just 36% of the men said their expectations for urinary function matched the true outcomes, and 40% said their expectations for sexual function matched reality.

Daniela Wittmann, the sexual health coordinator in the urology department at the University of Michigan and the lead author on the study, noted it’s hard to predict how likely a patient is to recover his urinary and sexual function.

“We can only (inform them) in terms of overall statistics, we can’t predict for the individual man” how well he will recover, Wittmann said, “which means that, if in doubt, people tend towards being hopeful and optimistic.”

One recent study showed that, one year after surgery, only one out of four men recovered the ability to have intercourse. (See Reuters Health report, April 21, 2011.)

Another research team recently found that some degree of incontinence was common, too, although men tended not to be significantly bothered by it. (See Reuters Health report, June 3, 2011.)

Dr. Tracey Krupski of the University of Virginia, who wrote an editorial published along with the study online June 15th in the Journal of Urology, said men’s unrealistic expectations can be a double-edged sword. On the one side, she told Reuters Health, optimism is known to help people heal, but on the other side, “it may ultimately lead to disappointment when adjusting to a long term disability.”

A different study, published along with Wittman’s, found that when men were educated about the risks and benefits of nerve sparing prostatectomy, and then given the power to choose the type of procedure, they were likely to make choices similar to their surgeons’.

In this study, by Dr. Hugh Lavery and colleagues at Ohio State University, the men had both a routine pre-operative counseling session and a separate appointment with a surgeon to discuss the risks and benefits of each procedure.

Dr. Krupski said additional pre-operative visits would be beneficial, but are generally not covered by insurance plans.

She said that a network of men who have been through the experience and can support new cancer patients might help them understand the realities of life after surgery.

Wittmann said that involving patients’ partners is also vital to successfully regaining sexual relationships.

“Sex is a partnered activity for most people. The partner can be very effective as part of an intimate team recovering from the side effects of this surgery,” she told Reuters Health.

The study did not examine whether men would make a different treatment decision given their hindsight after the surgery.

Wittmann said she thinks only a small proportion of men would choose not to have surgery if they fully understood the potential for erectile dysfunction, because there are other cancer-related reasons that drive their decision.

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