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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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From "The Decision"- An exam table paper illustration.

I commonly have to correct patients decision making reasoning as related to the title of this post.
“I think I’ll remove it because at least that way I know I got it all,” I hear often.
This reasoning is flawed as the above videocast explains.

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You can't turn back the clock. But you can wind it up again. - Bonnie Prudden

ProstateMd in the Itunes app store

I know what you are thinking….I shouldn’t have used Penelope as the background of the app…well…that’s what makes me different….irreverent informative prostate cancer stuff with an edge and a bit of humor…..

Well…a few months ago a friend of mine, well kinda sorta of a friend….I hate people and most insects….recommended that I have an app for prostate decision making.

I thought what good would that do? Here’s the deal. I eat lunch behind my ambulatory surgery center every day I can and listen to the radio and read stuff on my iphone. In other words there are those of us that are in certain areas without a computer and but want to do computer stuff.

Look around you…folks all around are looking at their phones in lines at the grocery store, on benches, in the waiting room, in the exam room and most commonly…while you are talking to them.

So…a prostate cancer decision-making app for those folks.

No market for a prostate cancer app you protest especially since all the talk that the PSA is a bad ole nasty test and the urologists recommending them are money hungry charlatans!

Well…16% of american men have it, I think that is one in six and that represents 250,000 new cases a year.  That is, I’d say, a reasonable market for the app.

I went on the App store and guess what? Not much there on the subject of prostate cancer.

So…I am putting a “boat load of info” on this app. The app service I have allows me to update seamlessly and in real-time. So today I uploaded all the treatment methods out there and my take on it. Good stuff…and the app allows the user to send as email, or post to Facebook or twitter. So if you purchase the app and want to help a friend who has been recently diagnosed….well…..

Viola!

Finally, I plan to set up a reward program for the “Best comment or question of the week.” If someone submits an issue and I use it as a post or for something on the app…I’ll autograph a book and send it out free of charge once a week. Not to shabby…huh?

I really think the best function of this app is access to info while one is on the run and would not otherwise get all this info in one place. Just like me behind my surgery center at lunch.

I hope it will help someone who otherwise would not have taken the time to learn about this tricky disease.

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whether you think you can or think you can't...you're right

First off all…look at the sentence I highlighted in bold. Are you kidding me? Concerns about a CT scan and radiation all the while finding no complaints regarding treating the prostate cancer with radiation regardless if it’s seeds, Proton, or external beam.

The use of “misuse” is an attention getter is it not.

We have known for years that the likelihood of a positive bone scan for bone metastasis and a positive CT scan showing pelvic lymph note involvement is low in the patient with low Gleason’s and low volume disease on his prostate biopsy report.

In today’s world I as a urologist can tell the patient that biopsy shows cancer and then say, “The chances of finding anything on a CT scan or bone scan is low. It is however a part of the staging work-up for the newly diagnosed prostate cancer patient. Would you rather not do these studies? The patient decides based on the information that I have given him. These test are most commonly negative…but not always. What is the consequence of not doing the tests in the face of unknown metastatic disease? Well you get your prostate out, or get radiation, or HIFU, or cryosurgery for local disease when in reality it is not. Are you Okay with that?

You see what all the studies and reports fail to “get” is that statistics are different from actually sitting down with the patient and family and making decisions.

I guess with a National Healthcare Plan…the doctor will just say, ” Your prostate biopsy shows cancer and there is no need to do a bone scan or CT scan based on statistics of similar patients with a biopsy like yours.” Done.

Which is right or which is wrong? Well…everytime I make the diagnosis of prostate cancer someone somewhere sends me a form to fill out about the stage of Prostate Cancer my patient has. Well…if I don’t do a bone scan and a CT…I am assuming. Maybe the forms…i.e. the National Cancer Registry, or your local hospital’s Tumor Board has a little box to check stating the stage is I but that because of parameters of the biopsy a staging work-up was not done. As of yet and as of today…that box does not exist, but I am continually having to stage my patient’s cancer on some form.

So what to do?

Doctors misuse scans? Is it really that simple? Dear Dr. McHugh quit doing bone scans and CT’s to stage your patients. Also please fill out the attached form informing us of your patient’s prostate cancer stage or risk losing your hospital privileges until your medical records are up to date. What’s a doc to do?

Regarding the title of this post-My patients, after I have explained the likelihood of the results of the scans, most commonly opt to have the studies done. It is more information about their cancer and allows them to make treatment decisions. Right or wrong? What would you do given the choice?

What did I do? I did not have a bone scan or CT.

Doctors misuse scans in prostate cancer: study

Fri, Aug 26 2011

By Genevra Pittman

NEW YORK (Reuters Health) – Too many men with low- or medium-risk prostate cancer get CTs and bone scans that aren’t recommended for them, suggests a new study.

The scans are intended to tell doctors if cancer has spread beyond the prostate in men with high-risk cancer.

Doing them in other cases is a concern because CTs expose patients to small amounts of radiation — which itself is linked to future cancer risks — and the scans cost the healthcare system extra money, but have little potential benefit.

The research also suggests that not enough men with high-risk cancer get the scans, which means some of them may get treatment for local (confined to the prostate) cancer that’s unlikely to help if the cancer has spread.

“In high-risk patients, those are the ones that have a high risk of positive lymph nodes or (cancer that has) spread to the bone,” said Dr. David Samadi, a prostate cancer surgeon at the Mount Sinai Medical Center in New York who was not involved in the new study.

“Otherwise for low-risk disease, the likelihood of finding a positive bone scan or CT scan is low,” he told Reuters Health.

Guidelines from the American Urological Association say that doctors should use other measures such as prostate-specific antigen (PSA) testing to determine a man’s risk of advanced cancer and then only scan those with high-risk disease to determine the best treatment.

Researchers led by Dr. Jim Hu of Brigham and Women’s Hospital in Boston wanted to see how frequently those recommendations were being followed.

They consulted a database of U.S. men covered by Medicare who were diagnosed with prostate cancer in 2004 and 2005 — a total of 30,000 cases.

Both bone scans and CTs were more common in men who were diagnosed with high-risk cancer.

Sixty percent of those men had one of the scans. Still, one-third of men with low-risk cancer and almost half of those with medium-risk cancer had a scan in between diagnosis and treatment.

Hu and colleagues calculated that the cost of unnecessary scans in men with low- and medium-risk cancer billed to Medicare during those two years was about $3.6 million for their study group. (The government-run insurance program paid an average of $226 for each bone scan and $407 for a CT).

Extra scanning not recommended by guidelines “significantly increases Medicare expenditure without improving quality of care rendered for men with newly diagnosed prostate cancer,” the authors wrote in the journal Cancer.

And each extra CT scan exposes men to a small amount of radiation, while also providing an opportunity for doctors to catch something “incidental” that may not pose a threat but still leads to more testing or procedures, Samadi said.

Another recent study found that coaching and feedback from peers about the proper use of the tests helped prostate surgeons reduce the number of unnecessary scans they ordered. Samadi thinks many doctors are just trying to be on the safe side by ordering more tests.

“A lot of it has to do with the fact that most urologists when they think of prostate cancer it’s almost like a knee-jerk reaction — automatically they think bone scan and CT scan,” Samadi said.

The researchers noted that finding four in 10 men with high-risk cancer aren’t getting a scan is also “worrisome.”

If doctors don’t recognize that cancer has spread in some of those men, they said, they won’t benefit from treatment directed just at the prostate.

SOURCE: bit.ly/pYwBrh Cancer, online August 5, 2011.

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god gave burdens...also shoulders

New Robotic Surgery Technique Maintains Sexual
Function After Prostate Cancer Surgery

The SMART Technique (Samadi Modified Advanced Robotic Technique) Enhances
Surgical Precision and Maintains Sexual Wellbeing After Prostate Cancer
Treatment

Dr. David Samadi, Vice Chairman, Department of Urology, and Chief of Robotics
and Minimally Invasive Surgery at The Mount Sinai Medical Center knows the wide
range of emotions and fears that men with prostate
cancer
face. As a robotic
prostatectomy
and prostate
cancer treatment
 expert, Dr. Samadi cares for the total patient, helping
them deal with all aspects of treatment, recovery and cure. Robotic
prostatectomy procedures, performed to remove the prostate gland and surrounding
cancer, can provide excellent cancer cure results, though many men fear the
potential side effects of the surgery. Top on their list of concerns: will they
be able to have and enjoy sex
after prostate cancer treatment
?

Dr. Samadi understands this concern. “For most men, sexual function is
equally as important as eliminating prostate cancer. Many of their fears about
sex after surgery are carry-overs from what they know of older open and
laparoscopic prostatectomy techniques. Thanks to robotic
surgery
, these fears can be greatly reduced.” Historically, the prostate
gland was removed through invasive surgery during which surgeons had a difficult
time sparing the tiny nerve bundles responsible for erectile and sexual
function. Often, a man’s ability to have sex after surgery was negatively
impacted. With the advent of robotic surgery techniques, experienced surgeons
like Dr. Samadi have an enhanced view of the prostate gland, allowing increased
precision and dexterity. As a result, the risk of damage to the nerves vital to
sexual function is significantly diminished.

When treating his prostate cancer patients, Dr. Samadi employs a
start-to-finish approach, including an individualized evaluation of sexual
function prior to surgery and on-going, post-surgical assessments of options to
aid the return of sexual function. “I consider robotic surgery successful when
the cancer is cured and the patient has full continence and potency. All three
criteria must be met for me to consider the surgery a success.” Dr. Samadi dubs
this whole-patient approach, “Treatment Trifecta.”

Dr. Samadi customizes robotic surgery with his own SMART
(Samadi Modified Advanced Robotic Technique) method
. Using the da Vinci
System, the commonly recommended treatment for localized prostate cancer, Dr.
Samadi is able to perform highly precise movements at the surgical site:
cancerous tissue is cleanly removed and critical nerves are spared. By not
opening the surrounding fascia around the prostate and not suturing the dorsal
vein complex, Dr. Samadi has improved the quality of men’s post operative sex
life. Ultimately, this leads to faster recovery and an improved outlook for
regaining sexual function and urinary continence.

“Men want to know they can return to a normal life when this is all over.
They want the cancer gone and they want to move on and enjoy sex the way they
always have,” says Dr. Samadi. While the resumption of sexual potency can take
up to 12 months or more, Dr. Samadi assures patients that this is within the
normal course of recovery. His comprehensive approach to prostate cancer
treatment and sexual wellbeing continues beyond surgery. “It’s not uncommon for
men to experience some ED immediately following prostatectomy procedures, but
this is not an indication of their long-term sexual potency. I continue to work
with patients to achieve the complete results they desire.”

More can be seen from prostate cancer expert, Dr. Samadi, who is also part of
the Fox News Team.

Prostate
Cancer Treatment Options Compared: Robotic Surgery vs. Watchful Waiting

Robotic
Surgery on Good Day New York

Related Links:

http://www.smart-surgery.com/

http://www.roboticoncology-it.com/

http://www.roboticoncology-il.com/

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we often hate most what we fear

Here’s a dirty little secret for you….prostate cancer patients often don’t choose the treatment that they feel gives them the best chance for cure. They are “I want my cake and eat it too type” patients. By this I mean, “Which treatment will best treat my cancer and limit my potential side effects and complications.” In this way prostate cancer decision-making is much different than in other cancers. Who are you?

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losers quit when they are tired...winners quit when they win.

Common searches about sex that end up on my site and some other various tidbits for you…

  • Having sex the night before having a PSA drawn can elevate the value.
  • Having sex before the Prostatic Acid Phosphatase will probably elevate the value.
  • A rectal exam before having the PSA drawn will not elevate the value.
  • A rectal exam before a PAP will elevate the value.
  • You don’t get cancer if you have sex with a man with prostate cancer. (Good try ladies.)
  • Your libido doesn’t change (physiologically wise) after the prostate is removed.
  • Climax after radiation or radical prostatectomy still occurs but the character of which may change…for the better or worse.
  • In both radiation or prostatectomy the male’s climax… will be dry or no fluid.
  • You can have sex before a prostate biopsy.
  • You can have sex after a prostate biopsy…expect blood in the semen. It looks dramatic but is harmless. It will stop … in time.
  • If you have chosen radiation because you expect to “spare” your sexual function…think again and research again.
  • There is a bit of luck in being potent after “any” treatment of the prostate. Sorry proton guys…sorry robotic guys whose doctor said he “spared” the nerves.
  • You are infertile after treatment, not impotent.
  • You are less likely to preserve sexual function if your function is waning before treatment. i.e. the guy with a 10 function will do better than the one with a 6.

So…Pick your poison.

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