tag:blogger.com,1999:blog-69019315883472794082024-02-06T18:16:38.593-08:00Now Without HesitationStephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.comBlogger372125tag:blogger.com,1999:blog-6901931588347279408.post-23261406818251770322019-03-09T12:43:00.000-08:002019-03-17T08:09:26.321-07:00Funeral and Shiva for Stephen J. Ellmann<!--[if gte mso 9]><xml>
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<span lang="EN" style="color: #454545; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">Stephen J. Ellmann<o:p></o:p></span></div>
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<br /></div>
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<span lang="EN" style="color: #454545; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">Stephen Jonathan Ellmann, son of authors Richard and Mary
Ellmann, was born on June 20, 1951 and died on March 8, 2019, surrounded by his
loving family.<span style="mso-spacerun: yes;"> </span>A distinguished author,
educator, and advocate for social justice, Steve was an expert on the South African
legal system during and after the apartheid era and a pioneer in the
development of clinical legal theory studies.<span style="mso-spacerun: yes;">
</span>Diagnosed with cholangiocarcinoma in 2015, Steve spent his remaining
years writing a monumental biography of South African judge Arthur Chaskalson,
a leading figure in the struggle against apartheid, which is soon to be
published.<span style="mso-spacerun: yes;"> </span>His legal career began in
Atlanta, GA, where he served as Law Clerk to Hon. Elbert Tuttle, U.S. Court of
Appeals, Fifth (now Eleventh) Circuit in 1976-77.<span style="mso-spacerun: yes;"> </span>From 1977-83 he worked as staff attorney at
the Southern Poverty Law Center in Montgomery, AL, where his practice included
institutional reform litigation for mentally disabled people and prison
inmates, voting rights cases, anti-Ku Klux Klan suits, and defense work in
capital murder trials.<span style="mso-spacerun: yes;"> </span>In 1983 he took
up the position of Associate Professor of Law at Columbia University, where he
founded the Clinical Theory Workshop in 1985.<span style="mso-spacerun: yes;">
</span>He pursued his passion for legal pedagogy with a move in 1992 to New
York Law School, where as Martin Professor of Law he has trained hundreds of
future attorneys in legal ethics and in support of social justice.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span lang="EN" style="color: #454545; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">A long-term resident of Upper Montclair, NJ, Steve is survived
by his beloved wife Teresa M. Delcorso Ellmann, his children Brian, David, and
Nora Ellmann, and his sisters Maud and Lucy Ellmann, </span><span lang="EN" style="color: #222222; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">Brothers-in-law John
Wilkinson and Todd McEwen, Daughters-in-law Karen Ellmann and Nevedha Rajan and
Grandsons Patrick and Zac Ellmann.<o:p></o:p></span></div>
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<br /></div>
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<span lang="EN" style="color: #222222; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">Donations in Steve's memory can be made to the New York Law
School Stephen J. Ellmann South Africa Judicial Fellows Program at </span><span lang="EN"><a href="http://www.nyls.edu/InMemoriam"><span style="color: #1155cc; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">www.nyls.edu/InMemoriam<o:p></o:p></span></a></span></div>
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<span lang="EN" style="color: #222222; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">Donations also may be sent to the program c/o New York Law
School, Office of Institutional Advancement, 185 West Broadway, New York, NY
10013<o:p></o:p></span></div>
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<br /></div>
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<span lang="EN" style="color: #454545; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">Additionally, donations can be made to the </span><span lang="EN"><a href="https://cholangiocarcinoma.org/"><span style="color: #1155cc; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">Cholangiocarcinoma Foundation</span></a></span><span lang="EN" style="color: #454545; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;"> to support research and
advocacy to find a cure for Cholangiocarcinoma.<o:p></o:p></span></div>
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<br /></div>
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<span lang="EN" style="color: #454545; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">We invite you to join us for Steve’s funeral on Monday, March
11, 2019 at 11:00 am at B’nai Keshet (99 South Fullerton Ave, Montclair,
NJ).<span style="mso-spacerun: yes;"> </span>A Jewish burial will then take
place at Our Lady of the Magnificat Cemetery (2 Miller Road, Kinnelon, NJ) at
1pm.<o:p></o:p></span></div>
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<br /></div>
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<span lang="EN" style="color: #454545; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">The family will sit Shiva at their home on Monday, March 11 from 4:00 pm to 8:00 pm and Tuesday, March
12th from 2:00pm to 4:00pm and 6:30pm to 9:00pm.<o:p></o:p></span></div>
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<br /></div>
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<span lang="EN" style="color: #454545; font-family: "times new roman" , serif; font-size: 12.0pt; line-height: 115%;">For more information please visit: <a href="https://proutfuneralhome.com/">https://proutfuneralhome.com</a><o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLnTM_ROQCmxMcYBEKsKxW0gWQ4_6foSxdOpHL3ifJtSiEtMgwLvGOybE6_FKWOHArAIIuCysk3zt2VR8JG5ewfEBs22ROav9oyyWUT0YaLqET1OCuOnF0JYK_asJi_cV4GQemtp6Q2Ys/s1600/Steve+with+Penny+and+Ford+Prez-3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="893" data-original-width="1600" height="178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLnTM_ROQCmxMcYBEKsKxW0gWQ4_6foSxdOpHL3ifJtSiEtMgwLvGOybE6_FKWOHArAIIuCysk3zt2VR8JG5ewfEBs22ROav9oyyWUT0YaLqET1OCuOnF0JYK_asJi_cV4GQemtp6Q2Ys/s320/Steve+with+Penny+and+Ford+Prez-3.jpg" width="320" /></a></div>
<br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-75929431205835022672019-03-08T06:24:00.000-08:002019-03-08T06:24:34.510-08:00Farewell My Love<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal;">
<span style="font-family: ".SFUIText"; font-size: 17pt;">Dear readers,</span></div>
<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal; min-height: 20.3px;">
<span style="font-family: ".SFUIText"; font-size: 17pt;"></span><br /></div>
<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal;">
<span style="font-family: ".SFUIText"; font-size: 17pt;">It is with great sadness that I write to share with you Steve passed away in the early morning hours on Friday, March 8, 2019.</span></div>
<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal; min-height: 20.3px;">
<span style="font-family: ".SFUIText"; font-size: 17pt;"></span><br /></div>
<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal;">
<span style="font-family: ".SFUIText"; font-size: 17pt;">Thank you for sharing in his journey with Cholangiocarcinoma.</span></div>
<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal; min-height: 20.3px;">
<span style="font-family: ".SFUIText"; font-size: 17pt;"></span><br /></div>
<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal;">
<span style="font-family: ".SFUIText"; font-size: 17pt;">We will post details about his funeral here, once they are available.</span></div>
<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal; min-height: 20.3px;">
<span style="font-family: ".SFUIText"; font-size: 17pt;"></span><br /></div>
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<span style="font-family: ".SFUIText"; font-size: 17pt;">—his loving wife Teresa</span></div>
Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-6470247483546819732019-03-06T13:38:00.001-08:002019-03-06T13:38:19.653-08:00One Final Post<div style="color: #454545; font-family: ".SF UI Text"; font-size: 17px; font-stretch: normal; line-height: normal;">
<span style="font-family: ".SFUIText"; font-size: 17pt;">Readers visit Steve’s blog to read his account of his journey with Cholangiocarcinoma. During the past three years writing about his illness, so many of you have shared with him how meaningful, inspiring and uplifting his writing has been to you. It gave him great joy to know that his writing held meaning for so many readers, especially those in the Cholangiocarcinoma community. </span></div>
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<span style="font-family: ".SFUIText"; font-size: 17pt;">Six weeks ago when he received his prognosis of six months, Steve planned many more posts that would explore deeply this next phase of his experience with the disease and his own mortality.</span></div>
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<span style="font-family: ".SFUIText"; font-size: 17pt;">This post is written by his wife Teresa who is not as eloquent or articulate as Steve. And I am sad to report that there will be no more posts from our beloved Steve. He is in the final days of his journey with us on earth.</span></div>
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<span style="font-family: ".SFUIText"; font-size: 17pt;">We want his readers to know that he is at peace and is spending his final days surrounded by his beloved family. Many of you have reached out and shared with him how special he is. Thank you. Knowing that our kind, loving, funny, intelligent and insightful Steve is treasured by so many people comforts us at this terrible time. Your love and support are carrying him and us through this final journey.</span></div>
Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-83152807414337299292019-02-15T15:27:00.001-08:002019-02-17T10:51:53.205-08:00Another MSK Fragment: My Harris ... Chair???<!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Before I became ill I rarely had occasion to visit the homes
of friends who were fighting cancer. So although I must have been in homes that
had been rehabbed more or less substantially to make the patient’s life work
more smoothly, I probably didn’t really focus on those features as part of my
friends’ fight against cancer. Among the things I certainly missed were many
changes in clothing; cancer changes your body, pretty much whether you want it
to or not. With the benefit of more understanding of what I was seeing,
however, here’s at least some of what I’ve noticed (leaving out the crucial,
crucial contribution of one’s friends and family, and for me especially those
of my dear wife Teresa):<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><u>Grab bars</u>: Those shiny bars that may accompany toilets?
Very helpful, and not just to provide <u>something</u> to grab on to, though
that by itself is a big help. It turns out that in getting on and off a toilet,
the exact number of inches above the ground that will give you the greatest
leverage is very important. You can have all the strength you need, but not be
able to bring it to bear – unless you have grab bars to provide you with
intermediate help as you get up. (For similar reasons, other aspects of toilet design, including how far above the china bowl your actual seat rests, may turn out to be important too.) You may also want to acquire a <u>bell </u>–
not the Victorian kind that you pick up and ring, perhaps embarrassing everyone
in sight, but the modern kind with electronic links between the call buttons
set up for you and your family so that when your grab bar saves you from some
problem, someone will arrive to help!<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><u>A cane</u>: I now have a cane, specifically my mother-in-law’s
cane from a bout of illness mostly in the past. (Very generous of her.) I don’t
actually need a cane; that is, I could get the leverage and support I need by
other, cruder means, like leaning against the wall. But the cane, which has
adjustable buttons, is more adaptable. It may also provide a new area for my
emerging fashion sensibility (you remember the arrival of the Croc’s, right?);
at any rate, my wife asked me if I preferred wood or metal, and a new cane will
arrive as soon as tomorrow. and then of course there are the models with concealed
weapons (all right, I admit my fighting days, which I don’t recall ever actually
beginning, have now definitively ended). Fantasies aside, a cane is useful. Its
only flaw as far as I’ve seen is that it is so useful that once you have one
you use it readily and frequently, and in the process you do get slowed down. (I also have a great, five-foot-long walking stick that my son and his family gave me; it arrived before the recent medical pressures and in this post I was focused on medical interventions, but I very much appreciated it too.)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><u>A staircase chairlift</u>: This device, of course, anyone
seeing it would recognize as a health care device. So I’m writing about it not
to reveal its secrets but to celebrate its virtues. And they are many! The one
we’ve rented really does exactly one thing but it does that one thing very
straightforwardly: after installation by just one person, it proceeds to carry
you up the stairs and down, again and again. No turns (though on a bigger
staircase those would be necessary), but a discreet alarm that will catch the
attention of someone else in the household so that if something didn’t work you
wouldn’t be stranded midway up the stairs. A safety belt, which you could get
away with not using, but why would you?<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Now the fact is that I didn’t absolutely need a chairlift
either. Using a combination of stepping sideways and adding to the leg force I
could exert with a firm grip on the bannisters, I could and did make it up the
stairs, and down was quite a bit easier. Especially going up, however, I was
seriously winded for up to as much as half an hour. That was time I had better ways
to use. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">So I’m really, really, happy with my staircase chairlift. I
felt that under the circumstances, I needed to give it a name. But what name?
Well, I felt the chairlift was doing work that’s typically done by men, but not
exclusively so; and that the chairlift also reminded me of clothes I’m
accustomed to wearing (but that women probably wear too). So its name is “Harris,”
as in “Harris Tweed,” and when I want to change floors I tell the people with
me that “Harris and I are going” up or down. And just to further mark
his/her/its value to me, here is a picture of Harris [plus me], provided that
Teresa’s technical skills enable us to post it. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCwMSvPn3DGlpQlIFYq_7hPbxyz7VMKytWMUBcmNFxEkbEoKXFDzIU4CVJGbdwUqxEqOJd1RS7CUZalygv1wNMKVgcm8ZB6ku16OiB-EchGk4qLqx6GTKG8hFx3MLkROw5w__q_UfMzOw/s1600/IMG_3581.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCwMSvPn3DGlpQlIFYq_7hPbxyz7VMKytWMUBcmNFxEkbEoKXFDzIU4CVJGbdwUqxEqOJd1RS7CUZalygv1wNMKVgcm8ZB6ku16OiB-EchGk4qLqx6GTKG8hFx3MLkROw5w__q_UfMzOw/s320/IMG_3581.jpg" width="240" /></a></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">And one question for all of you: if a lot of people started
posting this picture along with funny remarks, would the picture count as a
meme?</span><o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com2tag:blogger.com,1999:blog-6901931588347279408.post-4236633846861215152019-02-08T16:47:00.000-08:002019-02-08T16:47:52.928-08:00An MSK fragment<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: large;">At various points in my treatment at Memorial Sloan
Kettering, things have happened that shouldn’t just get forgotten. That doesn’t
mean that I think all the important medical developments are over; I don’t
think that at all, and we’re still vigorously looking for possible next steps
that could alter my situation, and about which I look forward to blogging. But
still, along the way, there’ve been some moments that deserve to be recalled
for other reasons. I’m going to try to find some of these moments and make sure
that they too have their place in the little history that the blog is meant to
be. Let’s call them “fragments” from MSK.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: large;">So: I’ve just finished a 5-day course of radiation, meant to
attack the tumor activity I’ve recently experienced. Needless to say, this is a
high-tech business. With the help of almost 10 different staff members, plus
the eery, powerful-looking radiation machines themselves, MSK carefully immobilized
me as much as possible, aimed the radiation beams at particular spots marked
out on my abdomen with tattoos, and monitored the success or failure of each
image-taking venture.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: large;">My role in this was to be more or less naked. This was,
sadly, not that exciting – but still members of that team of staff members (did
I mention they were all attractive young women?) were always on the job, aiming
the beams and, when necessary, moving parts of me out of the way so that each radiation
burst could reach its destination. It was all pretty clinical. As to privacy,
what privacy? For clothing, I was mostly reduced to a hospital gown that opened
behind me, and lifted up for easy access as needed; even as an enlightened adult
(I hope) I found this embarrassing, but a hospital gown opening in front of me
would have presented essentially the same problems and called for the same
responses.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: large;">None of that, however, is actually my point. My point is to
ask this question: where were my clothes during all this? Weren’t they in some
well-designed patient locker, suitable to accompany treatment designed and
administered with such technological sophistication? Well, no. Why not? Because
this particular part of MSK does not have well-designed patient lockers. The
secret of good locker design has been found, but not applied here; in the midst
of various buttons is a lock mechanism that does not, well, lock. Instead, the
patient carries his or her belongings with a somewhat older technological tool,
a <u>large brown paper bag</u>. I mean, really!<o:p></o:p></span></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-51950305528059220552019-01-28T18:02:00.000-08:002019-01-28T18:02:13.603-08:00The complicated news from MSK as of the end of January 2019<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The prologue: <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">MSK gave me a prognosis for the first time, when we met with
our oncologist on Thursday, January 24, 2019. The prognosis is six months. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The reasons: <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">I had been having difficulties. A scan back on December 11, 2018
had determined that my cancer was again in action. Shaping a response to that
took time, both because of the holiday season and because I’m sure the doctors
wanted to be as careful as possible. The conclusion they seemed to be coming to,
even before we met on January 24, was that there were no good affirmative
treatments likely to be available. We had no doubt this was a reasonable
assessment of the situation, but felt that it might still be true that even a
treatment unlikely to succeed was better than no treatment at all. Our
oncologist’s view was, we thought, evolving to the opposite perspective: that
if no treatment was likely to be successful then there was no point in trying
them at all. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">What decided the issue was a series of scans in late January,
which included a January 15 X-ray of my abdomen as well as a CT scan, that same
day, of my abdomen and pelvis done during my digestive blockage visit to MSK’s
Urgent Care ward (a visit I blogged about as well). They also included an MRI
of my pelvis on January 22. I had yet another scan on January 25, but that was
to diagnose whether I had suffered a broken foot or not, and didn’t otherwise
contribute to the study of my condition. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">In truth, the information in theses scans is hard to keep
clear and distinct. One scan is referred to as comparing its findings with data
from a scan done a couple of days later, but I had no such additional scan that
day. Another scan attributes the wrong disease to me – saying I have colon
cancer when I actually have a different illness, cholangiocarcinoma. These
mistakes are a bit unsettling, but the general import of the scan results
nevertheless emerges clearly.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If the scans proved determinative, what led MSK to determine
that they should do the scans in the first place? Their concerns were triggered
in good part by the MSK physicians’ growing suspicion about a lesion, a damaged
area, in my right iliac bone, which is part of the pelvis. MSK had been aware
of this spot since approximately April 2018, but had not been particularly
suspicious about it. Now, however, yet another scan in December 2018 had shown
growth in this spot, and growth is important. For our part, we too had hoped
not to need to pay attention to this spot. After all, I didn’t think I had any
symptoms of it at all – but over the weekend before the scan I began to realize
that maybe I did have symptoms, perhaps from walking further than was
comfortable, perhaps from such minor motions as bending over to do the dishes. Mostly
not a lot of pain – but cholangiocarcinoma is full of minor, yet ultimately
meaningful, symptoms. Meanwhile, growth is cancer’s specialty, so the fact that
this spot had recently started to grow was a bad sign. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The scan series in January 2019 appears to have confirmed
two thoughts for our oncologist. The first is that the cancer has escaped from
the liver and reached the bones as well. One report, on still another CT scan
done on January 15, 2019, indicated this but not elaborately; a second, on an
MRI scan done a week later, January 22, 2019, left no room for doubt. There has
been a lot of damage to the bones of the pelvic area, presumably the result of
its infiltration by the cancer, and all of it appears to have taken place in
the last 12 months. Parts of the bone have probably died. All of this makes me vulnerable
to things like bone fractures, including hip fractures, which would put me
right away in a wheelchair. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">When the skeleton weakens, you are at greater risk both for “spontaneous”
fractures, which can apparently take place while you’re doing nothing more
strenuous than sleeping, and for fractures caused by impact and accident. There
are things that can be done to reduce the chances of incident, such as
installing assistive equipment, like guide bars, machinery to help me get
around the house; as we do more with this I may blog about our progress, but in
any case this effort is now underway. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">As to the impact and accident fractures, for me those are
more likely than they otherwise might be because of all the water I’m still retaining,
especially in my feet. The water retention is another impact of my damaged
liver (and of its interaction with the diuretic medication, and in turn with my
kidneys). The water retention in itself isn’t a big problem, and doesn’t
contribute to my underlying cancer in any direct way. However, in the
Department of Irony, currently running strong, a couple of hours after we got
home from our Thursday meeting last week with the oncologist, at which we’d
received a lot of precautionary guidance, I fell at the bottom of our stairs.
Fortunately the fall was only two steps down. I landed hard, but even more
fortunately the fall didn’t fracture anything; it caused “just” a sprain. My
left foot did take on some remarkable colors right away. Depending on how many
separate sprains I gave myself, recovery could take as long as six or seven
weeks. So far, however, things seem to be moving quite quickly and positively. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The second conclusion our oncologist and her colleagues have
reached is that my liver has already been seriously damaged. One measure of such
damage is the growth of the cancer itself, and the January 15 CT scan of my
abdomen and pelvis lists a number of growing, and probably new, changes in my
liver and bile duct of this sort. Other evidence comes from blood testing of
liver function. My general sense is that my liver and kidney blood numbers were
good until the conclusion of the high-intensity radiation treatment this past
summer, and that at that point they began to deteriorate. It’s easy to see what
caused the damage: <u>not</u> the water retention, but rather the combination
of three years of different powerful treatments, including chemotherapy and,
most recently, high-intensity radiation. These all did their job, staving off
or pushing back the cancer for years – the oncologist has been happy to have me
as an “outlier” to the normal course of the disease – but the price was liver
damage. I’ve recently read that actually the liver handled over 500 different
functions in the body, not just the 400 I’d seen referred to earlier. Any of those
may now be malfunctioning. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">What’s bad about liver damage is that there is no cure for
it. It is possible for the liver to regenerate, but that is a slow process and
one under nature’s guidance; there seems to be little if anything a doctor can
do to bring about regeneration by direct medical intervention. There is no “liver-all”
pill to take 3 times a day! The only method available to doctors of which I’m
aware is resection – the complete surgical removal of part of the liver, but
MSK has never seen me as a good candidate for this approach. That means that
any heavy-duty treatment that gets applied at this point runs the risk of
deepening my current liver problems, and if the liver stops functioning, that
is really the end. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">What is to be done next?<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">That in turn suggests that what’s ideal for me is to stick with
exactly what I now have. The status quo has its inconveniences, such as water
retention, but they can all be managed. Evidently, however, our oncologist
anticipates a continued deterioration of the liver, presumably as a result of a
continued growth of my cancer.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">To stave that off as long as possible therefore becomes our
next goal. Happily, there <u>is</u> something that can be done about this: the
application of low-intensity radiation. High-intensity beams are too powerful
and too dangerous, but low-intensity beams have been in use for a number of
years and their capacity to slow, though not end, expansion of the cancer in
the bones (and perhaps even in the liver itself – a point I want to ask more
about) is evidently well-established.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">One other point: I exaggerated a bit when I said that MSK
took the view that there was nothing truly affirmative to be done. There is one
treatment available which, though not very promising for patients with my kind
of cancer (it wasn’t designed with this illness in mind), still could
conceivably help and even help a lot: Keytruda. This is the drug that helped
Jimmy Carter fight off brain cancer. MSK is comfortable with trying it because
they feel they know very well what its potential downsides in the body are, and
they’re mild. So they are quite confident that Keytruda won’t undermine what’s
left of my liver functioning, and though it likely won’t improve matters
either, it will succeed or fail without further weakening me. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The only problem with Keytruda is that it is very expensive –
I think over $10,000 for each treatment, with the treatments every three weeks.
Merck, which makes Keytruda, enables many potential patients to get around this
problem by giving them access to the drug as a “compassionate use” under federal
law; no doubt this is only partly an act of charity, while also serving as a
way for Merck to continue gathering data on its drug, with a view to the widest
possible use and sale of the medication. In any case, we and MSK have applied to
receive the drug as a compassionate use. Decisionmaking at Merck this month has
apparently been slow, for reasons no one outside the company is sure of, but we
will continue to press the point.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">There may be other possibilities, though with the
difficulties my liver and kidneys now face I may not easily be able to qualify
for most experimental trials. Even if I can qualify, we’ll have to determine
whether these experiments make sense for me. For example, we’ve certainly
considered the “CAR-T” experiment at the National Institutes of Health, a trial
in which the patient’s immune system is more or less entirely removed,
re-trained to focus on cholangiocarcinoma, and then returned to the patient’s
body. The general sense Teresa and I have is that steps like these are a last
resort, or no resort at all, because they do pose serious risks of danger to
the patient – especially, we assume, one with a damaged liver already.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">And meanwhile:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">I plan to live the life I’ve lived, valuing and spending
time with my family and friends. I also plan to continue the final steps in the
work that I’ve had underway, the biography of my late South African friend
Arthur Chaskalson, roughly since I received my diagnosis in 2015. I’ve often
felt since I became ill that each day in itself is a wonderful thing. In recent
months my sense of this has wobbled at times, so now I mean to remind myself,
and to take joy in each remaining day. And if there turn out to be a lot of those remaining days, so much the better!<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
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Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com4tag:blogger.com,1999:blog-6901931588347279408.post-76460151362195669592019-01-23T10:57:00.002-08:002019-01-23T10:57:53.580-08:00One last report of our mid-January 2019 stay at MSK Urgent Care<div class="MsoNormal">
<span style="font-family: Times, "Times New Roman", serif; font-size: large;">One thing that’s not supposed to happen at the hospital is
that the patient gets lost. </span><span style="background: white; font-family: Times, "Times New Roman", serif; font-size: large;">Here I don't mean
"lost" in what may count grammatically as a passive sense of that word: I always
knew where I was during our latest stay. Instead I'm thinking of
"lost" as an active verb: they forgot me and where I was! </span></div>
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<span style="font-family: Times, "Times New Roman", serif; font-size: large;"><br /></span></div>
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<span style="font-family: Times, "Times New Roman", serif; font-size: large;">To be sure, it's really not so simple to prevent this. MSK is a big institution with a lot of people
flowing through its hallways. No doubt because of this reality, they recently started
an electronic tracking system, a wristband with some sort of electronic link,
which I’ve used on each of my last two visits there, including the most recent
on January 15, 2019.</span></div>
<div class="MsoNormal">
<br /></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">We arrived around 3 AM that morning and I was connected at
once to the tracking system. (My last post gave our arrival time as 2 AM, but that was wrong; Teresa tells me that 2 AM was when we left our house to go to MSK. If you caught this discrepancy, my hat is off to you!) But some hours later – I really don’t know the
timing clearly, in part because I was being medicated – Teresa stopped by the
Urgent Care front desk and asked when someone would be coming to check on me
again. The person at the desk answered that they thought I’d already gone home.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">This was not a good answer for us to hear. We’re not Urgent
Care novices, so we’re familiar with the idea that its services can be slow. There is a lot going on. But it’s not good to just get lost. Aside from the fact that I was tired and
ill, I was also definitely not at home, 15 miles away. Just as important, if I <u>had</u>
left the hospital on my own, what was anyone doing about it? Shouldn’t someone
have come to look for me? Wasn’t it a matter of concern that I had just up and
left? Wasn’t that the very concern that the electronic tracking system was
meant to counteract?<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">We didn’t leave the matter there. Teresa talked with other
staff, one of whom, while also offering other reasons for what had happened,
confirmed that the hospital had lost track of me. Another staff person told us
that she was not questioning Teresa’s veracity, but of course this is the kind
of language people use precisely when they <u>are</u> questioning someone
else’s veracity. And we were at that moment in the very situation she was
contending could not happen!<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The hospital as a whole took the matter seriously and
respectfully, however: we received a visit from an empathetic patient advocate,
and the next day I spoke by phone with someone who I think was in charge of the
nursing staff overall. A doctor we spoke with seemed dismayed too, but
emphasized that issues like this are the domain of the nursing staff and not the
medical staff – an interesting glimpse of how MSK is organized internally.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">None of this makes MSK anything but an institution trying to
serve its patients well. It doesn’t even directly alter how we as patients and caregivers should behave; it always seems wise to be vigilant, politely vigilant, when
dealing with an institution like MSK, and that includes when trying to make sure
the treatment I need comes when it should. But still it didn’t leave a good
taste in our mouths.</span></div>
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</style>Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-79270615058216493492019-01-21T14:29:00.000-08:002019-01-21T14:29:20.029-08:00The latest from MSK<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Here's the latest -- a bit too action-packed, though also interesting from a sufficiently abstract perspective. Hopefully it's clarifying for you (and Teresa and me). </span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">So: as you may recall, I was admitted to MSK’s hospital on Thursday, December 27, and remained there until Monday, December 31. This hospitalization was fundamentally about the water retention in my feet, and to some extent throughout my body. The core question seemed to be how to balance the available treatment's impact on my liver with the impact on my kidneys; they sent me home when they felt they had a plan for doing just that. </span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, "Times New Roman", serif; font-size: large;">Unfortunately the next big event, which took place two weeks later, was another MSK hospitalization, or rather a prolonged stay at MSK’s Urgent Care: almost a hospitalization but not quite. The reason for this one was that I was suffering another of the partial – but very unpleasant – digestive blockages of which I’ve had 5 or more at various points in my treatment. This round began on Tuesday, January 15</span><span style="font-family: Times, "Times New Roman", serif; font-size: large;"> </span><span style="font-family: Times, "Times New Roman", serif; font-size: large;"> </span><span style="font-family: Times, "Times New Roman", serif; font-size: large;">2019; or to be more precise, it had begun late the previous night, around 11 PM on Monday, January 14. We hoped I would just feel better, as has happened in at least one of these rounds before, but I didn’t. So around 2 AM on the morning of Tuesday, January 15 we arrived at the Urgent Care Center, which is located in the same building as MSK’s hospital on NY’s East Side. We stayed there till around 5 PM on Tuesday, January 15, so I was in urgent care for well over 12 hours but never actually admitted as an inpatient. Why not? Well, one reason – the fact that the hospital staff lost track of where I was – needs an account all its own, which I hope to write later today. But I think the main reason I wasn’t admitted – aside from MSK’s complex logistics – was mainly that the treatment they gave me for the pain of the digestive blockage (intravenous morphine, available only in a hospital and definitely not at home) was effective.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">There was another reason that I felt better: a reason Teresa has put together. This is that since what is happening is some sort of blockage, where tubes of my digestive system rub up against some other part of my digestion and get kinked up together, I will feel better if the kinked up strands can be made to loosen up and un-kink. The first evidence we had had of this theory’s validity came the night I was taken by ambulance to the Barnabas Hospital in New Jersey to be treated for an earlier blockage (perhaps the second one I’d had). By the time we reached the hospital, after a drive in which an EMT and I discussed my forthcoming biography of Arthur Chaskalson, I felt distinctly better. Teresa hoped – it was really her call, because I was in so much pain that I didn’t have much strength for making a choice in the early morning of January 15, 2019 -- that on January 15, the drive from home in the New Jersey suburbs to MSK would help. As far as I can remember (which is not too far!), it did.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">We hoped that this theory came with a corollary: namely, that if the pain came from a blockage resulting from a temporary kinking, then it did not come from something permanent or semi-permanent, such as the renewed growth of my tumors. While we were at MSK on January 15, they did another X-ray and also an abdomen pelvis CT scan (back on December 11, 2018 they had done a “CT chest abdomen pelvis” scan). The January 15, 2019 scan showed continued cancer growth, but it is difficult to know how much weight to put in this reading, since different doctors with different amounts of time may reach different conclusions about what a scan says. But the urgent care doctor’s view is that the cancer could in fact be the cause of the latest digestive round.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Since I was discharged I’ve done my best – with Teresa’s careful support – to eat foods that won’t put any more stress on my digestive system than necessary. That’s not by any means easy, but since then the pain I’ve had has been manageable, and I’ve had no need for intervention against what doctors call “breakthrough pain.” I hope this continues!</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">And there is more to do as well. We’ll also be discussing treatment options again; these promise to be a major topic of conversation for an indefinite period. I will get an MRI of one suspicious area to see if it’s cancerous, early in the week; I may also get a "blood biopsy," meant to look for any "targetable" mutations in my tumors' genetic make-up that could be pursued with treatment. I also should receive, whether in a document or otherwise, my medical exemption from jury duty, which will remove that concern for two years. Later in the week we see the oncologist. She in turn has already agreed that it is appropriate for us to discuss matters with the radiation oncologist, whose high-dose approach over the summer was apparently both fatal for my liver tumors and quite a challenge for my liver’s condition overall, so we’ll be setting that up. And over the weekend we go to see … <u>Hamilton</u>! (I'll bet you didn't expect this paragraph to end with "Hamilton"; once again Teresa is the mastermind, having won a lottery giving her the opportunity to purchase tickets.)</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">And that’s the news.</span></div>
Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-73855488053242259232019-01-08T19:11:00.003-08:002019-01-09T17:37:46.932-08:00Health dramas, some bigger than others<!--[if gte mso 9]><xml>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
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<br />
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Well, I’ve had – Teresa and I have had – our share of health
drama since Christmas. Some of what follows you may have already read about in my last post, but this one at least brings quite a bit of information together in one spot.</span><br />
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">First we realized that my feet were retaining a lot of
water. In fact, it gradually turned out that much of my body was retaining
water. The hepatologist (liver specialist), into whose domain this fell, conclude
that the pills I was taking at home to get rid of this water just weren’t
enough; I needed to be inpatient. That meant it was time to return to MSK’s
Hospital, to which I was admitted as an inpatient late on Thursday December 27.
It also meant, or at least underlined, that we wouldn’t be able to see my son
Brian or his sons in the remainder of their short stay in New Jersey – not least
because their other in-laws, in central Jersey, were nursing the (infectious!)
ailments of their various small children.<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">So in we go to MSK. When we get up it is now Friday, December 28, and
it gets increasingly clear that MSK is in no position to do a lot of aggressive care -- unless it's required urgently, in which case they are unstinting as ever -- over the weekend leading up to New Year’s Day on Tuesday, January 1. So we see
a number of talented young doctors, who have more than one theory of what might
be wrong (the most alarming, quickly disspelled, being congestive heart
failure – don’t worry, I don’t have it!). Meanwhile everyone watched my water
levels and I took intravenous diuretic (anti-water) medication. And Teresa slept each
night in a singularly uncomfortable looking extend-out chair. Eventually the doctors decide that they think I’m getting better, though the blood test work attesting
to this doesn't strike me as really that clearcut. By New Year's Day the action heats up; the senior doctors were back on the ward and more decisions could be made. One was to send me home, which they did. Fortunately we<span style="mso-spacerun: yes;"> </span>had time
to receive, before we left for home, a couple of very nice visits from friends
who made the trip from Montclair or elsewhere in New York to say hello.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Of the personal saga of this hospitalization I won’t say
much, though I mentioned discussing this side of things back in my previous post. So I won’t discuss the friendly Italian-American family across the bedroom
curtain from us one night, except to say we liked them. And I won’t discuss the
patient who was moved into the empty half of my room (on the other side of that
curtain), and immediately turned out to have a very infectious disease
producing rapid bouts of incontinence, except to say we wish him well and are grateful to MSK for very quickly getting Teresa and me to a safer room. And I also won’t take up the moment one afternoon when I woke from a nap – my most
frequent activity, it seemed -- and heard two men in conversation, and gradually
realized that one was the patient now on the other side of my curtain and the other
was a priest taking his confession. Of what he confessed to, and for that
matter of what the deacon asked, I’ll say no more, and hope that in doing so I
am honoring religious and patient confidentiality.<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Back at home two major developments take place. The first
(which may have actually gotten started even before I returned to the hospital) is my entry, with Teresa's guidance, into the
fashionista world: you know, the one in which young people, starting in 2002, wore Crock’s rubber shoes with holes in them. Putting the crocks on over socks,
you wind up with polka dot feet. I mean, how cool is that?</span><br />
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-hDFU-mHA18yY60qXqv2OVp7Ev8O2uS-2ieENRVHStwg1JhW9oTU3gI_MGX93zxDXz2mJFF7B5uGRf5vGAbcnvLsdWZnEBcwZP61tb9VFJ3J8OM1BeteAwzcvodgls_XwkHfWoA4zPJA/s1600/IMG_3405.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-hDFU-mHA18yY60qXqv2OVp7Ev8O2uS-2ieENRVHStwg1JhW9oTU3gI_MGX93zxDXz2mJFF7B5uGRf5vGAbcnvLsdWZnEBcwZP61tb9VFJ3J8OM1BeteAwzcvodgls_XwkHfWoA4zPJA/s320/IMG_3405.JPG" width="240" /></a></span></div>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">You can get a view
of them in one of the three images attached. This is, actually, a big deal,
because it marked the first time in some while that I’d been able to put
shoes all the way on my feet and so wear shoes, any shoes, without causing more damage
to my feet. Thank you, Teresa!<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The second major development is that my feet, and the whole
water issue, get better. It’s not quite fully resolved, but Teresa also gave me
during-the-swelling and after-the-swelling photos which show pretty clearly how
big a change took place. I appear to have shed about 20 pounds of water, with
more still departing. It’s unnerving to see such a transformation take place,
and all the more so because I don’t think the MSK physicians understand even
now exactly which one of the liver's 400 functions had gone wrong or what has now gone right – but they seem to have found
the missing link, and that is really good.<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">So we’ve been home for a week, since Tuesday, January 1. I
still have very little energy – though Teresa has also gotten me a pair of bike
pedals (which can be used<span style="mso-spacerun: yes;"> </span>to push with
your feet or your arms) <span style="mso-spacerun: yes;"> </span>and I’m hoping
that will help me get more exercise even on cold days. (If you ask me, there’ve
been a lot of cold days lately, but my thinking that's so may be yet another liver symptom!). All this is enough for me to start focusing
on my book a little more, and I have, though there are many MSK appointments in our future too, including three in the next two days.<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Many thanks to everyone who’s been in touch; all your warm
messages are very much appreciated. </span><o:p></o:p></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">And here, for the sake of science, are two more pictures. I can't figure out how to provide a spoiler alert here, so I'll just say: my feet in the first of these two photos are not very pretty!</span><br />
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">During swelling: </span><br />
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAvNMgTxsvKIha3uwDI3cIsF1gypKwiHB6etFeO1O0WRprgSlr2J7X-9F-Wc8cVCdYAjyBRkqqE884ScMXVf03rfBWqgXLSFupvUD75PmYwQ2gwKJsXkP-PD3KOOEao9FgaugO4KeQFyw/s1600/IMG_3337.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAvNMgTxsvKIha3uwDI3cIsF1gypKwiHB6etFeO1O0WRprgSlr2J7X-9F-Wc8cVCdYAjyBRkqqE884ScMXVf03rfBWqgXLSFupvUD75PmYwQ2gwKJsXkP-PD3KOOEao9FgaugO4KeQFyw/s320/IMG_3337.JPG" width="240" /></a></span></div>
<br />
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">After swelling: </span><br />
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgN4EvRdeYqjyuEu5Gq9Z8XzR0LcTxgqg_-ZuVpQO31GQzS21x0ov8hfJ37F9a_rJD0mKaSlGGYN2Jm7QkSSalOyKRqAKdJPU7mcI3bjTkHAjaX_uMkRdZ6193mMeKIwlPAsC1Ln5aMBC8/s1600/IMG_3422.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgN4EvRdeYqjyuEu5Gq9Z8XzR0LcTxgqg_-ZuVpQO31GQzS21x0ov8hfJ37F9a_rJD0mKaSlGGYN2Jm7QkSSalOyKRqAKdJPU7mcI3bjTkHAjaX_uMkRdZ6193mMeKIwlPAsC1Ln5aMBC8/s320/IMG_3422.JPG" width="240" /></a></span></div>
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<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com1tag:blogger.com,1999:blog-6901931588347279408.post-70525896461124920722018-12-30T19:09:00.000-08:002018-12-30T19:09:17.186-08:00Medical update as of the end of 2018<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">So as you may already know I’m back in the hospital at Sloan Kettering again; Teresa and I have been here since late in the evening on Thursday, December 27. It wasn’t a perfect time to be admitted to the hospital: we’d missed an important consultation with our oncologist because she was ill, and now a lot of people seemed to be on their way to vacation. But it was the time we needed to come in. We have two big issues to deal with, plus the complication that it’s unclear whether these two issues are actually related, and, if so, how. None of these add up to a crisis, but they do require attention. Some of what we’ve learned may be confusing to you, and it certainly still confuses me, so in an effort to be as clear as possible here’s an end-of-the-year medical update.</span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">The first issues deal with the recurrence of the cancer, which I discussed at length in my previous post. These are mainly in the liver; there is a possible spot on my iliac (pelvic) bone too, but a senior physician from the National Institutes of Health (long-time friend of the organizer of my “dads’ dinner” group in Montclair!) said that if I didn’t feel any symptoms from this – and I don’t – I shouldn’t worry about it.</span></div>
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<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The question, in any event, is what to do about these spots of cancer. One possibility is more radiation, since many or all of these spots were not irradiated in the summer (because there was no activity there to be attacked). Another possibility is more chemotherapy, on the basis that even though my entire liver, and in fact my entire body, has received chemotherapy over the past three years, in many spots no tumors ever did appear, so in those spots – which may include the current instances of new growth – chemotherapy may actually have been successful up till now. The fact that the tumors have started growing does not disprove this idea, because I haven’t had any chemo treatment since the spring, and at that point these spots didn’t appear to be cancerous; the new growth may simply be the result of non-use of treatment over the past half a year.</span></div>
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<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Or there are two further alternatives. One is to do nothing, as the NIH physician suggested for my iliac bone spot. If the likely symptoms are slow-moving and low-intensity, this may actually make more sense than more dramatic interventions. It’s always possible that the side-effects will be more severe than the cancer effects themselves, and this is another reason for caution. I think my oncologist may lean in this direction.</span></div>
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<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">But the other is roughly the opposite: to try to become part of an experimental clinical trial. The fact is that in my case this would not be a tremendously radical step, at least in the eyes of the NIH physician we talked to talked to today; he felt that my radiation treatment this summer was a pretty radical step itself. To be sure, as a surgeon, he may start from a certain skepticism towards radiation as an alternative approach. But he concurred with our MSK doctor in being interested in a broadly-targeted immunotherapy drug called Keytruda, and he also described a dramatic treatment NIH has had some success with, in which the patient’s immune system is completely broken down and then completely re-constructed, with a view to creating a set of immune cells that would take on and take down my particular, individual cancer.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">All of that deals with the “first issues.” The second issue has to do with the various ways my liver functioning has been impaired. It turns out that virtually anything the body does, the liver may be involved with, not necessarily as a whole cause but as a contributing factor. So, for example, my ability to do multi-figure subtraction, which seems to have lessened, could be an effect of liver malfunction leading to ammonia in the brain; for that there is a medication I am taking vigorously every day. I’ve felt myself growing more impatient than I (hope I) usually am: liver again. And the retention of water in my feet – really quite a lot of water, and probably affecting my balance and if unchecked then generating bruising of the feet, which was the symptom that probably tipped the balance in favor of our coming in to the hospital: liver too.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">But since my hospitalization at MSK began a few days ago, we’ve encountered other theories about the water retention. One theory was that I had congestive heart failure, in which the heart and/or the lungs are unable to do the work involved in pushing water through the circulatory system and out. But they’ve done fresh testing of both my heart and lungs and I don’t have congestive heart failure. Another theory is that there is some sort of a block to the flow of liquid, conceivably a tumor that they haven’t yet been able to find on a scan, conceivably a clot. They did a scan looking for clots in my abdomen early in my stay here; it didn’t show anything but that they thought might be attributable to difficulties in the ultrasound process making these hypothetical clots hard to see. But then this afternoon one of the doctors said that a blockage of the flow of liquid would require a really big clot, that they hadn’t found such a clot in my previous CT scan with contrast, done on December 11 2018 or just under three weeks ago, and that the chance that a clot of the necessary size had developed since then that would account for my worsening water reduction was small – and so, in short, that the cause of the water retention probably is not a clot (logic that I think applies to the possibility of a new tumor too).</span></div>
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<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">So it seems possible that the water retention – though in some unspecified sense due to the liver’s damage in the course of the radiation and other treatment it has had – is not related to any physical structure created in the process. I evidently have renewed cancerous activity (see “the first issues” above), but that doesn’t seem to be the direct cause of my fluid retention. Meanwhile they’re contemplating at least two further scans to try to get to the bottom of my various symptoms, and still trying to treat the fluid retention as a symptom of its own, which can be alleviated better at the hospital than at home because the hospital can give me intravenous Lasix, (a diuretic, or in other words an anti-fluid-retention drug). And of course the hospital can play close attention – good-willed but sometimes maddeningly close attention – to my overall condition.</span></div>
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<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The personal tale of my hospital saga may deserve a separate post. Fortunately, Teresa knows better than I do what’s going on for me medically, and keeps a careful monitoring eye on my day-to-day experience here. So besides a lot of medical thought and effort, there’s a lot of monitoring of the monitors under way. Speaking as the patient (and I know Teresa feels the same way as the caregiver), I do find it rather exhausting! With luck, though, we’ll be home, with a plan, soon.</span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">Holiday wishes to all of you!</span></div>
Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-70906158427499535722018-12-14T16:49:00.000-08:002018-12-14T16:54:14.877-08:00Latest news -- back to the fight<br />
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Teresa and I spent yesterday at Memorial Sloan
Kettering. Unfortunately we didn't come home with news as good as we had gotten from other recent sessions there.</span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><o:p></o:p></span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The short version is this: they found from a CT scan on Tuesday, December 11, 2018 that a few tumors in my liver which had been quiet have now woken up and grown a
little (roughly a centimeter in each case). Meanwhile a very small lesion in my
iliac bone (a “lesion” is a damaged area, and the iliac is the largest bone of
the pelvis), which they’ve been aware of but have never seen any clear
indication of malignancy from, has also grown a little, which raises a substantial possibility that this is a metastasis (a spread) outside the liver.<o:p></o:p></span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">What to do? Well, we intend to fight the disease, which is
the strategy that has served us pretty well up to now. But it’s harder, because
we’ve already used most or all of the proven strategies. (Though perhaps not
all; we may talk with the doctor who administered the radiation this summer,
for instance, in case he sees something our oncologist – who was out during our appointment yesterday with
a respiratory illness, so we only really dealt with her nurses – did not.)
Assuming we’ve tried everything proven that Sloan Kettering offers, we might
actually sit tight, not getting treatment. This would not be because we’re giving up, but rather
because if the tumors in question are growing relatively slowly, then for my case (somewhat as in many cases of men with prostate cancer) it can actually make sense to be equally
patient – while we wait for researchers and clinicians to invent the next treatment that really works.
<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Or we may try experimental treatment ourselves. Experiments, in the form of clinical trials, are the process
by which those treatments that really work are found and developed. Getting a treatment that is currently unproven won't accomplish much if it turns out the treatment really doesn't work. But joining the trial means that you potentially get access to the latest possible approaches earlier than other people do, and if they work you get your
treatment before most of the world. </span><br />
<span style="font-family: Times, Times New Roman, serif;"><span style="font-size: large;"><br /></span>
<span style="font-size: large;">One especially attractive example of this would be the drug
Keytruda, which you might remember successfully pushed back Jimmy Carter’s brain cancer. Keytruda is an immunotherapy drug, and it helps to have the right mutations for Keytruda and other similar immunotherapy
drugs to target. So far it doesn’t seem that I have any particularly “targetable”
or “actionable” mutations. But some people benefit from these drugs even
without having the mutations at which they were originally aimed. The biggest
problem with Keytruda, aside from the fact that it certainly doesn’t always
work, is that it is expensive, unless they (Merck is the manufacturer) give it to you as a compassionate
gesture. That they often do, and we applied for it yesterday. <o:p></o:p></span></span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">A second place for experimental treatment is in other treatments being tried <i style="mso-bidi-font-style: normal;">inside</i> Sloan Kettering itself. MSK evidently has two sets of first-round (i.e. very tentative) clinical trials
going on. One set involves immunotherapy (that is, treatment aimed -- like Keytruda -- at the
targetable mutations that I seem to be short of, but that perhaps aren’t
essential to the success of treatment). The second set involves, I guess, <i style="mso-bidi-font-style: normal;">other </i><span style="mso-spacerun: yes;"> </span>experiments. It looks like we’ll be finding
out more about these in the next two or three weeks. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The third place for experimental treatment is, as you’d guess, in other treatments besides Keytruda that are being developed <i style="mso-bidi-font-style: normal;">outside</i> Sloan Kettering. Different
institutions are running their own trials. There’s a possibly promising one at
M.D. Anderson in Houston; another at the National Institutes of Health in DC;
and Teresa is applying her formidable web research skills to locating others
that show some promise. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">So that’s the situation. I intend to work hard on finishing the 400,000 word version of my book (and if I can also produce a shorter version, more suitable for trade publication, so much the better); look forward to spending time
with family and friends; and, as I said, Teresa and I plan to keep on fighting. <span style="mso-spacerun: yes;"> </span></span></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-7652986559309956732018-11-25T19:51:00.001-08:002018-11-25T19:51:28.801-08:00Three years in and still going strong<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Today, November 25, is the third anniversary of my receiving the diagnosis of cholangiocarcinoma. The actual diagnosis was not the first sign that I had cancer; in fact, tests had already made that clear. But the last round of testing convinced the doctors that the particular kind of cancer I had was bile duct cancer, a/k/a cholangiocarcinoma, and that’s what I’ve been treated for ever since.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">And here I am, three years in and still going strong. The doctors believe that the radiation treatment I had this summer either killed or knocked out of action all my remaining tumors. Based on that, my oncologist told us this month that she was completely comfortable with my not having another scan until January – and that in turn points to her feeling that there would be nothing for a scan to find. Hopefully the scan in January will confirm this, and that would be really good news. But if what it shows is that something has returned, and if that something can in turn be hit by another round of radiation, that will be good too. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The only downside, which I’ve written about already, is the side effects. I’ve got several, none terrible but all a bit of a bother. I’m tired a lot, and my energy for things like a regular daily walk has declined, as has my walking speed. I’m retaining water, though fortunately not too much; to deal with this, however, requires medicine that in turn can affect other parts of me (basically, the balance seems to be between my liver and my kidneys), so the doctors are doing their best to give me just the right amounts. And the side-effect that may puzzle the doctors the most is that I have cramping in my hands and legs. This one doesn’t seem to have a single cause; it’s evidence, I think, that the body is a complex apparatus and multiple factors can coincide in a particular effect, happily again not that severe. But the odd result of all this is that although fundamentally I’m clearly healthier – no active cancer! There’s a result I didn’t count on three years ago – in these various more superficial ways I don’t feel that great. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">All that said, however, here I am. Last night I woke up at 4 AM feeling nauseous, but a single pill did the job on that symptom. And today Teresa has spent making meat pies (with the inspiration of the British Bake Off show, which we both have been watching), and we will try these home made meat pies tonight. (We had one and it was great!) It is good to be here to get to sample this pleasure. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">While not eating pie or taking a nap to catch up on my sleep I’ve also been making revisions to my book; there is always more to do, and I’m still involved in complex dealings with potential publishers, but today I completed one set of reader’s comments, and so this day marked a writing milestone too. I hope the book will actually be published around mid-2019. If and when that’s done then I will face the interesting question of what to do next. One particularly intriguing possibility is that I write manuals for cholangiocarcinoma patients on the law governing their health insurance, a topic that turns out to have many pitfalls which can confuse a lawyer, e.g. me, and no doubt frustrate a non-lawyer even more completely. Or, of course, there’s the possibility of a European river cruise. Or other places to travel and books to read. I’m looking forward to the chance to choose. The world has so much going on in it! </span><span style="font-family: Calibri, sans-serif;"><o:p></o:p></span></div>
Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com2tag:blogger.com,1999:blog-6901931588347279408.post-16651075755467296602018-10-28T09:49:00.001-07:002018-10-28T09:49:46.538-07:00An update -- on side-effects and the subway
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">Back in the summer, as readers of this blog will <a href="http://nowwithouthesitation.blogspot.com/2018/07/radiation-treatments-complete.html" target="_blank">recall</a>, I
had radiation treatment, fifteen days of treatment which concluded in mid-July. It was high-tech and highly effective; the doctors who
reviewed the post-treatment scans found no clear evidence of active cancer, and
were very pleased. There’s no sign that this has changed; my cancer may come
back but it has been quite decisively defeated for now. <o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">What hasn’t gone away is (or are? - should this verb be singular or plural?) the side-effects of the treatment. There
seem to be two sources for these side-effects. The first is the radiation
treatment itself, which didn’t feel in any way unpleasant at the time but
evidently is a deep burden on the body. The second, Teresa and I think, is all
the prior treatment that I’ve had. My liver, in particular, withstood all this
treatment for years – but it seems as if the radiation treatment was a tipping
point, and now the side-effects are getting more play. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">Not that much more play, I should emphasize. I’m still
reading and writing for my biography of Arthur Chaskalson, South Africa’s
distinguished jurist. I’m also negotiating with the publisher with whom I have
a contract to see if we can find a way to agree on the right length for the book
(what I gave them was much longer than what they turned out to want); this
process is arduous enough to count as a side-effect all by itself!<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">But there are medical features, the main one of which is sheer
fatigue. An example: the day before yesterday, October 26, I was in New York to
attend an excellent workshop presentation by a former colleague, but before that got started I made a
trip to my dentist. This required coming up out of the subway at 54<sup>th</sup>
Street and Madison Avenue. Fine – except that at least in the subway hallways
that I walked through (and I don’t know any other routes because I don’t know
this station) – I confronted three ways out: an escalator running down; a
staircase; and another escalator, which wasn’t going up or down. The result was
that I had to climb 80 stairs, with only the stairway rest platforms to stop at
(there were more stairs afterward, but I’ll stick to these 80). It’s clear, unfortunately,
that I don’t have 80 steps of ready climbing ability available for the asking. I went
slowly up; along the way a woman asked me if I needed her to get me some water. I did, actually, but declined – I couldn’t really imagine how she would have
carried out this generous offer, there in the middle of the subway exit route. I felt that I went through much of the afternoon barely able to move any further at all. <o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">A side note on the subways: Subway performance is most often measured in
terms of on-time trains. At the same time, having a down escalator running but
no up escalator is also a sign of a system that isn’t working right – another symptom
of New York’s infrastructure breaking down, and another reason why I’m
fortunate to be able to stay home these days.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">This will pass. (My recovery will probably be quicker than the subway's!) I’m now doing physical therapy, and though I
haven’t been at it long I feel like it has already been helpful. It will be
sometime before I’m anything like “strong,” but I can certainly become stronger
than I’ve been. Still, the set of side effects is startling to experience. I
can and do fall asleep in a moment – and then I wake up in the middle of the
night eager to read a South Africa book. Then there’s been the swelling from
water retention, treated with diuretics: too little treatment doesn’t do the
job, too much seems to have other internal effects. And a new antibiotic. Cramping
in my legs and hands. And so on … </span><span style="font-family: Times, "Times New Roman", serif; font-size: large;">The radiation treatment information Memorial Sloan Kettering gave me warned of possible prolonged fatigue, and other symptoms, yet it’s all a bit wearing. </span><span style="font-family: Times, "Times New Roman", serif; font-size: large;"> Still it</span><span style="font-family: Times, Times New Roman, serif; font-size: large;"> will all pass, as I said, some of it literally
as well as figuratively. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">So that’s my news – nothing to get alarmed about, but a set of effects that I’d
like to shed as soon as possible. Sorry for this prolonged complaint!</span><o:p></o:p></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-13394277891687296702018-09-23T18:11:00.001-07:002018-09-23T18:11:18.534-07:00I get knocked over on my evening walk<span style="font-size: large;"><span style="font-family: Arial, Helvetica, sans-serif;">My evening walk today was more exciting than usual, as I got knocked over in an encounter with a small child on his training-wheel-equipped bike. I didn't ask for the father's contact information at the time, and Teresa posted on a Facebook group called "Secret Montclair" to reach out to him. That prompted a flurry of comments, some quite sharply critical; the nature of those criticisms will I think be more or less clear from what follows, which is my post (accomplished by my wife on her account) in response to them. The net result is that I feel partly ridiculous and partly outraged. Anywhere, here's what my wife just posted on my behalf on "Secret Montclair," a group to which we're now saying good-bye</span>:</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">*****</span><br />
<span style="font-size: large;"><br /></span>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">My name is Steve Ellmann. I am the person who was knocked over as a result of an encounter with a small child and his bicycle-on-training-wheels this evening. My wife posted a brief message about this incident, and as one commenter said, this being Montclair, 350 posts can now be expected. I should have written in the first place and I see that I must do so now. I should have asked the child’s father for his contact information, and my wife’s post and mine make that request now. I told the father that I thought I was probably okay, but wasn't sure; that remains true. </span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">One commenter raises his/her eyebrows because my wife’s post, based on what I told her, says that the child’s bicycle either ran into or almost ran into me. It would be nice if I could say for sure which happened, but actually people often can’t do that with sudden, startling events, and that is the case for me here. I assume the commenter would prefer that I be accurate rather than that I make up a more compelling story.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">As to what actually did happen: the first I knew that anything was happening was when this little boy on his bike came up behind me. I think he called out “Sorry” as he approached me. His bike and my legs intersected – though whether I was actually hit I don’t know. I do know that I did something like a hop, skip and jump trying to stay on my feet, but I failed and eventually fell down. I stopped my fall with both wrists (they were indented afterwards from the impact with the ground); probably with my head (my glasses wound up with a leaf or two between them and my face); and probably with one knee, which is currently hurting.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The child said repeatedly that he was sorry, and I responded on the lines that I wasn’t saying anyone was bad, but that you can’t ride a bike so fast that you can’t control it. The father at one point said, perhaps to his kids, that the event was his fault. I repeated that no one had been bad, but I certainly made clear that I was mad about this happening.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">What was I mad about? As I told the child’s father, I am a cancer patient. Specifically, I was diagnosed in November 2015 with stage IV cholangiocarcinoma, a cancer of the liver bile duct. No one wants to get any type of cancer, but if you look mine up you’ll see that it is a particularly nasty one. Fortunately my treatment has gone well. As it happens, the treatment included abdominal surgery in 2016 to insert in my abdomen what’s called an “intrahepatic pump.” Every two weeks, when Memorial Sloan Kettering has used this pump, it has injected chemotherapy into the pump, and then a catheter carries the medication from its insertion over to my liver. The result, the valuable result, is that the chemotherapy can be focused directly on just my liver.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">But there is a catch. The pump is a once-in-a-lifetime measure. If it breaks inside me – for example, because in an otherwise minor incident something breaks in the pump mechanism – it probably has to be removed (more abdominal surgery) and cannot be replaced. That means that my chance for chemotherapy targeting just my liver by this mechanism would cease to exist. Since my survival may have depended, and might in the future depend, on this treatment, I am not happy to see it put at risk, even as the result of the actions of a small child.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">It interests me that some of the comments seem to view me as clumsy or over-zealous. As to clumsiness: perhaps so; the radiation treatment I had this summer and the chemotherapy I’ve had since 2015 have all taken their toll on me in terms of side-effects. As my wife mentions in her second post, another side effect I’m dealing with is low platelets – which make me more prone to bruising from seemingly trivial events.</span></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<br /></div>
<div style="background-color: white; margin: 0in 0in 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">As to the supposed over-zealousness of my concerns: This criticism implies that in the comparison of survival from cancer and protection of the rights of inexperienced bike riders, or of riders who lack bike lanes, it is the riders whose claims should take precedence. I have to admit that I don’t recognize the moral world in which bike riding is more important than another person’s survival. I am not alone in being an older and somewhat infirm walker in Montclair's parks. There are also a lot of very young walkers. I think all of us who do so have a right to do so in relative safety. </span></div>
<div>
<br /></div>
Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-59238985697863480072018-09-23T11:00:00.000-07:002018-09-23T11:02:36.021-07:00Another Footnote, This One Ironic<!--[if gte mso 9]><xml>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">On <a href="http://nowwithouthesitation.blogspot.com/2018/09/disclosure-and-truth.html" target="_blank">September 12</a> I wrote about the failure by a senior MSK doctor
to disclose his financial interests in connection with many of the articles
that he was publishing. That story in the <a href="https://www.nytimes.com/2018/09/13/health/jose-baselga-cancer-memorial-sloan-kettering.html?action=click&module=RelatedCoverage&pgtype=Article&region=Footer" target="_blank">NY Times</a> was quickly followed by
another, about this doctor resigning from his job. That was perhaps predictable. It was
less predictable that a new scandal at MSK would be unearthed just a couple of
days later, though I did have the feeling the story hadn’t yet been told in
full. </span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">In fact I still have that feeling, and wonder what investigations
are now underway at MSK’s competitor institutions. It strikes me as unlikely that only MSK has been infected by the kinds of maneuvers that these articles reveal. After all, these maneuvers are presumably profitable, directly or indirectly, and health care institutions must be competing with each other to provide the best possible pay packages to their top employees. (They certainly are competing with each other to attract patients, as medical advertisements and hospital merger news attest.)<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">In any case, on September 20 it was <a href="https://www.nytimes.com/2018/09/20/health/memorial-sloan-kettering-cancer-paige-ai.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=rank&module=package&version=highlights&contentPlacement=2&pgtype=sectionfront" target="_blank">revealed</a> that senior
MSK doctors or scientists and some board members, along with MSK itself, were the co-owners of an artificial intelligence
start-up meant to use MSK’s immense library of accumulated tissue samples to
learn better how to diagnose the presence of cancer. In the process, it appears, the people involved
disregarded rules governing such "related party" dealing (which is not illegal in
itself, but must be correctly structured). They annoyed other MSK physicians by
using the results of those doctors’ research in analyzing the tissue samples
without their consent. And this venture turned the samples donated by patients towards the goal of
research into potential sources of private profit that surely were never
consciously consented to. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">I don’t want to say that the issues posed by the duties of
honesty, disclosure and frankness are always simple, as my earlier post on nondisclosure may have implied. Truth isn't always the commanding rule -- but it is an important rule, as the age of Trump underlines. Here, it appears that MSK
could not get venture capital funding for a project it believed was very
promising, and so the investors – as investors tend to do – took on some special
risk in the hope of some special gain. That gain in turn would have benefited <i style="mso-bidi-font-style: normal;">us</i>. </span><br />
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">But at the same time this series of
stories gives the impression that our major medical institutions have decided
that the way to provide care is to find profit to support it, and that the task
of finding sources of profit need not be undertaken with any over-punctilious
concern for virtues like disclosure. What’s perhaps most troubling about the
creation of such a culture of gain is that it undercuts the culture of cure
that so many of the staff at institutions like MSK pursue with daily
dedication -- including in my own case. <o:p></o:p></span></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-4749760189573560182018-09-22T18:00:00.000-07:002018-09-23T11:04:38.582-07:00A Sad Footnote<!--[if gte mso 9]><xml>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">While we were getting the good news I wrote about in <a href="https://www.blogger.com/blogger.g?blogID=6901931588347279408#editor/target=post;postID=2496339589299926047;onPublishedMenu=allposts;onClosedMenu=allposts;postNum=1;src=link" target="_blank">my last post</a>, another member of the cholangiocarcinoma community, Sarah Bennett, was
entering home hospice and dying. Today, September 22, we went to her funeral,
about an hour from our home in New Jersey.<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Every death from illness is a matter of sorrow, but Sarah’s
was especially so. She was the creator and guiding force behind the Facebook
patients’ group for people with this illness, the Cholangiocarcinoma Warriors.
This is a difficult group to lead, because the members are going through a very
wide range of different experiences. Some are at early stages and can report
successful treatment (a few can do so even at later stages); some are ill and
suffering; some are dying. I personally felt guilty about reporting my own
recent good news when I was aware that Sarah was rapidly declining. But the
Warriors group under Sarah’s leadership set out to be a home for all these
different people, as welcoming to those expressing confidence as to those
feeling despair. Sarah accomplished this almost impossible feat largely by
giving to the group her own tremendously strong commitment against the disease
and its impact, and her close personal connection to all the group’s members.
It was impressive and inspirational.<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">If the impact of this disease had anything to do with what
people deserve, she would have beaten its onslaught, and would still be on the
scene helping to inspire and remember other patients. I should add that I don’t
say this to challenge anyone’s religion. Some of the members of the Warrior
group do respond to events in their illness in very religious, mainly Christian
terms; but some don’t. All are welcome. I don't know exactly how religious Sarah herself was; certainly she could swear up a storm,
and members of the group took that in stride too. <o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Deaths like hers are hard for anyone from any system of
belief to come to grips with. Her eloquent family, however, brought her to life
for us during the service, and we learned that in the course of the service and
two days of visitation, approximately 1000 people had come to remember her. Some had traveled many hours to attend. That effort by so many reflects Sarah's exceptional contributions. And those must have gone
well beyond the Warriors group, since there aren’t close to 1000 active
participants in this group – cholangiocarcinoma is a <i style="mso-bidi-font-style: normal;">rare </i>disease. Nothing she did in her 35 years, however, seems more
remarkable than the effect she had on this patient community during the four
years that she herself fought against this disease, and helped
so many others to fight their struggles too. <o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">To our great sadness, she is no longer with us. </span><o:p></o:p></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-24963395892999260472018-09-22T15:04:00.000-07:002018-09-23T11:05:34.454-07:00Passing My Tests<!--[if gte mso 9]><xml>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">On September 7, I had two more scans, meant to determine
definitively what the effect of my summer’s radiation treatment had been. I’d
had one earlier post-radiation CT scan on August 21, but that was meant to make
sure that the various side effects I was feeling were in fact side effects
rather than something else. These two were focused on whether the radiation had
been successful against my tumors – the critical question.</span><br />
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Why two? Because the two scans had overlapping functions.
The CT scan looks for actual physical masses, such as tumors. But even if you
find a mass you don’t necessarily know what kind of object you’re looking at.
The other scan, the PET scan, doesn’t look for physical masses but for
activity: if the scan picks up signals of “avidity” – essentially, high
consumption of energy, which is characteristic of cancer – that’s a bad sign.
What you especially don’t want is for the scans to coincide, as they do if the
CT scan finds suspicious physical spots and the PET scan finds those spots fit
with cancerous energy consumption. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">My scans have now been read by three MSK physicians (and by
Teresa and me). They’re pretty technical documents, so we needed the doctors’
translations. But in another way they’re also pretty simple: that is, if the
scans are good the doctors are pleased, and if the doctors are pleased then we’re
pleased. <span style="mso-spacerun: yes;"> </span>All three doctors were pleased;
in fact, I think it’s fair to say they were all very pleased. And so we are
too!<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">What the scans showed was first, that all the tumors MSK was
attacking with the radiation were now smaller. They hadn’t disappeared, but
they were smaller. Second, the signs of extra hunger in the locations of those
tumors had also largely disappeared; energy consumption in those areas was now
roughly the same as in the normal, unaffected parts of my liver. And, third,
the only instances of either physical locations or energy consumption that were
at all out of line did <i style="mso-bidi-font-style: normal;">not</i> coincide
with each other, and so the doctors weren’t worried by these. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">In short, the doctors just weren’t worried. The radiation, delivered
by the latest techniques so as to give my tumors a high and lethal dose,
appears to have done just that. So what do I do now? The answer is: nothing. My
next scans are in two or three months; between now and then I won’t receive any
treatment for cancer itself, and if the next scans are similar, that will
continue. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">I should add that though I have no cancer treatment
scheduled now, I will continue to have treatment for side effects, such as
stomach problems and intense fatigue, and for the side effects of the side effects medicine. Sigh.
It was because of possibilities like these that I had yet another scan on
September 18. As readers of this blog will recall, <a href="https://nowwithouthesitation.blogspot.com/2018/08/some-treatment-surprises.html" target="_blank">one night some weeks ago</a> I
had trouble staying upright as I went for a walk, and I’ve also felt from time
to time that I’m losing track of my own arguments in conversation. </span><br />
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">With those
in mind I had a brain scan. This is an interesting experience in its own right;
as the patient, your head goes into a helmet/camera lens which looks a bit like
the helmets worn by the evil Empire soldiers in the Star Wars movies, and then
you spend 30 minutes being motionless while they scan your brain. The idea of
anything out of place in your brain is scary, of course, but the radiation
oncologist told us in advance that these scans are usually given to rule out
possibilities rather than because the doctors expect to find trouble, and
happily that turned out to be the case for me: there’s nothing going on inside
my brain except the usual, flawed as that may sometimes be! I think the moments when I don't seem to be functioning as acutely as I want to are expressions of the fatigue that the radiation has caused me.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Finally, as to my prognosis, I specifically did not ask the
doctors to give it a number, and they didn’t, but what the radiation oncologist
said is that my prognosis depends on what if anything emerges next; what I
already had has been so thoroughly attacked, it appears, that it is no longer a
factor. This isn’t quite “NED” – No Evidence of Disease, the modern phrase that
doctors use instead of “in remission.” But it does appear to be the next best
thing, which I’ll make up: “NEAD” – No Evidence of Active Disease. We certainly
didn’t count on achieving this state of affairs back in November 2015 when I
was first diagnosed with this insidious, but as we’ve learned <i style="mso-bidi-font-style: normal;">not </i>all-powerful, cancer. I’m very
grateful to MSK and to Teresa, and others, for all the help they gave me in
getting to this point. </span><o:p></o:p></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com2tag:blogger.com,1999:blog-6901931588347279408.post-44560376654567238822018-09-12T17:15:00.000-07:002018-09-22T14:23:04.011-07:00Disclosure and truth<!--[if gte mso 9]><xml>
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<br />
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Over this past weekend, on September 8, 2018, the New York Times </span><a href="https://www.nytimes.com/2018/09/08/health/jose-baselga-cancer-memorial-sloan-kettering.html" style="font-family: times, "times new roman", serif; font-size: x-large;" target="_blank">revealed</a><span style="font-family: "times" , "times new roman" , serif; font-size: large;"> that a senior
Memorial Sloan Kettering cancer doctor had not filed disclosures
of financial connections to his research – even for
articles in a journal of which he was at the time an editor. Sloan Kettering
for its part initially said that such disclosures were the responsibility of
the scientist and not of the institution, but the next day, September 9, it effectively </span><a href="https://www.nytimes.com/2018/09/09/health/cancer-memorial-sloan-kettering-disclosure.html?action=click&module=RelatedCoverage&pgtype=Article&region=Footer" style="font-family: times, "times new roman", serif; font-size: x-large;" target="_blank">revised</a><span style="font-family: "times" , "times new roman" , serif; font-size: large;"> this
position and issued a reminder to all its staff of "do[ing] a better job" of complying
with these rules.</span><br />
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Well, they are rules and so as a matter of general principle they should be complied with. No
one is immune from financial temptation and in fact a lot of money is in play
in cancer research and treatment, so there is good reason to require the disclosure of the movement of that money from corporate sponsors to individual scientists. (It has to be said, also, that the disclosure system as described by the<i> </i>Times<i> </i>does not incorporate very strict enforcement procedures; being obliged to meet disclosure rules still does not seem to be accepted by the medical community as truly integral to their work.)<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">But complying with these rules is not just a matter of
avoiding financial problems and temptations. The fact is that a lot of medicine
depends on truth. Doctors are expected to give their patients accurate
statements of their situation; there may be exceptions to this rule but they
are controversial exceptions, not the rule. And on the other hand patients are
expected to be truthful with their doctors. That’s partly a matter of
self-interest: the patient who doesn’t tell the doctor about drugs she is
taking, or behaviors she’s engaged in, is risking her own health being damaged
by unanticipated side-effects of either one.<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">But not all disclosure by patients is directly for their own good.
Clinical trials carefully select the patients whom they will admit for
treatment. A patient who reveals a disqualifying fact has just lost his best,
possibly his only, opportunity to get an experimental treatment. Why is this
sacrifice exacted? For the sake of science: the experimenters need to know who
they are treating so they can measure the significance of the results that they
get. </span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The patient’s sacrifice is all the greater if the clinical trial design is
not truly motivated just by science, but instead is part of a carefully
calibrated effort to generate results that will in turn lead to the approval
of some use of the experimental medication that the trial sponsor will market. Then the patient’s truth telling may
in practice have as much benefit for the health care company's profits as for scientific
understanding. But we live in a world where private motives of one sort or
another have a lot to do with the generation of knowledge; this world is
imperfect but productive, and so we apply the duty of truth to patients seeking
admission to the trials that our imperfect world generates.<o:p></o:p></span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">What we have, really, is a social contract that means to
call on all participants in the health care system to act truthfully. But a
social contract that only one side honors is a flawed contract. (</span><span style="font-size: large;"><span style="font-family: "times" , "times new roman" , serif; font-size: medium;">I suspect some patients decline to honor their side of the contract too; their need is more immediate and personal than the doctors', </span><span style="font-family: "times";">and there must come a
point at which the individual’s desire for life outweighs his or her
obligations to the social contract, but in principle patients too are bound by
this mutual agreement.</span></span><span style="font-family: "times" , "times new roman" , serif; font-size: large;">) Physicians and
patients need each other’s adherence to this contract, and that means the duty
of disclosure and truth runs both ways.</span><o:p></o:p></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-75482108000080021342018-08-31T13:17:00.001-07:002018-08-31T13:17:26.156-07:00Some treatment surprises<br />
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<span style="font-size: large;">My recovery from the radiation treatment is still a work in progress. It seems to be, fundamentally, a work that really is progressing – earlier this week Teresa and I reviewed the newest CT scan report and learned that it appears to show that my tumors are by and large stable or smaller. This particular scan was done because of my recovery side effects, and actually is premature in terms of assessing the true impact of the radiation on the tumors, so there is still plenty of room to hope – as I do – that more improvement in the tumors themselves will show up on the final scan.</span></div>
<br />
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<span style="font-size: large;"><o:p></o:p></span></div>
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<div class="MsoNormal">
<span style="font-size: large;">That said, matters have also been more surprising than I’d anticipated. I have a lot of not very startling side effects, but cumulatively they are a bit of a burden. For example, as I’ve mentioned already, I’m tired, sometimes so tired that nothing but an afternoon nap can restore me. I’m also not sleeping very well, and that may have something to do with the fatigue and also with another symptom: persistent leg cramping that I’ve been experiencing, and that so far Sloan Kettering really can’t explain. (Lack of magnesium causes cramping but I don’t appear to be low on magnesium.) As usual, I have any number of drugs to take to make sure my digestion keeps functioning smoothly; these address all aspects of my digestion, from “stool softening” to water loss, and I suspect that to some extent they all complicate each other’s operation.<o:p></o:p></span></div>
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<span style="font-size: large;">But the most startling events took place on Saturday night, August 25. That night I went out for a walk. As I walked, however, I noticed that I had begun tilting – literally, physically, tilting – to the right. I also began to feel more indigestion. By the time I had done most of my walk, and gotten within two blocks of our house, I felt I couldn’t continue on, and Teresa had to come and pick me up. Even getting in the car wasn’t easy. (A nice woman living at the corner where I’d come to a stop got me water to drink; fortunately, the next evening I felt easily well enough to stop by her house to say thanks.)<o:p></o:p></span></div>
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<span style="font-size: large;">What was going on? One possibility is that I was simply feeling suddenly and intensely off kilter digestively; that would make sense because I had just recently started taking another drug, lactulose, which I’d been told could give me diarrhea.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-size: large;">The second possibility is connected to the first: I was taking this new drug because the level of ammonia in my brain had risen beyond its acceptable levels, though not far beyond them. Ammonia can cause things like difficulty walking, and I hadn’t yet had a chance to get the extra ammonia out of my system with the new medication. Possibly I also had some degree of “chemo brain,” a term I don’t like but that I’m afraid has real physical content, and must be included on a list of potential, physical (not just psychosomatic) side effects of cancer treatment. Of course it was scary to think that I had ammonia or anything else in my brain, where it’s not supposed to be, and where besides impairing my walking it may also have impaired my focus and cognitive functioning. Presumably it got there as another side-effect of the radiation treatment. But in any case I’m relieved to be able to say that I am feeling far better now.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-size: large;">That in turn fits with the third possibility, which is that somehow momentum began to run against me; that I wasn’t really in such bad shape but had gotten into a pattern that I couldn’t readily shake. This idea, I admit, is hard to explain, but that’s at least partly because what happened to me on Saturday night is hard to figure out too. So, perhaps, I somehow fell into a pattern in which I couldn’t walk without tilting. Maybe I had bruised my hip? I didn’t know how to bring myself out of it, but 12 hours after Teresa had taken me home, I felt better. So if there was a pattern, it’s now been shaken. I still feel a bit stirred, but otherwise okay. (That’s a joke, dear readers: James Bond wanted his drinks shaken but not stirred.)<o:p></o:p></span></div>
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<br /></div>
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<span style="font-size: large;">This was, all in all, somewhat more reality than I actually wanted. Fortunately it seems to have been an incident, of somewhat unexplained origin, rather than a transition to a new stage altogether. So I am focusing now on resuming my walking – not so easy in a heat wave – and continuing final work on my book – which is coming along, step by step, but there are still a lot of steps to be taken – and in general keeping my various drugs, and their side effects, under control. Thanks to the dedicated staff at Sloan Kettering for all their help in these efforts.<o:p></o:p></span></div>
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<div class="MsoNormal">
<span style="font-size: large;">****<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-size: large;">I want to add to this piece my condolences to James Grimmelmann, a former member of the New York Law School faculty, for the death of his mother, Jan Lewis. I did not know James’ mother well, but I knew that she consistently supported my wife and me over the years of my illness; Teresa knew Professor Lewis from Rutgers, where Professor Lewis taught for many years and built an outstanding record of thoughtful achievement. Teresa and I were both shocked to learn the recent news that Professor Lewis died at Memorial Sloan Kettering, after a fight against what must have been a sudden, fierce attack of cancer. We are thinking of her and of her family at this sad time.<o:p></o:p></span></div>
<br />
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<br /></div>
Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com1tag:blogger.com,1999:blog-6901931588347279408.post-15686247372203346552018-08-04T12:41:00.002-07:002018-08-04T12:41:42.964-07:00An update
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">Some of you may be wondering what’s up with me, and I don’t
want to leave you in suspense – though the answer is that not much is actually
going on.<o:p></o:p></span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">It’s now three weeks since my radiation treatment ended. In
about a month I’ll have a CT scan and a PET scan, and then they’ll know what
the treatment has accomplished. Why the delay? I believe I’m in the process of waiting
for my liver to settle down enough from the impact of the treatment so that the
doctors can tell what’s really going on. In the meantime, again, nothing very dramatic
is happening.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">One thing that is interesting is that I’m still having
side-effects. “Still” isn’t quite the right word; I think my side
effects – though pretty modest – have increased over the weeks since the
end of the treatment. This doesn’t seem to be unexpected. Radiation is a blow
to the body, and its effects, and the body’s reaction to them, apparently quite
often only emerge over time. Probably my side effects were also somewhat
increased by the chemotherapy I had every day along with the radiation; if so,
that too should tail off since the chemotherapy ended the same day as the
radiation did.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">So I’m more tired than I used to be, and more prone to
getting out of breath; all of this is fatigue, evidently, and according to the
patient education brochure MSK gave us when this began, fatigue “can last for
several months.” I also have a patch of irritated and itchy skin on my back. I
never did quite figure out whether the radiation was all going into me from my
stomach side, or whether as the machine’s components whirled around me it was
giving me doses of radiation from underneath, through my back, as well. Either
way, something about this process has disagreed with my back. Skin issues, MSK told
us, “often take… 3 to 4 weeks” to resolve. And my bloodwork is off in various
ways, most clearly with respect to my platelets, which promote blood clotting. Mine are well below normal. That means I
bruise easily, and as a result I have various purple spots here
and there; my body is more colorful than usual! Meanwhile, of course, one should never forget one’s bowel regimen; mine
continues.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">All that said, I’m basically fine. I’m receiving no
treatment right now (except a steroid via my pump, since my liver seems to
appreciate a steroid infusion), It’s a little surprising <i style="mso-bidi-font-style: normal;">not </i>to be getting treatment, but it will be great if it turns out
that I don’t need any treatment for some time to come. <o:p></o:p></span></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com2tag:blogger.com,1999:blog-6901931588347279408.post-87010869090867978902018-07-14T14:00:00.000-07:002018-07-14T14:00:51.214-07:00Radiation treatments complete!<div class="separator" style="clear: both; text-align: justify;">
<span style="font-size: large; text-align: left;">At Memorial Sloan Kettering, when you complete a course of radiation treatment you're encouraged to ring a bell in the radiation oncology hallway to celebrate. So yesterday I finished my 15 days of radiation, and rang the bell. We have a video, but I haven't figured out yet how to post it here and get it to play, so in the meantime here are two still photos: the top one is of me and the bell (which by the way is nice and loud when you give that rope a good tug), and the bottom one is of a celebratory cupcake, shared with Teresa, the photographer, a little later yesterday afternoon. </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYBqE2K5EXJMI231r6Rzsw4w4LF1k034v27wyyqlmYyfLT54EmHP3Uv5XCd-viLECJMwNv8f7FRv_ijaNqIapgm3jH3otnOS_B5Rk-9ECEJ6pTVypJ_rRpKNPmv4YKDxQOUQckrhKJ3TU/s1600/IMG_2959.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYBqE2K5EXJMI231r6Rzsw4w4LF1k034v27wyyqlmYyfLT54EmHP3Uv5XCd-viLECJMwNv8f7FRv_ijaNqIapgm3jH3otnOS_B5Rk-9ECEJ6pTVypJ_rRpKNPmv4YKDxQOUQckrhKJ3TU/s320/IMG_2959.JPG" width="240" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgug6ehG1_bP5VQW5sMcoAeZUx7QSkpXool-C9LN4twlCtPALsJhITt4iE1YUcX-_ltsrpU9JHEdpbuWhE08aNaSVwsPj0c_obB6TlO9OGeFv8Q1JfVe4pMemfwftkF2kLMReZX6gV_kD8/s1600/IMG_2963.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgug6ehG1_bP5VQW5sMcoAeZUx7QSkpXool-C9LN4twlCtPALsJhITt4iE1YUcX-_ltsrpU9JHEdpbuWhE08aNaSVwsPj0c_obB6TlO9OGeFv8Q1JfVe4pMemfwftkF2kLMReZX6gV_kD8/s320/IMG_2963.JPG" width="240" /></a></div>
<br />
<br />
<span style="font-size: large;">As for the treatment itself, it's superbly high-tech and as beams of radiation fly through you -- hopefully stopping to destroy your tumors -- you don't feel a thing. My main concern as the treatments took place was to stay as still as possible, while breathing just as instructed, none of which is as easy as it might sound. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Your body does know that something is happening, however. I'm more tired than usual now, and this may continue for a couple of weeks. Meanwhile, the bottom of my right foot is a bit painful; this particular symptom may not be due to the radiation, though, but rather to the accompanying chemotherapy pills, Xeloda (also known as capecitabine), which softened the tumors up for the radiation. These and related symptoms aren't negligible, but they're certainly not very bad either -- especially not if what I get in return is the destruction of all my active tumors. </span><span style="font-size: large;">We'll know if that's what's happened in a couple of months when I get my next scan.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Incidentally, the next scan isn't actually scheduled yet. The reason isn't a scheduling problem, but some kind of insurance issue -- again. I'm guessing that this one is the result, somehow, of my having switched insurers in the middle of the radiation treatment, and I'm assuming that it will be resolved soon and simply -- I hope that's right! </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">One last note from the radiation process, and from the aging process: when I chose music that would play during my treatment, the young radiation staff person I discussed this with had never heard of Linda Ronstadt or Crosby, Stills, Nash & Young. I hadn't heard of some of the music she liked either, but that really only confirmed how dated my musical tastes have become. Fortunately she had a relative who liked Bob Seger, so we were able to find some common ground!</span>Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com1tag:blogger.com,1999:blog-6901931588347279408.post-19799750962723230582018-06-25T06:41:00.002-07:002018-06-25T06:42:28.883-07:00Getting irradiated<!--[if gte mso 9]><xml>
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<br />
<span style="font-family: times, "times new roman", serif; font-size: large;">Insurance aside, radiation treatment deserves attention in
its own right. Even after MRI’s, CT scans, and a PET scan, radiation still
strikes me as the most science-fictional experience I’ve had as a cancer
patient.</span><br />
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The basic problem with radiation is also its strength:
radiation destroys cells. If it hits cancer cells intensely enough, it's likely to destroy them. If it hits
healthy cells intensely enough, it's likely to destroy them too. (Incidentally, this doesn't have to be done just in one session; the doses add up, which is why my treatment will consist of 15 separate sessions lasting till mid-July.) So the job of radiation treatment is to
find a way to concentrate as much as possible on the cancer cells while sparing
the healthy cells nearby. In my case, that means sparing both the healthy parts
of my liver (still chugging away with blood test numbers almost entirely back
in the normal range). It also means sparing the important
organs nearby, notably the stomach and the intestine.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">There seem to be two basic ways of making sure the radiation
hits just its true target, or rather does so as much as possible -- absolute perfection
doesn’t seem to be attainable. The first method is by very carefully shaping
the radiation beam; the second is by making sure the beam is as precisely aimed
at the tumors it is meant to target as possible. </span><br />
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">As the patient, I don’t have
anything to do with shaping the radiation beam. That’s a technological feat
that the machinery is designed for, and the operators of the machinery
carefully manage. </span></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The basic idea, as explained on a </span><a href="https://www.cancer.gov/about-cancer/treatment/types/radiation-therapy/external-beam" style="font-family: times, "times new roman", serif; font-size: x-large;" target="_blank">National Cancer Institute website</a><span style="font-family: "times" , "times new roman" , serif; font-size: large;">, is to deliver beams of radiation from many directions, so as to “conform[]
to the shape of the tumor” – hence the name “3-D conformal radiation.” Further
refinement of the shaping of the beam can come from a version of 3-D conformal
radiation called “intensity-modulated radiation therapy” or IMRT; again
according to the National Cancer Institute website, “IMRT uses many more
smaller beams than 3-D conformal and the strength of the beams in some areas
can be changed to give higher doses to certain parts of the tumor.” Finally, in
stereotactic body radiation therapy (SBRT), the same website explains that “many small beams of radiation are
aimed at the tumor from different directions. Each beam has very little effect
on the tissue it passes through, but a precisely targeted dose of radiation is
delivered to the site where all the beams come together.” My understanding is
that IMRT and SBRT are overlapping terms, and that they describe what I’m
receiving.</span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">All that, again, is the work of the machinery and the
medical staff. Meanwhile my contribution is to assist with the aiming of all
these beams. My assistance isn’t very dramatic: my assignment is to lie in a mold that
was prepared at my <a href="http://nowwithouthesitation.blogspot.com/2018/06/beams-not-beads.html" target="_blank">“simulation” session</a> three weeks ago and that holds me
in a particular position, and then to follow instructions meant to get my
position even more precisely set. I start my assignment by lying down on the narrow table where
I’ll be during the radiation. Then the medical staff take over; at this preparatory stage I'm supposed to be a
dead weight, and not try to help the staff, who will move me to exactly where they
want me. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Then my job is to breathe. This is a lot harder than it
sounds. Most of the radiation seems to be sent my way while I hold my breath;
that’s because breathing itself moves the organs inside you quite a bit. But
naturally people hold their breath to different degrees at different moments,
and the radiation staff want me at exactly the right point. So I take a breath, then they tell
me to let just a little breath out, then a little more, then breathe in just a
bit … and then, when I’ve got just the right amount of breath in me, they start
the actual radiation. Only by then I’ve already used up quite a bit of the
oxygen from that first breath, and now I don’t get to breathe again till they’re
done! Two or three times they took me right to my limit, with my chest
beginning to shake as I needed more and more urgently to breathe. I wasn’t sure
whether that would be an aiming problem itself, but they told me afterwards that I’d done
a good job – so I hope they got the targeting they needed. I also hope I’ll be a
better breather today (Monday, June 25), when I go for my second session. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">But I haven’t yet said what really seems so futuristic about
this process. I lie on the table, with a linear accelerator behind me that’s
producing the radiation beams. (A linear accelerator!) Meanwhile three lenses,
all quite large – maybe two or three square feet – revolve around me. I wasn't quite sure where they were coming from or going to, because I was in the body mold
on the table and could only look up, but it appears that the group of lenses can revolve at
least part way under the table on which I’m lying. The whole apparatus looks
something like this picture (which happens to be of a Varian Medical Systems machine -- I'm not sure which brand Sloan Kettering is using):</span><o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtLr7qpYq9RKhmDirYuQ3VHc6dL6KrsWZ_BD2v-YC3wGcfIyy7Q5-zJnpAf4elq8ng0w6l-CWaEv_LchmZr4WjnGI7Dtv05NS9eJOKmPgh1K_l0D3lXUcF-VTWpZfe84HPQa7P2Or5y5g/s1600/Tx_Delivery_Clinac_iX_002_960x500+linear+accelerator.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: large;"><img border="0" data-original-height="500" data-original-width="960" height="207" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtLr7qpYq9RKhmDirYuQ3VHc6dL6KrsWZ_BD2v-YC3wGcfIyy7Q5-zJnpAf4elq8ng0w6l-CWaEv_LchmZr4WjnGI7Dtv05NS9eJOKmPgh1K_l0D3lXUcF-VTWpZfe84HPQa7P2Or5y5g/s400/Tx_Delivery_Clinac_iX_002_960x500+linear+accelerator.jpg" width="400" /></span></a></div>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">One of these lenses, perhaps the biggest, is round (you can see it near the top of the photo). The round lens is the
source of the radiation beams and has cross-hairs embedded in it that I think
are used for targeting. There are also laser beams, apparently coming from the
walls of the room, that help in the targeting too; I’m guessing these are aimed at the
tattoos that I was given during the “simulation” session. </span><br />
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span>
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The other two lenses
are rectangular and are used for taking x-rays as the process goes along, to
make sure that everything looks right inside me. (They're visible sticking out on the sides of the machine in the picture.) There was a moment during my first session, this past Friday, when everything paused, while the doctor reviewed the images they had so far, I guess to make sure that in fact everything did look right. Fortunately it did, and then my actual treatment started. In the future, I think the treatment will get underway at once, so the whole process will be quicker, maybe 20 minutes of actual time being treated per day. </span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The lenses revolve very near
me – the medical staff assured me that I would never actually be hit by one,
and this proved to be true, but they’re still really close – and they do so
quite silently. Meanwhile I’m listening to music; they told me I could choose
anything and I had a good time with Beatles songs I hadn’t heard in years. So
as I’m working on being a good breather these big lenses are quietly revolving
around me, and it looks like something out of <i style="mso-bidi-font-style: normal;">2001</i>. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">And I say: great! <o:p></o:p></span></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-88685936258548149042018-06-23T14:06:00.001-07:002018-06-23T14:06:34.378-07:00Further adventures in the world of insurance
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<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">First, the good – the <i>very good</i> – news: the third administrative
appeal by Memorial Sloan Kettering (MSK) against Empire Blue Cross Blue Shield’s
refusal to cover my radiation treatment was successful. We learned this news
yesterday afternoon (Friday, June 22) and a couple of hours later I had my
first treatment. That went fine, but was certainly odd enough to deserve a blog
post of its own, to come over the next few days. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Second, a few things we learned from our forced introduction
to the world of health insurance:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"># 1: Insurance companies don’t all have the same policies on
the same treatments. What one company considers appropriate only for palliative
care another will approve for treatment aimed at actually fighting the disease’s
progress. I don’t know if there are any limits on what policies an insurance
company can adopt, but I suspect they are allowed to follow any policy that can
be reasonably justified in terms of current medical literature, and in the
nature of things that must often mean they have a lot of leeway. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"># 2: Lawyers, or other people with legal knowledge, can be a
big help. Health insurance issues pose
technical questions of both medicine and law. New York State, for example, has
special legal provisions that appear to be meant to press decisionmakers in insurance coverage
appeals to approve coverage for patients with rare diseases (these are
contained in <a href="https://www.health.ny.gov/health_care/managed_care/docs/phlart49.pdf" target="_blank">Article 49 of the Public Health Law</a>). That’s the sort of thing
that a lawyer specializing in health insurance denial of coverage would know
and be able to work with – and yes, there are such lawyers, and we were
fortunate enough to get advice from a very good one. Other professionals can also
provide guidance, including patient advocates (we got referrals to three). Of course, lay people -- especially people who've had to deal with these issues, as cancer patients and caregivers do -- may know about these matters too, and we've gotten great advice from other members of the cholangiocarcinoma community. But one wouldn’t try to understand the medical issues of cancer treatment without a
doctor’s advice, and I think it’s also risky to try to understand the legal
issues without expert advice on them. That advice may be expensive, but so is paying for treatment that won't be covered by insurance or not getting needed treatment at all.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"># 3 Lawyers will often tell you that it’s best to consult
them early rather than late. That can mean the difference between preventing a
mistake and trying to fix one that’s already been made. Just for example, MSK prevailed in its third administrative appeal, but it can matter what
gets said in the <i>first</i> administrative appeal too. Moreover, even if you
as a “consumer” have appeal rights separate from those of your physician as a “provider”
– that’s the case in New York, and maybe in every state – what the provider says
may affect what the consumer can later argue. Of course inserting a lawyer directly into such a process may be delicate in various ways, and I’m not claiming that’s always a
good idea. Getting advice and understanding where you stand earlier rather than later, however, means
you won’t feel as in the dark as we did. And I say that even though I’m a
lawyer myself; this was an area I knew nothing about and certainly felt lost
in.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"># 4 All that said, it makes a huge difference if you have
your provider on your side, and if your provider is skilled at handling these
issues. We had a very skilled and determined provider on our side. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"># 5 It’s especially important to have the provider on your
side – and to have advice of your own from a lawyer or other expert on the rules -- because the
whole process is far from patient-friendly. Empire Blue Cross Blue Shield
initially denied coverage for my treatment, and then in identical terms
rejected the first appeal of this denial, on grounds that, as stated in their
letters to me, were just about completely unilluminating. The crucial sentence
said that the particular type of treatment MSK was seeking coverage for “is not
covered,” and gave no reason at all for that finding. I still don’t know what we would have had to do, or been able to do, to find out what Empire’s reasoning
was, and without knowing what they were thinking there’d have been no way for us to challenge it (even assuming we could figure out how to do that if we did
know their rationale). I do know now that each insurer’s policies on what it
will cover are available on the web; these documents aren’t easy to read but
they’re worth looking at, and for what it’s worth it’s far from clear to me why
Empire maintained that under its policy this treatment wasn’t covered.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Later on, when MSK filed its third appeal, this went to a
state agency for decision, and the agency in turn assigned the matter to a
company that evidently does appeal-deciding as its business. This company
received the matter on June 19, and its decision was due no later than June 22
(which is in fact when it decided the matter and, happily, in our favor). On
June 19 the company wrote to me to offer me a chance to submit any
documentation I would like included in the review. It said I must fax or
overnight mail this material within 24 hours of receiving the letter. But the company's letter
actually went out on June 20 by Priority Mail, and so it didn’t arrive until
June 22; we didn’t see it until we got home from the radiation treatment I
received that day! According to the letter’s terms, I was supposed to have
until June 23, a Saturday, to send in documentation – which would have arrived
after the decision had been made and issued. This is not a procedure meant to
facilitate patient participation. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">******<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">So the net result: Empire’s refusal to approve my treatment
wound up delaying the start of treatment by 9 days, from June 13 to June 22. It’s
not clear to me what Empire gained by it. Were they just mechanically applying
their policies, or is this part of an institutional strategy of resisting
claims so as to avoid payment to all but those few patients whose cases get
taken through the appeal system as mine was? Whatever Empire gained, the delay was
extremely stressful for us, and trying to deal with it took a great deal of
time. Hopefully stress and time are all that this experience cost us. The
radiation oncologist at MSK advised me early in this delay period that it was
worth waiting, and didn’t think that doing so was likely to compromise my
medical condition. Fortunately, my tumors apparently are “indolent”; may they
always remain so lazy, or even better be destroyed by the treatment that is now finally underway. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">And one last reason that we are grateful to MSK: on June 30
I will go on long-term disability at New York Law School. That day my insurance
will shift from Empire, New York Law School’s insurer, to a plan at Aetna that
is available to my wife through her employer, Rutgers University. Could Aetna
proceed to raise its own objections to the treatment that I’m now receiving?
The impression we have so far is that Aetna isn’t likely to do that. But if
they do, we’ve been specifically told by MSK that my treatment will
not be interrupted or cut short; they will complete the full course of
treatment and, if necessary, work through any difficulties with Aetna
separately. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">We had been assured years ago by someone in MSK’s business
office that the institution stood behind its judgments of medical necessity and
would treat me according to those judgments even if insurance coverage was
denied. It doesn’t seem they will go that far, since they weren’t prepared to
start my treatment without getting insurance coverage confirmed in advance. But they will go quite a bit of the way, since now that the treatment has started
they will finish it even if they encounter new insurance difficulties. These
treatments aren’t cheap, and so that’s a significant commitment on their part.
I still wish that MSK had kept us better informed as this process worked its
way along over the past two weeks, but overall Teresa and I are grateful for –
and impressed by – what MSK has been willing and able to do for us, not
just medically but financially and legally as well.</span><o:p></o:p></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com0tag:blogger.com,1999:blog-6901931588347279408.post-76007868073596295702018-06-15T15:42:00.000-07:002018-06-15T15:42:35.803-07:00We encounter the world of health insurance
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">I’ve been blogging for some time -- starting back in April with <a href="http://nowwithouthesitation.blogspot.com/2018/04/a-new-plan.html" target="_blank">this post</a> -- about the efforts Memorial
Sloan Kettering (MSK) has been making to devise a radiation-based course of
treatment for the tumors I have that are resistant to chemotherapy. It hasn’t
been a simple process, but it appeared to be coming to a very promising
conclusion: I was scheduled to begin a course of 15 or 25 sessions of radiation
beam therapy two days ago, on Wednesday, June 13. That, however, did not
happen, because Empire Blue Cross Blue Shield (New York) refused to cover its cost. Empire’s
stated basis for this denial was that this therapy is not medically necessary;
in fact, it is urgently necessary and Empire’s denial is a direct threat to my
health. (I don’t usually write in such blunt terms – but this has been a very
difficult week and the situation calls for bluntness. I also haven’t written
about insurance issues like this before, because MSK has dealt with every
insurance hiccup we’ve experienced up till now, and prevented any interference
with my treatment. But now I understand better how maddening insurance issues can be.)<o:p></o:p></span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: large;">The need for the radiation treatment can be seen in light of the history
of my treatment for the cholangiocarcinoma I was diagnosed with in November 2015.
Beginning a month after the diagnosis, I’ve been on <span style="color: black; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;">one version of chemotherapy or
another ever since. After all that chemotherapy the largest of my tumors
has become inactive, possibly even dead. That's a big success for the
chemotherapy. But meanwhile recent scans have found that in four areas my
tumors are still growing. These tumors, as I understand it, are smaller than
the large, inactive area -- but they are obviously dangerous, since they are
growing despite chemotherapy. However, MSK is enthusiastic about treating these
smaller tumors with radiation. Radiation is far from an experimental treatment
for cancer in general, and has been used on abdominal tumors with great
success. The radiation oncologist anticipates an 80-90 % chance that the
treatment they plan to give me will kill my still-active tumors. If that
happens, then -- with my largest tumor area inactive -- I would actually be
healthier than I have been since I first was diagnosed with cholangiocarcinoma.<o:p></o:p></span></span></div>
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<br /></div>
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<span style="color: black; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;"><span style="font-family: Times, Times New Roman, serif; font-size: large;">But time is of the essence. I am
currently receiving <i>no</i> treatment. When the radiation starts, I
will have an accompanying chemotherapy drug (capecitabine), meant to enhance
the impact of the radiation, but because my active tumors are not responsive to
chemotherapy alone, I have to have an alternative to chemotherapy or I have
nothing. My radiation treatment, a planned series of daily treatments over 5
weeks, was supposed to start on Wednesday, June 13, but my appointments for
this week were all cancelled by MSK because of Empire's refusal to approve
payment. Empire is, in other words, preventing me from getting treatment that MSK
believes will help me, and meanwhile leaving me in a position where my tumors
are going untreated. The potential consequences, obviously, are dire. MSK is
continuing to fight this decision by Empire, and is in the process of filing a
third appeal, this one to be heard externally by New York State rather than
internally by Empire itself. A decision on this third appeal should come within
72 hours of filing. With luck that means that I will be able to start my
treatment late next week – but even so my treatment will have been delayed by a
week. If the decision on the appeal is against me, the delay will get even
greater. <o:p></o:p></span></span></div>
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<br /></div>
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<span style="color: black; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;"><span style="font-family: Times, Times New Roman, serif; font-size: large;">Empire’s stated ground for denying
coverage was that the treatment MSK proposed was not medically necessary. But
this was really a misstatement. What the radiation oncologist has told me is
that Empire sees the function of radiation in liver cancer as the alleviation
of symptoms in terminally ill patients. No doubt that once was true. It is no
longer correct, however, and ignores the impressive body of research that has
recently been produced demonstrating that radiation with modern high-dosage,
careful-aim techniques can have <i style="mso-bidi-font-style: normal;">curative </i>effects
on cholangiocarcinoma. Meanwhile, faced with evidence from MSK that in fact
this proposed treatment was medically necessary for me, Empire refused to
cover it because it did not fit with their policy on when such treatment is
appropriate. What’s necessary should shape the policy – not the other way
around.<o:p></o:p></span></span></div>
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<br /></div>
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<span style="color: black; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;"><span style="font-family: Times, Times New Roman, serif; font-size: large;">The most striking published data on
the efficacy of radiation treatment come out of M.D. Anderson in Texas (and MSK
is employing equally sophisticated techniques). In an article called “Ablative
Radiotherapy Doses Lead to a Substantial Prolongation of Survival in Patients
With Inoperable Intrahepatic Cholangiocarcinoma: A Retrospective Dose Response
Analysis,” 34 Journal of Clinical Oncology 219 (January 20, 2016), Randa Tao
and thirteen co-authors report that large cholangiocarcinoma tumors in the
liver – which in an earlier era were considered too difficult to treat with radiation – can in fact be
treated in multiple sessions to produce cumulative radiation doses that are “ablative”
(i.e., tumor-killing), “with long-term survival rates that compare favorably
with resection” (219). (Resection is the surgical removal of parts of the liver
containing tumors; it has till now been considered the only treatment of
cholangiocarcinoma that can actually cure, rather than just control, the
disease, but most patients – including me – are ineligible for resection
because of the state of their illness.) And there are many other articles also
finding evidence that radiation treatment can be valuable.<o:p></o:p></span></span></div>
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<br /></div>
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<span style="color: black; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Calibri;"><span style="font-family: Times, Times New Roman, serif; font-size: large;">I hope I will have better news to
report about this next week. It was very reassuring to talk with the radiation
oncologist at MSK today and with his colleague who is preparing the appeal –
they are clearly “on the case” and I now understand much better where things
stand. (A lot of what happened in the course of the week was made worse by the
lack of information along the way.) But for now we wait.<o:p></o:p></span></span></div>
<!--EndFragment--><br />Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com2tag:blogger.com,1999:blog-6901931588347279408.post-53702295814371788852018-06-03T07:51:00.002-07:002018-06-03T07:51:48.779-07:00Beams not beads
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<br />
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The first step in my revised treatment plan -- the <a href="http://nowwithouthesitation.blogspot.com/2018/05/spoke-too-soon.html" target="_blank">"beams not beads"</a> plan -- is scheduled for tomorrow, Monday, June 4. It’s called a “simulation” session, but it’s not really just a
simulation of the radiation beams to come. Instead, during this session they
will create a mold of my torso, or rather of my back, and then I will lie in
this mold for all my future radiation appointments. The essential thing, it
appears, is to make sure that the radiation beam is as accurately aimed as
possible, and so they need to make sure that I’m actually lying on the table in
exactly the same position each time. They will also tattoo my torso, again to
mark the correct targets, and these tattoos evidently are the real thing – they’ll
never go away. (Perhaps after the treatment is complete, I can get someone to
tattoo “Momma” in a way that incorporates the medical markings.)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">And then we’ll start, I think probably in the week of June
11. I’ll either have 15 treatments or 25, depending on how big a dose
they want to administer each time. As I understand the schedule, those 15 or 25
treatments will take place every week day until the full dose has been
administered. I’ll go into Sloan Kettering each day, get a 20-minute dose of
radiation, and go home – or, for that matter, go out to dinner. They expect I’ll
have few side-effects, though perhaps a few weeks in I’ll have enough fatigue
that I won’t be dining out.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br />
It’s interesting that I don’t get treatments on Saturday or Sunday – as far as
I know – since it seems unlikely that my tumors or my liver are aware of the
difference between weekdays and weekends. But there may be some medical benefit
to pauses every few days, and I suppose weekends are the natural time for pausing.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The radiation oncologist, with whom we met on Wednesday, May
30, was very clear and quite encouraging. What I am going to have is called <a href="http://radonc.ucla.edu/faqs-sbrt" target="_blank">SBRT</a>, or stereotactic body radiation therapy: very precisely aimed and quite high-dose radiation treatment. It utilizes photon radiation, </span><span style="font-family: Times, "Times New Roman", serif; font-size: large;">which evidently for me will consist of X-rays. An alternative might have been proton radiation, and we asked about this, but the radiation oncologist told us that there was no evidence that the greater precision of proton radiation actually makes a difference in most patients, and he didn't think it would add anything for me.</span><span style="font-family: Times, Times New Roman, serif; font-size: large;"> </span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The radiation oncologist believes that he can reach all of my active
tumors with the radiation. (That’s better than what we were anticipating with
the radiation beads, because apparently my blood system didn’t offer good
access for the beads to reach at least one tumor area.) He also plans to continue the treatment
until it reaches ablation dosage; “ablation” in this context appears to be a
synonym for destruction, and this is the first time that we’ve been told that
they could achieve that. He said the chance of tumor death was 80 - 90 percent! If they can actually destroy all my active tumors,
that would be great – even if, as is conceivable, at some future time these or
other tumors may appear again. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">All this makes us wonder a bit about why I was never put
into radiation treatment before. Some part of the answer may be that I started
in chemotherapy, which is the standard treatment for people whose tumors can’t
be surgically removed, and basically Sloan Kettering’s strategy was to keep me
in chemotherapy as long as it produced results – and then to try something
else. It makes sense to get the most out of any one treatment approach before
trying another, as long as it doesn’t for one reason or another get to be too
late to switch by the time switching is needed, and fortunately I’m able to
make this switch. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">But another part of the answer may have to do with the
particular course my cancer has taken. Apparently the largest tumor masses
showed up on my recent PET scan as inactive. Our oncologist, I think, suspected
this was the case even before the PET scan, but that scan certainly added evidence
to support this assessment. Inactive might mean “dead,” which would be great,
or it might mean just “inert,” which would be good as long as we can keep them
this way. It's possible these tumor areas were originally too large to treat with radiation, but they are also close to various healthy parts of my body that could be harmed by radiation inadvertently hitting them; now, happily, it seems there's little or no need to try to treat these areas. So radiation now makes sense in a way it didn’t before, because
the parts of my cancer that it might be risky to target with radiation aren’t
active, and the parts that are active can be attacked with radiation without
significant risk to anything else.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">So the next step is the “simulation” session, and then, soon
after, the real thing begins.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">******<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">And in other news – at New York Law School’s graduation
ceremony yesterday, June 1, I received the school’s President’s Medal, for what
the award citation called my “innumerable, deep, and lasting contributions to
the Law School” and for my “lifelong work to advance social justice and uphold
the constitutional principles our community holds dear.” I also got 5 minutes –
apparently I actually took 7 – to speak to the graduates. I felt moved and very
honored and grateful. And here’s a picture Teresa took of me during my 7 minutes at the podium: <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgT5ITCE8yGtCFywBpIlm-r-Vrekp82XM8nUgPSRfOKIdu0yzICxWpjJ1Kbl1AAVjn8LcoWIAg1SBW8rkh6zMYbASWoXQLjwmid8W_7rWt2rDniaZ31_RelM3cwQUTXXn6qM6cbTdycu9k/s1600/2018+graduation+prize+IMG_6469-2+%25282%2529.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1067" data-original-width="1600" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgT5ITCE8yGtCFywBpIlm-r-Vrekp82XM8nUgPSRfOKIdu0yzICxWpjJ1Kbl1AAVjn8LcoWIAg1SBW8rkh6zMYbASWoXQLjwmid8W_7rWt2rDniaZ31_RelM3cwQUTXXn6qM6cbTdycu9k/s320/2018+graduation+prize+IMG_6469-2+%25282%2529.jpg" width="320" /></a></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<!--EndFragment--><span style="font-size: large;">(The picture doesn't show the event's principal speaker, US Supreme Court Justice Stephen Breyer, who got 15 minutes and used them really well!)</span>Stephen Ellmannhttp://www.blogger.com/profile/04616174421643618589noreply@blogger.com3