Elation!!

     The plastic surgeon called yesterday afternoon and since I was taking my husband in to get a mole (I hope, a mole) removed from the bottom of his foot,  the surgeon left a message that he had good news for me. Yes, the two sentinel nodes were clean -- no cancer. And there was no residual tumor in the arm either. So the original depth of lesion of 0.48 mm stood as the total depth -- a depth that has very low risk of spread. I am still to follow up with medical oncology but I don't think there is much to do unless there will be some followup chest xray and other imaging down the road, I don't know. Anyway after this last week of surgery followed by worry, fearing the worst, a great load is now lifted from my shoulders. Hopefully Amos' path will also be negative when we get the results on Friday. Then we will both be able to heal and then get back to normal life. It is certainly amazing how quickly a very positive outlook on life can be changed for the worse with one of these medical adventures. I feel that it is very important to keep up my spiritual practices and to continue to live each day with mindfulness to maintain some of the life learning that this experience has provided to me.
     Now on to other topics in this blog. I am working on the story of our sojourn in Moldova, land of Amos' ancestors. I want to combine this with some photos. I plan for that to be my next posting here.
    

Waiting, Waiting, Waiting ....

Yes, I am waiting ... one of the hardest things to do when associated with the diagnosis of cancer.
 My wide excision and reconstruction and sentinel node dissection and excison is completed. I did fine. I was of course nervous about it never having had a general anesthetic before. My blood pressure was 174/70, a number which has quite a high systolic compared to my recent blood pressure control (since I retired). This was a sign of my anxiety. The nurse was worried about my blood sugar because it was 65, a little on the low side. I had been increasing my insulin to handle my sugars in conjunction with a reinstitution of prednisone for a vasculitis which relapsed now as well.
I took a book to the day surgery suite because I had been told that the nuclear medicine procedure that identifies the sentinel nodes takes about an hour and a half and I pictured that I would be sitting and waiting for this radioactive tracer to go up my arm to the node basin in the axilla. Yes one does wait but that occurs lying down under a camara. And the wait was only about 1/2 hour. Then they saw the nodes light up and marked them. So the whole nuclear procedure took about 1 1/2 hour but there was really very little down time which would allow reading -- only about 5-8 minutes while I sat in a wheel chair and waited to be wheeled into the nuclear medicine suite. Once I was back in Day Sugery it was bam, bam, bam -- start the IV, get the venous leg pump wraps on, the electrocardiogram monitor patches on, speak with the plastic surgery resident, speak with the anesthesia resident clarifying my history twice, getting my blood sugar checked one last time, and speaking ever so briefly with my plastic surgeon who came in to sign the left arm as the correct arm on which to do the procedure.
I told the anesthesia resident that I had received 8 mgm of Versed when I had my colonoscopy and never went to sleep at all even with the Demorol. She just commented that they had different things than Versed to use also. Shortly later the anesthesia resident said she had given me some Versed in the IV right there in the Day Surgery room and asked me if I was starting to feel relaxed as they were starting to wheel my gurney out of that little Day Surgery room. I said, "Yes, I feel a little drowsy." And that was the last I remember until it was all over and I started to hear voices around me in the Recovery room and opened my eyes. The nurse said, " Why don't you try a good hard cough; you have been clearing your throat a lot just now." I didn't know anything about that. So you do things and make sounds that you don't recall afterwards. There was a little trouble getting off the oxygen; I was desaturating with oxygen but seemed to be able to remedy that with coughs and deep breaths. I proceeded quickly back to the Day Surgery area. My blood sugar was 150 so that was OK. I recovered uneventfully in the Day Surgery room, got a hydrocodone, one pill for pain at about 130 PM after I was back in the Day Surgery suite for about 1 hour. At home by 3:45 PM and took one hydrocodone at about 5 pm and then another before I went to bed. I slept in two large periods of sleep and took another hydrocodone at about 5 am. I had some sweating from low blood sugar in the middle of the night and had to get up to get something to eat and some juice to drink. After that all I took for pain was two 500 mgm Tylenols for Thursday and then after the dose on Thursday night I took nothing further for pain. The plastic surgeon saw me Friday morning mainly because he had jury duty to do next week Monday through Wednesday and he didn't think he should wait to look at me until Thursday of the next week. He thought I was doing OK also. But he does want me to see an oncologist. I had begun to think about this and realize that the plastic surgeon doesn't want to follow up on this. There will likely be a need for imaging, maybe even CT scans from time to time and the oncologists will order this I think. So that is the likely reason for that follow up.
I wanted strongly to go to my son's home for the weekend because our 3 1/2 year old was participating in a daycare program on Saturday. My husband didn't think I should go and my son on the phone didn't think I should try to ride all the way down to Indianapolis just 2 days post surgery. But I really wanted to go. I was really feeling down and worried on Thursday and I thought that going would knock off 3 days of the wait for the pathology results. I would be with my grandkids even though I would need to rest while elevating my arm and I wouldn't be able to pick up Will at all. But the weekend would pass much more quickly and much more pleasantly. It wouldn't be possible to worry as much as when just sitting nursing my arm at home. That's what we did and I am glad that I did go. Enjoyed seeing Sam perform; he was put in the lead of the small group of children just as last year. I am sure that the teachers do this because they know that Sam takes instruction well and he will do exactly as he is supposed to do. When I am with those two little kids, I am not obsessing and I am reasonably at peace.
Now it is Monday I am back home and back to waiting. I probably won't know the results until Tuesday. Usually it takes 5 working days to get the pathology readout. I am worried about the sentinel node because the path report on the shave biopsy says that it was at least a Clark's Level IV. But this doesn't make complete sense because the depth of the shave was only 0.48 mm deep so how could they determine it was a Clark's Level IV. That level is usually 3 mm deep. I don't quite understand this even as a doctor and my son the surgeon didn't understand it either.
I keep imagining the call about my results. I imagine hearing the first words saying there is good news, the nodes are clear. Or I imagine hearing the worst that there is cancer in those nodes. Then I will have to proceed to complete lymph node dissection under that arm, a procedure that will I assume carry more side effects and more risk of post surgical lymphadedema as a long lasting complication. Also I think I would also likely be recommended to have Interferon as a immunotherapy for a year which can also produce a lot of side effects. I really dread both of these possible needs. I really am having trouble getting these vascillating thoughts out of my mind. Periodically I reach some kind of equilibrium with the statement: "Hoping for the best; preparing for the worst." Concentrating on this provides some degree of relief in my obsessional thoughts. Does everyone go through this when they have had a biopsy? Am I just a worry-wart, or overthinking the whole process like my son says I am? Or is this a function of my being a doctor and knowing too much? I just know that it is the hardest thing that I am having to go through, much harder than the pain and morbidity of having a surgical procedure.

Hoping for the Best, Worrying about the Worst.

Tomorrow I go to have definitive surgery for my melanoma. If you have a strong mental constitution read on to find out my mental ramblings during this time.
 I am scheduled to arrive at Froedtert at 6:30 AM when I will be checked in for Day Surgery. Then I have an appointment at 8 AM in Nuclear Medicine where a radioactive protein will be injected into my melanoma lesion on my arm along with methylene blue which is a dye. Then I am told that it will take about an hour and a half for these substances to migrate up my arm from the lesion to the lymph nodes under my arm. I am not sure if they follow this migration with a probe or detector or whether they take nuclear images to follow it. I will know more about this after it is all done. The anesthesiologist called this afternoon to get my medical history from me personally; he has my preop and all my preop labs in front of him. He told me to hold all meds except to take my Bystolic (a beta blocker) and the 10 mgm of prednisone with just a sip of water before I leave. I am also to take only half my usual dose of Lantus the night before and no short acting insulin the morning of the surgery. He explained the anesthesiological procedure carefully to me. My surgery is scheduled for 10 AM. I will get undressed, be put on a gurney, and an IV will be started by an anesthesia resident. Then I will be wheeled into the operating suite and a mask will be put over my face with lots of oxygen. I will be put to sleep through a medication injected through the IV. Then when I am asleep I will be entubated and monitored closely throughout the procedure. He told me that they would probably be checking blood sugar about every hour during the surgery and recovery times. The surgery is scheduled to last 1 1/2 hours. Then I will be awakened and extubated when I am breathing on my own, and moved to recovery for about 1 to 1 1/2 hours. After that I will be sent to Day Surgery to further recover for about 1-2 hours. So I will probably not be released until mid afternoon.
     This afternoon, after a call from Freodtert OR Nursing to confirm that this is all to take place tomorrow, from the anesthesiologist, and from the surgeon's office to confirm that everything is ready to proceed, It is difficult to put this upcoming procedure out of my mind. I have never had a general anesthetic before so this will be a new experience. It brings to mind the spiel that a neighbor and friend who was an anesthesiologist used to present at parties. He would pretend that he is doing a preop visit to a patient in the hospital the night before their big surgery. At that time there were very few outpatient day surgery procedures so he was usually visiting the patient in person unlike now when this is all done over the phone. This effect of his spiel in person was highly impressive for party guests but it is not very effective when now years later I am going through with a general anesthetic procedure. Now there is nothing to laugh at. His spiell went something like this:
     "Hello, I am Dr. Smith. I will be your anesthesiologist during tomorrow's surgery. I must get your medical history and will be asking about 100 questions about your health history and various symptoms that you have. We need to know all the answers to these questions because you life will be very delicately in my hands during that surgery tomorrow. We will be monitoring you very closely because lots of things can go wrong during anesthesia and surgery. We could have trouble helping you breath; you could have bleeding during the procedure or afterwards, you could react adversely to any of the many drugs we need to give you, you have an increased risk of stroke, heart attack, and other major medical complications during anesthesia and during the surgery. Our tube that we place in your throat could cause damage to your teeth, tongue, throat, voice box, and breathing tube." (Nowadays  and in reality I can vouch for the anesthesiolgist who I just spoke to and he said all these things, not quite in this blunt a fashion and he interspersed with multiple statements that these complications are all very rare now adays with the degree of monitoring that is done during modern surgery. But he said them). But Dr. Smith would have gone on: "Basicly what we will be doing is putting you into a coma utilizing several drugs and we hope and plan that it will be a reversible coma and that you will wake up." How would you like to sign up for this after this spiel? Scary isn't it? Well now that I am going through this tomorrow I can't help but remember this party stunt carried our frequently by our neighbor.
     Unfortunately, also this afternoon with my mind on my disease, I have  been reading on the Internet about melanoma, its staging, the characteristics of melanomas that are high risk to return, and what can be done to prevent such a recurrance. I have learned that treatment for melanoma that gets away from the original lesion is very inadequate. Normal chemotherapeutic agents don't work very well, and even radiation is not very effective. There are sometimes indications to use a drug called interferon which is a body product that is artificially produced and injected daily at first and then three times a week. This treats the cancer cells with your immune system. This substance is like the body product that occurs with flu illnesses and so it produces flu like symptoms and in the large doses needed tends to be very very toxic. Many people can not take the full dose due to the severe side effects and symptoms, liver toxicity and general toxicity. It is given for a year. And still with all that there is controversy in the studies whether it really helps survival. There seems to be some indication that disease free intervals are prolonged by maybe 9 months or so. Wow that isn't very much! This means that if I have a high risk melanoma -- thick in original depth which we can't even determine in my case, or having already spread to the local lymph nodes (which this surgical procedure is designed to determine) -- I have to decide whether to make myself sick for a year to try to reduce my chance of having metastasis and local recurrances or I do nothing and just take the chances that the disease will metastasize in which case other treatments are not very efffective at all and you die. Really bad idea to read all this this afternoon  before my surgery though being a doctor I knew some of it anyway.
     I am still vacillating between hope for the best, believing that this lesion isn't all that big and so it shouldn't have gone anywhere else in my body, and then the fear that it has already spread. One tends to arrive at a state of mind that you are prepared but hopeful. But this state of mind is very fragile and it doesn't take much to start a spiral of dread again. For example, my surgeon had said that we would decide on a referral to an oncologist who would recommend regarding the use of this interferon -- we would decide on this after my surgical results were known in a week. We would then know if the tumor had spread to local lymph nodes which makes it a high risk that it will recur elsewhere. But I received a phone message while we were gone on our trip from the Cancer Clinic at Froedtert Hospital that said they had received a referral from my surgeon that he wanted me to make an appointment in follow up with the oncologist. That scared me! Dr. D had said we would decide about that later but now he has made a referral. Does he know something I don't know? Does he already think that it has spread? Seeing an oncologist puts this in a whole new level of concern. No longer is this just a shallow skin lesion that needs removal and will be cured, with sentinel node biopsy being done just for safety; an appointment with an oncologist would be cancer follow up. I am tipped off my fence and my fragile positive state of mind is destroyed for a while. I need time and have to build up my dose of hope again to get through the next week of waiting for the test results. Wow, this is shitty!!!

"When It Rains, It Pours"

For me the title applies to my current medical condition.
I have been battling with achy muscle, sometimes very significant, interfering with sleep and certainly with quality of life. I had thought it was due to my cholesterol medication because the strength of that medication had been changed recently. I had spent some time stopping and starting that medication to see if it made any difference with my symptoms and it did seem to me to help. My blood tests that might show the muscle damage that can occur with cholesterol medication were normal. Since I have recently been treated and cured from giant cell arteritis, a blood vessel inflammatory condition tht requires high dose prednisone to supress, I have a risk of a complication of that disease called polymyalgia rheumatica. This is a small vessel inflammation that involves the muscles of the proximal extremities that cause achiness and fatigue. But we had thought of this and the blood test that would help confirm this had remained normal. All through our trip to Eastern Europe I was very achy, and had difficulty sometimes getting around the castles and ruins that we explored on this trip. It made this trip very difficult for me and fraught with suffering. We arrived back in town on May 27 and I went through with my preop testing and exam as planned. My internist suggested I contact my rheumatologist about these aches. Id did and even over the phone he agreed that I did have polymyalgia rheumatica -- the complication I referred to above. He told me it occurs 60% of the time when patients are coming off prednisone for treatment of giant cell arteritis. He suggested I go back on prednisone but in low dose. In two days of 10 mgm per day my symptoms are about 70 % better, though not gone. So again my blood sugars are out of control due to even the low dose prednisone. I am told none of this should have any negative affect on my melanoma surgery planned for June 2 so that will proceed next week on June 2.

Even though I myself was (am) a physician, I never liked going to see a physician as a patient myself. I always went when I had to, but strangely enough I got nervous, my blood pressure would go up (so called white coat hypertension), and I experienced some dread about the visit ahead of time. As I have gotten older, I have had to go to the doctor more frequently to check my diabetes, my cholesterol, my blood pressure and then of course the giant cell arteritis, so I have become some desensitized to these visits and my blood pressure no longer goes up. But lately I am getting an idea that life is being unfair to me. There should be a rule that says any individual patient only needs to be struck with one life threatening illness at a time. Alas, there is no such rule. So I just plod along and do what I have to do to treat each individual condition but it ain't easy. As a physician, sometimes I have felt great compassion toward patients who are going through cancer treatment just because of all the tests, and treatments, repeat status checks etc -- constant visits and procedures. I wondered how these people keep going through all these machinations of their bodies. When an obituary says: "After a battle with cancer, so and so died of the disease..." I truly realized that indeed that person was in a battle, maybe more of a war with repeated battles won and lost against the cancer. I can see under some circumstances where the patient would just get tired of this battle and decide not to proceed with the next recommended treatment or testing procedure. Of course, I am not at that point; I will do what needs to be done. But the classical question: "Why Me?" and this feeling of unfairness, and "Enough is enough." are upper most in my mind right now. Again stay tuned.

Our Travels + Melanoma

After the last post, anyone accessing this site might be wondering what is going on. Well, we decided with the support of my surgeon, and my oncologist partner, my son the surgeon, and another surgeon partner of mine, that we would go ahead with the planned trip. Everyone agreed that it would not make any difference to postpone the definitive surgical removal and the sentinel node biopsy for 4 weeks so we could take this trip. I have spent some time off and on checking the lesion that still remains on my right upper arm. It will be nice to get it off though the trip of course has kept me occupied to block most of these thoughts.


Here's our trip itinerary. You may read here and there in my future postings about some of these sites: Prague, Czech Republic in off and on rain showers; Budapest in a gorgeous sunny day with this time a visit to the interior of the Great Synogogue, the second largest in Europe; a cruise with Avalon down the Danube from Budapest to the Black Seas past the Iron Gates of the Danube, and a high light visit to Veliko Tornovo, a lovely medieval town in Serbia; then Bucharest, Romania; a tour of northern Romania including the Bran Castle of Vlad the Impaler fame, the stimulus for Dracula; finally a tour through Moldova to seek out the villages of Amos parents' birth and other important sites for the family history. We have been traveling since May 3 and return home tomorrow.

We are staying tonight at an interesting litte hotel at Schiphol Airport in Amsterdam, Netherlands. We didn't want to pay the $300 a night to stay at the Airport Sheraton. At this point in our trip as we are travel weary and wending our way home, we didn't want to go into Amsterdam. We have seen it quite well on past trips. This little hotel is called CitizenM; the M stands for Mobile. It is certainly meant to house the mobile citizen. The rooms are almost like a small river cruiser stateroom. A king sized bed stretches from wall to wall and up to the window which overlooks the tarmack of Schiphol with its KLM planes coming and going, yet you do not hear the planes. The shower is open in the room as is the toilet with circular clouded glass enclosures that can be closed for some degree of privacy. The luggage is intended to be put in a drawer under the bed but ours was too big and too heavy to do that, so we stacked them by the door making it a little difficult to get in and out of the room. There is a remote control to alter the lighting, the background music, the temperature, and what is played on the large TV on the wall to the left over the bed. You can watch movies, TV, or play games, or you can just watch all the instructions and demo videos for the various assets of the room. The decor downstairs is very avant garde. There is a large internet cafe, and two small libraries, as well as a canteen where you can purchase any item 24 hours a day and heat it up or eat it cold. We also spent sometime exploring Schiphol while staying at this hotel. We have been through Schiphol numerous times but were always just following signs to get to another aisle of gates, or to get to the exit to get into the city. This time we explored the shopping mall and we ate a lunch at a very large Burger King. We even went up to the viewing terrace where children were going crazy at the sight of all the airplanes landing and taking off.  I recalled what my two boys would have thought when they were small. They would have been excitedly screaming as well. I think I will head back up to the room and try out some of that technology.

One day and I am home. Will fast on the airplane the last meal so I can immediately go and get my fasting blood drawn for preop labs. Also will get my chest xray and EKG done in preparation for surgery on this melanoma in 6 days. Ah, it is all coming back to me now. Back to reality. So that is what happened. I committed to living my life as planned and going on this trip as long as it was not foolish to do this. Now I must start to practice my meditation and my mindfulness training to get through the next couple weeks of procedures and of waiting for the results of the sentinel node biopsy. Stay tuned!

Where do I begin? A diagnosis of malignant melanoma!

     I am engulfed, embroiled in a universal experience and want to write about some of the events and the overwhelming feelings that become involved.

     Ten days ago I went to a dermatologist about a lesion on my arm. It had been there a long time and had at times been scaly, but then in the last couple months, it had developed some projections in its profile and the edges had become rolled. I knew the latter was characteristic of basal cell carcinoma of the skin which is a cancer, but a low grade one which does not usually spread elsewhere but can destroy normal tissue locally. There was no pigment in this lesion; it was a reddish pink. I knew it needed checking and probably removal. I went in and even the dermatologist was fooled. She thought also possibly a basal cell or a squamous cell carcinoma or lichen planus. She did not suspect melanoma and she did a shave biopsy. That is a no-no if you are considering melanoma because this interferes with the calculation of a depth of the lesion, information which is important in planning how to proceed with treatment. Well, surprising all of us, on Wednesday, 3 days ago I got the call from the dermatologist that she had bad news which she apologized for but I had a malignant amelanotic (without melanin pigment) melanoma. So now it is Wednesday night and we are due to depart on a 3 1/2 week trip on Monday -- 5 days later. The path report says the biopsy specimen had cancer clear down to the base of the biopsy and to the edge of the lesion in several places. So I still had the cancer on my arm. The dermatologist had told me that a new portion of the pathological report rates the mitotic rate of the tumor ie the number of cell divisions per mm squared. If less than 1 it is a lower risk lesion; if greater than 1 it is a higher risk lesion and very new changes to the classification of melanoma takes that into consideration also in determining who might need a further diagnostic test ie the sentinel node biopsy. My mitotic rate was greater than 1. So now I have an inadequately removed cancer still on my arm which has some high risk characteristics. Now what? A list of questions began to run through my head and my husbands. Should we cancel our trip that had been planned for 8 months? Is it safe to travel with this cancer still on my arm and to further delay definitive treatment. Should I push for a sentinel node dissection? Should we do something to try to establish the depth of the lesion by a small re biopsy or should I have the wide excision of the lesion done before we go on the trip. Which doctor should I see?
     I began calling everyone I could find to try to begin to answer these questions. Two of the surgeons that I have worked closely with as a colleague over the years were out of town at conferences. Another third surgeon who is a close friend was not available by phone. My own internist is out on medical leave. I tried to get ahold of a plastic surgeon in town who trained with my surgeon son to see what he could tell me. He was supposed to call me back. And I was trying to get ahold of my son of course but they were not answering their phones because they were busy putting the kids to bed at this time of night. Finally when I couldn't get ahold of anyone I called the clinic to find out which surgeon was on call. It was Dr. Brooks. He was very thoughtful and when I explained the situation with the inadequate biopsy and our upcoming trip, the first thing he said was; "Well, I can see you tomorrow and we can talk about the pathology and we can try to redo the biopsy to try to get a Breslow depth with the second try. I can give you a suture removal kit and you can take the stitches out yourself on your trip." At this point it sounded like a plan. But he did not know about the mitotic rate being used as an indication for a sentinel node biopsy, a fact that the dermatologist had said was entirely new. He said there was always vascilation back and forth, whether Breslow 0.75 or 1 mm should be the cutoff and it always just comes back to the 1 mm as the cut off. If your depth is 1 mm or more you need the further surgery so we would try to reestablish the Breslow depth with a further excision or punch biopsy at the site. That was the plan.
     But by the next morning I had heard from Don, from Dr. Pele*, the oncologist I had seen in the past for a polyclonal gammopathy which is a benign condition, and most importantly from Dr.  Whit* and his partner at his plastic surgery office who does only melanoma surgery. Dr. D was very nice and after I explained the situation to his nurse, she got a message to him and he called me back directly. He said we would never restablish a Breslow level and this unknown in and of itself was an indication for a sentinel node biopsy.  Now I felt like I had a plan and some options. I went to see Dr. Brooks in the afternoon, but after some discussion we decided not to do any further excision of the biopsy. I had sort of decided to go with the surgery.  He had researched the situation and now realized that the mitotic rate is now used in the risk assessment as of new guidelines about 2 months old and therefore I probably should have the sentinel node biopsy.
     But jDr. Brooks had found another issue. He even as a surgeon had heard a new heart murmur that I didn't know I had. Where did that come from? I wasn't really worried about it but the surgeon and my internist would probably want an echocardiogram done before the surgery. And now my husband was throwing a fit and maintaining that he was not going to take a wife with a new heart condition to Europe with him. He was almost yelling at my cardiologist friend I was talking with to do the stress echo immediately.  How was I going to get that test done within the next day when my internist was out on medical leave and as I learned through another phone call the echo technician at the clinic was out on Friday due to her own minor surgical procedure. So I began throwing my MD after my name around again, calling other clinics and hospitals in the area. I finally found a 10:15 appointment at CSM Ozaukee Hospital. But now I needed an order. So I called my old roommate from when I was working who is on the staff at that hospital and he called in the order. So now I was off to get the echo. I had spoken with my friend and cardiologist who wanted to do a stress echo since I should have the stress part because I am diabetic, but he strongly maintained that this could all wait until I had returned and even til after all the surgical management of the melanoma. But I knew my internist and my surgeon would need the echo so I still worked to get it.
       My cardiologist friend read the results and called me in the afternoon with the non-serious results. "No one every listens to me," he whined. "I wanted to do the stress echo so we would have both the echocardiogram results and a stress at the same time."   
     " I know," I said, "but you would have had to write up a consult saying I could wait for the echo and you haven't even seen me in person. My hands were tied so I got the echo. But you're wrong, I did listen to you." My diagnosis was tricuspid valve regurgitation and a slight elevation of the pressure on the right side of heheart. Nothing needs to be done about this, though I don't know why this has developed now. Anyway the echo is done and checked off my list.
     I slept on and off those two nights, actually getting maybe 6 hours each night but the first thing you think about when you wake up is this diagnosis and what it might mean. I vascillated between complete confidence and optomism and panic and assumption of the worst. This must be almost universal feelings in everyone who has received this diagnosis. My husband says he went through the same thing when he got his diagnosis of prostate cancer. He is telling me that these obsessions finally subside though they never completely go away. I did have times when I was feeling more spiritual than usual, trying to live each moment and feeling a great gratitude for this gift of life and vowing to myself to maintain that gratitude at this high level.
     On Friday, two days after receiving the diagnosis, I saw Dr D, the melanoma plastic surgeon. He was very nice and was very complete with me. He certainly had little pieces of information that no one else had given me. He told me that he was going to proceed as though I didn't have any medical knowledge so he used his audiovisual chart to explain the pathology. Indeed I didn't know that my cancer was a Level IV tumor, having extended beneath the basement membrane and he said that in and of itself was an indication for a sentinel node. I was surprised about the smaller size of his planned incisions and yet he was going to more widely excise the lesion than Dr. Brooksarad planned. He does the axillary node resection through a 1 inch incision. I changed my mind. I decided to go with him. He does this type of surgery all the time. He has a surgical suite for giving the radioactive injection and for the patient to wait for this magic stuff to do its job to identify the sentinel or "gateway" node that is removed to look for the cancer. He quoted studies to me and one of them was that the prognosis was no different for those patients like myself whose tumor had been cut through by a shave biopsy or other type of inadequate biopsy. That was good news to hear. So I left there with my surgery scheduled for June 2nd when we get back. When I got home I called the nurse for my internist who was working in the WIC even though my internist was not there. She said they had put me in for a preop exam on Friday May 28 at 11 am and the receptionist had been supposed to let me know this. So that was set up. I would get the chest xray and EKG either Thursday when we returned or Friday morning as well as the fasting blood work. I think I was finally scheduled up with everything.
     I had to let Dr. Brooks know that I was going with plastic surgeons for this operation. I felt bad that he had been so helpful but now I was not going to have him do the surgery but he had said that he wouldn't be hurt if I went with someone else. But I still worried that he would. I left a message with his nurse about my decision and told her I wanted to speak with him anyway and to thank him. But he didn't call back. Probably to be expected. What surgeon in his right mind would want to call back the old woman/colleague who had just thrown him over for another surgeon. I spoke with my son that night and told him of my decision. He chastised me and said Dr. Brooks had every right to be pissed; that I was engaged in blatant doctor shopping. I guess I was, but people do get second opinions and they sometimes go with the second opinion. If you get a second opinion and you then decide that's the way you want to go, you go with that option and that doctor. right? Well, I am still feeling bad about that. I should have handled that better and told Dr. Brooks that I was going to see a plastic surgeon and there was a possibility that that is where I would go. When he didn't call me back I sent him a long email and told him why I was switching and thanked him for all he had done for me. I hope that helps. I want to make amends and I want to apologize if I caused any negative feelings in him. What else can I do? I think the need to get something done fast in this case because of the trip has led to me moving much faster and impulsively than I usually would.
     So we are going on the European trip with the remains of this lesion still on my arm. I have my pre op and tests, and the wide excision and sentinel node biopsy scheduled with the plastic surgeon at the medical school. I hope I can enjoy the trip. My husband said he was able to do so when we went to Peru with prostate cancer riding in his mind and the need for radiation treatment right away when we returned. I think I will be able to enjoy the trip. Actually given that adverse events in life often increase the appreciation for positive moments in life may help me maintain this positive mindfulness and appreciation, gratitude for every moment.
I had said half jokingly that "life sucks, then you die" but I don't really believe that. Life is good and every moment of it that we have is a beautiful gift. I can truly say that I believe that even in the face of this adversity.