June 29, 2007 - Sicko

I couldn't resist. This afternoon I go down to our local movie theater, and view Michael Moore's new documentary, Sicko – which is about our nation's broken health-care funding system – on the film's opening day.

I generally avoid movies on opening day. I don't like crowds. But, I'm so passionately concerned with the subject matter of this film, I don't want to wait.

Evidently, lots of other people feel the same way. The theater is two-thirds filled, at 3:15 in the afternoon on a Friday – for a documentary, for crying out loud! This is also the first movie screening I've been to, for a very long time, in which the audience actually applauds at key points in the film. (Biggest applause line: British Labour Party elder statesman Tony Benn – comparing America's bloated military budget with our paltry health-care expenditures – "If you can find money to kill people, you can find money to help people.")

I'll admit that Michael Moore's films are often over the top. He's not averse to taking the occasional cheap shot at his opponents, for comic effect. Sure, there are a few of these low blows in Sicko, but by and large he just lets the ordinary Americans he interviews speak for themselves. They speak powerfully indeed.

Moore asks, over and over, some very basic questions about why we do things the way we do, in this country. Why, for example, do we permit doctors who review medical-insurance claims to be paid literally millions in bonuses for denying people medical care? Why does the law require insurance companies to value their fiduciary responsibility to their stockholders more highly than their responsibility to their policyholders? Why do we, as a nation, consider it efficient for the government to run our firehouses, but not our hospitals? How is it moral to allow private companies to waste 14 cents of every health-care dollar on paper-shuffling bureaucratic overhead for people under 65, when Medicare does the same job for seniors, for just 3 cents? Why is it that, of the 25 leading industrialized nations, 24 of them offer their citizens universal health care (guess which one doesn't)?

Central to the film is a risky publicity stunt Moore engaged in: taking several ailing 9/11 heroes to Cuba by boat. First stop: the waters outside Guantanamo Bay, where Moore calls out through a bullhorn, asking the guards if his passengers can receive the same medical care the Al Qaeda inmates are getting from our government, gratis (which is significantly better care than these uninsured or underinsured people get on the U.S. mainland). Next stop: a Cuban hospital, in which these disabled rescue workers receive pulmonary treatment free of charge – care they were unable to get in the U.S., because they weren't New York City employees, but rather, patriotic volunteers. Having been to Cuba, I can appreciate what Moore's trying to do, but he failed to mention one important detail: that ordinary Cubans must suffer every day through a dreadful shortage of medicines. Yes, they have excellent doctors, but the Cubans have nowhere to take the prescription scripts their doctors write for them, because the pharmacy shelves are typically bare. (The U.S. trade embargo is partially to blame for that, and Cuban government inefficiency for the rest.) Yet, for all that, Moore's absolutely right in pointing out that the life expectancy of U.S. and Cuban citizens is about the same, and the Cuban infant mortality rate is actually lower.

In France, Moore interviews a group of American expatriates who have nothing but good things to say about the French government medical benefits they receive, free of charge. These Americans abroad sheepishly confess to feeling guilty that they have so much less to worry about, medically, than their family members back home.

In Canada, he takes his camera into a government health-clinic waiting room, and asks the ordinary people sitting there if they can confirm all the bad things he's heard about unreasonable waiting times and inferior care. None of that's true, the Canadians tell him, matter-of-factly. Their system works, and they're proud of it.

There's much more I could say about the film – a little of it negative, but the vast preponderance of it positive. Go see it, with an open mind. Listen to the stories of ordinary people, whose lives have been ruined – and who, in some cases, have lost loved ones – due to medical-insurance profiteering. Then, as Moore himself does in the film, ask the really tough question: which system – universal health care, or private insurance – is more moral?

Go see Sicko. It just could be the most important movie you see this year.

June 28, 2007 - In Search of the Lost Node

This afternoon, I go to Ocean Medical Center for an ultrasound test ordered by Dr. Gornish. He handed me the test script on Monday, just after my aborted surgical procedure, but suggested I check with Dr. Lerner before scheduling it. It took me a couple of days to track Dr. Lerner down through phone messages, but eventually his benediction came back: do whatever Dr. Gornish suggests.

So, today I lie back on a narrow examining-bed in the dim light of an outpatient radiology procedure room, while a friendly, efficient technician squeezes warm goo around the base of my neck, then slowly sends her handheld transducer gliding over my skin. She concentrates on the right side, where the phantom lymph nodes are, but also takes a quick look at the left, for comparison purposes. She peers into a computer monitor, looking at the watery, black-and-white images. (They don't look like much to me, but diagnosis is in the eye of the beholder.) Every once in a while, an automaton beep emanates from the machine. This, I take it, means she's capturing a screen shot for the radiologist to look at, to compare with my earlier CT scan images.

I ask her if she can pick out the infamous, distended lymph node, behind the collarbone, and she says yes, she can. She points it out on the screen: a roundish area, darker than the surrounding tissue.

So, no miraculous disappearance. I didn’t think so, anyway.

After five minutes or so of this, the tech asks me to just lie there and stay comfortable, while she steps out to confer with the radiologist. A few minutes later, she returns. He wants a few more pictures. More goo, more images – then, she steps out again.

This time, she returns with the radiologist, Dr. Jeffrey DiPaolo, who smiles and introduces himself to me. We go through the scan routine a third time, this time with the doctor looking directly at the images on the screen. He instructs his assistant to tweak them here and there, before the two excuse themselves once again.

The technician returns: "You're all done," she says, cheerily. When will the results be ready, I ask? Possibly as early as tomorrow afternoon. It all depends on how fast the doctor's report gets transcribed.

A staffer from Dr. Gornish's office told me yesterday that he probably wouldn't get any word to me before Monday, so that sounds consistent. I wonder if he's going to be in the office on Friday – and, if so, if there's any chance he could get back to me before the weekend? It would be nice to hear sooner, rather than later: to find out what my next step on this journey will be. I'm getting tired of this interminable, one-day-at-a-time vagueness. It's been more than a month since Dr. Lerner told me I'd need a biopsy, and I'm still not any closer to having one, let alone knowing the results. This is playing havoc with my summer plans, particularly with knowing whether or not I'll get any significant chunk of time up at our Adirondacks place.

I could really use a vacation – although, as I should know by now, there's no vacation from cancer.

June 27, 2007 - A Miracle?

As various people have learned of my experience in the operating room the other day, some have wondered whether it could be a miracle. Based on the very limited facts we have at the moment, it does seem like it could fit the profile of a modern miracle-story. That profile goes something like this:

Patient has cancer. Modern medicine prepares its usual array of therapies to treat the cancer. Friends of the patient pray for healing. Patient goes in to receive medical treatment, but the doctors are baffled: there is no longer any sign of cancer in the patient's body! Patient goes home praising God. Doctors are left scratching their heads in wonderment.

We've all heard such stories before. Even with its impressive arsenal of high-tech tests and scans, medical science is still unable to explain certain things that happen. When doctors make predictions – based on empirical evidence and past experience – about how a particular patient's cancer is likely to progress, they do tend to be right in a large majority of cases. Yet, there is a significant minority in which their predictions are a bit off. Among that small number of cases, there is a tiny – no, minuscule – number in which they're completely wrong: in which the cancer that had been predicted to spread not only goes into remission, but seems to completely disappear.

Is this the hand of God at work? Or, is it just something that simply happens on occasion, within the normally-accepted range of statistical error? A person's faith perspective plays a big role in how he or she answers such questions.

As for me and my faith perspective, I don't spend a lot of time sitting around, waiting for that kind of spectacular intervention to take place. Yes, I do believe in miracles, but I also do believe they're rare as can be. I'm far more likely to spend time thinking about a different sort of miracle, one far more widely-distributed in our world. C.S. Lewis has described it thus: "Miracles are a retelling in small letters of the very same story which is written across the whole world in letters too large for some of us to see."

Or, as the Welsh poet Huw Menai put it, in a little poem, "Paradox":

If the good God were suddenly
To make a solitary Blind to see
We would stand wondering all
And call it a miracle;
But that He gives with lavish hand
Sight to a million souls we stand
And say, with little awe,
He but fulfills a natural law!

Yes, we people of faith ought to cultivate an eye for the miraculous. Yet, we do well to look for miracles within the natural order, not outside of it.

I have cancer. Chances are, as a result, my life could end up being shorter than most. Am I happy about that? No. There are times when I'm still filled with anger and disbelief, that such a thing has happened to me. Yet, is it really such a theological scandal that one person among billions – a person who’s going to die eventually, anyway – could end up having a decade or two shaved off his lifespan? Do I consider this to be such a violation of cosmic justice that I look to God to spectacularly intervene, supernaturally removing every mutated lymphocyte from my body, once and for all?

No. I have no reason to expect such divine intervention. Why should I be more deserving of such a blessing than anyone else?

There are a few who seem to think I do deserve such a thing, because I'm a minister (much as, in the old days, the shoemaker's kids weren't expected to go barefoot). When I was talking with Dr. De La Luz on the phone last week, about anesthesia issues related to my sleep apnea, he picked up on my fear, and tried to comfort me. He said, cheerily, "I know the guy upstairs is looking out for YOU" – with a big emphasis on the "you," as though to say, "God's looking out for you, of all people." In the same-day surgery staging area the other day, one of the nurses – upon learning that I'm a minister – said something similar, about God surely being on my side. I always receive such comments graciously, in the spirit of caring and support with which they're meant – but, I don't believe them for a minute. (I've never put a "Clergy" sticker on the rear bumper of my car, either, hoping for preferential treatment from the police.)

Bruce Almighty is a rather silly movie – a Jim Carrey vehicle, so you know it's silly – which yet wrestles with some serious theological issues. The background is that God, played by Morgan Freeman, gets fed up with the laments of Bruce, played by Jim Carrey, about how badly his life is going. God decides to hand the reins of the universe over to Bruce for a little while, so he can glimpse the big picture. In one scene, Bruce gets to sit at a computer that's handling God's daily inbox of prayer requests.

"You've got prayers," says a cheery little message. Bruce decides to see just how many prayers are in the ol' inbox. "You've got 3,152,036 unread prayers," says the computer. Bruce tries to answer one or two, but realizes it's an impossible task. He selects "Answer All," then the word "Yes."

The scene then shifts to someone who had prayed to win a big lottery jackpot, and whose prayer has been answered – but then, so have the prayers of hundreds of thousands of other people. The payout is tiny. All those winners are mightily disappointed.

Bruce then seeks out God – who, in God's idea of a vacation, is taking simple pleasure in a janitor's daily tasks, mopping the floors of a vacant office building. "What happened?" asks Bruce. "I gave everyone what they wanted."

God sets the mop aside. "Since when does anyone have a clue about what they want?"

God then proceeds to show Bruce the implications of some of the prayer requests he's just answered in the affirmative. See that kid who's been bullied at school? God asks. You just gave him huge muscles. He'll soon become a bully himself. He would have become one of the world's great poets, giving voice to suffering and vulnerability, but now he's going to become a professional wrestler.

The bottom line is, we just don't know. When we shift our reasoning faculties into high gear and try to puzzle out huge cosmic questions like why one person died in the World Trade Center but why the person at an adjacent desk - who had a dentist’s appointment that morning – lived, we simply can’t account for it. Was one really more divinely favored than the other?

I'm trying to look elsewhere for miracles, these days, than in my own lymphocytes. Like the other day, for instance, when there was a torrential summer rainstorm with the sun still shining, and we all rushed out to the front porch to look for a rainbow, and sure enough, there one was. Or, when I walked out of the church after a meeting last night, and was gifted with the vision of a luminous, nearly full moon, hung in an iridescent purple sky. (I remember thinking that, if it weren't for the cancer, I probably wouldn't have slowed down to give that moon a second thought.) Or, when I marvel that there are people who love me, despite my faults.

Miracles? They're everywhere.

June 25, 2007 - The Operation That Wasn't

Today I go to Ocean Medical Center for my long-awaited surgical biopsy (removal of a swollen lymph node near my right collarbone). I get all the way to the operating table, but then the operation is abruptly called off. Here’s the story.

I arrive at 2:30 p.m. (My original time was 1:30, but the hospital same-day surgery department phoned me to push my appointment back an hour, due to operating-room delays). I’m ushered back into the pre-op area, then prepped for surgery (don a hospital gown, get an IV line inserted, answer lots of medical-history questions). I meet Dr. Jeffrey Winkler, the anesthesiologist du jour, and discover that this doctor – unlike the one who sedated me last week, for my colonoscopy – has no problem with my using a BiPAP machine in the operating room. He does explain that I’ll be under “conscious sedation” – which means I’ll probably be aware of some of what’s going on in the O.R. With this kind of surgery, he explains, most of the pain control is local anesthesia, administered by the surgeon. The sedation is just to keep me comfortable, while all this is going on.

Two and a half hours after we arrived at the hospital, an orderly shows up to wheel me into the surgical area. After 10 or 15 more minutes’ waiting outside the O.R., a nurse wheels me inside, lines up my gurney next to the operating table, and has me slide over. Dr. Winkler is busy behind me, preparing to administer anesthesia. Dr. Gornish, the surgeon, comes in and greets me. “Let’s find this thing,” he says – all business – and he begins feeling around the base of my neck with his fingers. He seems to be taking longer than I’d expect, and soon I learn the reason why. He can’t locate the swollen lymph node he’d distinctly felt nearly a month ago, when I saw him in his office.

Dr. Gornish consults the diagram he drew at the time, then comes back and palpates me some more. Still no sign of the swollen node. It wouldn’t be responsible to proceed with the surgery under these circumstances, he explains. He could end up cutting me in the wrong place, then have to enlarge the incision until he found the suspect node. I could end up with way too much muscle and nerve damage. The best thing to do, he thinks, is for me to go for an ultrasound-guided needle biopsy. It won’t produce as large a tissue sample for the pathologist to look at, but at least the procedure can be accurately targeted. First, though, he’ll write me a prescription for a simple ultrasound, for a quick look-see.

In moments, the O.R. team swiftly undoes all the pre-op preparations they’ve just taken me through. There’s some light-hearted kidding around, among these twentysomething nurses and technicians, about my having missed out on the drugs (not the first thing on my mind, to be sure). I never do receive any anesthesia – although Dr. Winkler does tell me that, just before the cease-and-desist order, he gave me an anti-nausea medication through the IV line. It should cause me no ill effects.

Someone wheels me back to the same-day surgery staging area. In the curtained-off cubicles around me are several other patients, the few stragglers remaining after a long day of surgery. The woman across from me is holding an ice pack to the side of her face. In the cubicle next to her is another woman with a vomit bucket on her lap. Both of them have that ashen, post-surgery pallor. The nurse calls Claire in, removes my IV, and tells me I can get dressed. I don’t know whether or not I should feel fortunate – especially considering the fact that I may have to go through this whole routine soon again. We’re home by 6 p.m.

What does all this mean? It’s anybody’s guess. Because the swollen lymph nodes have been visible on various scans since March, I don’t think they were merely the by-product of some transient infection – though I’m no medical expert. If they were cancerous, then did the cancer suddenly and inexplicably reverse itself? Or are they still hiding out, but too deep, now, to be detected by touch?

It’s too early to say. The only certainty is that more tests are in my immediate future. Tomorrow I’ll leave a message for Dr. Lerner at his office, and find out what he recommends.

One way or another, cancer is forcing me to live one day at a time.

June 23, 2007 - A Smart Bomb That Could Be In My Future

Searching the Net today, I come across an Associated Press article from about two months ago, about two lymphoma drugs I've heard of, but don't know too much about: Zevalin and Bexxar. These are radioimmunotherapy drugs: a hybrid of radioactive material and genetically-engineered medicine. The gist of the article is that, while these treatments are highly effective against lymphoma, for some inscrutable reason they haven't caught on in a big way. Oncologists have been slow to recommend them to patients. The manufacturers of Zevalin, the article goes on to say, are so disappointed with the sluggish sales that they're seeking another pharmaceutical company to buy the patent from them.

Zevalin and Bexxar work much like Rituxan, in that they target a certain protein, called "CD-20," that's found on the surface of certain types of lymphoma cells (the same type I happen to have, fortunately). The difference is that, instead of chemically neutralizing those cells, Zevalin and Bexxar deliver a tiny particle of radioactive material that accomplishes the same thing. Furthermore, they often bring about longer remissions. The protocol is relatively easy on the patient: just two intravenous infusions, one week apart.

Here's an excerpt from the article:

"The issue: Despite research showing they work well, fewer than 10 percent of lymphoma patients who are candidates for Zevalin and Bexxar ever use them, says Dr. Mark Kaminski of the University of Michigan, a hematologist who co-invented Bexxar.

Why? Specialists cite a complex list of reasons, including that most oncologists aren't licensed to administer the radioactive infusion and must send their patients to a nuclear-medicine doctor. There's also confusion about the risks of radiation, which studies suggest are minimal, and when the drugs work best – early, not as a last-ditch therapy.

‘There's lots of reasons to use them, and there seems to be an inertia against them,' says Dr. Mitchell Smith, lymphoma chief at Fox Chase Cancer Center in Philadelphia. ‘I do see it as unfortunate.'....

‘Basically, [the drug companies] hit a home run' scientifically, says Kaminski. ‘The shock wave that goes through here is that if you can't get this to work in the marketplace, what's the sense of developing anything else along this line?'"

Part of the difficulty, evidently, is the hybrid nature of these drugs. Because they contain radioactive material, the Nuclear Regulatory Commission has to be involved in licensing oncologists to use them. Not many have received that permission, to date. The NRC is used to working with nuclear medicine doctors, not oncologists – yet, this material is delivered through a syringe, not through huge radiology machines in a hospital or clinical setting. And, without a lot of oncologists licensed to give the medications, it's hard for patients to gain access to them.

I remember asking Dr. Carol Portlock, of Memorial Sloan-Kettering, about Bexxar when I was consulting with her at the end of my chemo treatments. She didn't seem too much of a cheerleader for it, at least as a first-line treatment. I remember her saying something about the unknown effects of radiation, years down the road – suggesting that I probably wouldn't want to put radioactive material in my body unless I'd first exhausted all other options. (Of course, I already get radioactive material injected into my veins every time I go for a PET scan.)

For me, this raises questions about the marketing of cancer drugs. A big part of oncologists' profits come from the drugs they sell to patients. Unlike most other medical specialties, oncologists – at least those oncologists who own and operate their own infusion suites – are both physicians and pharmacists to their patients. If there's a drug they're not yet licensed to sell, it's understandably not going to be on their radar screens – at least, not the same way the medications sitting on their shelves are.

Anyway, it will be interesting to see how the thinking about drugs like these may change, in the next few years. If it turns out that my upcoming biopsy indicates a relapse, I wonder if I could be using oncological "smart bombs" like these sooner than I think?

June 22, 2007 - You Takes Your Chances

Dr. De La Luz (my pulmonologist) and I have been playing telephone tag for a couple of days. Late this afternoon, he calls back. I begin by telling him there was “some confusion” in Same-Day Surgery, when I was there the other morning (see yesterday’s blog entry). He corrects me immediately: let’s call it “commotion,” he says, not confusion.

OK, I say. Fair enough. We’ll call it commotion. (He’s sensitive about undermining his colleagues, evidently – which speaks well of him.)

I explain what happened: how the anesthesiologist basically overruled his recommendation that I use a BiPAP machine to keep my airway open during the colonoscopy. Turns out, Dr. De La Luz heard something about it that very morning. He didn’t actually talk to the anesthesiologist, but to one of the respiratory technicians, who evidently called him while the debate (“commotion”?) was going on.

As I talk with him, it becomes clear that there’s an established hierarchy of authority in the hospital, with each specialist having absolute sway over his or her own little area. When it comes to the choice of anesthesia techniques, the anesthesiologist reigns supreme. That means Dr. De La Luz’s suggestion that I use a BiPAP machine during my procedure is just that: a suggestion.

I can understand that. The anesthesiologists do know their narrow, little area of medicine better than anyone else. The only thing is, as a pulmonologist, Dr. De La Luz knows far more about obstructive sleep apnea than most other doctors. It was clear to me, from Dr. B’s unfamiliarity with BiPAP machines, that he’s considerably less well-informed about sleep apnea. Yet, because of the established pecking-order, Dr. De La Luz isn’t about to challenge him.

Anesthesia is a little, self-contained principality within the larger medical world. It’s like walking from Rome into St. Peter’s Square, thereby crossing the border into Vatican City. In that rarefied atmosphere, the ordinary rules no longer apply.

Having learned this, I can’t say it gives me a great deal of confidence. Anesthesiology is one of the few medical fields where patients don’t get to choose their doctors (pathology is another one). You pays your money and you takes your chances, as they say. Whichever doctor you get is the luck of the draw.

That means patients can be put in the position, as I was, of having our longtime physician’s professional judgment overruled by some seeming newcomer we’ve never met before. That unfamiliar doctor’s word is law. To me, that’s scary. What accountability is there, for those who rule over these self-contained medical principalities? With other medical specialties, one can make the case that market forces will eventually cull out the bad apples, as patients avoid doctors with bad reputations. With anesthesiologists, who rarely have any repeat customers, an awful lot of patients could experience unnecessary pain before anyone catches on and starts flagging a doctor as less than competent.

I’m not saying anything like that about Dr. B, the anesthesiologist I had the other day. After all the commotion, he did a fine job of keeping me comfortable during the colonoscopy. I can’t say the same about the nameless anesthesiologists who watched over me my last two times in the operating room – they evidently didn’t pay sufficient attention to my sleep apnea. The problem is, having had bad experiences on the operating table in the past, you want to take proactive steps to prevent that happening again. The “pay your money and take your chances” system of assigning anesthesiologists – which effectively bars those doctors from talking to their patients until moments before their surgeries – stymies any attempt of patients to advocate for themselves.

I think the system needs to be changed. Why can’t patients meet with their anesthesiologists at the same time they come in for their pre-admission testing? That way, they could share their medical histories far enough in advance that the doctor wouldn’t have to make snap judgments about which techniques to use – and, the patients would be looking upon a familiar face the morning of their surgery, rather than some stranger.

Most medical specialties have caught up with the fact that it’s a new world out there: patients are better-informed about health care than ever before, and want to participate in their own care decisions. It’s about time anesthesiologists got with the program.

June 21, 2007 - What the Right Hand Doesn't Know

This morning I go to Ocean Medical Center for a colonoscopy. This is a routine “wellness” test – the obligatory 50th-birthday look-see by a gastroenterologist. Inasmuch as this is a screening test for colorectal cancer, I suppose it falls within the purview of this blog (even though it has nothing to do with lymphoma).

Do not fret, gentle reader. I promise to spare you the grisly details. Suffice it to say that the test itself isn’t bad (I slept through most of it). It’s the fasting-and-purging regimen of the previous day that’s the worst part – as any colonoscopy veteran will tell you. Yet, even that doesn’t live up to the negative hype.

The most significant aspect of this colonoscopy, to me, is its timing. It happens to take place a few days before my excisional biopsy (which is scheduled for this coming Monday, June 25th). With all my anesthesia woes during my last two surgical experiences – the pain I felt during my core-needle biopsy in December of 2005 and during my port-implantation surgery a month later – I'm looking on the colonoscopy is a sort of practice run: a chance to work out any communication difficulties among my doctors.

That’s the theory, anyway. The reality proves to be very different. Here’s what I did, in a vain effort to try to prevent the communication snafu that did, in fact, happen:

1) I informed my gastroenterologist, Dr. Aaron, that when I had my port-implantation surgery a year and a half ago, I woke up on the operating table, feeling pain. I told him I have sleep apnea, and use a BiPAP machine every night. He told me I ought to speak to the anesthesiologist, to make sure that doc’s informed of my history. (And who will the anesthesiologist be, I asked? Search me, says Dr. Aaron. It’s a group. You don’t meet your anesthesiologist until the morning of the surgery. But, he says, if I call his office the day before, maybe one of his staff can scope it out.)

2) Earlier, I'd scheduled an appointment with Dr. De La Luz, my pulmonologist, to consult about anesthesia issues (this, with my biopsy surgery in mind). Because that appointment was already scheduled for a few days prior to the colonoscopy, Dr. Aaron suggested I ask him about that procedure as well. When I saw Dr. De La Luz several days ago, he repeated what he’d said to me some months before: there’s no reason you can’t use a BiPAP machine in the operating room. Dr. De La Luz scribbled a prescription for me to give to the anesthesiologist that morning, listing my BiPAP settings. Should I try to talk to the anesthesiologist ahead of time, I ask him? No need, says he. You don’t know which one you’ll get, anyway. Just give the doc this slip. They have BiPAP machines on hand. All the respiratory technician has to do is calibrate it to your settings, and you’re good to go.

3) I call Dr. Aaron’s office, anyway, the day before, to see if I can get an anesthesiologist’s name. No luck – they have no idea which one it’s going to be. Based on what Dr. De La Luz told me, though, I don’t worry any more about it.

Sounds good in theory, right? Wrong! When the scrubs-clad anesthesiologist (I’ll call him “Dr. B”) comes in to see me in the outpatient-surgery prep area, he picks up Dr. De La Luz’s little missive that's clipped to my chart. What’s this, he asks?

I’ve got obstructive sleep apnea, I explain. This is so you’ll be able to hook me up to a BiPAP, so I won’t slip into an apneic episode, so you won’t scale back the anesthesia, and so I won’t wake up in flagrante surgico, as happened the last two times I had surgery. (Truth to tell, I wasn’t so glib at 7:30 in the morning, after a day subsisting on clear liquids, jello, and a 64-ounce bottle of laxative – but, a story like this one does gain in the retelling.)

Dr. B. furrows his eyebrows. I’ve never seen a machine like that used during a surgical procedure, says he. Then comes the real kicker: “What’s a BiPAP, anyway?”

Uh-oh, I think to myself. I’m in trouble. My anesthesiologist has never heard of a BiPAP machine.

Non-medical types are more likely to have heard of the more-common C-PAP – the BiPAP’s kissing cousin – but I’m surprised to meet an anesthesiologist who isn’t familiar with it. (And Dr. De La Luz had been so confident: all I had to do was hand over his little note, and everything would be fine!)

The thought crosses my mind that maybe I ought to just get up, go home, reschedule the colonoscopy, and start all over again: making a more energetic attempt to breach that impregnable, bureaucratic wall that keeps anesthesiologists from communicating with their patients in advance.

No, I say to myself. Think about this carefully. A colonoscopy is more of a diagnostic procedure than a surgical operation. Sure, it’s invasive, but – except for the possible removal of a polyp or two, deep within my intestines where there aren’t so many pain receptors – I’m not going to be cut. Besides, I’m not crazy about the idea of trudging back to the pharmaceutical barkeep for another of those jumbo laxative cocktails.

Dr. B explains his reservations. If I should have a problem with acid reflux in the operating room, while my gag reflex is suppressed by the anesthesia, the positive airflow from the BiPAP could cause me to aspirate some nasty stuff into my lungs, causing pneumonia.

Well, then – says I to him – I’m confused. Could you help me understand why a pulmonologist – an expert in BiPAP machines – would tell me it’s common to use it as a piece of operating-room equipment, to ward off apnea?

Hold on just a minute, says Dr. B. Let me talk to a respiratory technician.

Sure enough, the respiratory tech shows up a few moments later – wheeling in a BiPAP machine. She leaves it at the foot of my gurney, ready to go. Dr. De La Luz must have been right, after all, I think to myself.

But, not so fast. I’m still not out of the woods. Who should show up next but the head respiratory technician? There’s a problem, she says. They don’t have the same sort of face mask I use at home. The home version covers the nose only. The hospital version covers both nose and mouth, and is actually used more for emergency resuscitation than for keeping the airway open during routine surgery. You’ll have the mask strapped very tightly to your face, she tells me – more tightly than your BiPAP mask at home. As you’re drifting into or out of consciousness, you might feel disoriented and try to rip it off. And that would bring the whole procedure screeching to a halt.

Nasal C-PAP or BiPAP mask

Moments later, Dr. Aaron shows up, looking concerned. He’s evidently been talking to the other two. He tells me he strongly recommends against the BiPAP machine. The risks are just too great. He’s done hundreds of colonoscopies, many of them on people with sleep apnea, and he’s never had that kind of problem. The procedure is brief, the anesthesia is light, and it will all be over before I’m likely to have any breathing difficulties.

With that, I give up. I’ve run up against an all-too-typical problem of hyper-specialized American medicine: dueling doctors, with the patient caught in the middle. The right hand doesn’t know what the left hand is doing. How do I decide?

Well, at this point it’s is two docs against one – and the chances of tracking down Dr. De La Luz for a confab, at this early hour, are probably nil. Yes, I’m scared to repeat my previous, waking-on-the-operating-table experience. But, I sure don’t want to repeat the colonoscopy prep at some later date, either.

Just forget the BiPAP, I tell them. Let’s go ahead without it. With the procedure being so short, I think I can probably get through it.

It all turns out OK. I do open my eyes at one point, and twist around to look at the monitor. There, I catch a glimpse of a cavernous-looking orange tunnel that is my large intestine – but, I feel no discomfort. Moments later, I hear a voice telling me to settle down, and I close my eyes and go back to sleep (I expect Dr. B may have given me another squirt of sleepy juice, through my IV line).

Later, back in the recovery area, Dr. Aaron stops by to tell me things looked pretty good in the ol’ intestines. He did excise a couple of “innocent-looking little polyps” and is sending them off for a precautionary biopsy, but he doesn’t think they’re likely to be cancerous.

I’m relieved by the results, but a little rattled at how the medical bureaucracy foiled my best efforts to try to head off a very real problem, one I’d experienced twice before. I’m really not trying to second-guess the doctors. I just want to be sure the doctors do talk to one another. Is it too much to expect that the right hand will know what the left hand is doing?

June 16, 2007 - Labyrinth

I arise today at Presbyterian Camp Johnsonburg, where I’ve spent the night. It’s our church’s Family Retreat weekend. I like to attend at least a portion of this event each year, before heading back home to finish my sermon and conduct Sunday worship services.

Most retreat participants are families with young children. It’s a nice opportunity for them to get away and spend time together and with other families. Because Robin, our associate pastor, advises the planning committee, I have little to do, other than be here and enjoy the kids and their parents at play. It’s a refreshing change.

This morning, between the fishing and rowing on the lake and the noontime barbecue, I take a stroll over to the camp’s labyrinth – a walking-path in a sort of spiral pattern, whose boundaries are laid out with smooth stones. The camp staff put it in a few years ago, at the height of the labyrinth craze, as Christians were rediscovering this medieval devotional practice.

Most modern labyrinths are modeled after the famous one in Chartres Cathedral, in France. The idea is to spiral your way slowly into the center, then turn around and make your way back out again. Nothing could be more simple – or, more weighty with non-verbal meaning.

Johnsonburg’s labyrinth is pretty rustic, which is part of its appeal. It’s overdue for a little spring cleaning, but I don’t mind. Bright green seedlings poke their heads up amidst the stones, and the walkways are dusted with the crumbling detritus of last fall’s leaves.

From walking other labyrinths in times past, I’ve learned the best thing to do is to simply empty my mind and see what happens. This one has a rude wooden cross set up on a cairn of stones in the middle. When I reach it, I stand there and contemplate the cross for a moment, then realize I was probably meant to carry a stone in with me and place it on the pile. No matter. I see someone else’s stone lying on the ground nearby, evidently toppled from the top of the cairn. I pick it up and drop it onto the pile. Recycling is a good thing.

As I make my way out again, it occurs to me that this labyrinth-walk has some parallels to a human life. The first part of our lives is spent on a Godward journey, a spiritual quest. At one point or another – typically, closer to the end of life than its beginning – most of us start to become more concerned with what we’re leaving behind, than with what we’re attaining for ourselves. This is a fundamental turning, and for Christians it can occur as we’re contemplating the cross of Jesus. In one sense, it’s the vision of the cross that allows us to complete that turning.

Not that religious people have a monopoly on this kind of thinking. It’s a common- enough experience, in any human life – part of the process of maturation. The adult developmental psychologists speak of it as a season of generativity, as we come to think more about giving back than getting (see my November 20, 2006 blog entry for more on this).

Political scientists speak of second-term Presidents becoming increasingly concerned with their “legacy” – with how future historians are going to view them. That’s just one example of the secular form of this turning, which is expressed in Christian spiritual terms as a mid-life call to repentance and renewal.

At 50, I’m already a bit past the mid-point of my life (according to the average life expectancy for American men). The cancer adds a whole new ingredient. Sprinkle some positive CT-scan results into the actuarial stew, and you’d be well-advised to set the kitchen timer to go off a little sooner. I don’t think I’m being morbid or pessimistic as I say that. It’s just the facts – and, incidentally, the reason I got turned down last fall, as I tried to buy additional life insurance. Maybe I’ll be lucky, and live well into my 80s or 90s, as I always figured I would. My cousin Andy, who’s always touting the value of “good MacKenzie genes,” will insist I’m being alarmist in even thinking this way. But the actuaries, squinting through their Coke-bottle glasses, think not.

Cancer has carried me to the center of the labyrinth, to the place of turning, a bit sooner than most people. At the moment, I’m alone in this peaceful, woodland spot – yet, if I envision the company of all my fellow travelers walking beside me, most of them look older and grayer than me.

Of course, when I look at myself in the mirror, I realize I’m a good bit grayer than I used to be. It happens. Yet, still, I don’t feel ready to make the turning.

Enough of this. Back to the children.

June 13, 2007 - Cap and Gown

This evening, Ania graduates from Point Pleasant Beach High School. Despite a questionable weather forecast, the school administration decides to proceed with the plan to hold the ceremony outdoors, on the school's football field. It's an unseasonably chilly night, with ominous gray clouds threatening a damp conclusion to the festivities – which does, in fact, happen, halfway through the reading of the graduates' names, as a misty rain begins to fall.

Not many spectators get up and leave, though. This is a small high school, in a small town. There are only about a hundred graduates, and most of these kids have been together through four years, if not longer. In a community like this, folks stay and wait for other folks' kids to have their moment of glory, even if it means a little rain in the face.

In his address, Robert, the salutatorian, mentions something about nursery-school classes at The Learning Center (a little preschool run by the Central United Methodist Church). My memory flashes back to four-year-old versions of Ania and Robert, as well as Kevin, the valedictorian, shyly arriving for preschool classes. In a town like this, at a moment like this, there's a precious continuity to celebrate – one that's not so common in other, more mobile, parts of our society.

As I look across the field at our little girl, now a soon-to-be college woman, sitting there in her white cap and gown, I marvel at how quickly the years have flown. I feel glad we haven't pursued opportunities we've had, over those years, to move to another church. Roots and wings – that's what they say parents are supposed to give their children. Well, wing-spreading time is coming soon enough for this lovely young woman, as she heads off to Chapman University, in Orange, California, in a couple of months. Tonight, though, is an unabashed celebration of roots.

For me, this milestone celebration is something to hold onto, in an uncertain time. Not knowing how the biopsy's going to turn out, it's hard for me to plan the next few months, let alone the upcoming years. Will I, in fact, be able to fly out with Claire and Ania to California in mid-August, for Chapman's "family orientation," as we've planned – or will I have to give it a bye, because I'll be receiving some form of treatment? Cancer's slow-motion diagnostic process plays havoc with any sort of planning.

Tonight, I push these thoughts out of my mind. Yes, I'll cheerfully look back over all the wonderful years Ania's had in the Point Beach schools. Claire and I have managed to give that to her, and that's something to be proud of. Tonight is a night of certainties: a diploma earned, post-ceremony photos to snap, damp hugs from classmates. Tomorrow is, as always, a cipher. Joy may be harvested only from today.

June 7, 2007 - Whack-a-Mole

How long have I had this cancer, anyway?

That’s a question that’s been on my mind, lately – not only as I’ve thought back to my initial diagnosis, but especially now, in this awkward, transitional time of wondering whether or not I’m having a recurrence.

Dr. Vance Esler, a hematologist-oncologist from Texas, has a helpful perspective on this question in the June 5 edition of his blog. Dr. Esler points out, in vivid terms, just how many malignant cells – and just how much time – is typically involved in a burgeoning case of cancer.

Cancer cells multiply exponentially. Cancer begins with just one malignant cell, then that one splits, then both of those split – and on and on, until there are tens of thousands, then millions and, eventually, billions. It’s not until those mutating cells hit astronomically high numbers that they surface on our most sophisticated cancer-screening tests.

In Dr. Esler’s words,

“Advancing technology is helping us to detect smaller and smaller cancers, but as a general rule, the smallest mass that we can currently detect within internal organs is about 1 cubic centimeter (.06 cubic inches) – about the size of a small marble. This equates to about 1 gram of tissue, or .04 ounces!

This is a little tumor – small enough that a woman could easily miss feeling it in her breast (for example), but large enough to probably be detectable by a mammogram. Everyone feels good when we detect cancers this small – until you realize that a tumor this size consists of approximately 1 billion cancer cells!”

How do all those cancer cells accumulate? They do it by doubling, as each cancer cell splits, creating two new cells. To get to that small-marble size, Dr. Esler estimates, a tumor may well have gone through 30 doublings: a process that – depending on the type of cancer – could take 5 years or more. With some cancers, the oncologist’s response is “Come right in for surgery.” Other times, it’s “Let’s try watchful waiting.”

I don’t know how long it takes lymphoma cells to grow, but if that five-year figure is at all accurate, my cancer could have taken a very long time indeed to reveal itself. When my largish abdominal tumor – between the size of a baseball and a grapefruit – first showed up on an ultrasound in the fall of 2005, it could have been growing inside me since well before the turn of the millennium.

That also means that, in May 2006, as Dr. Lerner declared there was no longer any sign of cancer on the PET scan, there could still have been renegade cancer cells hiding out in small clusters, in various parts of my body. (Or then again, maybe not – the results of my upcoming June 25 lymph-node biopsy will have something to say about that.)

“Chemotherapy,” writes Dr. Esler, “generally kills dividing cells. If most of the cells are resting, then they are not susceptible to chemotherapy agents which only attack dividing cells. So with repeated cycles, we simply hope that we will catch enough cells dividing each time to expect a reasonable kill.”

It’s like a giant game of Whack-a-Mole – that arcade game that keeps young children, especially boys, gleefully occupied for many minutes. The goal is to pound those little mechanical moles with a foam-rubber maul, as they poke their heads out of various holes. Even using the most sophisticated chemical and radiological agents, the oncologists are just hoping to pound enough of the pesky cancer critters that none of them will stick their heads up again for a while.

T.S. Eliot has a famous line about “measuring out our lives in coffee-spoons.” We go about our daily activities – thinking about tomorrow, and maybe next week or next month – but cancer has a much longer time frame. Cancer measures out its life in backhoe-buckets. We cancer survivors put so much stock in pronouncements like “one year cancer-free,” or “five years cancer-free,” but – especially in the time frame of some the slower-moving cancers – such intervals don’t mean a whole lot.

The hard truth is, lots of cancer survivors are walking around saying, “My cancer is gone,” when, on the microscopic level, it’s not. Years (or even decades) later, after the doubling process has done its work, and cancer rears its ugly head on a scan, they commiserate, saying, “My cancer came back” – when, in fact, it never left. It just went underground. “Cure” is an elusive concept, when the terrain investigators have to scour is so unimaginably vast.

In one of the Indiana Jones movies, the swashbuckling archaeologist fights his way into the inner sanctum of an ancient middle-eastern church, where a wizened old knight is guarding the Holy Grail (the cup used by Jesus at the Last Supper). This pious Crusader has survived, all those centuries, because he’s been imbibing regularly from the Grail. His time frame is no longer the same as that of ordinary mortals. He’s been wetting his whistle with tincture of eternity.

Maybe the ancient knight is a model for long-term cancer patients. He’s sort of like the old yogi who’s learned through meditation to slow down his breathing and heart rate, entering a state resembling suspended animation. In living with cancer, it’s not the quick, frenetic whack-a-mole response that makes the difference. Slow and steady wins the cancer race.

June 4, 2007 - God and Cancer

A few days ago, a blog reader named Vicky sent me a link to an article written by John Piper, who's a Baptist megachurch pastor and also a prostate cancer survivor. It's called "Don't Waste Your Cancer."

With a title like that, how could I resist reading it? The article's got ten points, each one beginning with "You will waste your cancer if..."

Most of Dr. Piper's points I agree with:

"You will waste your cancer if you seek comfort from your odds rather than from God" (I've never been a gambling man, anyway).

"You will waste your cancer if you refuse to think about death" (No problem there – I was a philosophy major).

"You will waste your cancer if you think that ‘beating' cancer means staying alive rather than cherishing Christ." (I'm already on record as opposing violent imagery – "winning courageous battles against cancer," and similar expressions – when it comes to dealing with this disease. It may work for others; it just doesn't work for me. And, of course I believe eternal life in Christ is more important than mortal life on our own – that's a no-brainer).

"You will waste your cancer if you spend too much time reading about cancer and not enough time reading about God." (This point's pretty much a repeat of the preceding one.)

"You will waste your cancer if you let it drive you into solitude instead of deepen your relationships with manifest affection." (Bravo, Dr. Piper, on this one! I tried going it alone, during those long months of diagnosis, when I didn't share my worries with anyone else, except Claire. It didn't work very well. The support of a community is critical.)

"You will waste your cancer if you grieve as those who have no hope." (Hope is what it's all about – but, that's a no-brainer, too. Even Lance Armstrong and others like him, who come at cancer with a purely secular approach, aren't afraid to talk about hope. Lose hope on this grim and arduous journey, and you've got little else left except grieving.)

"You will waste your cancer if you fail to use it as a means of witness to the truth and glory of Christ." (How could I argue with that? I hope my life – at least, in its better moments – is all about witnessing to Christ. I hope and pray this blog has been about that, as well, for at least some of my readers.)

In case you're counting, that's seven points. Much as I'm able to affirm the foregoing, Dr. Piper's three remaining points make me gag. They are:

"You will waste your cancer if you do not believe it is designed for you by God."

OK, I'm a Presbyterian. I believe that predestination is a viable concept to use in describing a God who is sovereign, all-knowing and all-powerful. But even I respond with revulsion at this glib assertion that God went into my DNA blueprint before birth, erasing a chromosome here, adding one there, all to create a genetic time bomb that would go off when I turned 49.

Does Dr. Piper actually believe his prostate cancer was custom-designed for him by God – that God went down the rows of souls waiting to be born, and said of the one who would be baptized "John Piper," "this one gets a rotten prostate, it will make him a better person"?

Here's what Dr. Piper says, explaining his rather provocative statement (which is number one on his list of ten):

"It will not do to say that God only uses our cancer but does not design it. What God permits, he permits for a reason. And that reason is his design. If God foresees molecular developments becoming cancer, he can stop it or not. If he does not, he has a purpose. Since he is infinitely wise, it is right to call this purpose a design."

Well, the people who flew airplanes into the World Trade Center had a design, too. They imagined, in the fried moral circuits of their terrorist brains, that the evil they were doing was justified because it would yield a greater good: the humbling of the United States of America – a nation they had demonized, in those same fried brain-circuits, as the nexus of all human evil. I'm sorry, but Dr. Piper's image of God does not differ substantially, as I see it, from that of a terrorist.

Did God fail to prevent my cancer, as well as Dr. Piper's? Of course. Yet, to me, that's a far cry from saying God actively designed our respective cases of cancer, smiting us with custom-made strands of defective DNA.

The question of why God permits human suffering is among the toughest of all theological dilemmas. I tend to come down on the side of God's having withdrawn from active manipulation of human events, in order to allow space for a greater good to flourish: human freedom. There are a whole lot of ancillary consequences to that withdrawal, one of which is cancer. But, did God specifically design this or that particular consequence, for my life or Dr. Piper's? I don't think so. I don't think "design" is a meaningful word to use, in such an instance.

A little analogy may be in order. Fans of the various Star Trek television series and movies are familiar with a standing order called “The Prime Directive” that starship crews must follow, when visiting planets more primitive than their own. Basically, the Prime Directive boils down to “hands off.” Crew members who beam down to the planet must avoid doing anything – like leaving an advanced space gadget behind – that would interfere with that culture’s normal process of development. God has voluntarily adopted a sort of Prime Directive when it comes to human illness, and other forms of suffering. It’s not that God can’t intervene. It’s that God generally won’t, because to do so on a regular basis would undermine human freedom.

I do believe God sees, and knows about, my cancer. Yet, God also knows that, in order to preserve the greater gift of free will, God must lay aside the marionette-strings and let the human experiment spin itself out, in all its beauty and agony. One day, we are promised a place where "mourning and crying and pain will be no more, for the first things have passed away" (Revelation 21.4). But, sadly, not today.

Dr. Piper's point #2 is, "You will waste your cancer if you believe it is a curse and not a gift."

My objection to this one lies in the false dichotomy Dr. Piper sets up, between a curse and a gift. I think my cancer is both. I would never describe it as anything other than a curse – yet, I would also say that the experience of having cancer has been a surprising gift, in many ways. It's led me to new sources of strength, opened up new relationships, forced me to think more about others, centered my mind on higher things.

I would agree with Dr. Piper if he were saying, "cancer is not only a curse, it can also be a gift." But, set it up as an either-or, and I have to cry foul.

The final point where I differ from Dr. Piper is #9: "You will waste your cancer if you treat sin as casually as before."

Here's his further explanation:

"Are your besetting sins as attractive as they were before you had cancer? If so you are wasting your cancer. Cancer is designed to destroy the appetite for sin. Pride, greed, lust, hatred, unforgiveness, impatience, laziness, procrastination – all these are the adversaries that cancer is meant to attack. Don't just think of battling against cancer. Also think of battling with cancer. All these things are worse enemies than cancer. Don't waste the power of cancer to crush these foes."

Oh, pull-eeeze! Do you actually expect me to swallow the line that cancer is just another means God uses to smite sinners? If that's true, then what does it imply for those who don't have cancer – that God doesn't think they're as bad sinners as the people who do have it? Or – stranger still – maybe God doesn't care about those people enough, not to have supplied them with their own, custom-designed bitter pill that's necessary for full spiritual health?

In the course of my pastoral ministry, I've encountered way too many sick people who are laboring under the misapprehension that their illness is a form of divine chastisement visited upon them by God. I try to free them of that particular monkey-on-the-back. I won't deny that some illnesses have a psychosomatic element, through which, say, unresolved guilt or suppressed anger can manifest itself as physical illness. Such illnesses can, indeed, be seen as a result of human sin – but they're a causal outcome that grows out of the sin itself, not a divine punishment imposed from above.

I don't think cancer is God's design for any person. It just is. Or, perhaps it's more accurate to say it just isn't. What do I mean by that? Genesis 1:2 says the earth, before creation, was "a formless void and darkness covered the face of the deep." When God spoke into the void, creating the universe, the forces of chaos were pushed back, but not obliterated. Some of that formlessness and void is still hanging around, just beyond creation's ragged edge, causing havoc. Cancer's part of that. Faith teaches that its days are numbered, but in these between-times, we are forced to deal with it.

That's what I'm thinking these days, anyway, about God and cancer. I'm just not on the same page as Dr. Piper, when it comes to the relationship between physical illness and sin, and when it comes to God's role in handing out the cancer genes to particular individuals.

As for the rest, it's all good.

June 2, 2007 - Fear of Failing

There are few things more refreshing than waking up out of a nightmare.

That's what happens to me, early this morning. I open my eyes, and consciously push back a tortuous chain of thoughts that have been plaguing me for what seems like hours (although I know most dreams are actually of brief duration). I feel like a wreck, physically, but I resist going back to sleep, for fear I'll find myself cocooned in the dream-web again.

Here are the details: Claire and I are leading some kind of international tour (we've done that once before, a bus trip around the Scottish highlands and islands). For whatever reason, everyone's traveling separately. The plan is for all of us to meet up at some rendezvous-point in Britain, for a trip to India. Claire and I are traveling though some country that's a conglomeration of Scotland and Ireland. The airline has checked our luggage through to our final destination, but in order to accomplish the transfer, we've got to do a good deal of walking along country roads n this Celtic country, from one airport to another.

We're walking along one of these rustic roads, when suddenly it occurs to me that I've forgotten to pack any clothing in my suitcase. I realize, to my horror, that, for the next couple of weeks, I'll be limited to what I've got on my back – and I know that, traveling through a land as foreign as India, on a tight timetable, there will be neither time nor place for shopping for the kind of items I'll need.

Calculating the remaining time before our next flight, I realize that, if I rent a car, I have just enough time to drive back to the airport, fly back home, rent another car, drive back to finish my packing, then return. It seems to be the only solution to the problem: but, if it's to work, I've got to turn around and go back immediately. (Our itinerary evidently includes the granddaddy of all airline layovers, but who says dreams make any logical sense?)

Claire and I agree this is the only thing to do, and so we ask someone to help us find a car-rental place. Helpfully, he takes us back to his home, and lays out on the dining-room table a whole collection of travel brochures, telling us there's rental-car information in there somewhere. Aware that our layover time is growing ever shorter, we start riffling through these, trying to find the phone number of a car-rental place. We have no success – and, our helpful host seems to have disappeared. The more time slips by, the more my feeling of panic grows. Maybe we should just forget about extra clothing, I think: I'll just wear what I've got on, no matter how unpleasant that will become in time – for my traveling companions as well as myself. No, I can't do that. Quick, look through those brochures again! There's got to be a phone number in there somewhere...

It's then that, in a semi-conscious decision, I push back the suffocating blanket that is my nightmare, and start repeating to myself the healing mantra, "It's only a dream."

Someone skilled in dream interpretation would have a field day with this one. Even an amateur like me can identify the feeling of isolation, of being a stranger in a strange land. That's cancer, for sure.

Then, there's anxiety about professional competence. Advertising myself as a tour-group leader, then forgetting to pack my own bag, is the height of incompetence (although, to be fair, who knows how to pack for the journey of cancer?).

The tour group – offstage in the dream, and unable to witness my momentary panic – is surely my church.

The fear of body odor, from living in one set of clothes for weeks, could have something to do with the physical symptoms of illness, or even – to be perfectly blunt – the stench of death.

As for the rental car, there's a prosaic explanation for that. I had to rent a car yesterday, a temporary-replacement vehicle provided by the insurance company while my son's car is being repaired in a body shop. I felt frustrated that, for various reasons related to fine print in insurance-company and rental-car contracts, I couldn't avoid paying $20 a day out of pocket, for collision insurance on the rental – even though I can usually avoid the surcharge in other circumstances.

Running through the dream, like a rhythmic scratch on an old, vinyl record album, is the steadily-escalating pressure of time – something I'm very aware of in my life, on the micro-level, as my surgery date looms larger, and also on the macro-level, as I'm dully aware of the possibility that my life could be shorter than most.

Finally, there's the aspect that I'm not entirely alone on this journey. Claire's along for the ride, but she doesn't share my problem, personally (her suitcase, evidently, contains everything she needs, although she's sympathetic).

The most significant aspect – and, perhaps, the real lesson imbedded in the dream's surreal landscape – is that my illness isn't my fault. Much as I'm beating myself up, in the nightmare, for forgetting to pack clothing for the trip, there's nothing I could have done to prevent my cancer. Just keep saying to yourself, It's only a dream, (it's not your fault)... It's only a dream (it's not your fault)...

I'm glad it's only a dream. But, then again, in the usual fashion of dream-logic, it's remarkably true to life – at least, to the way I'm living my life right now, in this surreal, extended layover between medical tests.