Chapter 3 of Hell Week: Climactic Cromulence(1)

It has been quite a week-- a transcendentally turbulent trifecta of truculent tulgeyness!(2) 

In Chapter 1, I had a transient episode of damnable diplopia.(3)  In Chapter 2, I had a fearfully fetid fever.  But Chapter 3 is horrendously hirsute.  (It's getting really hairy now and it's threatening to get hairier, and I don't just mean the way I can't go out to get a haircut).

To increase the suspense, I will start by resolving (mostly) the cliffhangers of Chapter 1 and Chapter 2.

In Chapter 1, as you may remember, I had double vision, but I wasn't sure why.  I took bets as to the cause.  It couldn't be retinal detachment because it got better.  It's not eyedrop, because it got better so fast; I had something similar in 2005 and it took months to resolve.  I ruled out migraine, because it was nothing like any migraine I have ever had.  There was no ministroke (or maxistroke) on the MRI.  That leaves TIA, aliens, and, well, you'll have to read on for a couple more paragraphs - hang in there!

In Chapter 2, despite my negative COVID-19 test, I was not sure I should leave isolation, because sometimes the test is wrong.  But by Wednesday, my doctor agreed that it was not COVID-19 and gave me the OK to end the self-imposed isolation. 

What it turned out to be was a particularly nasty case of facial cellulitis.  I hadn't had a fever like that since 2005 when I was on chemo--such a lovely little trip down memory lane.  Luckily, the cellulitis has responded quickly to antibiotics.  So I feel better, and I am free to hide from society just like everyone else.  Hooray.  Yippee.  Rah, rah, rah.  Nasty infection in what's left of my right cheek.  Just super. 

And now, the climax that you've all been waiting for:  It's the star of the show, the little (not really little) tumor that could, Bartleby the Tumor!  Yes, the MRI showed that Bartleby grew.  He just grew "a little bit."  But "your head cancer grew a little bit" is like saying, "I'm just going to put this needle in your eye a little bit."

Where has Bartleby grown?  Bartleby has popped back up a little bit where they scraped him out from behind my nose.  But, most suspiciously, Bartleby has filled up my right Meckel's Cave.(4)  Meckel's Cave is a little pouch of connective tissue, and a superhighway of nerves runs through it.  Next to Meckel's Cave runs the 6th cranial nerve, aka, the abducens nerve.  That nerve signals my right abducens muscle to rotate my eye to the right.  Although Bartleby is not touching that nerve, Dr. Manhattan says that he might have caused temporary inflammation that irritated the nerve, thus messing up my eye rotation and giving me double vision.

That brings us back to the really important stuff--the betting pool for what caused my double-vision. The answer is: we still don't know!  There is a three way tie between remaining options -- aliens versus transient ischemic attack versus tumor.  I would hold a trial by combat to determine which participants should win the monopoly money, but with the physical distancing and all, that seems impractical.  And to the retinal detachers, ministrokers, migrainers, and eyedroppers, sorry you lost, but I'm sure you'll get a chance to play again sometime!

Look, folks, this is not even the beginning of the end. This is still a possibility that Bartleby could start shrinking on pembro, which is why Dr. Manhattan went ahead with my infusion on Friday and is recommending we give it 1 more cycle after that and then get another MRI.  And if it hasn't started shrinking by then, we'll start looking hard at clinical trials.

Not even close to giving up here. 

Still, let's face it: this was a very cromulent week. 

(1) Shamelessly lifted from the February 18, 1996 episode of The Simpsons.  According to the Merriam-Webster Dictionary, the definition of cromulent is, "a truly cromulent word."  I kid you not.

(2) Also shamelessly lifted, this time from Alice in Wonderland.  It is from the "tulgey wood" in the poem Jabberwocky.   It is a dark, forbidding place, home of the Jabberwocky, the Bandersnatch, and the Jubjub Bird. https://aliceinwonderland.fandom.com/wiki/Tulgey_Wood 

(3) Diplopia means double-vision in Doctorese.

(4) You would think Meckel's cave is just where Meckel keeps his treasure.  Disabuse yourself of that fanciful notion.

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"Hey, Meckel, you in there?"

Tumoriffic Tom’s Trip to the Emergency room, A Little Golden Book

First, an update on the betting pool.

By yesterday, the double vision had gone away (except for the double vision that I always have when I look far up, down, and to the right.)  That eliminates tumor (good news!), eye-drop, and retinal detachment (proposed by my old friend Trevor).  These are unlikely because of the quick recovery.

That leaves migraine, transient ischemic accident (TIA), ministroke, and aliens (as pointed out by my cousin Camilla).  My instinct is not a migraine.  That's not what my migraines are like.  If there is no stroke on MRI (currently scheduled to happen tomorrow), that leaves TIA and aliens.   That can never be completely settled, so in that case, the winners would have to split their winnings.

4/14/20

Meanwhile, everybody who knows me knows how much I always go along with the crowd.  Like a sheep, I joined the pandemic.  (Possibly.  But also possibly not.)

Today, I started getting cold.  My basement office was 74 degrees, and I still was chilly in two sweaters.  I took my temperature at 6 pm: 100.7. (1)

Oh, crap.  Just what I need.

I spoke to employee health at my home hospital, and they wanted to test me for COVID-19.(2)  The plan was that tomorrow (Tuesday) morning, I would get in line of cars at the hospital and have a swab shoved so far up my nose that it feels like it's tickling my brain.  Turns out, I don't find that so bad.  A lot of the nerves back there are dead, and Hygeae shoves a whole bunch of equipment back there every 6 weeks to pick away the gunk so I don't get infected.(3)  There's a silver lining to every cloud.

Then K-BWE and I got ready to put me in self-isolation.  I would only use the master bedroom, the master bath, and the study.  Willow would be the only one to cuddle with me, and she had to wear a mask.  I was was not looking forward to 2 weeks of this.  However, I went willingly into my isolation cell.(4)

But by 9:00 pm, I felt very cold, and I took my temperature.  It was 102.7.  Yikes.

K-BWE called my infectious disease doc and told on me.  The doc immediately told me that if I didn't go straight to the Emergency Department at Man's Best Hospital, she would be very mad at me.  It's not fair.  Just because I have a giant tumor behind my face and next to my brain; just because the area behind my nose is like a cheap, overcooked hamburger filled with dead bone from radiation and surgeries; just because I have a fever in the middle of a pandemic, I had to go to the emergency department.  Not only is the infectious disease doc worried about COVID-19, she is also worried that it could be a bacterial infection.  Not fair!

K-BWE insisted that I listen to medical advice.  So she helped me pack up a few things, just in case they make me stay, and drove me to Man's Best Hospital's ER.  And now here I am, all by my lonesome. 

I actually feel better than I have felt all day.  My temperature is 99.1.  If I'd just stayed home, I would be asleep in my bed right now.  Sure, K-BWE wouldn't be there, but Willow would keep me warm.  Trying to sleep in an ER is such a bummer.

4/15/20

That was from the ER last night.  Now I am writing from home. 

In the ER, they got bored with me fast after my fever went down.  Aside from the fever and mild headache, there was nothing to see.  I haven't had a sense of smell since 2005, so that didn't matter.  I wasn't coughing up a lung, I didn't feel short of breath, I didn't have chest pain, I didn't have belly pain, I didn't have diarrhea,  I didn't have body aches or anything else that screamed COVID-19.  There were lots of more interesting (sicker) patients. 

The really irritating thing last night was that they kept taking away my urinal every time I filled it up.  They were running fluids into me, for crying out loud!  I would wake up ready to burst, and I would hit the nurse button.  They would finally show up, and by that point I would practically be crying, begging for a urinal before I wet the whole gurney.

In the morning, they told me to go home and to stay in the house for 3 days.  My chest x-ray was negative, and I felt better.  So K-BWE came back to take me home.

Then in the afternoon, my COVID-19 test came back negative, which is nice, but not the end of the story. 

A negative COVID-19 test does not guarantee you don't have COVID-19.  This is a very new virus, and we don't have ways to reliably test for it.  A positive test gives us more information, but since it's an imperfect test, the safest thing is to assume you have COVID-19 anyway and isolate yourself.

So I'm back in home isolation.  I am staying inside my own little part of the house for the at least a week (except for my MRI tomorrow).  K-BWE has erected a brick wall and a locked steel door.   

(1) The standard definition of a significant fever is a temperature of 100.4 or higher.

(2) I am a little skeptical of the COVID-19 test.   It may be only about 70% sensitive, depending on which imperfect studies we should believe.  70% sensitivity would mean that if you test 10 people who actually have the disease (as verified by repeat testing and PCR), 3 of them will test negative.  So if I as your doctor (no, I am not YOUR doctor! unless one of my actual patients is reading this) send you back to work based on your COVID-19 test instead of your symptoms, there is an unacceptably high probability that you actually have it and will spread it to your co-workers.

Honestly, I just don't think the test is worth much for individuals.  For the broader population, sure, especially since if you do a lot of tests on healthy people, you can estimate how many people are wandering around and infecting other without be very sick or even sick at all.  (There's a nightmare for you.)

(3) Back in the '70s, there was as very famous porn film called Deep Throat (the title was used as the pseudonym of the guy who leaked the Watergate Tapes).  Perhaps there will be a sequel called Deep Nose.  I want nothing to do with it, thank you.  I don't even want the royalties from the name.

(4) I am very privileged in that I live in a house where I can have a bedroom and a bathroom to myself.  Some of my patients are not so lucky.  People who can't afford a big enough place cannot protect their families this way.  This one of the many reasons why the effects of this virus are much worse lower down the economic ladder.(5)  I will be in here for the next two weeks, but there are worse things in life.  

(5) Other factors include:

a) less access to healthcare.  Insurance companies have to pay for COVID-19 testing.  They might not cover the visit to the ER or the hospitalization that might follow.

b) inability to take time off from work.  The COVID-19 stimulus bill requires that employers give their employees two weeks of paid sick leave for COVID-19.  However, there is an exemption for employers that have more than 500 employees (because they can afford to buy Congress).  Resting is an important part of healing.  Even though my employer has more than 500 employees, they are unlikely to lay off a doctor.  Not so for others.  For them, it's 'your job or your life.'

c) fear of job loss.  Employers are laying off lower level workers who have COVID-19.

d) chronic diseases.  The less money you have, the more you are likely to have asthma, heart disease, diabetes, and other problems.

e) their hospitals are more crowded and also lower quality.

f) they are more likely to be black.  For unclear reasons, independent of all other factors, black people are more likely to die of COVID-19.

g), h), i), j), yadda, yadda, yadda.

(Sorry to go all serious on you, but this stuff is important to know.)

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Here, I am properly wearing a surgical mask in the Emergency Department.  For the mask to help, you have to cover the nose.  Put the mask on with the little metal strip on bridge of your nose.  Then, bend it down so that it hugs your nose and cheeks.  Next, pull down the mask to cover your chin.  Easy!

Taking Bets

Hello, Tumor fans!

Weird day in a weird time.

K-BWE and I planned to go on a walk with Willow late this afternoon.  I was driving us all to the park when I noticed I was seeing double when I look up, down, or to the right.  It turns out that it is really annoying to see double when one is driving.  It was a very short drive, and I was OK if I closed one eye, so I got us to our destination.  Then I handed K-BWE my car keys.(1)

So, like I said, weird, and a bit distressing. But on the bright side, if I look a certain way, I have two dogs now, and I have always wanted to have two dogs!

Anyway, I've decided to start a pathology betting pool.  For the next 24 hours, I will be taking bets on the cause of my sudden double vision.(2)  Please place these bets as comments within the webpage instead of e-mail, Facebook, or Twitter comments.

Is my double vision from:

A) A ministroke? 

This is a pretty good bet.  I have had lots of ministrokes, and I have never even noticed them before.

B) A transient ischemic attack (TIA)?(3)?

Like in most strokes, with a TIA, there is blockage of an artery but it goes away, sometimes as much as 24 hours later (which is why I am only taking bets for the next 24 hours).  Only time can tell.

C) A migraine?

Migraines can mimic strokes.  I do get migraines occasionally, and I do have a litte headache.  (I get headaches all the time because the tumor has infiltrated the muscles in the right side of my jaw, so it doesn't necessarilty mean anything.)

D) The tumor?
The tumor could be on the move and attacking my eye muscles or the nerves for them.  That's kind of grim.

E) Eyedrop?
Since the giant blast of radiation I got in 2005, the right side of my face has been slowly turning to goo, and my right eye has been gradually dropping downward.  Kathleen noticed that it seemed to have dropped a little further lately, and that can give me double vision if it happens too fast.

I will be taking bets until 6 o'clock, April 12, 2020.  But please note that I will accept only monopoly money as currency.

Anyway, I don't love this turn of events, but I refuse to freak out.  Even if we were not living through the zombie apocolypse, I would not go to the ER for this.  Strokes and TIAs are boring, and I am already taking aspirin to prevent them.  If I were taking anticoagulants like warfarin (aka Coumadin), I would bleed to death through my nose, so there's nothing to do about that.(4)

If it's a migraine, it'll get better.  If it's the tumor, we'll deal with it later, and, if it's eyedrop, well, whatever.  One gets kind of jaded after a while.

I'll let you know what my doctors think when I finally get around to telling them. (Doctors make the WORST patients.)

Finally, I am announcing my new product for the prevention of COVID-19 infection!

By mixing the essences of beans, onions, garlic, brussel sprouts, and cabbage and distilling them down to pill form, I have developed a special way to prevent infection with COVID-19.  It creates a special "forcefield" that means that no one ever gets within 6 feet of me!  Instant physical distancing. I call it Flatulessence.  Look for it in stores soon.

Be safe. Wash your hands.  Stay home if you can.  

Tom

(1) We took a brief walk because Willow decided to be a brat and run off into the woods for 10 minutes at a time, so we had to leash her.  That and the double vision thing really made is less fun than I had expected, so we went home early.

This is the second time our canine brat has done something like that in that particular park, and we're not going back until I train her to come back more quickly.

(2) Anyone know the going rate for bookies?  I don't want to charge an exorbitant cut, but it seems wrong to do this for free.

(3) The medical TIA is different from the government's top secret TIA, the Temporarily Ischemic Agency.

(4) Patients often call warfarin and other clot-preventin drugs 'blood thinners.'  Technically, they do not thin the blood.  The blood flows just as it always does, but the drugs will prevent the blood from forming clots (which are like scabs) where it shouldn't.

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This is the mask I wear when I go out!

Tumor in the Time of COVID-19

(I don't have it.  Don't worry.)

Hello, tumor fans!

K-BWE has been urging me to write an update.  Honestly, my health problems are nothing compared to the whole world's right now, but here's a little cancer news to cheer you up.

I don't know about you, but every time I step out the door, even to sniff the breeze, every time anyone in the house even touches the door, I scrub my entire body with pure bleach using steel wool.  Then, I bathe in pure alcohol.  Yes, it stings, but it's a good sting--like habanero chili peppers, but on your whole body, including the wiggly parts.

Anyway, back to cancer.  When I last wrote, I had just had an MRI of my head.  The results were OK.  The tumor hadn't grown.  It didn't shrink, but beggars can't be choosers.

Since then, we have all entered the zombie apocalypse.  I wanted to keep working in my medical office, but, after the infectious disease specialist at Man's Best Hospital (MBH), my colleagues (1), and my wife ganged up on me, I gave up.  They told me that, although the exact effect of my immunotherapy on my immune system is unclear, I am at "higher risk." 

So I have started seeing my patients via telephone and sometimes video from the guest room in my basement.  I miss seeing patients in person, but I don't miss the commute, and it's certainly nice to have the dog sleeping on the guest bed an arm's length from me while I work.

Meanwhile, treatment continues apace, so I went back for more on Wednesday. 

MBH resembles a military zone.  No one who is not a patient is allowed in, so while K-BWE drove me there, she was not allowed to accompany me inside the building.(2)  I had to go through three checkpoints to get to my first appointment.  That's three strip searches and a colonoscopy!  Not really.  They just asked me for my name, date of birth, whether I had been out the country(3) or had recently French-kissed someone with COVID-19.

At the first appointment, they stuck a funky needle into the strange bump under the skin of my chest and attached a little rig so that someone could hook-up a my immunotherapy later.  Then I went to see Dr. Manhattan, my excellent and suave oncologist.  After we discussed how much I am at risk for getting COVID-19 because of my permanently messed up nasopharynx(4), we spent the rest of the visit reminiscing about our overlapping times working in labs at Wicked Famous Cancer Institute almost 30 years ago.  We knew several of the same people and worked one floor away from each other.  Small world.

About the treatment, I said this on Facebook:

"Sitting in an oncology infusion room here at Mass. General.  Service is slow!  I got the appetizer (saline) quickly enough, but it took them another half an hour to get the entree (immunotherapy). They don’t even have a liquor license!  I’m giving my nurse no tip, and this place is going to get a terrible review from me on YELP!"

After my treatment, I made my way out of the fortress MBH has become, rejoined my best wife ever(5), and she drove me home.



On a serious note, don't get too excited about 'cures' for COVID-19.  You cannot cure or prevent COVID-19 by blowing a blow dryer up your nose or any other orifice.  In fact, you will do great damage to your nose and sinuses, making them more vulnerable to it. Also, don't gargle bleach, essential oils, or anything else.  Don't go to tanning salon.  It just gives you skin cancer. 

There are scammers taking advantage of the crisis to sell fake cures.  I won't name the latter.  I don't want to advertise for them.

There are scientifically illiterate reporters jumping the gun on potential cures that have not been adequately proven to work yet.  Slow down.  There is no proven cure, and there is no vaccine.

And if you are a doctor, don't prescribe hydroxychloroquine or chloroquine to yourself or your friends and family.  It is highly unethical.  There is already a shortage because too many doctors are doing this.  People who need the drugs for diseases that the drugs are proven to treat are are not getting them, and those people are suffering.  Even if hydroxychloroquine and chloroquine are definitively proven useful for COVID-19, they should go first to those who are very very sick.

Everyone, just stay 6 feet away from anyone outside your household.  Wash your hands or use alcohol sanitizer every time you touch anything that someone outside the household has touched, especially plastics (like grocery cart handles), or metal (like doorknobs).  You can go outside, and you should.  Walk, run, enjoy the spring, but take care of yourself.

Everyone be safe.

--Tom

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(1) The Chief of my practice (I will not call him Dear Leader, though I was tempted just now.  He's a very nice man.  I will just call him Chief.) also pointed out that the inside of my face resembles a bomb crater, and is probably like a giant vacuum sucking up viral crunchies.

(2) K-BWE, who is a superhero, was on the phone fighting for justice from the car in the parking garage while I was in treatment.

(3) At every checkpoint, I told them that I had just gotten back from a lovely trip to Wuhan, China, and that it's really cheap to stay there right now.  For some reason, they didn't believe me. 

(4) She said, "Tom, the inside of your face resembles a bombed out sewage plant overrun by a hoard of toads, snakes, cockroaches, and zombies coated in leeches.  You'll be in deep snit if you come within 10 miles of work!  Stay the truck away!"

Alright.  Enough already.  I get it.

(5) K is my best wife ever (BWE).  All of the others were too smelly.


_________________________________________________________________________________

Willow is my new office-mate.  Here she is, hard at work.

Bartleby!

The name of this tumor is....Bartleby the Tumor! Thank you for the suggestion, Karen Donaghey.  Ed McMahon will be coming to your house with your prize!(1) 

For those who don't know, Bartleby is the name of the eponymous character of Bartelby the Scrivener, a short story by Herman Melville.  Bartleby is an enormous white leviathan. . .  No.  That's a different Melville work: Bartleby the Whale. 

Anyway, Bartleby (the human, not the whale) is a strange young man hired by the narrator of the story.  At some point, he starts responding to work requests with "I would prefer not to."  He gets more and more passive and intransigent.  When he is fired and asked to leave, he responds, "I prefer not to," and will not leave.  Eventually, Bartleby stops doing anything at all and dies. 

Bartleby the Tumor is descended from one of my own cells.  I hired him to do what my other cells in the area did (mostly produce snot).  Then (after radiation treatments), when I asked him to produce snot, he said, in the squeaky little voice that tumors have, "I prefer not to," and just sat there growing.  Now that I am getting immunotherapy, if all goes well, he will slowly die.

Last week, after the third of my every-three-weeks infusions, I got an MRI of my head.  There was Bartleby.  And like that other Bartleby, he has stopped doing anything (i.e. stopped growing). 

This is actually pretty good news.  Sometimes, when it works, all that pembro does is freeze the tumor in place.  I can live with that, maybe indefinitely.  And it might even shrink. 

We'll have to wait another couple of months to find out, but I am hoping that Bartleby the Tumor, like Bartleby the Scrivner, will eventually fade away.

In the meantime, I'm seeing patients, walking my dog, hanging with my family, and feeling OK.

(Apropos of nothing, do you have a favorite microbe name?  Mine is Malessezia furfur.  It causes a harmless rash, but the name sounds like the evil twin of Winnie the Pooh.)

(1) Actually, I am pretty sure Ed McMahon is dead (not bothering to Google), so that's a very creepy image.

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"Are you finished writing, Dad?  Can we please go for a walk now?

-->

And, We're Off!

Quick announcement: 

I am back at work.  Make an appointment if you need it.

Second quick announcement:
(You may not be ready for this, and it may shock you.  Really, you might want to sit down.  Ready?)

You have more than one sphincter.  Yes, you.  In fact, you have many sphincters.  ALL OF YOU!  Ponder that!(1)

OK, no more announcements. Back to the story!

About a week ago, I got a port.  Port is a fortified wine that originates in Portugal.(2)  I am drinking some right now.  I find port delicious. 

However, the kind of port I've got in my chest is used to deliver chemotherapy.  My new port is more formally known as a portacath.(3)   It is a thin, hollow tube (about 6" long) that goes into a major vein of your body attached to a small disk (about three quarters of an inch wide) that is surgically implanted just underneath the skin of the chest.  A special needle can be inserted through that skin fairly painlessly, allowing easy access to the vein for medicine or for blood draws.  It's a lot nicer than getting a needle stuck in the arm every few weeks or having a tube hanging from the side of my arm all the time.

So, a week ago, in the same way they stabbed in the groin and inserted an arterial catheter into my artery in November, Dr. Abe Porta, Jr. stabbed me in the chest and inserted the portacath.  Then, he left it in and sewed up the wound, leaving a little disk under the skin of my chest that is attached to the catheter in my vein. (4)  

After we got home from the port procedure, in the last 45 minutes of December daylight, I took Willow to the woods up the hill, and she hopped her heart out while I took a little hike in the snow.  Then while K/BWE had her usual Wednesday night 'girls' night' with her friends, the Professor and I went out to our favorite restaurant with HB and his son for dinner.

That was last Wednesday.  My first pembrolizumab infusion was last Thursday.

My first appointment at Man's Best Hospital was at 11:30am.  K/BWE drove me into Beantown.  We hit traffic, so she had to drop me off and go park while I rushed to the seventh floor.  I was called in, a medical assistant took my vitals, and a nurse inserted the special needle in the special place (my port).  She drew some blood and left the needle device in the port with a tube attached so I could be hooked up to an IV.  I went back out, and K/BWE was in the waiting room. 

Almost before I sat down, I was called back in to see Dr. Manhattan.  This time, her pants were not leather, but, as before, she had a warm, reassuring manner.

I asked her about work.  I had already been back for a few days, but could I expect to be there for my patients long term?  "Is it fair for me to let my patients book appointments with me for a year from now?"  I asked.

"Yes," she replied.  She said that, even though it's cancer, this tumor has probably been growing for years, hidden beneath inflammatory schmutz.  It is reasonable to think that I could still be here in a year from now even without treatment. 

No one had said anything like that in all this time.  I felt like a load had been lifted from my shoulders.  Then I felt angry at myself for giving up those season tickets to Wrestlemania.

As for treatment, she repeated that most people have almost no side effects at all from pembrolizumab.  Right before my third treatment cycle, about 5 weeks from now, I will get another MRI.  If the tumor is standing still, or, better yet, getting smaller, they will continue the pembrolizumab, checking with an MRI every 9 weeks.

Building on what she had said the week before, she told us that, even if pembrolizumab fails, there are vast numbers of drugs being developed for this type of tumor.  "We have more clinical trials than we have patients."

Then, K/BWE were sent upstairs to the sweetest infusion suite of all time.  The hallway on the way has a floor to ceiling window on one side, and the view is fabulous.  I got my own infusion room.  If I schedule it, I can get a massage therapist to come in during my treatment.(5) There was a lounge singer and piano at the nurses' station, and there was a bar with free drinks.  (That last sentence is entirely false.)  Half an hour after the infusion started, they unhooked my port, and home we went.(6)

I've been feeling fine, although tired sometimes.  Still working.  Still hiking with the dog.  Still enjoying my family.  (Let's not forget the cat.  Her too.)  It's not over, but there is time, and there is hope.

P.S.  I need a name for my little companion/tumor, and I am asking for suggestions!  This tumor has been here for a long time, and he will probably continue to be here for a long time even if they eventually poison him into nonexistence.  However much I wish he had never shown up, he is truly a part of me, but what shall I call him when we have our heart-to-tumor talks?  Ideas, please!

(1) I am serious.  I have been to medical school, and they taught us stuff like this.  You have two anal sphincters--an internal one and an external one.  Try and clench them both.  Good.  But that's just the beginning.  You also have a urinary sphincter, which you might expect. But there are fifty more, such as your sphincter of Oddi.  That sphincter is named after the dog in the Garfield cartoons.

(2) The drinking kind of port was actually instrumental in getting me and K/BWE together.  Long story.  (Actually, I am going to get a glass right now.)

(3) The portacath was invented in 1992 by Dr. Abe Porta.  (Oddly enough, he is the great grandson of the man who invented the portapotty.)

(4) The vein I am talking about is my superior vena cava.  It is a giant vein into which the veins of the upper part of the body.  The veins of the lower part of the body empty into the inferior vena cava, but, really, no veins are truly inferior.  They are all special.

Regarding the procedure, technically speaking, it was more of a cut this time than a stab.  I won't go into detail, because it's gross, but it was not nearly so unpleasant as I thought it was going to be.  The oldies music that MBH has is much better than the music at Wicked Famous.  All I felt were a few lidocaine injections, none of which were bad at all.  Really, the only downside of the whole experience was that I could not make the surgeon laugh while he was putting it in.

I have to lay off upper body exercise for a few weeks after the procedure.  Prize fighting will also have to wait.

Meanwhile, that last crack just sent me into a Google deepdive into 'senior' boxing.  I don't qualify yet, but, in less than a year, I will.  Apparently, there is even something called 'chair boxing,' which sounds horrible.  This is even endorsed by the Livestrong website, usually a pretty good source of health information.  (https://www.livestrong.com/article/545699-boxing-for-people-over-50-years-old/ ).  As a primary care doctor, I'm horrified.  The whole point of this 'sport' is to give your opponent a concussion.   Not OK.

(5) Meanwhile, some of my patients can't get their insurance companies to pay for basic asthma and diabetes medications.  I was just talking to a patient with this problem today.  It is a strange system.

(6) I just spoke to a friend with cancer who recently had chemo at a hospital in a wealthy suburb near here.  So, want a short stay in a room with a view and free access to a massage?  Get cancer, and go to a fancy hospital.  It's a great deal!