Doppio

Two medical things happened today.

And one personal thing:

Thank you to all my internet women attorney friends who sent me the above ingredients for a healing charm bracelet to wear during my chemo. The last charm was soldered on by my friends at MaMo Jewelers in Seattle, who did the whole thing gratis. As you can see, the finished product is quite lovely. I would like to say I will wear it in good health. And I will eventually.

Now down to the mundane things.

First, I got a "Power Port" installed in the right side of my chest, this morning. The port will make it easier to receive chemotherapy by injection. Rather than finding a vein with a needle in my hand or arm each time, one that has to last for up the 6 hours for the chemotherapy treatment, the port gives an immediate pathway for injection of the chemotherapy into my subclavian vein. The subclavian vein is located next to my collarbone.

My friend, A, drove me to Group Health Central early this morning where it was installed. I had to disrobe and don the ever famously attractive hospital gown, my blood pressure and pulse were taken, and an IV was inserted. The nurse on duty hit a nerve going in, so that was quite painful, and then the pump for the IV didn't work so that had to be replaced. I was not in a very steady state by the time they wheeled me down to lower level A for the operation. Luckily the fellow who did the insertion, was a real pro. He said he had done in excess of 500 of them in the six years he had been at Group Health. So even though I was tearing up at an alarming rate, I felt comforted. Especially when they added the sedation to the IV drip. The team that worked on me was very professional and it seemed I might not have been the first one to lose it in the pre-op phase...

The team worked smoothly to drape me. They used an ultrasound to see if they could reach the subclavian artery with the tiny catheter that is attached to the port. If not, they would have gone for the jugular (literally). Then, they created a one inch incision directly below the artery. And, using a continuing series of xrays to guide them (this is what I remember him telling me they were going to do before we started--I have to confess I was rather out of it at this point in the procedure, thank G*d), they first inserted a wire all the way down to my abdomen and then used it as the guide to insert the catheter into the artery. After the catheter was inserted, they withdrew the wire, positioned the port right below my skin, and sewed it all up. Now I have a 1-2" purple plastic triangular-shaped 'pincushion' in my chest about 6 inches below my shoulder. Phlebotomists and the oncology infusion staff can insert a needle into the port for either blood draws or chemotherapy, and always be assured of good access to my blood supply.

The chemotherapy drugs, when injected into the port, will enter the subclavian artery and mix with my blood which is in the process of flowing into the atrium of my heart. The atrium is not the active part of the heart, but more of a holding chamber. From the atrium, the chemo/blood mixture is pumped into and out of the ventricle of my heart; the right ventricle pumps blood into my lungs to be oxygenated and the left ventricle pumps the oxygenated blood out to the body through the aorta. I am assuming that the chemo will enter the left atrium and exit goes through the left ventricle, but I am not the expert here, so I may have gotten my right and left mixed up. Particularly because this is lung cancer we're talking about and maybe it will go directly to the lungs. I blame the sedative agents for my amnesia. I also bless them too.

I really don't know much more of what went on during the procedure other than I dozed off and woke up after all the exciting parts were done. My intrepid team told me it went just perfectly and I was wheeled back up in a haze to the 4th floor, where they kept me for observation and breakfast until 11 am, at which point I was discharged and my dear, patient friend, A, drove me home.

Second, I received a call this evening from Dr. F at Group Health, who is covering for Dr. N, while he is attending a medical convention in Colorado.

The Seattle Cancer Care Alliance Tumor Board met and discussed my case today. Dr. F talked with Dr. M, the lung cancer specialist from SCCA afterwards and here is where we are going:

There is too much disease in my mediastinum to do a mediastinoscopy. Apparently Dr. N thought a mediastinoscopy could remove the tumor as well as biopsy it, but Dr. M and SCCA et al were of the opinion that there would be too much danger that microscopic portions of the disease would be left in the mediastinum following surgery, and eventually spread again. The CT scan already showed the lymph node involvement, and the damage to the nerve of the vocal cords was already indicative of the presence of the tumor. Of consideration was that it was also difficult to get at by surgery.

Because a biopsy of the mediastinal nodes was likely only to confirm the presence of the disease that has already been diagnosed, the Tumor Board recommended that I go straight for treatment. They recommended chemotherapy first, followed by maybe surgery and then radiation. There is a less than 50% chance that I will be cured, but they think it's worth taking. Dr. M wants to aim for cure by using a combination of cisplatin and pemetrexed. This would be done in 3 (not 4) cycles of chemotherapy, once every 3 weeks. At the end of the cycles, or at 9 weeks, plus a week or two for recovery, they would do a CT scan. If the response was very good, then they would look at surgery to excise the remainder, followed perhaps by radiation. If the response to chemotherapy was good, not very good, meaning no further growth, they would drop the idea of surgery and go on to radiation.

There's a lot of controversy, Dr. F said, in the field of how to time the cancer treatment. The cisplatin/pemetrexed combination looks good together as a chemo modality but there is no data on how it mixes with radiation. Dr. F said that NCCN, the medical organization that develops professional practices for cancer treatment, recommends a combined chemo and radiation therapy using cisplatin and another chemotherapeutic agent known as etoposide, but that Dr. M thinks the regimen he has proposed would work just as well for me.

I will start the chemo not immediately, but next week, because they need to give me a shot of Vitamin B-12 a week before commencement to lower the toxicity of the effect of the chemotherapy on me. I also will need to start taking folic acid daily in the week before. I also will be taking a high dose steroid, dexamethosone, the day before and the day after chemo.

The second punch biopsy of the lower left lobe of my lung that Dr. M initially proposed, would be to see if the tumors had EGF receptors which, if so, would mean that erlotinib (Tarceva) could be used--but Dr. F said that erlotinib has not been shown to be curative. So if I want to go curative, it would mean doing the chemo/surgery?/radiation route.

The other news is that Dr. F went back over the PET scan with a radiologist today and I have a fairly large cyst on my pelvis coming off an ovary. It did not light up during the PET scan so it's not metabolically active, and probably only a simple cyst. But Dr. F wants to check for the presence of OCA 125 markers in my blood. This is indicative of ovarian cancer, but there can be lots of false positives with the test too, so he proposes testing for the CEA marker as well, which is an indicator of lung cancer.

After I return the loaner car to Carter Subaru and pick up my car (they were great about returning the car a day late as I was too woozy today to drive), I will be going to Northgate Group Health tomorrow for the B-12 shot and the various meds, as well as the blood tests that Dr. F has ordered. He is also ordering the vaginal ultrasound, which will be done at Group Health Central.

Finally, if my voice does not return after treatment, Dr F suggested collagen injections into the vocal cord. He said they could last longer than a few months.

My chemotherapy should start next Wednesday or Thursday. I am leaning toward Thursday because I would have the weekend to recover from some of the worst of it. I hope I got most of the facts here straight because it has been a long, tumultuous day.

Spezzato

"...Things fall apart; the centre cannot hold..."
-----William Butler Yeats


More mundane yet somehow aptly expressed by the foregoing verse of The Second Coming, there seems to be a piper to be paid these days, mainly for the sin of deferred maintenance.

The Subaru Outback (in Kentucky it is referred to as a "Sa boo roo") is in the shop for a head gasket replacement, among other things. It is 9 years old, so not too surprising. What was surprising was the range in bids on the replacement. $4,000 was the highest. I took it to 2 other shops before ending at Carter Subaru, the dealer where I had purchased it, and it is being done for substantially less, plus they have provided a loaner car, which is so essential. They did all this for me, Friday afternoon, when I called a friend of mine who worked there. She is a fellow soccer mom and quickly became the catalyst for such good care from them.

Then the washing machine, 7 years young, has been dancing a very loud, drunken jig, on the spin cycle for a few months. Her behavior went from bad to worse, when I discovered yesterday that she's also become incontinent. And of course she's part of a stacking duo and irreplaceable: there is no washing machine that will fit properly under the matching dryer, so do I replace them both or try for something I can put side by side? I hate to part with a perfectly capable dryer.

And finally, my multi cd player has gone rogue, refusing to play any of my cds, no matter how nicely I punch his buttons. As one who thrives on music, this is simply unacceptable, so it was hied off to the repair shop this past week and a half. However, in the pattern of repair persons everywhere, repair person has been on vacation so it will be some time before I learn whether to fix or to replace. My preference is to fix, but the modern consumer culture makes it much cheaper simply to toss the old one away and get something new.

These things come in threes. I am hopeful my triplet is finished

Second Movement

Yesterday I had an appointment with an oncologist who specializes in lung cancer at the Seattle Cancer Care Alliance ("SCCA")for a second opinion. One of the nicer aspects of Group Health membership is that they authorize and pay for a second opinion, and I took advantage of that.

I met with Dr. M and his oncology resident, Dr. O at SCCA. Before arrival, Group Health had sent over all the tests and results, and I had filled out a lengthy form, which SCCA had sent. I turned it over at the check in desk and was given a green sticker that proclaimed I had passed their "do you have a cold" test--everyone, including visitors--had to fill out a questionnaire concerning current symptoms before being allowed to stay at SCCA. Can not be too cautious when you have folks going through chemo all around.

The view from the waiting room, overlooking Lake Union, was tremendous, and probably very calming for many. Me? Not so much.

After a 15 minute wait, we were shown into a standard examination room, and first met with Dr. O, who asked additional questions and did a short physical exam. Dr. O asked if I had considered genetic testing given the history of cancer in my family and said that it might not be of assistance to me, but it would help my children. Dr. O then took her oral history notes along with all my test results/readings and questionnaire answers to Dr. M for consultation prior to his meeting with us.

Dr. M is tall, charming, and very direct. First, he asked me what I understood about my current condition. I gave him my two minute precis: lung cancer diagnosed 9/18/09, stage 3-B, course of treatment prescribed, etc. I then asked what he thought.

Dr. M responded that (and this is in no particular order from our conversation) he wanted to take my case, which he found interesting, to the SCCA Tumor Board and solicit their opinions on the best course of treatment.

The Tumor Board meets Tuesday next week (I've been saying Wednesday to friends, but a quick check of my notes shows that is in error). This includes oncologists and radiologists and Dr. M wants input from the radiologists whether to do radiology concurrent with or consecutive to the chemotherapy. Dr. M agreed with Dr. N that surgery was not an option to the lymph node involvement, and the desire to recover my voice which would mean treating the nerve to my vocal cord with kid gloves.

Dr. M also wants a second biopsy done to see if the tumor has EGF receptors:

http://en.wikipedia.org/wiki/Epidermal_growth_factor_receptor

If so, this would give them a reasonable chance of finding the original source of the cancer and it could also change the treatment modality, perhaps significantly. They could shift to a pill(erlotinib*, not gefitinib which is not approved for use in the USA) and not employ chemo. Dr. M suggested a second punch needle biopsy of one of the lower left lobe tumors using a larger needle to obtain sufficient tissue to do the biopsy. It could take ten days to receive the biopsy results. Dr. M also proposed a different chemotherapy combination, using a drug named pemetrexed instead of the paclitaxel, and perhaps keeping the carboplatin, or using cisplatin in its place. The pemetrexed would lower the possibility of hair loss but would increase nausea, and there would still be potential problems with neuropathy if cisplatin is used in lieu of carboplatin.

Dr. M was presently of the opinion that chemo followed by radiation was the correct course, unless the Tumor Board determines otherwise.

Dr. M thinks that a month ago the cancer was 3-A, but that taking additional time to try to figure all this out would not be too slow for starting treatment. At some point, I said that this shows why medicine is an 'art' not a 'science' and he gave me the look he said his 12year old daughter gives him when she thinks he's been goofy. Still, I think that at the outer limits, medical diagnosis is an art, perhaps informed by science, but still an art nonetheless.

Dr. M talked about using the term 'control' rather than 'palliative' if it was found that we could not eradicate the cancer. He said that if I had been diagnosed with AIDs in 1985, I would have been dead within 6 months, but now those with AIDs have a likely chance to live our their normal lifespans. My prognosis gives me 2-2 1/2 years on the pill, before recurrence of the cancer. Using chemo together with radiation, the intent would be curative.

So he recommended that I get the port installed in my chest Tuesday morning, and await the determination of the Tumor Board deliberations before starting chemo--likely Thursday. That left the biopsy question unanswered.

I asked him to call Dr. N before I had my telephone consult with himf at 4:40 that day, and he agreed to do so. I said it was my hope that he and Dr. N could work collaboratively on my case and asked him what happens when doctors disagree. He laughed and said it was not at all common to disgree, that he fully expected that they would be on the same page. When I returned home, I emailed Dr. N and mentioned that Dr. M was going to call him. He later responded via email that he had talked with Dr. M at noon and was looking forward to our phone conversation.

So 4:40 came and went. So did 5:00; 5:15, 5:30; 5:40. During this time I emailed Dr. N, I called his office several times and was referred to the oncology voice mail that stated the office was closed for the day. Now I operate on the belief that my word is my bond, and if I cannot reach a client or fellow attorney at the time agreed upon, I have my legal assistant contact them to let them know that things are running late. This did not happen. In fact when I called Group Health's front desk, after being sent to the closed oncology office, I hung up and called Group Health back, and the woman (once again she complained about not being able to hear me) said sharply, "This is the number I have to refer you to. I can't do anything else." This all too common lack of care with the Group Health administrative staff reduced me to tears. But luckily, I called the main number once more and this time spoke to a different, more empathetic main operator who must've heard my distress and agreed to page Dr. N, so he would be aware that I was waiting. She put me on hold for a while, then got back to me and said he was running behind on my calls and would be calling shortly.

At 5:50 Dr. N finally called. I had managed to put myself back together again, but I was not on top of my game for this discussion. Dr. N said that he had spoken to Dr. M and he was in agreement with his recommendations concerning the Tumor Board and the shift in chemo meds. But he wanted to talk with Dr. L, a thoracic surgeon at Virginia Mason, he had earlier mentioned, to see if he could do a mediastinal biopsy of the tumor growing on the nodes next to the nerve for my larnyx. He was hoping that it could be done before Thursday, but because he was leaving shortly for a weekend in Colorado delivering a paper at a conference, he was not sure if it could get pushed on through fast enough. Although, Dr. N thought a week's delay would not be problemmatic. Dr. N said that if the thoracic surgeon agreed to do this, VM would probably run my case through their Tumor Board as well.

You know at this point, I just want to say that women of my mother's age aspired to be pin ups, and women from my generation wanted to be centerfolds in Playboy. Well my goal in life is that I want to have my PET and CT scans reviewed by Tumor Boards. Don't tell Sarah Palin.

The plan, which is still not fixed is that the port will be installed on the right side of my chest on Tuesday and chemo will begin Thursday. Once Dr. N returns from Colorado I hope to take up the issue of the biopsy and settle that fully as well. But as Dr. M said during our second opinion consult, you don't want to use a tank to kill this if all you need is a rifle. I can get behind that opinion. And I can be patient a while longer if this means the treatment is more tailored to my situation and it gives me just as good a chance for remission/cure, as well as fewer side effects during treatment.

And I got an email from Dr. N apologizing for his late call.


*erlotinib is a drug marketed by Genentech--which merits a shout out to Fred, a college classmate, who is a research scientist for Genentech!! Howdy there and tell them to keep up all the good work!

Dentistry notes from all over

I had my teeth cleaned by an expert today. He really knew his business. It was over in less than an hour but by the end, I could really feel the difference. He was not too timid to scrape off the plaque, although it was not entirely painless. And he showed me that I have been brushing my teeth wrong for, oh, more than 50 years. Here's the deal. You don't want to approach your teeth with the toothbrush at a 90 degree angle. Rather it should be at a 45 degree angle. And scrubbing hard does not mean getting the job done. As he asked me, do you use a scrubber on your fine china? Ooh. That hit home. He also said not to use a mouthwash that had alcohol in it--too harsh on the gums, even when they are at their healthiest. Finally, he suggested doing my evening dental hygiene routine an hour before bedtime, so I am not crashing while I am brushing my teeth--I will pay better attention to the tasks at hand. And there are three that should be done in the following order: 1) floss, 2) brush teeth for 2 minutes or more at the 45 degree angle, and 3) rinse with the non alcohol mouthwash. If I manage to eat or drink something afterwards, he said I should just floss or brush again depending.

So nothing like upending a 50+ year habit. We'll see if I can do it.

He also told me about some of the travails of Dr. W, the specialty dentist. As I mentioned before her practice is focused on cancer patients but also patients who are waiting for transplants. In order to do a transplant, one of the requirements is that you cannot have a mouth infection and she works to make sure that her patients are 'clean' there and ready to go otherwise. But not so fast. She has had situations, where a $250,000 transplant, after years of waiting, has been approved by Medicare or the state or a private insurance provider. But they won't approve the $1,000 in dental work that is a pre-requisite for the transplant to take place. This is absurd. In some situations, she has (forgive the expression) eaten the costs and done the work without compensation, so that someone who had been waiting 15 years for the transplant could finally get it. Again, this does not make sense. It's being pennywise and pound foolish.

Being at the dentist twice in less than a week, sent me on a reminiscence of dental visits past. I grew up in a small town in northwestern Ohio and our family dentist was a very nice guy, but he didn't believe in anesthetics for fillings. I remember a number of fillings installed where he hit the nerve and I jumped rather high. It's amazing I didn't lose part of the inside of my mouth or worse as a result. I wonder if he changed his practice at some point.

I also remembered my torts class my first year of law school. Our professor, who was just starting teaching law, was a nervous fellow who had a tough time standing in front of the class and talking for 50 minutes. But he was discussing one day the doctrine of res ipsa loquitor which translates to "the thing speaks for itself." And the example he used to illustrate this doctrine was a story about a woman who went to a dentist's office for a major treatment of some kind, one where the dentist had to put her under general anesthetic while she was in the dental chair. He administered the anesthetic and she went under, only to wake up and discover that one of the fingers of her right hand was broken. She inquired of the dentist and was met with stony silence. So, she eventually sued the doctor for negligence, alleging that the broken finger was res ipsa loquitor of the negligence because obviously she was not being treated for anything other than something wrong with her mouth. At trial, on the witness stand, the dentist finally broke down and confessed that the anesthetic he had given his patient was one, that at times, would cause the patient's muscles to seize up as she went under. And when the patient went under in the dental chair, her hands had clenched and the right hand had caught his testicles in a vise-like grip that he could not release until he broke one of her fingers!!

The story was amazing, but the fact that it was told to us by this fellow who was probably the shyest professor I ever had, was all the more amazing.

Off to brush my teeth--the right, no, the 45 degree way!

Open Thread

The fun theory

Oh, the link attached to my title really made my evening. I hope that y'all enjoy it as much as I did. Now how do we go about making chemotherapy that fun? I'm thinking a portable DVD player and lots of Paul Gross or Hugh Laurie or Nathan Filion or Viggo Mortensen. I'm not too picky!

Tickling the Ivories

The specialty dentist, Dr. W, had room in her schedule today, so I went in at 2pm to have a dental exam and consult before chemotherapy next week.

Dr. W had me do a full x ray and then she measured my gum line for pockets and visually inspected my teeth to make sure there were none in need of new fillings or crowns. Although I have some deep pockets, particularly in the back, it looks like my mouth and teeth health are good to go for next week. I learned a number of new things:

* one of the fallouts of chemotherapy is mucositis because the mouth is a place where the cells are rapidly growing, just like the tumors in the left lower lobe of my lung. So chemo can and probably will cause shedding inside my mouth, and consequently irritation and pain.

* there is a mouthwash I can make from two over the counter items to numb the inside of my mouth. She gave me a prescription for a gel to coat the sides of my mouth before I eat when it gets too bad. She said ice can be used but to be careful, so I don't craze or crack the enamel from too vigorous ice chewing.

* eventually I will be unable to use my Sonicare toothbrush because of the tenderness, so she provided me with an extra soft toothbrush for those days. While I am still able to use the Sonicare, she recommended the smallest size brush because it reaches more places in the mouth.

* because the port for the chemotherapy they are planning to install in my chest next week will be below the skin, I will not need to take antibiotics before going to any future teeth cleaning appointments with the dentist.

* I should get my teeth cleaned before chemo, even though they were back in August, just because it is a good precaution. An appointment has been set for this Wednesday at noon.



To celebrate, I took myself to see Steely Dan at the Paramount Theater tonight. They performed their album, Aja, in order--all the way through. And if that was not enough, they then played some of my favorites from their albums over the years including "Do It Again (click on the title of this post to hear the recorded version)," "Show Business Kids," and "My Old School." They ended their concert with an encore, "Reeling in the Years." I could not have asked for more. I have never heard them sound better. If they show up near you, I can highly recommend them, even though the tickets cost an arm and leg. The music was absolutely first rate. And Donald Fagen told the audience that the Paramount was Steely Dan's first big venue back in 1972. They opened for the James Gang!

Improvisation

I think I'm on target about the connection of music with life. I've used some musical titles and analogies in here, and related it to what I am experiencing. According to the CNN article that is embedded in the title to this post (just click the title to read) music may promote healing even more than we have ever given it credit.

So, expect the analogies and links to music and song titles to continue.

Yesterday I learned something new. One of the possible side effects of the pending chemotherapy would be to my mouth--the mucous membranes might be affected and my mouth and surrounding tissues could become inflamed or sore. So I called my dentist, David, on Saturday. He's a good guy because he leaves his home phone number on the answering machine for emergencies and I left him a voice mail message. He called back promptly and said in fact his former partner had just spun off a practice that in part consisted of dental hygiene for chemotherapy patients and one thing I should think about is getting a dental exam to rule out any infections because undiagnosed, untreated mouth conditions could compromise my cancer treatment. So he will call his former partner to see if I can be seen this week before the chemo starts.

Then on to the practical preparations. My friend A and I helped each other clean out our refrigerators. I seem to recall that good Jewish households always clean out the pantry in the spring before Passover, and I have to say, after my experience yesterday, that is a good idea. There were a number of chemistry experiments going on under my nose (truly) that ended yesterday with our joint efforts. The fridge has not been that clean since I purchased it 4 years ago. And the dogs got a few not too toxic treats out of it.

The dogs also were treated to a walk around Greenlake today. My dear friend from work, D, called me and said, "Let's meet!" We've been walking around Greenlake for over a year as both exercise and as talk therapy as we try to hash out problems from the personal all the way to the national and international. We don't always get things solved, but it's good to talk them out. I relented and brought all three of my dogs (an aging black lab and two miniature dachshunds) with because I figured I could talk D into holding one leash for me as we rambled around the lake. And I brought the throw toys for the lab and the older dachshund as they both love to fetch in the water. It's a hoot to watch Scooter, the dachshund as he goes after his water toy because his legs are so short, he can't find his balance swimming, without using his tail as an air rudder. So the tail is flailing about madly as he paddles out and brings it back for another throw. He'd spent several years watching Max the black lab do it and get the lion's share of attention, and finally he decided that he could swim too, so now I have to throw for both of them when we go to the lake.

On the drive over to the lake, Truffle, the puppy, apparently could not wait and a huge rancid odor wafted up from the back of my Subaru station wagon. I thought at first it was passing gas but as the smell did not dissipate and in fact grew over time, I realized that I was SOL (so to speak) until I parked the car. It was bad enough to cause me to roll all the windows down and hope that I was not next to someone at an intersection for more than 15 seconds. I found a parking place, and then tied the dogs up while I tried to figure out how to clean out the back end because I was NOT returning to this mess after a 2.7 mile walk. Luckily, I had some windshield cleaner and some dried out cleaning towelettes for the leather upholstery, so with a little ingenuity and a plastic bag, things were good to go. The walk was beautiful with the sun dappling the leaves of the trees and warming the dogs after their vigorous swimming in the lake. D and I once again solved all our problems--if only every one else would do what we said!! I packed the dogs in the car and returned home. Only to find that the puppy had gotten car sick on the ride back!

Figures.

Hope

Hope is the thing with feathers
That perches in the soul,
And sings the tune without the words,
And never stops at all,

And sweetest in the gale is heard;
And sore must be the storm
That could abash the little bird
That kept so many warm.

I've heard it in the chillest land,
And on the strangest sea;
Yet, never, in extremity,
It asked a crumb of me.

--Emily Dickenson

Unlike the Scarecrow of Oz

It appears that I have a brain. At least that is what the brain MRI I underwent today showed. It also showed no metastases. So a big Yay for Friday night.

An MRI is an interesting thing. Once again I couldn't have any metal on my body, so the sweatshirt with the grommets had to go, though I was given a heated light weight blanket to stay warm. I was packed onto a plastic platform connected to the MRI machine and my chest and arms encased by a wide cloth velcro seatbelt, and an open mask type of restraint for my head. The nurse gave me earplugs, placed disposable pillows between my ears and the cold plastic restraint, and put an iv into my right arm, so she could inject contrast dye into me for the last two MRI sequences. However, the first 20 minutes consisted of a series of MRIs that ran for varying periods, from 11 seconds to 4 minutes. Each MRI had its own distinctive resonance, some being deeper in tone than others, with most being a steady burst of noise and I actually fell asleep during most of the procedure (heck I was the mother of 3--I used to fall asleep at the neighborhood pool where there were loads of kids making far more noise than this machine). From time to time the bed pulled me out from under the MRI machine and then reinserted me, probably at a different stopping point each time so all areas of the brain could be mapped.

Before the last two MRI sequences, I was pulled out from the machine and the contrast dye injected. No noticeable effect like during the CT scan. Once again I fell asleep trying to remember some aspect of my days as a camp counselor at a camp named Camp Ladyglen in the early '70's in Grand Rapids, OH. Worthy of several posts on its own, but for me today, a wonderful soporific.

I was done and out the door and had to pass 2 hours before coming back for the next consultation with Dr. N, my medical oncologist who would read the MRI and tell me results. Took my dear friend and driver for the day, A out to lunch and we picked up the charm bracelet that was a group gift from my women attorney friends online at Delphi forums, and then was passed an enjoyable time visiting the Japanese garden in the Arboretum. Truly a pleasant afternoon, if you don't count the stress of waiting for the results.

Back to the meeting with Dr. N and he informed that I did have a brain and that it was clear of all metastases. Then we got down to business.

In response to my question about the New England Journal of Medicine article that I cited in my previous post, Dr. N explained that this study was done of palliative care and the cohort was Asian women. So there was some relevance for me, but not so much. In response to my question about why the recommended treatment now more closely resembled what he had initially proposed for the possibility of stage 4 lung cancer, he explained that my original radiation oncologist, Dr. C, was out of the office when the PET scan results came back, so he consulted with Dr. H and Dr. H was of the opinion that the treatments should run sequentially not concurrently. Dr. N said that once Dr. C was back in the office, he would consult again with him and once again the course of treatment could change. It could also change once I've obtained the second opinion from Dr. M at the Seattle Cancer Care Alliance. He stressed that he would be working collaboratively with everyone involved in my care and that it is and will be a fluid situation depending on outcomes. He recommends a ct scan after 6 weeks of treatment to determine whether there is shrinkage but he is not averse to doing it after 3 weeks, just doesn't think it will tell him much.

So, it looks like October 19 is D Day for beginning chemotherapy. I am also now scheduled for a procedure Oct 20 to install a port in my chest to facilitate the chemotherapy injections in the future. And there is a lung function test coming up plus some blood work, again as well. As I wrap up and turn over my cases to my attorney colleagues in my office, it seems that my dance card is not emptying out, but rather filling up with new sorts of appointments and deadlines.

The immersion is beginning. Let's hope that I can learn the steps required.

Do you have your seat belts on?

This is a cleaned up version of an email I sent the medically oriented members of my family and friends tonight.



The news was not so good today. There's not a clear path to take for treatment and each involves major risks.

The first option involves surgery, including checking the right mediastinal nodes for additional cancer (though the PET scan was clean there) while trying to dislodge the left mediastinal mass as much as possible plus a lobectomy for the left lower lobe. Then possibly on to chemo and perhaps radiation. In this case my GH oncologist, Dr. N, wants to use a thoracic surgeon, Dr. L, from Virginia Mason but that would take about 3 weeks, if lucky, to set up and get through the surgical process.

The other option would involve starting chemo Oct 19, after the second opinion on Oct. 15 at Seattle Cancer Care Alliance with Dr. M, assuming Dr. M agrees with this approach. But Dr. N wants to use carboplatin-paclitaxel for the chemotherapy, and the latter part of the chemical equation can cause neuropathy. Hair loss is assured as well as some other side effects There's another drug out there, geftinib, which has shown better long term results if the adeno carcinoma is positive for the epidermal growth factor receptor gene (EGFR) mutation, but we don't know that's what my carcinoma shows because there was not enough material from the first biopsy to test for that. So we'd have to do another biopsy, which I thought was a possibility, but Dr. N didn't bring it up today except as an afterthought to the major surgery path. The following New England Journal of Medicine article looks interesting. I sent it to to Dr. N tonight and asked for comment.

http://content.nejm.org/cgi/content/short/361/10/947


The proposed chemo would take 12 weeks, and be administered once every 3 weeks. Then possibly radiation, then possibly surgery. When we met with Dr. N the first time, this was going to be the course of treatment if I was stage 4. Stage 3 would involve a combination chemo and radiation on a weekly basis. I have put the question to him via email tonight: why the change?

I meet with him tomorrow again at 4:40 pm to get the results of the brain MRI which is to be done at 12:30. So there will be more info later. And of course if the brain MRI shows something, then it all goes back into the cocked hat.

I'm the kind of person who reads the ending to mysteries if they get too tense because I can't stand the uncertainty. I'm still trying to figure out how to do that with my life. So far, reading horoscopes is not sufficient.

Brain MRI moved up--UPDATE

There is no way that I can really take this at this point, but I got a call today from the MRI department at Group Health and the radiation oncology nurse that we met with last Thursday asked them to move up my brain MRI from Monday Oct. 12, to sometime this week. The only time they had available was Friday at 12:30. Could I make it?

I said yes.

Update: I got a call from my new nurse navigator, that I was offered last night in a phone call from Group Health. This is a new program where a cancer patient is assigned essentially an advocate within the system, to help navigate the bureaucracy and also to assist with personal issues. So in the middle of our conversation I asked her if she could view my PET scan results because I was feeling a bit insecure about moving the brain MRI up. She said, yes she had access to the file, would I like her to look at it? Of course, I said, which she did. And she was happy to report that the PET scan showed what was already there and nothing more. No distant malignancies elsewhere in the abdomen or pelvis. So that was the first good news I've had yet.

Small rejoicing going on right now.

The PET Scan

Note: The above is NOT my PET scan. It's just for illustrative purposes.

My PET scan was today at 12:30. My friend and co-program advisor, D, was very kind and drove me to the appointment in Olympia. It served a dual purpose as we could discuss work all the way down and all the way back. Major distraction, which I never ever anticipated would be the case with work.

Once there the folks at Group Health were reasonably prompt, although a PET scan takes more time to prepare for than it does to administer.

I had to not eat for 6 hours, in order to lower my blood sugar. More about why later. But this meant I had no food or coffee (the worst) from the time I went to bed until about 3pm. Reminiscent of fast days when I was a Catholic. I don't miss that part at all.

PET scan headquarters was a large shipping container parked in the back parking lot of Group Health. This PET scan is mobile and is driven to a different site--not just Group Health-- in Washington each day. The technician, Tim, told me he travels between 1100 and 1600 miles to administer the tests each week. I asked him if he drove the truck too, and he laughed and said no they had a driver who transported the PET scan to a different location each night. They do it at night because there was less likelihood of the truck having an accident then. Turns out he is from Pittsburgh and a Steelers fan, but I tried not to hold that against him.

Tim drew some blood to test to make sure that my blood sugar was low. It was 113 which is midway between the way low score of 50 and the high score of 200, so I was good to go. He then injected a dose of radioactive sugar along with saline solution to make sure it all got into my bloodstream. I asked if the dose of sugar would help my hunger pangs and stop my stomach from its very loud rumblings. He laughed and said that the amount of sugar in the injection syringe was 1/40 of a treaspoon of sugar so it would take a lot. The body, all of it, needs sugar to perform its functions. I thought of each organ having hands extended out grabbing the sugar molecules as they circulated through my bloodstream. If my blood sugar was high the hands would not be grabbing--there would be no uptake of the radioactive isotopes that showed up on the PET scan--so it was good to be hungry. This radioactive sugar shows up brightly on the PET scan, and the sites where more radioactive sugar has been grabbed, will show up more brightly than those that don't have as many grabby hands. Cancer is fast growing and needs lots of energy, i.e. sugar, so cancer sites are very greedy; they will show up brighter on the PET scan than sites that have not yet been invaded. Cancer is the physiological equivalent of the mercenary troops of the Holy Roman Empire which sacked and looted Rome in 1527 because they had not been paid by their immediate commander, Charles III, Duke of Bourbon. (Completely OT: Hella Haasse wrote a wonderful book about this titled The Scarlet City)

I had to wait 30 minutes to make sure the radioactive sugars were fully circulated in my body before they could do the PET scan so Tim put several blankets over me to keep me warm (they have to keep the unit very cold to make sure the PET scanner does not overheat), and left me with the recliner chair fully extended to relax. As if. I was briefly overcome, contemplating my own mortality, and Tim heard my sniffles over the intercom and came in offering Kleenexes. At that point, I forgave him his misguided football affiliation. (vbg)

Then my waiting was over and I moved to the room with the PET scanner. And here is where some advice to those who have yet to undergo this is in order: Make sure your clothes have no metal on them!!! I had to take off all my jewelry, my bra which had metal hooks and my fancy sweatsuit which had metal in the zipper of the top and metal on the ties to the pants. Two flimsy hospital gowns plus blanket were not much insulation. So that meant really really cold for the scan, which Tim said took 20 minutes and felt like an hour

And of course, when I was in position for the scan, with my arms above my head, I got a cramp in my right shoulder. Figures. I shifted it ever so slightly when the scanner was doing my lower torso and managed to maintain stillness for the majority of the scan. I even dozed off briefly. Finally Tim came into the room and announced that I was done and could get dressed. Which I did and then we waited for another 45 minutes for a copy of the scan to bring to Seattle Cancer Care Alliance, for a second opinion. Group Health offers this service, and I applaud them for it. SCCA is NCI approved and I've always been told that it is good to get a second opinion, no matter the operation/diagnosis. So now there is a copy of my scan in my briefcase, that I have only the faintest desire to open up and put in my computer (if it would take the disk, which it probably would not) to see if I can spot the bright spots. Uh...not so much. I will wait until Thursday when I meet with the medical oncologist for a followup. My daughter will go with me and either way, I know I will cry.


Now to curl up with a good book.

Divertimento

Well it's the night before the PET scan. Just like the night before the Bar exam, except this time I want to get a low score, not a high score. Reminds me of the Phyllis Schlafly cheer squad from the Doo Dah parade, which was an alternative to the Rose Bowl parade. Anyway, the cheer these cheerleaders would yell at the top of their lungs was, "Sixty nine cents is toooo much!" Sixty nine cents then being the average wage that women made compared to men.

And my co-program advisor forwarded this to me today as well. I thought it broke up the seriousness for a bit. Which I find I need because lately I've been crying a bit--more than I have since my divorce ten years ago. So here goes:

YOU KNOW YOU LIVE IN WASHINGTON STATE WHEN:

If someone in a Home Depot store offers you assistance and they don't work there, you live in Washington.

If you've worn shorts, sandals and a parka at the same time, you live in Washington. If you've had a lengthy telephone conversation with someone who dialed the wrong number, you live in Washington

If you measure distance in hours, you live in Washington .

If you know several people who have hit a deer more than once, you live in Washington.

If you have switched from 'heat' to 'A/C' and back again in the same day, you live in Washington

If you install security lights on your house and garage but leave both doors unlocked, you live in Washington

If you can drive 75 mph through 2 feet of snow during a raging blizzard without flinching, you live in Central, Southern or EasternWashington.

If you design your kid's Halloween costume to fit over a 2 layers of clothes or under a raincoat, you live in Washington.

If driving is better in the winter because the potholes are filled with snow and ice, you live in Washington.

If you know all 4 seasons: almost winter, winter, still winter, and road construction, you live in Washington

If you feel guilty throwing aluminum cans or paper in the trash, you live in Washington.

If you know more than 10 ways to order coffee, you live in Washington.

If you know more people who own boats than air conditioners, you live in Washington.

If you stand on a deserted corner in the rain waiting for the "Walk" signal, you live in Washington .

If you consider that if it has no snow or has not recently erupted, it is not a real mountain, you live in Washington.

If you can taste the difference between Starbucks, Seattle's Best, and Dutch Bros, you live in Washington.

If you know the difference between Chinook, Coho and Sockeye salmon, you live in Washington.

If you know how to pronounce Sequim, Puyallup, Abiqua, Issaquah, Oregon, Umpqua, Yakima and Willamette, you live in Washington.

If you consider swimming an indoor sport, you live in Washington.

If you can tell the difference between Japanese, Chinese and Thai food, you live in Washington.

If you never go camping without waterproof matches and a poncho, you live in Washington.

If you have actually used your mountain bike on a mountain, you live in Washington.

If you think people who use umbrellas are either wimps or tourists, you live in Washington.

If you buy new sunglasses every year, because you cannot find the old ones after such a long time, you live in Washington.

If you actually understand these jokes and forward them to all your Washington friends, you live or have lived in Washington.

Think No. 3!!

Movement

"Change means movement. Movement means friction. Only in the frictionless vacuum of a nonexistent abstract world can movement or change occur without that abrasive friction of conflict. " --Saul Alinsky

Group Health called this morning at 8:38 am to tell me that the PET scan was approved. I am driving down to Olympia tomorrow and it will take place at 12:30. No solids for 6 hours before.

I'm not sure what worked, but I'm sure part of it was all of your good thoughts. Pat yourself on the back for a job well done.

Thank you.

This is why it's such a big deal

I finally decided to see what the big deal was about stage 4 lung cancer. Click on the title of this post and you can read for yourself.

So let's all pray/hope/imagine seriously that it's stage 3B.

Question for my loyal, but shy readership

Does anyone know how I can upload a music file to my blog? Consider that I am a luddite to this and respond accordingly.

Thank you.

Girls, Jump Rope and Sports

If you'll click on the title of this post, you will be directed to the web site for the King's Firecrackers, a middle school jump rope team. At the bottom left of the page is a video of their performance at the US Naval Academy. Amazing and thanks to Joe K for the tip that took me to their website.

When I was a child, attending Spencer Elementary School in Defiance, OH, exercise was really not emphasized with girls. At recess we had kickball games that were coed. I was always one of the last to get picked along with Butchie Raabe. And the standing around games for girls were 4- square, some plain jump rope and dodge ball against the side of the building. But by the 6th grade, when we would line up in two rows, boys in one, girls in the other, to go back into Mrs. Stratton's class, the girls were singing "We love you Beatles, oh yes we do. We love you Beatles. And we'll be true. When your not with us, we're blue. Oh Beatles, we love you." Boys and clothes and hair and makeup were starting to become more important than getting dirty playing outdoor games. We didn't have jump rope teams, but you could become a baton twirler and wear fancy white boots with tassels. My mother would have thrown me to the wolves had I asked to do that.

In junior high and high school there was no recess. There was gym. I hated gym. In addition to being around girls in the showers which I was mortified by because everyone else had boobs and I didn't, there were things like cartwheels which I couldn't do (that automatically deducted me from trying out for cheerleading), and basketball was played only half court. I was automatically assigned the defensive half of the court because I couldn't shoot. And I continued to be picked last for competitve games at girl's gym too.

Eventually I learned how to play a bit of football because these guys from Bryan used to drive down and visit my very good looking friend JoAnn and me, her less good looking friend. My dad had purchased a pool table, and we would spend weekends playing pool and going outside and playing tag football. The guys taught me how to throw the football. I was looking forward to the powder puff football game traditionally played between the junior and senior girls in high school. Flag football. But when I became a junior, the game was called off by the School Board. They determined that it was too dangerous for us girls as we could injure our reproductive organs. US???? What about guys, I wondered? Aren't their reproductive organs a little more 'out there' so to speak? But, because my father, my PEDIATRICIAN father, was on the School Board, I didn't talk back or ask any questions.

At college there were competitive women's teams in tennis and perhaps one in swimming, but without a background in sports, I had neither the interest or ability and so did not sign up. I can recall swimming in the college pool (which was really rather gross--Shaw tub it was called) once, to collect on a bet from my then-boyfriend that I could actually swim a mile. My parents had belonged to the country club in Defiance, and in the summers I would ride my bike to the pool and hang out, vainly trying to get a tan to be cool. I picked up swimming almost as an after thought and spent one or two summers in junior high on the swim team. The only time I received a ribbon, was when there were only 3 girls swimming in my event. But somehow I managed to obtain my lifeguard certificate, so unbeknownst to the boyfriend, I really could swim a mile! I think it got me a dinner at the Chanhassen Dinner Theater.

It was not until my last year of college, that I started understanding exercise and sports added, rather than subtracted something from your life. During interim a group of friends formed a volley ball team (the Kirk Carousers) and we got the crap beat out of us regularly. But our broomball team, the Bharath Special Beedie Works, won the Intra Mural Championship. Somehow ice hockey played with brooms and a soccer ball and no skates was a levelling experience--we actually beat the team composed of members of the football squad because they could and did fall as much as we did, and harder too! Rather than a trophy, each team member was awarded an orange tshirt with "MAC IM Champ" emblazoned on it. The early '70's version of a letter jacket. They were items of pride, worn often. I still have mine, ratty with small holes throughout. I took it back for the class reunion this year and wore it when I participated in the fun run Saturday morning.

College was my first real glimpse of what exercise and sports can do for women as well as men. I went on in the limited time I had left there, to be on a women's full court basketball team, take tennis lessons and join a soft ball team (Chastity and the Belts). Not until I joined an adult swim team some twenty years later, did I ever participate in sports so fully.

I am glad that opportunities for women in sports have expanded as a result of the successful Title IX lawsuit against WSU for not fully funding women's sports, brought by the Northwest Women's Law Center in the early '80's. I am proud of my small work for the Law Center as a volunteer, and on the Board,which helped sustain their mission. And I am so glad that my daughter, when she grew up, was on a soccer team for ten years, and high school tennis and swim teams. These were opportunities beginning in kindergarten, to develop friendships with other girls that involved teamwork, not cutthroat competition. Something I only began to learn in college.

Group Health roadblocks up and functional

This is a feature not a bug.

When we met with the oncologists yesterday, they told us that I needed a PET scan and a brain MRI so that they can stage my cancer appropriately. And, if it is below a stage 4, then they will biopsy more tissue to try to put together a chemotherapy regimen that is targeted to my particular cancer.

It seems obvious, that a PET scan is required to put this plan into its first steps. And that the longer one waits, the more time the tumor has to grow, divide and perhaps migrate in search of more, friendly host sites. So, one might think that speed would be of the essence because you would want to get the information quickly to start treatment and stop the process in its tracks.

You would be wrong. The only process that counts is the administrative process within Group Health. This administrative process is in place to somehow make sure that my doctors are not lying their asses off and that in fact I do merit a PET scan. And after a number of calls to Group Health throughout the day to inquire, I was told at 4:15 pm for the first time, by the same person I had been talking to all day, that this process generally takes 2-4 business days at a minimum to be approved. My 'relationship' with this individual got off to a rocky start during the first call, when this person rather impatiently said, "I can't hear you, can you speak up?" I yelled with all my might, which brought my whispery voice near to cracking, that I could not speak up, that I had lung cancer causing this and that I needed the PET scan stat.

Some good that did. I suppose I could complain to the Insurance Commissioner's office. I have a meeting Tuesday in my offices with the Deputy on another matter. How frakkin' ironic.

Not a good day.

A Small Ray of Hope

Met with the radiation oncologist and the medical oncologist today. It ran 4 hours and was, without a doubt, some of the most intense focusing that I have done in my life.

In summary, this is what I took away from our meetings.

The doctors do not think that the spot in my upper left lobe is a tumor. They think it is too regular and round in form to be metastatic. This is good because it means that then there are only two tumors in the lower left lobe, plus lymph node involvement at the mediastinum, resulting in a preliminary diagnosis of stage 3, B cancer (out of 4 stages). But I need to have a PET scan, which is a full body scan, following an injection of radioactive sugar solution into my body, viewed on a type of CT scanner. If there are areas of fast growth, ie tumors, they will show up brighter on the PET scan than other areas. The doctors are looking at throughout my body, including my bones for possible sites for metastasis.

Then a brain MRI to rule out brain involvement. The brain is going to show up on the PET scan according to my daughter, because it is active all the time, so the PET scan results can't be relied on there or in the kidneys or the bladder (which is different than I originally wrote here--good thing she's on top of this!). They did some physical testing today to measure basic brain function, which involved standing on my feet with my eyes closed, then standing on one foot and then the other, and I passed with flying colors there. But of course that is not definitive.

If there are no other areas that indicate cancer, then I am stage 3,B and they will next do a mediastinal biopsy of the affected nodes to get a better read on the exact type of cancer it is. This will help them devise a chemotherapy protocol that is more closely tailored to the type of cancer that I have.

And after that, next comes treatment. This would be 7 weeks of radiation and chemotherapy. It would be a big hit to me, but the end goal is to put the cancer in remission and maybe ultimately cancer free.

If there is metastasis in other parts of my body, this would put in me in stage 4, and that would mean a further biopsy is not necessary and that only palliative treatment would be indicated. They would be trying to keep me stable and not get worse, in other words. At that point, I would consider more experimental treatments or clinical trials, because I would have not much left to lose. The doctors have no problem with me seeking a second opinion from either within or outside Group Health. Of the 4 folks that we met with today, I was very impressed with the knowledge and skill of the physicians and the radiation oncology nurse. When you are good at what you do, you don't mind if others are consulted on their opinions.

We will deal with this as it comes up. The brain MRI is set for October 12 and the PET scan will either be Monday or Thursday of next week. Once again, patience is indicated. Of which I have less and less.

The prognosis after 5 years seems to be around 20-25%.

Life on the edge. What a concept.

A Different Sort of Surprise

This evening, I got home after a very long day at the office for me--closing old cases, getting ready to transfer those that have not gone to hearing or trial to other attorneys who can handle them during my absence, which is still not really determined. And spending two hours in a meeting to deal with the problem client. I drove into my driveway, stepped out of the car and went to my p.o. box on the street to retrieve my mail. Now my front porch is small and you enter it from the side, so it was not until I was going up the stairs to my doorway that I saw that my porch seemed to be completely covered in white packages.

For more than ten years I have been in contact on the internet with a group of women attorneys from all around the United States. We have been there for each other through divorces, child rearing problems, pets, and health issues, just to mention a few topics of sometimes intense and spirited discussion. When my cancer was diagnosed, they were some of the first folks that I told. I put it in our weight loss files.

Well, almost immediately after that, it seems that they all got together and came up with a plan to each send me a charm with one woman (probably the ringleader--you are so great Mel!) sending me a bracelet to put the charms on so I can wear it while I go through my cancer treatment-- a visible symbol of their love and care. It was amazing and humbling to experience this. And although we have chatted regularly for over a decade, some of us have never met face to face! But through the years, via the internet we have become good friends.

In addition, there was a box of fresh Hawaiian papaya (didn't open the box til the morning after) from a dear friend in Honolulu there too.

What gifts. I am truly blessed. Thank you all.

Interval

Sometime in the '90s, I recall watching a tv movie about the ill-fated Antarctic expedition of Robert Falcon Scott. He was a famed English explorer who decided to rely on horses, not dogs to reach the South Pole in 1913. Big mistake. And he and his party made it to the South Pole, only to discover that Norwegian, Roald Amundsen, had beat him there.

Scott and all who went with him perished on the return trip. What made an impression on me was the penultimate scene with Scott in the explorers' tent, his comrades gone, writing furiously, his last letters to friends and family.

The urge not to be forgotten is strong, isn't it?

Winning the Trifecta

The biopsy results are back and they are not good. Yet they are still incomplete. Adenocarcinoma is diagnosed, moderately differentiated. They did not have enough material to identify the 'phenotype' and it is not definite that the lung is the primary site of the tumor.

I mentioned to my primary physician during the phone call that I wanted a full body scan or a PET scan to see where the cancer was in my body, and her immediate reaction was that the treatment was going to be targeting all fast growing cells in my body, so I didn't really have to identify the primary or other metastasizing sites. It's too hard to argue with my voice a mere whisper, so I will wait for when I meet the oncologists I have been scheduled with on Thursday afternoon.

Until then, I leave you with this thought. I had a chest x ray in 2005 and it showed no abnormalities. 4 years. If any of you have been considering a chest exam, I think it might not be a bad idea. This sort of cancer can remain undetected for quite a while.

Waiting

I sing to use the waiting,
My bonnet but to tie,
And shut the door unto my house;
No more to do have I,

Till, his best step approaching,
We journey to the day,
And tell each other how we sang
To keep the dark away.

--Emily Dickinson

What I would not give for a good solid burp

When you have a paralyzed vocal cord, the opening to your lungs is always open. So you have to be careful while eating and drinking that you don't get any solids or liquids down the windpipe. Generally it is not difficult. In my case it is the left vocal cord that is frozen, so when I'm drinking I turn my head to the left to close it off a bit more and avoid water going down the wrong hole, as we so blithely proclaimed during childhood.

But one of the problems with having it open constantly is that for some reason I cannot get a good burp on. And I rather miss that. It kinda hurts to burp and sometimes it feels like a pain in the chest as the gas expands and slowly drifts out. Now if I were a worrywart, I could've taken myself to the emergency room last night when the chest pains became significant. But there were no other symptoms like a racing pulse and I had just eaten a Thai salad with lots of cabbage so....What I found helpful was to take the dogs for a walk. A little movement eased things significantly. But in the end I'd still like a good solid burp. It's like putting a period at the end of a sentence. All I got are commas right now.

Damn.

Postscript: When complaining about this to my daughter, she confessed that at the dinner table once, she and her two younger brothers burped out the alphabet. They could do every letter except "W" which was left to my oldest son. I suppose his long career on swim team and water polo gave him the edge there. Which weirdly fits in with the birthday card I am sending him for his 23d next month. It reads: "You know son, when you were just a baby, I remember burping you." The inside reads: "Now that's just one of the many things you do on your own."

And well too, it seems.

Digging for Gold

The biopsy.

To do a biopsy on a lung is rather different than doing a biopsy on a more stationary organ. The lung moves constantly. That's its job, inhaling and then exhaling; without we suffocate. So nothing stays still unless you will it. And even then you can hold your breath and your lung is in one position and hold your breath a second time and the lung has moved ever so slightly yet putting the tumor out of reach of the needle that is poised to retrieve some matter from it. In addition to moving in and out, your lung also moves up and down the stationary rib cage, so you have another shift that the doctor has to account and adjust for in a successful retrieval. This tumor measures less than 3cm by 3cm so even though that sounds huge to me, it is rather slight for purposes of capture when it's a moving target.

I learned this after we showed up at 6am to the hospital and I was checked into a day room where I disrobed for the procedure, was given an intravenous shunt on top of my left hand, hooked up to a saline drip, and waited. Luckily C, my ob/gyn, who has delivered all three of my children, and who has become a good friend was there to greet us and engage in small talk with my daughter and me, which was reassuring and helped pass the time. Eventually I was wheeled down to level A for the procedure. At some point I met Dr M, the radiologist in charge of the procedure, who was very highly recommended by my ob/gyn. He explained both the process and how the working of the lung made it difficult. He told me that they were going to try both ultra sound and ct scan to visually locate the tumor and then shoot it with the needle punch. He fired the needle punch for me so I would know what it sounded like and then a sedative was added to my drip, but not so much that I would fall asleep as that would negate the process because they needed me to be alert enough to hold my breath.

Dr. M began by numbing the section of the back that was going to take the needle. It took 4 stages to completely numb the area, as he went into the surface tissue first and then into the deeper skin levels with the anesthetic. Then they used both the ct scan and the ultrasound to look into my lung and locate the tumor or growth. The ultra sound did not seem to be providing a clear enough image so they gave that up and positioned me in the donut hole of the ct scan machine. Then I was instructed to breath and then hold it. When Dr. M was prepping me, he said not to take a big breath like I would if I were singing, but to take a normal breath and then hold it. I probably took a breath and held it for them at least twenty times. First they had to mark where it probably was with an 'x' on my skin, then I had to take a similar breath so it showed up in the right position so that the needle punch could take a core sample. At one point Dr. M said, "we're almost there," and then of course my breathing went all off base, so we were back to 4-5 rehearsals, and without warning, he stepped in and >bang< it was done. The ct scan showed the needle going into the tumor and he was quite certain that he had retrieved the desired matter. Which, he then told me was a good thing, because if he had had to do additional needle punches, the danger of lung collapse increased greatly. It was a little like putting a small hole in a balloon.

So, he showed me the material which was a tiny whitish thread held in clear liquid preservative. The nurse and tech cleaned up the punch site, which turned out to be right below my left shoulder blade. That was rather a shock because I thought our lungs were much longer. And then I was whisked upstairs in the new gurney by a wonderfully polite orderly, where I visited again with my daughter and C, and then slept until they took me back to level A to x ray my chest to see if the lung had caved in. It had not so I was taken back upstairs for another hour or so of wait time and then a second chest x ray.

They had given me dilaudid for the pain, and at some point after the second x ray, I became severely nauseous as a result. Apparently it is a common side effect of opioids. That held up my discharge for a bit, but I was home by 1:30pm.

Now we are waiting again. First for the biopsy results, then either for more tests and eventually for a meeting with the doctors to determine a treatment protocol. I am assuming that this is cancer because of the growth on my vocal cord that has reduced my voice to a whisper and barred me from singing was identified on the first ct scan as a metastasis. What they are trying to do right now is learn where it metastasized from. But if by some miracle, they were to tell me that there has been some screw up and it is all benign, I could live with that. Right.

On to more waiting!! My favorite.

I remember as a child not being able to sleep Christmas eve and getting up and taking apart and putting the wind up clock in my bedroom back together. But quietly so I wouldn't wake my younger sister. Right now, I'm looking for something similar that will last longer and it could even be slightly noisy. Have not found it yet.

At the top of the roller coaster

Twenty four years ago plus or minus a month or two, I was in labor with my first child. It wasn't until I was in labor that I realized, "I can't back out of this. I can't quit just because it hurts too much. I have to see it all the way through no matter what I want to do." After 23 hours of labor and no epidural or spinal, I finally gave birth to a 7lb baby girl. At first I couldn't even bear to look at her because it had hurt so much for so long. But when I did, the magic started.

That was my first major ride on the roller coaster, where I was teed up at the top--looking at the yawning abyss below, without a clue as to what was going to happen next, and without any semblance of control.

I am back there tonight, waiting for the biopsy tomorrow and the results and the treatments and the reactions, and, and, and. Only this time, that baby girl is with me and she's telling me things she's learned in medical school, where's she's just started her third year. And we laugh and carry on but a lot of that knowledge is not easy to hear. Things like, I probably have either stage 3 or stage 4 cancer, depending on where the primary situs of the cancer is. And there are only 4 stages. And if the primary site is in another organ, that is a stage 4. But if the primary site is in the lungs, that's a stage 3 but it could have metastasized to another blood rich organ, particularly the brain.

So once again I am teetering on the top of the roller coaster, looking at the darkness below, absolutely terrified, and not knowing what bright birth this portends.

Waiting for Godot, Group Health's second cousin

As you may recall, I received the news of the probable cancer in my lung on Friday last.



At the conclusion of the visit, Dr. H, my ENT doc told me that I could expect a call from oncology on Monday or Tuesday to set up my biopsy appointment. But if I didn't receive a call from them by Wednesday, I should call Group Health.

This is a feature, not a bug in Group Health service. I have learned over my 26 years as a Group Health member that you cannot sit back and expect to receive service: no, you must be an aggressive, informed consumer, unafraid to get in peoples' faces to obtain the service you think you are entitled to.

So over the weekend, I stewed, wrote emails, said thank you a lot to well wishers from many facets of my life and tried not to think about it too much. Fat chance. Luckily there was a wedding Friday night and I had houseguests for the weekend for that ceremony, who kept me well entertained.

Come Monday at 8am I was on the phone, dialing my primary care physician, Dr. Mc, someone I have seen regularly in the past 15 years, and someone with whom I am on a first name basis. I explained my situation to Dr. Mc, something she was already familiar with as I had emailed her Thurs last week and asked if she could give me the CT results early. She demurred, saying that they weren't all in. Of course, now I knew that she really wanted to reserve the tough job for the ENT guy, the one with whom I was meeting in person--something I understood. No hard feelings there. But I did tell her that I wanted her to talk with oncology and get them to call me today, Monday, to set the biopsy appointment as soon as possible.

First I got a call from Dr. N, the pulmonologist, who said he had read the CT scans and that he thought 1) the primary tumor was in the lung not elsewhere in the body, and 2) there was an opening for the type of biopsy which I needed (a CT scan or an ultra sound guided needle biopsy to be placed in my back in the lower left lobe of the lung) on Friday, and if they did not give me that time to call him back. He released my two CT scans to my GH web page, so now I could read them online and see the narratives for myself. And he gave me the number for Radiology, which I called, immediately thereafter. The woman who answered the phone could not help me and sent me to another number where I was told to leave a message. Which I did.

An hour went by. I didn't actually register the passing of time for a bit as I had to drive to Olympia for a big work related meeting and was driving to meet my co counsel, who could drive us both there. Once I got in her car, though, my cell phone rang and it was P from radiology. She started by telling me that I could not have any Motrim, Aleve, aspirin, ibuprofen, fish oil or Vit E before the procedure. No explanation why. I said fine. Then she said, "We have a date open to do this on October 8th." At that point, I jumped in and said, "No. I was told there was an opening this Friday." P said, "Yes, but you have to not have taken any of those drugs for ten days before the biopsy." My thought, not articulated but lit up in red neon at the front of my cortex was "YOU HAVE TO BE FUCKING KIDDING ME, LADY. TEN DAYS FROM TODAY IS NOT OCTOBER 8." What I instead said was, "That's fine, I will be in the clear by this Friday. Please give me the appointment." Which she then did. And then instructed me on the appropriate preparations for the procedure which will be this Friday at 6 am.

Not to be too didactic, but, this is not the first time that this has happened to me at Group Health. Unless I had spoken up for myself, I could have been waiting for 17 days for the biopsy of a tumor that in less than a month had destroyed my voice. Perhaps this is true for private medicine as well, but if so, it is not helpful in the least. I have heard that the oncology staff is very much different from other specialities in terms of their willingness to reach out and assist their patients. I hope that is true.

Again, nothing to do here but wait now for another three days. By then it will have been a week since my life shifted into a different reality.

Health care reform up close and personal

I've written a couple of posts lately about health care reform in the abstract. It's rather easy to do when it's all hypotheticals. Imagination is a wondrous thing--you can get a frisson of fear by thinking of taking up skydiving, but you don't have to go through the actual leaping out of the plane. Same with all those poor people who get sick and what do they do with their jobs and how can they afford this?

Well, I am about to find out firsthand. In the middle of August, my voice started going. That was odd. I had just spent a week at a music camp for adults, singing my lungs out in large and small groups and generally getting jazzed at being with people from all different walks of life doing one thing we loved so well--music. So at first I attributed it to vocal exhaustion.

It didn't get better. It got worse. So then I attributed it to a nasal inhalant I had been taking to relieve allergy symptoms. Stopped taking the inhalant. It got worse. I was reduced to sounding like Marge Simpson only softer.

Four weeks into this, I hauled my butt into Group Health one Sunday afternoon to be seen. The physician's assistant on call that day did a full blood workup and looked in my throat and found nothing remarkable. He suggested that I make an appointment with an ENT. So I called my AP's office the next day to see if she would do a referral. Found out I could self refer. That was a good thing. But that was it for good things.

An appointment with an ENT was made for Wednesday afternoon. Dr. H anesthetized the back of my throat and put a scope down through the nasal passage to the vocal cords. "Say 'eee,' "he said. I complied. "Say it louder." Once again I tried to increase the volume. "Your left vocal cord is paralyzed," he said. He told me that he didn't know the cause but was scheduling me for a CAT scan first to rule out cancer. "It's been 5 or 6 years since I've seen one of these cases where it was caused by cancer, but we should get that out of the way first," he assured me.

So a week later, I was back at Group Health for my first ever CAT scan, with contrast dye. When they inject you with the dye, you get a metallic taste in your mouth and it feels like your are wetting the table. You are not. They injected me twice for two different CAT scans.

Friday at 9am I returned to Group Health for the results. Well, I beat Dr. H's odds. The CAT scan picked up 3 distinct growths in the left lung--two in the lower part and one in the upper lung. It was the upper growth that was pressing on my vocal cord and causing my symptoms. It also appeared that this growth was a metastasis from another, a primary site. Dr. H inquired about family and friends who might live nearby and whether I was a member of a church. When I indicated that I was, he responded, "That's good. They will help you as you get your affairs in order."

So, here we are. On a new, completely unexpected and frankly unwelcome journey. But, because we have this raging health care debate going on in our country right now, and as I am a member of one of only two medical cooperatives in the nation, perhaps my journey can provide some insights into this highly political charged issue. I invite you to come along for the ride.

September 1, 1939

That is the date that the Germans invaded Poland.

September 1, 1939

by W. H. Auden

I sit in one of the dives
On Fifty-second Street
Uncertain and afraid
As the clever hopes expire
Of a low dishonest decade:
Waves of anger and fear
Circulate over the bright
And darkened lands of the earth,
Obsessing our private lives;
The unmentionable odour of death
Offends the September night.

Accurate scholarship can
Unearth the whole offence
From Luther until now
That has driven a culture mad,
Find what occurred at Linz,
What huge imago made
A psychopathic god:
I and the public know
What all schoolchildren learn,
Those to whom evil is done
Do evil in return.

Exiled Thucydides knew
All that a speech can say
About Democracy,
And what dictators do,
The elderly rubbish they talk
To an apathetic grave;
Analysed all in his book,
The enlightenment driven away,
The habit-forming pain,
Mismanagement and grief:
We must suffer them all again.

Into this neutral air
Where blind skyscrapers use
Their full height to proclaim
The strength of Collective Man,
Each language pours its vain
Competitive excuse:
But who can live for long
In an euphoric dream;
Out of the mirror they stare,
Imperialism's face
And the international wrong.

Faces along the bar
Cling to their average day:
The lights must never go out,
The music must always play,
All the conventions conspire
To make this fort assume
The furniture of home;
Lest we should see where we are,
Lost in a haunted wood,
Children afraid of the night
Who have never been happy or good.

The windiest militant trash
Important Persons shout
Is not so crude as our wish:
What mad Nijinsky wrote
About Diaghilev
Is true of the normal heart;
For the error bred in the bone
Of each woman and each man
Craves what it cannot have,
Not universal love
But to be loved alone.

From the conservative dark
Into the ethical life
The dense commuters come,
Repeating their morning vow;
"I will be true to the wife,
I'll concentrate more on my work,"
And helpless governors wake
To resume their compulsory game:
Who can release them now,
Who can reach the deaf,
Who can speak for the dumb?

All I have is a voice
To undo the folded lie,
The romantic lie in the brain
Of the sensual man-in-the-street
And the lie of Authority
Whose buildings grope the sky:
There is no such thing as the State
And no one exists alone;
Hunger allows no choice
To the citizen or the police;
We must love one another or die.

Defenceless under the night
Our world in stupor lies;
Yet, dotted everywhere,
Ironic points of light
Flash out wherever the Just
Exchange their messages:
May I, composed like them
Of Eros and of dust,
Beleaguered by the same
Negation and despair,
Show an affirming flame.

Health care reform, part two

I'm in the midst of a discussion about health care reform on another internet forum. A point was raised by Paul, the author of my previous thread here, which I think merits mention because focusing on it and thinking about it, and talking about it could change the tenor of the debate.

"Having everyone in the risk pool is not an 'arbitrary' definition of meaningful at all. It is how you make insurance work economically, efficiently.

Let's take a different tack here. We have mandatory auto insurance laws. Illegal to drive without auto insurance. Matter of responsibility and economic efficiency. No partisanship. No significant political opposition to such laws. No opportunity to say that you should be exempt because you have an exemplary driving record and are willing to take the chance. We determined a long time ago the social costs of your personal risk tolerance are too great to allow you the decision to do without.

The same logic applies. When healthy people exclude themselves from the risk pool, economic inefficiency is created, regardless of outcome. When unhealthy people are excluded from the risk pool, the costs of their care don't disappear, rather they are simply exported off the books of insurance companies and onto the books of a different system--either the provider who gets stuck with the bill that the patient can't pay, or the government (which means taxpayers, which means *you*) that has provisions for providing care to such persons.

Because individual insurance companies are allowed to exclude such persons, *all* of us pay bigger hospital bills, and *all* of us pay more taxes.What all of the people shouting about the cost of the health care bill are ignoring is the costs we are all bearing, right now, of the current inefficiency of our system. When they insist that the kinds of changes contained in the proposal will drive up medical costs, they are also ignoring the empirical evidence of every single other western country that making coverage and access universal is associated with lowering overall costs, not raising them. "

The Health Care Bill--a damn fine summary

Over the years, I have had the opportunity to meet some very good people via the internet. It's the new wave, I guess. But this fellow is a former ERISA attorney and a very sharp thinker. He's read the entire House Bill concerning health care reform and has summarized it without inserting any political opinion whatsoever. I offer it for your information herewith:

http://docs.house.gov/edlabor/AAHCA-BillText-071409.pdf

The Bill is divided into three divisions, A, B & C. Only Division A is concerned with what we think of as 'health care reform', and it is the first 215 pages of the 1018 page pdf document.

Division A

Title I is concerned with reform of the health insurance marketplace. Contrary to disappointingly common criticism, there will still be a health insurance marketplace.

Although people call this a health care reform bill, it is nothing of the kind. It is a health insurance reform bill. It is concerned with changing the rules applicable to health insurance companies, and it does that by asserting federal power into an area previously left to the states: regulation of insurance. It does not abolish state insurance licensing and regulation. Rather, it adds a number of rules at the federal level that must be adhered to.The main features:

Subtitle A

--contains the grandfathering provisions for current health insurance plans and policy holders; current policies and policy holders will not be subject to all that follows, as long as the current arrangements continue in effect

--as has been noted, employer based plans are not grandfathered, but have a 5 year transition period to be subject to the new rules; and while some critics have tried to make this into ERISA armegeddon (the WSJ erroneously stated that ERISA would be repealed--hogwash), the reality is that most of the new rules imposed in Subtitle B are already rules employer plans must follow (including bars to pre-ex, guaranteed issue, no risk rating, and certain mandated benefits); consequently, the effect on employers presently offering health insurance would seem to be rather minimal

Subtitle B

--pre-existing condition exclusions will be barred
--all policies must be guaranteed issue
--risk rating of insurance premiums will be prohibited
--community rating (charging premiums by risk rating the entire population of a geographic area) will replace individual risk rating to price policies; the only other pricing variances to be allowed being policyholder age and family coverage
--mental health parity and substance abuse benefit requirements currently applicable to employer plans under ERISA will be applicable to all health insurance policies (if it matters to anyone, my professional experience was that these benefit mandates had a negligable impact on employer plan premiums)
--PPO and HMO style plans still allowed, but the feds will now determine the standard of adequacy of provider networks to constitute a legitimate plan, instead of leaving it to state by state insurance commissioners
--in an apparent attempt to prevent cherry picking, the federal government will monitor the 'medical loss ratio' of insurance issuers to ensure that they are providing adequate access

Subtitle C

--establishes an 'essential benefits package' for all health insurance sold; inaddition to enumerated benefits, the essential package also limits copays and prohibits annual and lifetime maximums on the enumerated benefits
--the ten enumerated benefits are: hospitalization, outpatient hospital/clinic services, including ER, health professional services, services, equipment and supplies incident to professional services, drugs, rehab (all kinds), mental health/substance abuse, preventive care and vaccines, maternity, well baby
--copays and deductibles prohibited for preventative and well baby care
--copays and deductibles limited by an acuarial value that I don't really understand, but also by a hard cap of $5k individual $10k family annual out of pocket
--establishes a federal committee to determine if more essential benefits need adding in the future
--establishes a mechanism for developing better plans than the minimum at greater premium cost

Subtitle D

--is concerned with 'additional consumer protections'
--creates a federal standard for grieving/appealing insurance claim denial
--creates a set of reporting and disclosure standards familiar to administrators of ERISA plans applicable to all insurance
--creates timely reimbursement standards
--federalizes coordination and subrogation issues

Subtitle E

--establishes the Health Choices Administration, a new federal agency to oversee all this

Subtitle F

--contains legal housekeeping rules that I doubt will be important to anyone

Subtitle G

--applies the anti-cherry picking rules to everyone, including the grandfathered group health arrangements
--applies anti-recission abuse rules to everyone, including grandfathered insurance
--creates electronic data transfer standards for the industry in an attempt to reduce administrative cost by getting the medical profession onto the information superhighway with the rest of us
--creates a federal retiree re-insurance program; this appears to me to be a bailout of private sector employers who can't afford to keep their retiree insurance benefit promises any more

Title II establishes a new health insurance marketplace called the Health Insurance Exchange

Subtitle A defines the HIE

--All of the new health insurance plans, the ones not grandfathered, that meet the requirements of Title I, will be bought and sold through the HIE, which will be overseen by the new agency created by the Act.
--In addition to individuals, employers can also purchase health insurance plans for their employees through the HIE
--employers will be transitioned into the HIE over a three year period, smallest first; individuals will be transitioned over a two year period, those without health insurance coverage, first--the Act contemplates four tiers of coverage being available, 'basic' (the minimum benefits described in Title 1), 'enhanced' (basic, with lesser copays), premium (even lesser copay responsibility), and 'premium plus (additional benefits like dental and vision)
--the federal government essentially replaces brokers as the intermediary matching consumers to insurance products; insurance companies develop a product, and submits it to the feds for approval as an HIE product; insurance company tells feds the maximum number of enrollees it is willing to accept; the feds will be responsible for enrolling people in the plans--although the fed handles most broker functions, the Act provides that premium payments are to go directly to the insurance company, not through the feds
--there are a number of rules for coordinating the interaction of low income subsidies for health insurance provided elsewhere in the Act, as well as coordinating between Medicaid and the HIE
--the HIE will be funded through a dedicated trust fund; the trust fund's income will be: taxes on individuals who do not obtain 'acceptable coverage', taxes on employers who do not offer acceptable coverage; excise taxes levied under the Act
--a mechanism is there for states to opt out of the HIE, if they provide a state level equivalent system

Subtitle B provides the public health insurance option

--the public health insurance option is only vaguely defined; it is supposed to generally comply with all the rules being applied to private sector health insurance plan, but with the feds in the role of insurer; pretty much everything is left for the agency to develop, from coverage options to premium pricing
--there are more detailed rules about how the feds are to behave in setting provider reimbursement rates (personally, I would not expect these rules to survive)

Subtitle C provides "Individual Affordability Credits"

--citizens and lawful immigrants whose income is below 400% of the federal poverty level for the family size involved, who is not being offered insurance by an employer, and who are not Medicaid eligible, get a rebate on the cost of buying insurance from the HIE; the amount of the credit will depend on the relationship between the persons' income and the premium rate for a basic health insurance plan
--there will also be rules developed for giving people a break on copay requirements, based on their income/affordabilitiy to themTitle III sets forth the Individual and Employer Responsibility requirements for obtaining insurance
--Individuals who do not have health coverage from an employer and do not buy any coverage will be assessed a tax of the lesser of 2.5% of income or what would have been the cost of a basic coverage option plan.
--Employers satisfy their responsibility requirements by offering health plan coverage that meets all the minimum benefit requirements, and pay at least 72.5% of individual premium cost, and 65% of family premium cost. If an employee opts out of their employer's plan coverage and buys other insurance, the employer must make a premium contribution to that coverage cost.--Employers who do not satisfy their responsibility requirements will have to pay an excise tax amount into the HCA trust fund equal to 8% of their payroll. Lesser amounts will be assessed against 'small employers'
-- generally employers with a payroll under $400,000. Employers with a payroll under $250,000 would be completely exempt.
--The HCA is empowered to create rules to prevent employers from steering employees out of their plans by offering them inducements not to enroll.
--ERISA is amended to make complying with the employer responsibility coverage provisions an ERISA requirement, subject to ERISA enforcement. Offering a plan, but failing to offer proper coverage or make proper contributions becomes an issue of fiduciary duty, and subjects you to the full arsenal of ERISA enforcement. This enforcement scheme will run in parallel with the HCA's own audit and enforcement scheme set forth in the statute. [As a old ERISA hand, I find this odd, as this was the way that ERISA was set up with both DOL and IRS having overlapping jurisdiction and responsibility. This was unwieldy and led to a 'treaty' being signed between IRS and DOL setting forth who would do what, in terms of ERISA plan audit and enforcement.]

--Title IV makes amendments to the Internal Revenue Code consitent with the provisions discusses so far.

In addition:

--Small businesses will receive a tax credit incentive to elect to provide coverage.

--People with an AGI of $350,000 to $500,000 will pay an additional 1% tax. People with an AGI of $500,000 to $1 million will pay an additional 1.5% tax. People with an AGI of more than $1,000,000 will pay an additional 5.4% tax. The two lower bracket rates will double in 2012 unless the HCA calculates that certain minimum health care cost savings have been achieved.

This brings us to the end of Division A of the bill, and the portion that deals with health insurance marketplace reform. This brings us to page 215 of the 1018 page PDF document that is the House version of the bill.

Division B of the bill is all about buffs to the Medicare and Medicaid programs. It takes up pages 216-856 of the bill. Apart from the gross mischaracterization of the proposal in this part to expand the scope of reimbursements for end of life counseling as "death panels", these 640 pages don't seem to have generated any controversey. My take on this portion of the bill is that it is a mixture of needed changes and benefit expansion wishlists/pet projects. It's attachment to the Division A proposals discussed above isn't particularly necessary, but was probably intended to help make the bill an offer you can't refuse as a legislator, lest you be branded in your next election by your opponent as having voted against Medicare benefits.

Division C of the Act is Titled Public Health and Workforce Development

--It takes up the remaining 152 pages of the bill.

--Though nearly as long as the health insurance reform provisions, it is not nearly as ambitious, appropriating a modest (by modern budget standards) $4.6 billion in 2010, escalating to $12.7 billion in 2019 for everything in Division C of the bill

--Activities funded by this appropriation include: community health centers, a national health service corps, expanded student loan programs to fund students of primary care, family, general internal, pediatric and geriatric physicians, as well as nurses, dentists and dental hygenists, a public health corps workforce program, prevention and wellness programs, drug discount programs, school based health clinics, a national medical devices registry

That's it. That's the whole bill.