June 29, 2007 - Sicko

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

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

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

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

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

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

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

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

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

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

(06.29.07) Recommends:

Concert Photography, Vol. 9.
a first opening band,
Fair to Midland,
a headlining band,
Slim's,
San Francisco, Calif.
06.29.07.

So the cool folks over at Sneak Attack Media invited me out to see Fair To Midland at Slim's. I didn't know anything about the band, but their publicity photo has the band in a swamp with a banjo-wielding lead singer:



So eschewing the whole "don't judge a book by its cover/don't judge a band by its PR photos" I headed out to Slim's. The first thing I noticed was that the band is proud to be from Texas:



Texas is home to lots of good music, so in my mind I was expecting something along the lines of Southern headbanging bluegrass. Bluegrass, because of that banjo pic. Headbanging, because as I wandered through the crowd, my mind kept repeating one line: "I love you but I've chosen darkness..." This crowd was rocking mohawks (I'm not talking about those obnoxious hipster fauxhawk things, I'm talking honest-to-god three foot mohawks) and lots of black and etc. This seemed like handbanging people. Oh yeah, also headbanging because:



The bassist looked like a cross between Slash and Iggy Pop. So the band came out and started their aural assault on the crowd. The crowd really seemed into it (but then, maybe everybody was into just because it was one of those rare occasions where you can wear your three foot high mohawk and people would give nods of approval rather than rolling their eyes, or shielding their children). I was mainly just confused, and stubborningly holding out hope for some heavy metal bluegrass in the middle of the song.

Now, some of you readers may be scoffing at the notion of heavy metal bluegrass. My love of bluegrass is well documented on this blog. Same goes for my love of alternative forms of bluegrass. In fact, certain blog readers will recall my days as the manager of the infamous, debaucherous, peerless (naysayers may claim "wholly" "fictitious") China Man Bluegrass Band. I managed them starting from their legendary Shanghai Lonesome Sound Tour to the day of that untimely and fiery crash that ended the band in Sandusky, OH. Playing Chinese Bluegrass in the middle of Sandusky, OH. While it may or may not have actually happened, that, my friends, is Alternagrass. Around the same time as CMBB, I fell into the Bloodshot Records scene with Split Lip Rayfield and others playing that indie-rock-country-punk for which the label is known. I'm telling you, in the early 2000s cowboys with tattoos screaming Hank Williams songs was way more dangerous than MTV generated gangsta rap. And that's probably still true today. So all of this is a roundabout way of saying that Heavy Metal Bluegrass seemed completely plausible to me.

Meanwhile back at the show...

I'm not sure how this music is officially classified by those on the internet who have finely calibrated music labeling apparatuses (apparatti?). Does this music qualify as screamo? I think it does. The lead singer is very emo. I don't know if he's emo in real life, but when he steps on stage he has the role of Emo Lead Singer down pat.



But he also really reminded me of the lead singer of local heroes Magic Bullets. As by this I mean he was insanely frantic the entire set.

The wind up:


The delivery:


The pitch:


FTM left the stage, and all the mohawks went wild for the next band. But two songs into the headlining act I left Slim's, head down, slightly dejected. I guess heavy metal bluegrass will have to wait for another day. Until then, I still have Cookie Mongoloid.

June 28, 2007 - In Search of the Lost Node

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

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

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

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

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

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

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

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

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

(06.28.07) Recommends

Web Royalty Redux.

I thought that today I would add a little more meat to the bones of yesterday’s post. I want to look at the mechanics behind the royalty rate increase "controversy."

The first thing to think about is how the Copyright Act is implicated when you, e.g., listen to a CD (I know that it is so old school to actually listen to CDs, but just play along). There are at least two copyrights in a CD: first, there is copyright in the "musical work" (what you think of as "the tune," both the underlying arrangement of notes and any accompanying words), 17 USC 102(a)(2); secondly, there is copyright in the "sound recording" (the actual recorded sound that comes out of your speaker), 17 USC 102(a)(7). The copyrights are not necessarily held by the same party: copyright in the musical work is initially owned by the party who wrote the music – the composer and lyricist – while copyright in the sound recording is initially typically held by the producer who arranged for the song to be recorded. Of course, the holder of the right may be determined by contract, with the record label often owning at least the latter copyright, if not both.

Okay, so now that we understand that there are two distinct copyrights in play, what rights actually attach to these copyrights? Copyright owners hold four basic rights, the right to: reproduce, prepare derivative works, distribute, and to publicly perform. 17 USC 106. The "musical work" copyright gets all of these rights. The "sound recording" gets the first three, and a modified version of the fourth. The modified version is the right to perform publicly by means of a digital audio transmission, and this right did not come into being until the Digital Performance in Sound Recording Act of 1995.

So what does all of this mean? Well, let's go through an example. When a terrestrial radio station plays a song, it is publicly performing the musical work and the sound recording. It pays the song writer (or whoever owes the musical work copyright) for its use of the copyrighted musical work, but it does not pay for its use of the copyrighted sound recording. Why? Because copyright in sound recording only applies to digital transmissions, which by the terms of its definition in the Copyright Act exempts terrestrial radio. When an internet radio station plays a song, it has to pay for use of both of the copyrights. Arbitrary, you say? Of course it is. But, anybody who has ever paid taxes or been pulled over for speeding when every car around them was going faster has experience with an arbitrarily written or enforced law. Arbitrary laws are nothing new in this country. But to be clear, this sound recording performance right result cannot be justified on the basis of copyright law; it is solely to be chalked up to the power of the terrestrial radio lobbying efforts (let me repeat this for all of you out there who think the recording industry is the root of all evil: radio broadcasters using the political process to reach a result that is favorable for their side, but that makes no sense from a legal standpoint).

The rate increase "controversy," then, is dealing with the price of that digital sound recording performance copyright. Webcasters (as is true with the musical work fee paid by terrestrial radio broadcasters) pay one statutorily based rate - a per performance "compulsory license" -- for each performance, rather than having to negotiate a different rate for each performance (if I didn't write that sentence clearly, think of it this way: rather than broadcasters having to negotiate, and therefore pay a lot more, to play an Elvis Presley song than an Elvis Perkins song, there is a single rate that is paid per performance, regardless of the song).

The Copyright Act provides a mechanism to reach that royalty rate. First, it encourages the copyright holders and the internet broadcasters to privately negotiate and reach a desirable rate on their own. 17 USC 114(e). Only after these negotiations fail do both sides come before a Copyright Royalty Judge who commences trial-type proceedings, 17 USC 114(f). This means that both sides put on witnesses and evidence, just like they would if they were having a trial, and at the end the Copyright Royalty Judge comes down with a ruling.

So let's apply this to the "controversy" at hand. At first, the copyright holders and broadcasters came together to negotiate. Some of the initial members of the internet broadcasters included: Microsoft, America Online, Yahoo, and Clear Channel Communications (it is worth keeping this in mind when you see coalitions such as Save Net Radio framing the issue as Big Govt vs. Mom and Pop Radio). Both sides presented a proposal, bolstered with evidence and witnesses. Included among the internet broadcasters' witnesses included economics professors, finance experts, and corporate executives. At the end of the trial, the Copyright Royalty Judges (there were three that presided over the hearings) came down with their ruling.

In this case, the copyright holders proposed a rate of either 30% of gross revenues or a per performance rate starting at $0.0008 and increasing to $0.0019 by 2010 (the statute calls on the Copyright Royalty Judges to set rates in five-year blocks), whichever was higher. The internet broadcasters offered various revenue-based percentages, and various per performance rates, starting at $0.00025 per performance (so note that when critics of the fee increase call the rate "outrageous" they are talking about a difference of $0.00055 per performance; I'd calculate the percentage difference in those two numbers but I don't have a calculator that allows me to enter that many digits on the right side of the decimal point). Both sides presented their proposals and evidence and witnesses, and after a 48-day hearing, the judges came out with the numbers I presented yesterday.

The biggest complaints I've read regarding this "controversy" are that this is an example of Big Govt v. "Little Mom and Pop" and that the music industry was the only player in setting the rates; that somehow the internet broadcasters were not at the table in the rate setting discussion. Plainly, both of these are just false.

And, on a personal note, whenever I see shadowy coalitions talk about "Little Mom and Pop," and then fail to mention that "Little Mom and Pop" includes parties such as Microsoft and Clear Channel, I start thinking that the "controversy" is nothing but a big budget PR campaign (see, generally: smoking is not bad for you, presented by shadowy coalitions brought to you by tobacco companies; lawyers are bad for you, presented by shadowy coalitions brought to you by insurance companies).

Think what you want to think about these rates, leave me comments, email me, etc. But at least take a few minutes to read the ruling before you buy into the conspiracy.

AF-200FG Flash

Here are a few quick photos of the AF-200FG flash mounted on a K10D. I thought a few folks would like to see the relative size of this flash when in use. I shot these images outdoors under our tan patio umbrella, so I apologize in advance for the color cast in these photos.

(06.27.07) Recommends:

Reading Rules Before Complaining About Them.

I don't know how your web surfing has been going lately (btw, do people even use that word anymore -- websurfing? So quaintly 90s, right?) but I'm growing increasing exasperated at all these blogs complaining about the Copyright Royalty Board's implementation of new royalty rates that webcaster's must pay to play music. A bunch of web radiocasters engaged in a Day of Silence in protest. Coalitions have been formed, to get people aware of the "problem."

Here's the thing. Go ahead and Google this problem. What do you come up with? A bunch of blogs complaining of "outrageous rates" that are "putting webcasters out of business" and "taking food out of people's mouths" by charging "more in fees than we can possibly make up in revenue."

Which is all very concerning. Except that none of the blogs or articles say what the rates are, or what the rates were, or how much money they are losing. Editor's note: this is not a good way to convince people of your point.

So, for my sanity, if not yours, today I present the CRJ's Final Determination of Rates and Terms. Now, I'm not completely finished hashing through the opinion, but here's something that immediately jumps out at me: it includes the rates! And here are the rates:

$0.0008 per performance, 2006 (the fees are retroactive).
$0.0011 per performance, 2007.
$0.0014 per performance, 2008.
$0.0018 per performance, 2009.
$0.0019 per performance, 2010.

These numbers are conveniently left out of all anti-fee discussion I have seen. Why? I'm not sure, but here is a possibility. For people who live in the Bay Area, and pay...

$3.50 per gallon of the cheapest Rotten Robbie gasoline;
$4.00 per grande cuppashittychino;
$10.00 per cheapest six pack of beer;
$1000 per month for small one bedroom apartment;

...it would be awfully hard to work up the energy to write passionate blog posts about zeros and zeros of cents. But it's much easier when we can scream : the govt is interfering with our lives, harming the little guy and making the rich richer! Editor's note: Everybody stop your damn screaming.

Read the opinion first. I'll be sure to wake you up in the middle up it, because I'm pretty sure you'll fall asleep reading it -- it turns out the reality is much more boring -- and much less outrageous -- than the screaming blog posts suggest.

Copyright Royalty Judge -- Final Determination of Rates & Terms -- pdf.

June 27, 2007 - A Miracle?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Miracles? They're everywhere.

(06.26.07) Recommends:

Miranda July.

She's like an artistic octopus: filmmaker, performance artist, musician (on no less than Kill Rock Stars), writer, and at least four other things to make the analogy complete. Her new collection of stories is "No One Belongs Here More Than You," and while it is still currently merely on my "To Read" list, I have unrealistically high hopes based on its promotional website -- easily one of the most perfect uses of the internet ever. Seriously.

Miranda July -- No One Belongs Here More Than You -- website.

June 25, 2007 - The Operation That Wasn't

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

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

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

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

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

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

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

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

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

Snapshots from Weekend

We went back this weekend to New England to check-up on our elderly parents. We were relaxing Saturday afternoon on my mother's patio, and I had a chance to walk around her property to capture a few photos with the 50mm f/1.4 lens.

Note about last image: As my mother was just given an award for her efforts to promote the arts in her community, we decided a photo of the "artist in her studio" was appropriate. I switched to the 31mm lens for this photo.

(06.23.07) Recommends:

Brian Michael Roff, the track "The Underpainting" from the album "The Underpainting" (CSP, 2007).

This is a lovely song that magically appeared in my email this morning, from the vital Cat Bird Records. So I wanted to share it with all of you.

Brian Michael Roff -- The Underpainting -- mp3.

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

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

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

Here's an excerpt from the article:

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

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

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

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

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

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

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

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

(06.22.07) Recommends:

Seymore Saves the World, s/t (Royalty, Etc. Records, 2007).



Seymore Saves the World is my Band of the Month for June. Here's how it came to be. So, everybody who has a Myspace page gets about ten friend requests each day from bands. As a fan of music, I have no problem taking a few minutes out of my day to go to the band's page and listen to what they have streaming...before usually cringing, denying the invitation, and never thinking about the band again (I know, I'm a horrible person, but I'm only one person, and there is a fixed amount of room in my head to store the constant onslaught of information we are given everyday. I'm trying, people.). I try to be an optimist with things like this, but sometimes the sheer volume of requests gets on my nerves. So then I started a new policy: anytime I get a friend request from a band, I reply saying if they send me a copy of their CD/demo/whatever, I'll take a listen and review what I receive.

So enter Seymore Saves the World. I shouldn't be surprised that the first band to take me up on the offer would be from Minneapolis, home of reasonable people and great rock bands. And for the amount of crap that one wades through on Myspace, I've been pleasantly surprised with this album. I received it way back in the long-ago days of May, but have designated them as my Band of the Month for June, because they have a classic summer sound. Very pop-rock, with keyboards, and "do-do-doo" harmonies. They could be played in the Two For Tuesdays slot on any Classic Rock Station in the country without the listener realizing that the classic sound is being made in the Here and Now. And there's something to be said for that.

Seymore Saves the World -- Summer 2005 -- streaming audio.

June 22, 2007 - You Takes Your Chances

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nasal C-PAP or BiPAP mask

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

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

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

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

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

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

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

June 16, 2007 - Labyrinth

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

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

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

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

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

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

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

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

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

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

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

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

Enough of this. Back to the children.