In My Hands

by Steven A. Curley

  Bad golf for us means losing a dozen or so golf balls in the desert or rocky arroyos running alongside a perfectly cut fairway. If one of us breaks 100 it is a cause for major celebration, and a reason to require the offender who earned a respectable double digit score (without mulligans) to buy drinks for all at the nineteenth hole. All four of us were athletes in our younger years but never found the time to become skillful at the game. I emphasize I cannot bring myself to call golf a sport. I am hard pressed to designate an activity a sport when there is a person who drives around the course to provide snacks and beverages, both alcoholic and otherwise, while playing the game. And riding from shot to shot in a golf cart, this is exercise?

  A few years ago my friends and I played a new course in Las Vegas that was much too fancy and difficult for our group. We were required to take a caddy with us, which was not something we had ever previously done. On the first hole he politely explained where we should place our tee shots to be well positioned for a second shot. Our group glanced at one another and each proceeded to tee off and strike the ball. At the conclusion of four opening shots that landed nowhere close to the caddy’s recommended destination, we looked at him and said, “Your job today is to help us find the balls after we hit them into random and unpredictable locations.” He nodded and maintaining a calm, professional demeanor stated, “I get it. Game on!” Good sport! Plus, he did need to think about his tip at the end of the day, so laughing at us could have had an undesirable consequence.

  Occasionally, I have a patient semi-jokingly ask if I plan to play a round of golf after I complete an operation. There are still plenty of people who believe doctors spend lots of time on the golf course. Perhaps there are some who do, but I am not one of them. I explain to patients I am only invited onto nice golf courses if they have a need to aerate their usually well-groomed lawns. I also admit I have a tendency to annoy the serious golfers because I spend a great deal of time boisterously laughing or faux-contemptibly commenting about my own wildly errant shots. It is not uncommon for my Chicago-based surgical friends or me to note sarcastically after one of us strikes the ball, “Hey, nice shot; you’re in the fairway.” The problem is, frequently it’s the fairway for the next hole. And out of bounds? We created an entirely new definition for hitting balls out of bounds. We need a bullhorn to shout, “Fore!”

  Some years ago, a new patient asked me if I played golf. I explained I was an occasional golfer and not at all proficient at the game. I remember the conversation vividly.

  PATIENT: What’s your handicap?

  ME: The clubs, the balls, and the golf courses.

  PATIENT (laughing): I understand.

  And I knew he did.

  I asked him if he played, and to my surprise he replied, “Yes, I’m a professional golfer.” He went on to tell me he was the Professional Golf Association (PGA) player and instructor at a course in a well-known East Coast golf destination. I was impressed, but told him we would talk about his cancer-related issues first and perhaps sometime later he could offer advice on my golf swing. This was an agreeable arrangement and he appreciated my prioritization of problems.

  I met this gentlemen and his wife three years after he was diagnosed, in his early thirties, with a rare situation, a carcinoid tumor of his bile duct. This tumor had been removed at another institution but as carcinoid tumors frequently do, the cancer had putatively reappeared in his liver. His treatment had involved removal of the bile duct and reattachment of his liver bile ducts to a loop of bowel and, subsequently, six weeks of radiation therapy. Ionizing-radiation treatments to the base of the liver are not without risks. Proving the saying “No good deed goes unpunished,” the radiation therapy to prevent recurrence of his bile duct carcinoid tumor caused a significant problem: he developed bleeding and pain from a duodenal ulcer which required treatment. Fortunately, the ulcer resolved with intensive antacid therapy and tincture of time.

  When we met, the golfer brought CT images suggesting the presence of small, new tumors in his liver. The scans showed a couple of really small nodules not definitive for recurrent cancer, and he had no evidence of carcinoid syndrome. After obtaining new imaging studies, we decided to follow him closely and not intervene with any therapies until he showed signs of obvious tumor growth or developed symptoms.

  Over the next several years not much happened. We continued to detect a couple of small spots on his liver with CT scans, but the spots didn’t grow or change in appearance. Nothing new developed in his liver or elsewhere. He was still playing golf and functioning normally. His blood and urine tests showed no endocrine symptoms or biochemical evidence of hormone overproduction. Things were stable, and he felt well. So we watched.

  Patients who have cancer can have other medical problems arise. About eight or nine years into our relationship the golfer developed severe jaw pain. He saw a physician who diagnosed him with temporomandibular joint (TMJ, the hinge joint where the lower jaw connects to the skull) dysfunction. The pain persisted and worsened so his doctor ordered a CT scan of his head and neck region. At this point I received a call from the golfer’s wife to report he had been admitted with a dissection of his right carotid artery. This means a small tear had formed in the innermost lining of the large artery (the one with a pulse that can be felt on either side of the neck). When this happens, blood is able to enter the space between the inner and outer layers of the vessel, causing narrowing or complete occlusion, which can cause a major stroke. This would be disastrous for anyone, let alone a fortysomething, active professional golfer.

  Thankfully, he had no neurologic consequences beyond local pain related to the arterial dissection; the jaw pain was caused by reduced blood flow to the muscles and tissues of the jaw. The arterial problem was addressed and the symptoms resolved. The golfer’s wife asked if carotid-arterial dissection was associated with carcinoid tumors. I explained I had never encountered such a problem in a carcinoid patient but promised to get back to her after doing some research.

  My research showed no propensity toward carotid, or other, arterial dissections in patients with carcinoid tumors. And the golfer did not have high blood pressure or other risk factors for arterial dissection. When I next saw him in the office, I happily reported there was no change in the small, asymptomatic liver tumors on his CT scans. Sardonically, I added he just had to be different and develop an arterial dissection to cause increased bother and worry. With his customary wry smile he retorted that the “unusual was usual” for him.

  I have only a single patient who is a professional golfer, but I have met one other somewhat recognizable golf pro. Someone you may have heard of: Arnold Palmer. We met seven or eight years ago because he is a friend of a great guy I was collaborating with, Jim Rutkowski Sr., from Erie, Pennsylvania. Jim knew I was giving a medical lecture in Florida so he arranged for me to meet Mr. Palmer. I had dinner with Mr. and Mrs. Palmer at his golf course in Orlando, Bay Hill. He told great stories and we had a marvelous time.

  Later the same year he came to Houston as host of a Senior PGA Tour event. Thoughtfully, he called and invited me to lunch at the course during the tournament. We dined and then walked out to check on the proceedings. We didn’t get far because every few steps a fan would deferentially ask for an autograph or photo with Mr. Palmer. It took us thirty minutes to walk fifty yards. He was kind, patient, and turned nobody away. He smiled for pictures and signed balls, caps, shirts, and programs along the way until we finally arrived to watch the shots land on (or near) the eighteenth green. I found him a noble, considerate, and wonderful man, and I greatly enjoyed our conversations.

  A few years ago he asked me to visit him again in Orlando two weeks before his annual (Bay Hill) Invitational PGA Tournament. I took my father-in-law, one of the aforementioned serious golfers, and he and I played two rounds. On the practice tee the second day, Mr. Palmer quietly ambled up behind me and watched a few shots. He asked, “Can I give you some advice, Doctor?” Are you kidding? Free golf advice from Arnold
Palmer! I readily accepted his offer, and with a solemn face he said, “Don’t give up your day job.” He slowly walked away, laughing. Thank you, Mr. Palmer. By the way, the rough at Bay Hill was so long I lost four golf balls in two days on shots that simply rolled from the fairway into the long grass. It was as if the balls had crossed the gravitational field of tiny black holes that had sucked them into the weeds, never to be seen again. How do those professionals hit out of the stuff?

  About five years ago, my professional golf patient had another strange medical event. He developed a large abscess in the right lobe of his liver. He had fever, chills, and upper-abdominal pain. CT imaging revealed an area of infection in his liver. It was not clear if the area represented an infected tumor or some other cause. A drain tube was placed through the skin into the infected fluid in his liver, and he was placed on high doses of intravenous antibiotics.

  I reviewed the CT images with a radiology colleague, who was worried that the infection might have arisen in one of the small tumors and progressed into a large, dangerous abscess. The golfer was still having symptoms, and I wanted to control the infection because of the direct connection between his bile duct and a loop of his intestine. I discussed and considered options with the golfer and his wife. Concerned about infected tumor tissue, which may not heal or resist infection like normal tissue, we came to an agreement, and I removed the right lobe of his liver. The intraoperative ultrasound revealed he had evidence of ongoing inflammation and what appeared to be small tumor nodules around and near the liver-abscess cavity. However, he persisted with his medically unusual propensities and the final pathology showed only an abscess of the liver with no tumor in any spot in the liver, carcinoid or otherwise. He recovered well, and thankfully has had no recurrence of any odd infections in the liver, nor at any other site. His wife and I are waiting cautiously. There’s no telling what he’ll do next.

  Carcinoid and some other neuroendocrine cancers can be odd actors and patients can survive with the disease for many years. It’s been almost twenty years since the golfer was diagnosed with carcinoid cancer. He moved a few years ago from the seaside golf resort to another beautiful location in the Appalachian Mountains. He serves as the full-time PGA professional at his new job and golf course. About three years ago he developed some of the classic symptoms of carcinoid syndrome. He started flushing as many as fifteen times a day and was having loose bowel movements. For the first time, his blood-test levels measuring carcinoid-tumor-related hormone production were very elevated. Despite the symptoms, we saw no obvious tumors in his liver or elsewhere, but microscopic deposits of carcinoid-cancer cells within the liver can release the excess hormone. Despite the absence of detectable tumor nodules, the noxious carcinoid symptoms were negatively impacting his life, and I started him on a once-monthly injection to block the effect of the excess hormone release. He has thanked me for controlling the symptoms, but he also informed me I’ve become a real pain in his butt. The agent is injected in a relatively large volume with a long, hefty needle directly into the gluteus maximus muscle. Left cheek one month, right cheek the next, repeat indefinitely. You are welcome.

  The golfer is a thoroughly pleasant and persistently patient individual. I have benefited from the lesson his patience has taught me. He is unflappable and implacable—characteristics I must remind myself daily to seek and achieve. After caring for him for many years, his wife informed me that he had independently initiated an annual marathon-golf event to raise awareness of cancer and money for research. This requires him to play hole after hole of golf for twelve to fourteen consecutive daylight hours. He has been marathon-golfing and attracting pledges per hole for about a decade now. He has played between 99 and 127 holes in a single day. Yet he golfs on, living with his cancer, and has gone the extra distance to help fund research. Fore to cancer!

  The golfer accepts and lives with his carcinoid disease. Interestingly, when he comes to see me twice a year we still are not able to detect any carcinoid tumors on CT or MR images of his chest, abdomen, or pelvis. We know the cells are there, however, because his serum hormone levels are still elevated and he develops severe symptoms if he doesn’t receive his monthly pain-in-the-butt injection. The treatment doesn’t stop him from maintaining his coy smirk and enjoying his daily life. And, as he told me, he gets to earn a living playing a game, so what does he have to complain about? I can’t argue with that.

  A few years ago, I happened to see the golfer a few weeks before my annual Las Vegas golf junket with the boys from Chicago. I told him I should probably come to him for lessons, and courteously he said, “Well, show me your swing.” I addressed an imaginary golf ball on the examination room floor, executed my back swing and down swing through the ball, and finished with a follow-through flourish. I looked at him expectantly. He nodded thoughtfully, shook his head and said, “You know, some things just can’t be fixed.” And then he laughed heartily. Payback, Baby, for the pain I caused him!

  I’m now two for two on acerbic remarks from golf professionals who have evaluated my broken golf swing. These negative comments cause me no consternation. I am pleased to be a source of mirth to golf professionals, who seem like an overly serious bunch when I watch them on television. Any day I give another person a reason to smile or laugh is a great and blessed day. And I’m definitely heeding Mr. Palmer’s advice, “Don’t quit your day job, Doctor.”

  26

  Million-Dollar Man

  “You may not be able to change a situation, but with humor you can change your attitude about it.”

  Allen Klein

  “Who sows virtue reaps honor.”

  Leonardo da Vinci

  Humor: The quality of being amusing or comic, especially as expressed in literature or speech

  Honor: High respect; great esteem; the quality of knowing and doing what is morally right

  Cancer is indiscriminate and promiscuous. It strikes people without regard to socioeconomic status, education, title, gender, ethnicity, religion, or geographic location. Cancer doesn’t care if you are a hard-working farmer, a housewife putting in twelve-plus-hour days raising a family, a student, a mechanic, a teacher, or a high-level executive at a big corporation. Cancer quite frankly doesn’t give a damn how important you think you are.

  It is my good fortune to meet and assist patients from highly variable and distinct backgrounds. I always enjoy learning about them, their families, and their lives. Surgical oncology is one of the specialties in medical practice that affords us a long-term relationship with our patients. The surgical operations I performed, along with multidisciplinary care, has successfully eradicated or controlled my patients’ cancer in many cases. I have been seeing some patients in follow-up for more than fifteen or even twenty years. They have gone from asking about my kids’ schoolwork and soccer teams to looking at photos of my kids’ young children. A few weeks ago one of these patients commented that she was amazed to be seeing pictures of my grandkids. I replied, “Yeah, unbelievable isn’t it? I’m way too young, don’t you think?” She snorted and politely refrained from commenting on my age but corrected me by stating she meant she was happy to be alive for so many years after a diagnosis of stage IV cancer spread to her liver.

  Some years ago I met a new patient referred to me by the medical oncologist who was treating him for six liver metastases from colorectal cancer. This particularly jolly, congenial, and animated gentleman was accompanied by his wife and three adult daughters at the initial clinic visit. When I walked in and introduced myself, he enthusiastically shook my hand and with a warm smile said, “I hope you can help me, Doc.”

  The patient had undergone removal of the primary tumor in his colon approximately nine months earlier. He was diagnosed with stage IV cancer because the adenocarcinoma had metastasized to lymph nodes near his colon and to his liver. He received six cycles, three months, of chemotherapy initially and the liver tumors had shrunk. After three more months of chemotherapy the tumors were stable, with no furthe
r reduction in size. When he came to see me his CT scan showed no evidence of tumor in any other location.

  A part of any complete medical evaluation includes asking about a patient’s occupation, activities, hobbies, and social habits. The last of these includes history of alcohol consumption, smoking cigarettes or other forms of tobacco, and any so-called recreational drug use. My patient was not a smoker, denied any illicit drug use, and told me he liked an occasional glass of wine or martini with dinner. We ask the other questions to learn about exposure to any types of hazardous chemicals or materials and to assess the fitness of our patient. The man sitting in front of me was well dressed, not overweight, and looked as if he could go out and run a mile or two. When I asked what he did for a living, he quickly replied, “I am a professional silver-tongued devil!” Never one to be outdone by a humorous remark, I shot back, “Your tongue looks red to me, but what’s left of your hair is silver.” He laughed and said, “Touché! You and I are going to get along famously.”

  This silver-haired/tongued gentleman and I finished his medical history, and I performed an examination. We then reviewed the images of his liver and decided an operation was indicated. At this point he revealed his true identity. He informed me he was a senior pilot for a large commercial airline. I knew this was important information because any patient who is a professional pilot must undergo rigorous testing and physical examinations to maintain his or her Federal Aviation Administration certification to fly. He informed me he would need written statements from me after his operation to allow him to return to the cockpit. I had done this before for other patients, so I assured him I was prepared to provide all appropriate and necessary documentation and certification of his medical fitness to fly.