A Christmas Story; Medical Training

by Larry Puls @larrypulsauthor

Christmas, Medical Education, Cancer

Our plane began its descent on the way to our destination. It was the week before Christmas and I was amazingly, or maybe stupidly, flying to my eighth interview in a short three months--yet another chance at landing a training fellowship. My wife, patient as she was, realized we had very little money left from all my traveling. Therefore, this trip was my Christmas present, the price required for me to have a shot at my dream.

Aa a Texan flying to New York, one can only imagine the thoughts swirling about in my mind, heading to such a faraway place in search of an elusive job. And yet there I was, flying to this interview, actually considering transplanting my wife and two young children to this cold climate—all in the name of my education.

Medicine in Third World Countries; Pregnancy; Unsuccessful Labor

By Larry Puls @Larrypulsauthor

Medicine in Third World Country; Pregnancy

The Jammu and Kashmir state in India are home to part of the Himalayan mountain range. Five doctors lived there and handled two hundred patient visits a day in this very remote and isolated area. When the story occurred, four of them left for their annual national meeting, leaving one physician behind to tend the flocks. At the same time, an American medical student arrived, enticed by an opportunity to gain an experience. And an experience is what he received. These events occurred before the birth of words like Internet, Google, or cell towers.

Choriocarcinoma, Treatment of Molar Pregnancy, Cure of Cancer

By Larry Puls  @larrypulsauthor

Choriocarcinoma; Cancer from Pregnancy

Standing outside the door, I collect my thoughts. Walking into her hospital room, I see the young lady who is struggling to breathe. Oxygen is flowing to her. At her rate of decline, she will be on the ventilator soon. And this will not change unless therapy is started quickly. Time becomes a key element. Her breathing is increasingly labored. Her diet is pure oxygen. It is the relative calm before the storm.

Treatment is defined by the word aggressive. A five-drug regimen going by the acronym EMACO. Etoposide. Methotrexate. Actinomycin-D. Cytoxan. Oncovin. Each of those successive letters standing for the listed drugs. But each represents different side effects. All with the potential to eradicate those rapidly growing cells--the little parasites taking over her body. And although they will all be administered through an IV, one is also given directly into her spine. A needle into the back. A drug that will bathe the nervous system with cancer poison. We have to hit the tumor where it lives and breathes--in her brain.

Choriocarcinoma, Cancer From Pregnancy, Hope

By Larry Puls @larrypulsauthor

Choriocarcinoma; Cancer from Pregnancy

It is tough enough to be pregnant, what with the backaches, the nausea, and the getting up and down all night. Guys like me will never really comprehend it, though we appreciate some of it while watching our sweet wives endure it. But I would say to those who have been pregnant, imagine how much tougher those inconveniences would be if the events surrounding that joyful time turned tragically against you. A life full of hope transforming into just hoping for a chance, all in the blink of an eye. Those are the events that shake our very foundations. That is what tests our faith. And interestingly, but not surprisingly, that is what grows us.

Hysterectomy; Trauma; The Uterus That Saved a Life

by Larry Puls @larrypulsauthor

Trauma; Hysterectomy

The uterus. Arguably, the most fascinating organ in the human body. No bigger than a tangerine ninety-eight percent of the time, no smaller than a watermelon the other two. Fertile soil, doubling as a temporary home, a safe haven, where the beginnings of life take hold. Where an embryo morphs and divides, transforming into billions of unique cells that make up the intricate pieces of the human body. All woven together and permanently bonded with a soul. The baby incubator that graciously and generously supplies all the nutrients and oxygen a small child will need to thrive. It provides the human race with the most beautiful, precious, amazing, heart-warming gifts we call children, made in the image of God.

Family History of Cancer; BRCA mutations; The Second and Third Sisters

By Larry Puls @Larrypulsauthor

Sisters with Ovarian Cancer; Family History of Cancer

A year had passed. I had not forgotten the young woman who lost her battle to ovarian cancer. Her smile was still visible and I could almost recall her laugh. Thirty-two-year-old patients are particularly memorable. So few women die that young due to gynecologic malignancies. Many of the details about her final days were still fresh on my mind. In many ways, the more tragic the scenario, the more you remember. But her death in my career was not in vain, for I learned much about the chronic use of chemotherapy and its long term side effects. Things you don't always learn in training. She changed my style of practice. Her bone marrow death in the midst of treatment has to this day, influenced my use of drugs, their duration and their dosing, well past her life—even now. Her death I believe, has helped me help others.

Family History of Ovarian Cancer; A Tale of Three Sisters

By Larry Puls @larrypulsauthor

Family History of Cancer, Ovarian Cancer

By the early 90’s, oncologists had obviously observed for some time that certain families were far more affected by various malignancies than others. They knew intuitively that a gene, or genes, tied these cancers to the families, but that genetic component couldn't be readily identified by testing. Today, advances in the study of genetics is changing all of that, allowing us to frequently identify who might be at an increased risk for cancer, even before they develop one. The rapid discovery of new deleterious (bad) mutations allows us to identify individuals who are at an increased risk and to tell them what that risk is over the norm. Knowing this presents us with an opportunity to screen more effectively, to potentially intervene before the cancer starts, to counsel multiple generations within a family, and often prevent certain at risk members from losing their own lives secondary to a malignancy.

Cancer in Pregnancy; The End of Life; A Young Mother's Final Day

By Larry Puls @larrypulsauthor

The Death of a Mother

I walk into the room and cannot even recognize her face anymore. How far we have come over the last two years. Laying there, I see a very thin layer of skin covering her collar bone, painted with an ashen pallor. A physician's heart is crumbling. I conclude the end is very near. My desire is to leave the room. My job is to stay by her side. The smell of death is unforgettable.

I pull back the bandage and stare at her wound. There, gazing back at me is the enemy, the cancer, the "small cells" I could not eradicate—though for two years I tried—in fact, many of us tried. Looking at the wound, I see the pulsating beat of the major artery moving her skin up and down, up and down, surrounded by the advancing malignancy. Her pain meds have rendered her groggy and minimally verbal, but at least she looks comfortable. She wakes up enough to ask about end points, about timing of other treatment, about whether or not I have further plans for her. I don’t honestly want to answer those questions. How do you say "I have run out of plans"? I have no other magic pills, magic bullets, magic cocktails. I can only wait. And wait for what? I just can't verbalize that, since I don't want to think about what is to come. God is totally in control of all things now—and always has been, lest I think differently. But what I do know, from where I stand, is that there is very little time left--and that the life here before me is hanging on the edge.

Cervical Cancer, Recurrence of Cancer, A Young Mother's Story

by Larry Puls @larrypulsauthor

Recurrence of Cancer for Young Mom

Two weeks after the cesarean and her lymph node dissection, she comes back to see me. Before we discuss the tough stuff, she proudly shows me her child. Looking down at the sleeping baby, I wonder how will I explain eight positive lymph nodes, the small cell carcinoma, and give hope all in the same breath. The little girl looks so peaceful, dreaming childhood dreams. Deep slumber. An amazing gift. Her understanding of her mom’s situation will not come for years. And I question if she will ever really know her mom--or remember what she looked like. Time will answer that. Yet I know intuitively her pressing journey is about to begin, and it will be every bit as taxing as childrearing. She will need God-given strength for the marathon of therapy facing her... “Where do we go from here?” she asks. Where do we start? I ponder my first words.

Cancer in Pregnancy; A Young Mother Fights for Her Life

by Larry Puls @larrypulsauthor

Pregnancy and Cancer

Even now, I still remember the unspeakable sadness and the tragic outcome. It was twenty years ago, and counting. The events still flash back into my mind every time I walk onto the floor where the saga culminated... And ended... The beginning of the two-year journey started something like this--as my mind remembers it anyway: A colleague called and asked me to see a patient she believed had cancer... And was thirty-six weeks pregnant. 

Within an hour, a young woman walked into our facility. She was graced with beautiful long blonde hair, a subtle trace of a German accent, and a very gravid abdomen. Her pleasant smile and handshake could not hide the trepidation I sensed was trickling through her veins. I'm just sure that that morning when she woke, her life had felt so full of promise. And now in the blink of an eye, it was marked with a growing sense of uncertainty.

A Gun in the Hospital; A Shooting

by Larry Puls @larrypulsauthor

Medical School, Fear

Kaboom... Kaboom... Kaboom...

A tsunami of terrified people running in every direction, some left, some straight, some right. We suddenly see them bounding into our hallway packed with gurneys, equipment, and injured human lives. Twenty or so people, fleeing towards us into a "safe" zone. Who could possibly know how safe it would prove to be? The wave of frantic runners was stirring up increasing chaos. Panic that stimulated more panic. All the frightened individuals were now engaged in a game of musical rooms, trying to secure safe places for themselves. Someone bad must be stalking the ER and we were all in harm's way. Fears forced the treatment room doors open. People dove in, and then barricaded themselves inside respective fortresses. My first patient was no exception, flying off his table as well, with his stitch and needle swinging from his arm. Desperation was plastered on his face, on every face.

Run for Your Life; Who Said Medical Education Was Worth Dying For?

By Larry Puls @larrypulsauthor

Medical Education, A Brush with Death

Three AM. The witching hour. I was twenty-four, naïve, roaming the hallowed halls of Parkland Hospital, trying to piece together what I’d learned from my first two years of medical school. Living on short naps. Living on a hope that one day, all of this would make sense. Our team’s mantra was, "sleep is for the weak". I think that’s how it went. Such a different world back then.

We finished rounding. Yes, three AM. Did I say that already? Do patients really want to be seen then? Mine was not to reason why, mine was but to do and (?)... Concluding the floor work, I was hopeful I might slip off and sneak a little sleep before prepping for “morning” rounds. But that thought disappeared with a phone call, a pleading request. Help was needed down in the Emergency Department. A backlog of cases had been created by the nebulous Dallas Knife and Gun Club—or so it seemed. My next three hours had just been defined. Not going to be pretty.

Remission; A Cause for Celebration

By Larry Puls @larrypulsauthor

Remission from Cancer, Celebration

Remission. A coveted word. The sought-after goal. A destination that encapsulates both hope and light in the midst of a precarious future.

Over my career, I have witnessed numerous reactions to that word, to that idea. And in all those observations, one thing I have undoubtedly learned was that achieving remission could incite unpredictable responses.

Walking into the room, I had finished studying the chart and her CT scans. I was hopeful that her chemotherapy was now relegated to the past. Remission, which is what I was hoping for, had at one time seemed almost untenable. But now I had a hunch it might happen. Call it the oncologist's sixth sense. We had likely achieved what initially seemed impossible. The patient sitting before me was probably wondering where our conversation would go. In some ways, I wondered too.

Supporting Women with Ovarian Cancer; A South Carolina Foundation

by Larry Puls  @larrypulsauthor

Ovarian Cancer, Patient Support

Today I am going to do something a little different. Normally, this blog is dedicated to telling medical stories (usually about cancer) from both the physician’s vantage point and from the patients’. Hopefully, the tales will be heart felt, often informative, and at times may deal with some complicated subjects (that is life's journey). My sagas will always be sprinkled with a dash of emotion and may even require some kleenex. I will commonly bring to light the personal side of cancer, from the individual stories I have been allowed to watch. But today, I will take a slight detour and pause from my normal conversation in order to relate to you a story about a most inspiring collection of individuals. These people have done a beautiful work, bringing increasing awareness to an often-ignored malignant process, ovarian cancer. This story is being told by me today to bring more “voice to the silence”. 

A Step of Faith; Allowing the Chemotherapy to Flow

By Larry Puls @larrypulsauthor

Fear of Chemotherapy; Ovarian Cancer

I sit across from a widow. A new patient. A terrified face. Tears filling her eyes. Somehow, I think she knows where this conversation will land. I utter the first word concerning her treatment—chemotherapy. Before I even make it to the last syllable, her head drops and she shivers. A weighted tear hits her lap. Her daughter reaches over and offers a hug. The start of a journey.

I explain the dreaded C-word. But her preconceived fears about that topic cannot be erased. She tunes me out. I now witness a mind heading to default. I try to soften the blow, but my efforts fail. Paralysis owns her.

Fear of Elevators; A Funny Story of Cervical Cancer

By Larry Puls  @larrypulsauthor

Cervical Cancer; Embarrassing Moment

A long day on my feet. Numerous surgeries, but all of it a blessing. What else is there to do before I leave this place? I wondered, scratching my head. Two dictations, a set of charts to sign on my desk, a final talk with a family, those tasks remain. Living the dream. My desires turn toward home.

I dictate the final surgery while it remains fresh on my mind. The charts, they could wait until morning. Home just got that much closer. I make it up to the waiting room to chat with the last family of the day. So many questions, but not enough answers until I have pathology reports back. Done. Just change clothes, find the car, and I am off to that other half of my life, the family part. Leaving the final meeting, I find myself next to the public elevator, the one the hospital employees are not supposed to take. A good day. Maybe I made a difference. I hope so anyway. Realizing that no one else is around, the forbidden elevators entice me like like forbidden fruit, and they’re just five feet away. Who is going to know? I give in. I hit the down button.

Denial and the Enormous Ovarian Mass; A Story of Surviving Ovarian Cancer

By Larry Puls @Larrypulsauthor

Ovarian Cancer Surgery

Midday, Friday afternoon, a long week. There’s a call on the line. A referral. One that my memory will not let go of—even after two decades. Transport will have her here in two hours.

I walk into her room—now five o’clock. A glance defines a thousand words. Her shoulders yield information—skin over bone, a starving patient? I look back at the chart. She is over three hundred pounds. Really? I turn again to this woman. Those shoulders, those emaciated shoulders, say malnourished. My eyes move lower. There under the covers is something that I cannot adequately describe. A mass. A growth. Big, beyond comprehension. My eyes rudely continue their stare. Shock and awe. The power of denial lived out in front of me. How long has that been there? I can only imagine.

Death and Dying of the Cancer Patient from a Doctor's Perspective

By Larry Puls @Larrypulsauthor

Death and Dying

I stand at the door—afraid. Take a deep breath. Just another room. One I have been in a thousand times before. Inside a bed, a bathroom, an IV pole—a friend. And while I stand there, inside my head resides angst over the unrevealed information. Still frozen in the hallway, I cannot reach out and touch the door handle. It seems so foreboding and ominous, so far away. When I finally attempt the move, a choking feeling ascends in my throat, weakening me—even for a minute. I am paralyzed. You have to go in.