Home for Christmas: Friday 29, December, 2017

Sunday, December 17, after singing the choir anthem, I became chilled and shivered uncontrollably.  After bundling up with my scarf, down vest and coat, it was not helping.  I connected with Linnea in the front row to get me home under our electric blanket.  At first my temperature measured 100.4 (Guideline to call was 100.5) I told Linnea to leave me alone and I’d be all right.  She came after 15 minutes to check the temperature again.  This time it registered 103.  I requested a recheck with a different gauge, it read 103.2.  I had another one in my shaving bag and asked her to use it, this one recorded 103.6.  We called Dr. Picozzi; he didn’t want to hear any details, just ordered us to go directly to the ER.  We took the next boat.

At the hospital they found that I was leaking bacteria from my liver abscess trapped by my metastatic cancer ‘shell’, but they had no way to get there at the dome of the right liver to drain it.

After having taken multiple cultures, they initiated strong IV antibiotics through my Power Port and luckily I responded very well with almost immediate reduction in my fever and decrease in my white blood cell counts.  We were housed on the 18th floor (penthouse!) of Virginia Mason Hospital and once again, well cared for, encountering some familiar staff from our September stay.  Pastor Paul, in spite of his incredible schedule and responsibilities, came and accompanied Linnea while I had another relatively dangerous endoscopic procedure.

After 4 days of observation, they discharged me on Wednesday evening having instructed me on self application of the daily IV antibiotics along with a prescription for oral Flagyl tid.  I am doing OK.  A home visiting nurse checks me weekly with blood draws.  We’re again impressed with how well the team of physicians, nurses and technicians work positively together to provide the best outcomes.

Meanwhile, my daughter Catherine, husband Mark, daughters Mira and Saya  and 10 month old Davin arrived from Boston; they made a short visit at the hospital and then came daily to our home through Christmas Eve.  Marco/Shaheena, Leila and Emil arrived from MD on Saturday, and David/Ana, Fiona and Juliana came over early Christmas Eve Day from Seattle.  My Mom and my sister Elizabeth/George also joined us. We celebrated with a fabulous dinner of homemade Gyoza, (a family activity) Salmon and roasted prime filet mignon.  Linnea and I, joined with Marco, attended the Bethany Christmas Eve Service as the snow began to fall.  On Christmas Day, our first officially White Christmas in many years, Matthew/Kattarina and Ariana arrived from Olympia and we had another fabulous meal of giant sea scallops and roast beef.  Definitely a memorable Christmas holiday time indeed with all 8 grandchildren ranging in age from 10 months to 12 years – and their parents.

Thus far I am still doing very well.  Thanks Everyone for all your good thoughts, fervent prayers and well wishes.

Merriest 12 Days of Christmas to ALL !!!

Professional Activities: WSAO board ’82, President 1987 AAO Western Councilor, Chair ’88-‘93 AAO State Affairs, Member ’93-‘97

The environment of medical practices was rapidly changing beginning in the 1980’s until present time.  Because of the multiplying effect of CPI overtime, the Medicare’s payment schedule increased in dollar amounts much faster for ‘procedural’ than ‘diagnostic’ services.  Throughout the country, the primarily office based doctors rather felt an injustice that the surgical doctors were much better reimbursed than they were.  A palpable rife was developing amongst US physicians.  A federal commission was established to study the inequities and develop a fairer solution.  They concluded by proposing a new system of resource–based relative value scale,  (RBRVS) and adopted and instituted a nationwide Medicare reimbursements in 1992; a system of payments to physicians for treating Medicare patients that takes into account the work done by the physicians, malpractice insurance premiums, and practice expenses including staff salaries, overhead, supplies, and equipment.  They tried to equate commonly performed procedures such as a Gynecologist doing a Pep Smear, to an Ophthalmologist doing a Chalazion excision as equal to a Pediatrician treating tonsillitis or an Internist caring for a diabetic wound infection.  Major procedures were similarly matched up to such as a cataract procedure was equal to a simple common gall bladder extraction or a gynecologic D/C.  Never mind what the Feds determined, obviously there were striking and heated ‘discussions’ among the physicians.  Medicare stated that this formula was only intended to apply to Medicare patients only, but clearly the private insurance companies also adopted this approach rapidly to save their payouts.  For example, a physician was paid over $1200 for cataract surgery before; the new reimbursement was cut to less than $500 after RBRVS.

Entrepreneurial ophthalmologists began developing alliances with groups of area optometrists to form co-management clusters.  These ophthalmologists advertize themselves as cataract specialists and paid the referring optometrist a percentage of the fee as ‘co-manager’ among equals fee rather than ‘fee-splitting’ which was/is against the law.  These ‘cataract cowboys’ operated on 25 plus patients per day, 5-days per week.  The well-deserved elite reputation of Ophthalmology was in jeopardy.

I became active politically when these not-my-colleagues runagate ‘prostitutes’ began to tout the equality of expertise of the optometrists to Eye MD ophthalmologists.  Optometrists do not have a medical degree.  Ophthalmologists are college graduates who go on to become medical doctors, and then specialize through three or more years in residency to qualify for the Board of Ophthalmology exam.  How is that training equal?

Initially in 1980 I testified in front of legislators that allowing optometrists dilation diagnostic eye drops would be a disservice to the population because they would not be able to discern what they saw.  They countered that I was demeaning to each of them and their profession; after all, they all have attended 4 years of optometric school.  The bill passed into law.

Then I testified again in futility that the optometrists were unqualified to manage post-op cataract patients.  The problem was that we became the victim of our own success, because cataract surgery was 98% successful; there were few complications to follow.

Later, I testified to propose a bill to define surgery, as using instruments in penetrating the human integument and removing human tissues, to be reserved for MD’s.  Here I was blindsided by a line of objectors including tattoo artists, ear piercers, phlebotomists etc.  The optometrists were never called forward to make their case for the session ran out of time.  Needless to say, this proposal went nowhere.

Nationally, I served as the American Academy of Ophthalmology’s Councilor representing WA.  The western region comprised of HI, AK, CA, OR, WA, ID, MO, NV, UT, AR.  At the first meeting, (the group not wanting CA to dominate with more delegates while all the rest of us states had just one representative) they chose me to be their president and spokesperson on the Council Executive Committee.  Apparently I did OK because I served in that capacity for 5 years and went on to serve on the AAO State Affairs’ Committee for 4 years.  In 1998 I was also nominated (but did not win) to be a voting member on the Board of the American Academy of Ophthalmology representing ‘grassroots’ EyeMD’s.

With the distinction blurred between the professions of optometrist and ophthalmology the already confused public now truly are bewildered; add on to the list: the oculist, the ocularist, and the optician, no wonder the consumers are mystified.  To be sure, the proper training of the optometrist is meticulous refraction to provide patients with the most accurate prescription for the best corrected vision.  I respect them when they devote their attention to doing this for their clientele.  But when they encroach towards practicing medicine, then they need to attend medical school.  One principle I maintained dearly was that in spite of every societal pressure, I never stooped down to the level of co-managing any of my patients with less qualified personnel for financial gains.   I am proud to have been able to uphold this dogma throughout my professional career.

MSI Mission China, Sichuan, Huili April, 2001

There is no argument that eyesight is one of our most precious senses.  Imagine life being blind… unable to work or care for yourself.  You’d be totally dependent on your family and others for all simple tasks — everyday simple tasks such as feeding, cleansing and clothing yourself.  Then you hear about a group of Christian foreigners who have come to town to help people see again.  How happy would you be?  It was my great privilege to be with Operation Eyesight, a new mission launched by the Medical Services International to Huili, Xichang, and HeQing Sichuan, China over the past several years.  Our teams witnessed firsthand this joy and indescribable gratitude in the hearts and on the faces of those we served.

Having enjoyed a steady solo ophthalmic practice in Kitsap County for over 25 years, I often had wondered what direction to take near the waning days of my medical career.  I had considered serving as a medical missionary back to China, but was too busy fulfilling the mundane responsibilities of running a private practice, and never took time to “think outside the box.”  My friend, Dr. George Chin, the MSI eye project director, talked to me about going to China.  George discovered, through the MSI’s site selection process, that the Chinese authorities frowned upon any “show-off” projects, where American or other international teams flew in, demonstrated what great ‘miracles’ they could do and then left.  The people were exposed to the ‘moon’ but were not given any means to reach for it.  The local doctors gained nothing useful to better themselves nor how to better serve their patients.  Dr. Chin convinced the authorities that the MSI group had a different approach, and that our purpose was to teach the local personnel “to fish and eat for a lifetime.”  The governor of Yunan remained skeptical, but the Sichuan authorities consented to authorize MSI a trial visit.

When he first approached me, Dr. Chin had no inkling that my very first spoken words were Sichuanese!  I had lived in Sichuan province at ages 1-2, when just learning to speak.  The idea of going to Huili piqued my interest more than he expected.  I was anxious to spot if my Sichuanese still resembles their speech after almost 60 years.

Three teams were assembled for the launching of this maiden MSI Operation Eyesight Project.  Each team consisted of 10 members – Christians, from various walks of life, most without any medical training.  The foremost requirement was simply a sincere “desire to serve.”  All team members performed necessary functions according to their talents.  As physicians, we all realize the importance of the “supporting cast” of any surgical team.  The team leaders were the ophthalmic surgeons.  We were then responsible to assign duties to all of the rest of our team members.

The first site, Huili, is a poor farming community with a population of 450,000, located near the southern part of Sichuan province.  The average worker’s monthly wage is about $30 (US) per month.  Hospital doctors receive a salary of about $100 (US) per month.  Our goals were to train local doctors to better perform cataract surgery and to better provide eye care to the region’s farmers.  Prior to our visit, cataract surgery was essentially unavailable in the nearby area, hence many able bodied peasants were unnecessarily visually handicapped.

To get to Huili, we literally had taken Planes, Trains and Automobiles.  The Seattle volunteers first flew the 17-hour leg to Hong Kong and spent the night there.  We then entered Mainland China by flying to Chengdu; where via the Red Cross MSI was allowed to import ‘duty free’ the needed supplies.  We stayed another day there, took the opportunity to visit the China National Panda Preserve, and boarded a night train to PanZehHwua.  The train journey was 14 hours long, but the time was well spent getting acquainted.  My team, Team 2, consisted of members who came from other parts of US, Hong Kong and the UK.  At PZH, we were met by an ambulance van sent by the Huili County People’s Hospital and taken on a 3-hour ride along a bumpy mountain road through China’s scenic rural countryside.  When we reached Huili, we were quite surprised to see that this rural community had internet cafes, cellular services and countless stores stocked with everything, including some of the latest electronic equipments.  The air was clean and the scenery was magnificent.  As we walked through the main market area, the Caucasian team members invariably attracted crowds of curious on-lookers.

The facilities at the hospital were very basic, lacking many essential supplies.  It reminded me of the VA Hospitals in the 60’s.  The local personnel re-cycled everything, including needles, rubber gloves, and scalpels.  Sometimes they even used soup bowls to hold saline solutions for their surgical cases.  The hospital is a six-story building but didn’t have an elevator to transport patients or supplies.  Patients either walked or were carried by stretchers up and down the stairs.  We witnessed a woman lifted off the operating table onto a stretcher and taken up the stairs immediately following a caesarian section.

Thanks to our meticulous preparation, we were able to ship everything that we possibly could have needed: (medications, lens implants, surgical instruments, operating microscopes, autoclaves, etc.) so that we could perform cataract surgeries without any dependence on the local goods.  Needless to say, this was a huge logistical task; over 90 boxes of donated medical supplies were shipped in advance.  Additionally, most of us carried an extra suitcase full of equipment and/or supplies as our personal luggage.

As stated, each team member had a different task, some more publicly visible than others, but all important.  Dr. Chin’s team included a pharmacist who quickly organized and labeled the contents of 50+ suitcases and boxes of supplies.  When my team arrived, my Bainbridge receptionist, Jan Hurley, entered the inventory into my lap-top computer so we were fully aware of what we had at all times.  Someone else set up the electronics, such as the operating microscope with video and monitor connections, the cautery unit, and other essentials.  We had an engineer on my team who ably ran the autoclave and steamer, and set up our own “internet café” in my hotel room.  We also had a photographer who recorded and captured those special moments.  The OR nurse organized everything in the surgical theater.  Though I received the most exposure and appreciation, in all honesty, I felt that my job as team leader and as one of the teaching surgeons was the most effortless of all!  At least I was in back in my own environment.  The others, by necessity, all had to be more creative and flexible.

We worked effectively, efficiently and harmoniously during the entire mission.  The comradery was absolutely great!!!  We were reminded to work together through a Bible passage that we read together during one of our devotions:

I Corinthians 12:12

“The body is a unit, though it is made up of many parts; and though all its parts are many, they form one body.”

Besides treating patients, team members also scheduled presentations for the hospital staff on subjects ranging from treating allergies to making scarves.  Some members taught English, both at the hospital to the staff, and to children in the evening.  Since all cataract patients, as well as other patients, stayed in the wards and didn’t have much to keep them occupied or amused, other team members visited with them, entertaining them with music.  It wasn’t necessary for them to speak any Chinese, as their actions spoke volumes.  The team showed the people of Huili that we cared, through smiles, by holding their hands, and by just listening (even though most members couldn’t understand the patients at all).  Our team also held a “concert” for the patients, which attracted a large audience that included members of the hospital staff and patients from other wards.  On our last day, the team distributed small gifts and postcards from the USA and played with the patients using hand puppets!

The Huili hospital staff were wonderful hosts.  They took us on an outing to a lake retreat, entertained us with Karaoke and treated us to three marvelous meals each day.  We enjoyed foods such as steamed pineapple rice, Peking duck, steamed dumplings, and spicy Sichuan dishes.  Some of the local delicacies were quite difficult for our westernized palates to appreciate: dishes such as turtle soup, stir- fried snakes, fried sand worms, and cock testicles – food which would have been more enjoyable, not knowing what they were.

Although we were advised that preaching was forbidden, we did have the opportunity to worship on Easter at the local Christian church.  It was a dreadfully small building considering the size of the congregation.  We witnessed as many as 2000 people at worship, squeezed into a space which at best should seat 600!  Most peasants in China are illiterate, so they chanted simple hymns repeatedly, led by a church elder.  Team members who understood Chinese translated the sermon for the others in English.  We were pleased to hear that the same message of Christ’s love and grace transcends all cultures and languages.  Easter Service began at 8 AM and lasted until 4 PM.  More than 300 people were baptized on that day.

After the church service, we held an eye clinic to provide reading glasses and eye drops to those in need.  We served and dispensed over 300 pairs of readers within an hour.

We successfully met all our objectives and established good relationships with all the people we encountered.  Without exception, everyone treated us magnificently.  Mutually our eyes and hearts were opened.  With the assistance of the local doctors and nurses, the three MSI teams performed over 100 cataract operations and treated others with eye-related problems.  The local hospital staff is now fully trained in performing cataract extractions and lens implantations independently and with success and confidence.  People in Huili now have local access to cataract surgery, without any need to travel at least three hours to PZH.  We learned to use the various gifts and talents that GOD has granted and entrusted us, and we gained elevated awareness and in actual fact of how blessed we are.  Truthfully, one doesn’t have to be a skilled doctor or nurse to serve on a medical mission trip: only a loving heart.  The people of Huili greatly appreciated our presence.  They are very humble in listening to our opinions.   Our patients and the hospital staff were all sad to see each team leave.   Our unselfish, good work ethics, love towards all patients, ‘preached’ the Gospel quietly and steadily.  St. Assisi was spot on when he admonished us to ‘preach the Gospel always, and use words only when necessary.’  Moreover we in turn also will never ever forget this special positive experience.

Matthew Visit in Germany Experienced Best Air Flight Service Ever !!!

When Matthew was stationed at Germany in 1995, we visited him around the period of the German Oktoberfest.  We used Baumholder where he was stationed as our home-base but one long weekend we traveled east through very dreary Slovakia, Poland into Czech Republic. Prague was simply beautiful and drastically different.  (The principal site of one of Tom Cruise’s Missions Impossible movies.)  That bridge shown in the show does not do justice to witnessing the real thing in person.  Very talented Classic musicians played beautiful music everywhere.  There were also multiple free concerts in the evening at beautiful church venues.  People were friendly and helpful.  An unforgettably wonderful experience and lasting memory.

From Bomholder, we were flying to Italy to visit our friends Tom and Maureen Jurcak.  Baumholder was equal distant from Frankfurt and the Luxembourg airports, but the flight cost from Luxembourg was actually cheaper!  I believe it was Lux Air (although I no longer can find that airline via Google) that transported us to Frankfurt for the same flight to Italy.  Needless to say we left earlier to get to Luxembourg to board our plane, but it would be a new country we can mark as having ‘visited.’

Well it was quite an experience flying Lux Air.  As we walked on to the plane via a red tarmac, we were passed a warm towel to clean our hands. Then we were served fresh squeezed orange juice before we walk up the stairs of the plane.  Our luggage was left to the handlers at the base of the plane stairs.  After we got on board and seated, the staff immediately served us croissant with cheese and eggs with a dish of fresh fruits, of cause asked us if we preferred tea or coffee.  After takeoff, we were given another warm fresh towel and a pastry dessert with a piece of fine chocolate.  On our departure, they also gifted us a small souvenir and thanked us profusely for choosing to fly with them!  All these pampering within a 30 minute flight!!  Those day are long gone,  with that we are all certain.

Health Report: 8 December, 2017

On Thanksgiving Day, Linnea and I boarded a SWA direct flight to BWI and were picked-up by Marco to their home in Silver Spring, MD, and eat our delicious Thanksgiving dinner ala microwave.

We drove in their Prius to the Johns Hopkins Medical Institute for our 8:30 orientation on Monday but were delayed 15 minutes because of an accident off our ramp along the highway.  Nevertheless we were cordially welcomed and properly acknowledged.

After the orientation I was scheduled for a CT scan with contrast and a blood draw.  Smart as I am, it dawned on me that if I get the contrast material in me first, it may alter my blood results.  Therefore I insisted on getting my blood drawn first.  The technician was very accommodating, gave me a later time for the CT and directed me to the blood lab.  The phlebotomist wanted to draw from a new needle site.  I inquired an explanation.  She said that she is licensed to draw blood, but not licensed to place IV’s, whatever needle she introduces must be removed before I can leave the lab. Brilliant of me Hah!!

Linnea and I ate Baltimore blue crab for lunch and returned to Marco/Shaheena’s to stay overnight.  Next morning, my Cousins, Carl and Meide Fu, acted as our Uber escort in their bland new Tesla Model S to Hopkins for the physical exam.  I was interviewed by an oncology fellow, Dr. Lee.  She asked if I wanted to hear the preliminary CT report.  I answered affirmatively.  She then stated that their findings showed new lesions at the dome of the R liver, possible new lesion on the omentum, a new enlarged lymph node, and suspicious new growth along my ileum.  This logically corresponds with the rapid increase in my CA 19-9 marker.

We later met with another Dr. Le, the pancreatic oncologist attending physician.  She basically reiterated that although my physical health seemed remarkable, the CT scan was telling another story.  She suggested adding Abraxane, a cousin of my previous medicine Docetaxel which may have played a role in my developing pulmonary fibrosis (although we hope it was more due to Gemcitabine.)  She also suggested that we search for clinical trials which are targeting my condition.  She was not at all encouraging and to her, my prognosis was not very hopeful.

We made the best of the remainder of our time and enjoyed the DC area as I have already reported in the previous entry.

On arrival home, I had an appointment with Dr. Picozzi on Tuesday December 5th.  He was surprised at the report from Hopkins and wanted verification by the radiologists here.  We scheduled a Chemo session for Thursday to discuss further results and future plans.  Beforehand he wanted an opinion from my Pulmonologist Dr. Gerbino’s position re: the toxicity of Abraxane and previous pulmonary fibrosis.  Dr. Gerbino responded that the untoward effect of Abraxane seems to be less than Docetaxel and that I should have a baseline pulmonary test beforehand and monitor the lung function closely.  So I had a pulmonary function test at 9 am and started the regimen of Abraxane, Leucovorin, Irinotecan and 5-FU at 11:00 am.  Dr. Picozzi said that the radiologist at VM stood by the findings of the CT and PET scans done here as late as November, but that they also concur with the new findings at Hopkins of the new lesions via their more recent CT scan.  (My cancer appears to have blossomed and growing on steroids!)  Although the blood test here on Tuesday showed my white blood cells down to just 1000/cmm, we elected to get the full treatment and add a shot of Neulasta after two days.

Dr. Picozzi stated that he’s had 4 recent patients with good responses to this regimen and hopefully I can follow suit.  Meanwhile, in the next two weeks, Linnea and I are evaluating the hundreds of clinical trials available, but unfortunately because of my cancer being Adenosquamous rather than the much more common Adenocarcinoma I don’t qualify for many of these trials.  But we are still searching.  Meanwhile Dr. Picozzi wants at least 4 sessions of the current medications before reassessing my condition.  He will also try to direct us to the most fruitful trial possibilities when that time comes.

Words cannot describe our appreciation for all the expressions of good thoughts, prayers, best wishes and general concerns by our friends, family and loved ones.  Each of us ought/must live each day as full of Grace as God is giving us.  The Present is truly a precious gift.  Hug your loved ones freely.  Take nothing for granted.

I’ll keep you in touch.

Health Report: 30 November, 2017

As I have reported previously, on Thanksgiving Day, Linnea and I set out to Baltimore seeking other opinions regarding further treatment plans for me and my condition from the experts of my alma mater, the Johns Hopkins Medical Institute.  We have not received any formal report as yet and will be meeting with Dr. Picozzi tomorrow to discuss all possible options.  Unfortunately, based on preliminary information given us, our options are not very good, but we dearly hold onto hope and divine guidance.  I shall write a report update after the visit.

Meanwhile, I want to detail our trip to Baltimore and the new experiences we encountered.  Before we left, I rented a car but was insisted to cancel it because Marco and Shaheena went out of their way to make available their Prius for our use as we needed.  Marco met and drove us to their home on our arrival and had Thanksgiving dinner for us.

The next day, we reacquainted with Shaheena’s parents, Rafiq and Sonia, as well as her siblings Sharif and Soheila, went to Zoo lights at the National Zoo and had dinner at a South African restaurant where Marco insisted on treating everyone and simply would not allow me to pay.

Sunday we attended St. Luke’s Lutheran, an ELCA church, in Silver Spring, MD.  The organ music and the organist pompously celebrated Christ the King Sunday.  After worship we visited my cousin MeiDe and Carl Fu.  They proudly showed us their home, their 4 newly renovated bath rooms and lastly their ‘grandchild’, Maggie’s ‘baby’, a pristine brand new gun gray classic colored Tesla Model S with pure white leather interior.  Carl demonstrated how the car accelerates from 0 to 60 mph in less than 4 seconds without any detectable ‘sound’!

For dinner that evening, Maggie Fu, not willing to take no for an answer, insisted on treating all of us, including Marco’s family who met up with us, to a Cantonese banquet at the East Pearl Restaurant.  Her rationale was that since Melissa Ye, her cousin here in Seattle treated us, she must be granted equal opportunity to do the same.  Juleh Eide, Florence’s and John’s daughter also joined us.  She’s already graduated from Stanford U, and is doing an externship at NIH before applying to medical school.

Carl and MeiDe escorted us to Johns Hopkins and also to BWI airport in their Tesla.  Surely Uber rides have miles to go to attempt any comparison!!!

Wednesday, prior to leaving DC, Linnea and I visited the African American Museum of History and Culture and the Bible Museum.  Both were excellent and well worth spending at least an entire day at each.  We just had a quick cursory tour due to our time constraints, nonetheless, we enjoyed and appreciated both greatly.