A good sign

I was in Guam over the weekend. I went over on Thursday, and spent Friday morning at Island Eye Center with Dr. Margie DeBenedictus. She's an expert at blepharoplasties (cosmetic lid lifts) and I'm an expert at an advanced type of cataract surgery (phaco chop), so we spent the morning teaching and learning in the operating room. The rest of the weekend I was at the National Convention of the Bahai's of the Mariana Islands.

When I got back, I looked at Arman, and not having seen him for a few days, I'm pretty sure that the lumps have gotten smaller. A few other people who hadn't seen him over the weekend said the same thing. I'm hoping it's not just our wishful thinking that helps us see a smaller lump. But I don't think so. I think it really is smaller. Smaller would be a very good sign.

From Uncle Hoo

Here is an email I received this morning from my uncle in California. I had forgotten that when I was Arman's age, I went through a big evaluation for leukemia.

We have been following the up-dates and the reports. Our prayers are with you and your family. I understand your pain and concern as any parents should have.

I have two sons with asthma and peanut allergy, which both are deadly in a matter of minutes. It has been 15 years and not a day goes by that I am not thinking of this and wondering what is going to happen today or tomorrow.

When you where a kid at the same age, you had nose bleeds all the time... your parents went through hell to figure out why. And your dad is a pediatrician.

Take your time, don't rush and consult with others and then make a decision. Because as a parent the decisions we make, shape their future.

Thank you for letting us know and if there is anything we can do to help, please let us know. In meantime you should take it easy and with this prayers you will concur.

Love, Dai

O God, refresh and gladden my spirit, purify my heart, illumine my powers. I lay all my affairs in thy hand. Thou art my Guide and my refuge. I will on longer be sorrowful and grieved, I will be a happy and joyful being. O God, I will no longer be full of anxiety, nor will I let trouble harass me. I will not dwell on the unpleasant things of life.

O God, Thou art more friend to me than myself, I dedicate myself to Thee, O Lord.

Introducing... Uric Acid

Thank-you to all of you who’ve shared your concerns and prayers both through the comments and by email. Your support has helped calm our spirits.

Here’s where things are now. The most common cause of swollen lymph nodes in a kid is “mono” – a viral infection. The problem is, with Arman, there is enough that is not consistent with mono that the doctors were immediately concerned. The spleen can get big in mono, but Arman’s spleen is huge, which is not typical. Mono usually comes with a fever, which Arman has not had. And, no sore throat. His white blood cells don’t show signs of an infection either. So, the concern about lymphoma. Luckily, not everything is consistent with lymphoma either. Foremost, he hasn’t been experiencing weight loss, weakness, fatigue, or any of the other constitutional signs of cancers. He’s a pretty active healthy-looking six year old boy with an unexplained enlargement of his lymph nodes and spleen.

So, last week we drew blood to test for mono. The problem is, because we live on a remote island in the Pacific, there are no facilities here to perform a mono test. The blood has to be sent to Hawaii. It will take a week or so for the results.

Some of the doctors have felt that because it’s not typical for mono, we should quickly remove the lymph node, and send it for analysis. The problem: it would be a big operation, splaying Arman’s neck open. The danger in waiting: if it is lymphoma, it could grow quickly and cause severe problems.

My thinking has been that since it hasn’t grown over the past week, we should be okay to wait for the results of the mono tests. If they’re positive, then we have a diagnosis. We can relax and just wait for the mono to get better. We're off this hellish ride. If the mono tests are negative, then we can go ahead with the biopsy.

So, the pediatric oncologist in San Diego (with whom Arman’s doctors at CHC have been consulting via telephone) recommended getting a test for uric acid. Uric acid comes from the breakdown of cells. If there is a large tumor, or a rapidly expanding one (what’s called "large tumor load") then the uric acid will be high. If the uric acid is high, then the likelihood of mono is low, and we need to move immediately to biopsy. If the uric acid is normal, then there isn’t a large tumor load (even though there may still be a tumor). In that case, we can wait for the mono test results instead of moving urgently to biopsy. The uric acid test was run here on Saipan, and the level was normal. So, if there is tumor, it’s not rapidly expanding. So we're safe to put off the biopsy for now and wait for the mono test results. Our hopes are high.

The mono test results should be back by Friday. Right now, it’s just a matter of waiting.

In the meantime, the great thing about Arman is his general obliviousness to all of this. He’s unaware of our concerns and worries. He’s happy playing. He feels fine. He knows that he’s got a lump on his neck and that we’re trying to figure out what it is, but from his perspective, it’s just another minor annoyance like an ear infection. What a great perspective to have in the midst of all of this.

Thoughts of a father

Arman with a 6.5 cm lymph node, now ultrasound shows an 11.4 cm spleen, huge, upper limit of normal for an adult, much less for a six year old, blood work mostly normal, no clear diagnosis, mono test results two weeks away.

Thus the recommendation to biopsy. Look for cancer – lymphoma, Hodgkin’s disease, childhood death.

I held Arman as he screamed yesterday, the needle entering his vein, and I thought, “I hope and pray this is not the beginning.” My sweet six year-old child, so full of life and joy and determination and creativity and enthusiasm and lost in his plans to go up to the elementary.

We’d move the family of course, to MD Anderson or Sloan-Kettering or wherever could give him the chance for cure.

And should he be taken from us, such an emptiness would be left all my days. For Nava, her life a dance with his, she just two years older, a gaping emptiness. And every day I would talk to his soul beyond, and ask for his intercession on behalf of his father, for strength and patience to make it without him.

I can imagine all this, but in my heart, it has to just be an exuberant immune response to mono, right? Please? How can Arman have cancer?! Diverse genetic mix, mostly vegetarian diet, clear island air, no carcinogens. It’s just not possible.

And I try to cut a deal with God. The bargaining -- one of the five stages of grieving (I recognize it from my medical school days). Save my son, let this all be a lump of nothing, make it all smaller, and I promise I will be good. In however many ways that I’m not, I’ll be good.

All my personal concerns, various worries, evaporate under the heat of this lump.

I saw my friend Robert, from residency, last year in Hawaii at the eye conference. “How many kids to you have now,” I asked. “Two,” he responded, “a 12 year-old and a 10 year-old.” “I thought you had twins.” “We did. One died two years ago. Lymphoma.” He talked of how this trip now was the first he and his wife had been able to take. There was no time to mourn two years ago. “What can you do,” he said. “You’ve got these other kids that are alive and who need you. They need your love, your presence, your joy and enthusiasm for them. So you bury one child and try to keep moving forward.”

The universe and God I do not understand. Suffering and the suffering of the innocent, I do not understand. And at times like this, I don’t try to understand, fearing my explanation or theory may just be false placation. It’s just the way it is, and there is nothing I can do about it. Will my magical thinking help? Will the universe still respond with “your wish is my command”? Is my son any more important, just because he is mine? Thousands of despondent parents bury their children every day, death by lymphoma, or leukemia, or tuberculosis, or starvation or war or murder. And the world just keeps going on. I just keep going on, thinking about me, my concerns, my pursuits, my hopes, oblivious of their pain and the fragments of their broken hearts. Why would I be so special to receive my special request from the universe, from God? I feel reticent even to ask.

Over the last few year when death would come up in conversations (your great-great grandmother died, Duke died, the cat died), Arman has so often said, “I’m scared to die, I don't want to die alone, can you die with me, Dad?” We realized he thinks that the next world is in the ground, somehow related to the grave. “We’ll all see each other in the next world, Arman.” “But what if we get buried in different holes?”

For most of the day, I’m just doing something else. And I look up from my work, and wonder what it was that was causing my anxiety? Briefly forgotten. And the knowledge quickly rushes in, pushes the fragile calm out, my tears well up and I sob.

Arman

It’s amazing how your perspective on life can change in just 24 hours.

Our six year-old son, Arman has had a lump the size of an egg on his neck for about a week. We took him to the hospital yesterday. He saw two pediatricians and an ENT specialist, all of whom are very worried. He had some blood tests, and an ultrasound which showed a very enlarged spleen, which is not good. We went in for more tests this morning, and his doctors have been in touch with pediatric hematologist-oncologists in Hawaii and San Diego, who recommend some more tests, which we'll get this afternoon. Arman may need surery to biopsy of the lymph node in his neck if the tests are not reassuring.

The best case scenario is a very unusual manifestation of a common infection like “mono.” The worst case scenario is, well, the worst case scenario. It will be at least a week before we know anything. Please keep Arman in your thoughts and prayers.

No-Reading Week Ends

...and I'll have to say, I'm sad to see it go.

I actually pulled it off, much to the disbelieving amazement of my friends and family. I went a whole week without reading (well, maybe I read a couple of T-shirts as people walked by, but otherwise, I made it.) I probably haven't done this since I was five years old.

Here is what I learned. First, most of my reading these days is "incidental" reading, usually online. I don't sit down with a book or magazine and read in long stretches. Reading often just serves to fill some snippet of time -- an email when I get home, a blog between patients, an article in the newspaper while the bread toasts. I realized how cluttering it all is. Like filling every nook and cranny of time with words.

I thoroughly enjoyed the empty space this week. What did I do with it? I wrote a lot more (but dared not go online to write -- high risk of clicking a link). I called friends instead of emailing them. I watched my two-year old smear peanut butter on his face while the bread toasted. I sat and thought a fair bit (and thought about significant issues like how long do you have to sit and think before you can say you were meditating). I looked at pictures. I cooked up an idea for a line of T-shirts (where did that one come from?!). I was generally much more present, able to silence the beckoning of the waiting words.

Now the challenge: applying what I've learned. I'd like to stay word-clutter-free. I'd like to contain the clutter in a space of time, kinda like keeping all junk but having it in a drawer or closet instead of scattered on every shelf and table top. Maybe I'll give myself an hour a day for all that snippet reading. Contain it all between noon and 1 PM. I'm still mulling this over, and I'm being careful on this, my first day back. I didn't get on the computer until now, 10:45 am, unlike my usual 5:30 am.

It was a great week.

I'm about to do a very scary thing...

For the past few weeks I've been working through a book many of you may have heard about: The Artist's Way, by Julia Cameron. It's honestly one of the most powerful books I've interacted with. I don't say "read" because it's not really a "reading" book. It's a "doing" book, with weekly assignments focused on various facets of developing creativity.

Well, here is this week's assignment: reading deprivation. Nothing reading. That's right. One week with no reading. No newspaper, no email, no websites, no books, no blogs, no magazines, no brochures, nada.

It's just a way to turn off the distractions and to turn inward; to find some inner quite space. Kinda scary for some of us. After all, what will I do if I'm not checking my email six times an hour, jumping from blog to blog, and paper to paper?!

I'm looking forward to the week. I've got my email autoresponder set, and I'm ready to see what chaos breaks loose. It's always fun to shake yourself up a bit. Care to join me?

Advanced Cataract Surgery at Marianas Eye Institute

We made the business section of today's Saipan Tribune. (That's the Commonwealth Health Center's two cataract surgery technicians, Lea Estinopo and Chris Batenga, in green). Here's the full story:

MEI Acquires New Device for its Cataract Patients

Marianas Eye Institute has purchased new equipment that improves the recovery time and enhances the safety of cataract surgery. The new device, called the Sovereign Compact cataract removal system, enables the surgeon to efficiently remove a patient's cloudy cataract using digitally modulated ultrasound.

Marianas Eye Institute CEO Russ Quinn and medical director Dr. David Khorram met with representatives of Advanced Medical Optics in Hawaii to arrange purchase of this newest technology.

“Advanced Medical Optics had announced the release of its latest Sovereign Whitestar technology, and we were eager to provide the latest and best for our cataract patients here in the CNMI,” explained Quinn.

A cataract is the clouding of the eye's lens and is part of the aging process that affects more than half the adults over 60. It is also very common in diabetics in whom it occurs at younger ages.

With over 2 million cases performed each year, cataract surgery is the most common surgical procedure in the United States.

The two Marianas Eye Institute official said they felt it was imperative to purchase this new equipment in order to continue providing the most advanced techniques and the highest quality care.

“With this brand new technology, there is nowhere in the world that is more up to date with cataract surgery technology than Marianas Eye Institute,” said Quinn. “We pride ourselves in providing world-class eye care. We have a multi-year agreement with Advanced Medical Optics to provide ongoing technology updates, ensuring that our cataract surgery system remains state-of-the art as new advances are made into the future.”

Prior to this new technology, the Marianas Eye Institute has been using the phacoemulsification technique (or “phaco”) since 1999. This type of cataract removal technique allows the cataract to be dissolved using ultrasound, and removed through a tiny incision, just over 2 millimeters in size. In most cases, stitches are not even needed. The procedure takes about 20 minutes and patients are home and back to their regular activities the same day. Khorram said it is virtually painless.

“This new Sovereign Whitestar technology is a major upgrade to the “phaco” technique. It is even gentler on the eye, and promises faster, easier recovery,” said Khorram. “We have used the Sovereign Whitestar cataract removal system for 14 patients so far, and it is an amazing piece of technology. For example, during the cataract surgery, the Sovereign Whitestar measures the pressure inside the eye 50 times per seconds and makes adjustments which make the surgery very smooth.”

To install the new “phaco” technology, AMO regional technician, John Garland, visited the CNMI from California for the first time and was impressed with Khorram's surgical skill. “He uses the latest cataract extraction techniques that are being used at U.S. mainland facilities. He has a brand new phaco machine which is the latest on the market and his microscope was recently upgraded to have the best view possible. Your patients in the CNMI are truly getting a world-class cataract operation,” said Garland.

Garland also praised the facilities, noting that it is more advanced than most in the US mainland. “I was very impressed with Marianas Eye Institute's office, overall organization, and cataract surgery facility. The office set up is a higher quality than most ophthalmologist offices here in the U.S. Very few facilities here have the advanced electronic medical records that Marianas Eye Institute has and very few have the ability to custom-make their own lenses for glasses. I was very impressive with the friendly extremely helpful staff.”

For more information visit Marianas Eye Institute or call 235-9090.

Come Fly a Kite!

On Saturday a great event is taking place on Saipan – the Marianas Wind Kite Festival. Started by Brilliant Star School, and now co-sponsored by the Marianas Visitors Authority, the festival has a potential to become one of those gems in the island’s series of events. I’m always advocating more family style events as tourist draws, and the Kite Festival is one such event. (I also hope that a playground will be put into the center of Paseo de Marianas, much like the one in the central square in Cairns, but that’s a different column.)

The Kite Festival will be held on Saturday April 14 at American Memorial Park from 10 AM – 3 PM and will also feature a Cultural Food Faire with Japanese, Korean, Chinese, American, Filipino and Chamorro food. There will be an arts and crafts booth, and kite decorating contests for the most beautiful, the most innovative, and the funniest kites. Awards will also be given for the best stunt kite and the highest flying kite.

Come on down to American Memorial Park on Saturday to support this MVA co-sponsored event.

How I Spent My Saturday Afternoon

This gentleman had a corneal transplant done years ago in San Diego. The graft failed, which means it did not remain clear -- it turned white. A cornea is supposed to be clear, so that the light can shine through it. When it is opaque, the vision is poor. In his case, he could see light, and nothing more.

He came in because he was playing with his four-year-old son, who jumped up and banged his father's eye with his head. The eye ruptured, right along the interface where the graft had been sutured to the "host" cornea. Of course the sutures had been taken out years ago, but this area remained the weakest of the eye, and any significant stress would cause it to rupture right here at the interface.

It wasn't just a simple rupture though, since a bunch of the "guts" of the eye had also squirted out (Ewwww!) -- iris, intraocular lens, vitreous and more blood than anyone likes to see seeping out of an eyeball.

I spent about 3 hours getting everything sewn back together. This kind of eye surgery (actually almost all eye surgery) is done through a microscope (that's why it's called "microsurgery"). You can see that the sutures are thinner than the diameter of his eyelashes. Click on the picture or the diagram to enlarge them.

He's doing well now, and this photo is from yesterday. The goal was to simply put Humpty Dumpty back together again. There was no expectation that the vision would improve because of his previously failed graft. Luckily, I didn't need to remove the eye. He still has light perception vision, same as before the surgery. He's very happy to still have his eye. His other eye is normal.

What to you guys think? Want to see more of this kind of stuff? Click on "comments" below.

Wax Museum of Saipan

Every couple of months, our staff at Marianas Eye Institute gets together for a staff outing. Recently, we’ve gone to race go-carts, played beach volleyball, gone to PIC happy hour, and now last week, visited the Wax Museum of Saipan.

I’ll have to tell you, I was impressed. I don’t remember ever being to a wax museum before. After all, there never seemed to be much appeal in seeing statues of a bunch of famous people. You’re there to look at the wax, and ooh and ahh at how lifelike/waxlike everything appears.

Well, the Wax Museum of Saipan is different. In fact, it’s really not about the wax nor the statues. It’s an interactive lively museum of the history of Saipan. I learned a few things about our history that I had wondered about and hadn’t understood from visiting other museums on Saipan. Saipan history is depicted in scenes using life-size statues and figures. It is amazingly well done. It starts with the pre-history of the Marianas, and moves, room by room and scene by scene to the present day. The grand finale is a replica of the Governor’s Office, where you can sit at the desk, flags behind you, and have your photograph taken.

Each scene has a written description of the scene in English, Korean, Chinese and Japanese. The reading is brief enough that you get a good idea of the history without having to spend more than a minute reading – great for those like me who get a bit restless in museums.

The photographs throughout the museum are beautiful depictions of past and present scenes of Saipan life. There are sound effects and lighting effects, which bring many of the scenes to life.

The museum has also produced a documentary interviewing some of the local survivors of World War II. It’s playing in the reception area, and is worth seeing.

For local residents, the admission price is about the cost of a movie. If you are looking for a family outing, a place to take the kids on the weekend, an educational trip for your classroom, or a place to take a date, the Wax Museum of Saipan is a worthy option. I plan on going back.

The Wax Museum of Saipan is located in the heart of Garapan near GIG Discotheque. You may reach them at 233-7447. Support this great addition to Saipan.

Burp

Sorry to all you far away friends who are wondering why the posts stopped after the tsunami warning. All is safe. The tsunami, by time it got to Saipan, was about 2 mm in height. The typhoon was what we call a "banana typhoon"-- it was strong enough to knock over a few banana trees and nothing more. We were without power for a few hours on Monday and Tuesday evening, but apparently not due to the typhoon. A power pole had caught on fire.

And now a tsunami??!

This just in. An earthquake in the Solomon islands has set off sensors indicating that a tsunami has been generated. The wave is due here in about an hour. If we survive this, we'll have a typhoon tomorrow (see below), and the following day, locusts, pestilence (more than usual) and the plague.

From the Pacific Tsunami Warning Center:

TSUNAMI BULLETIN NUMBER 003
PACIFIC TSUNAMI WARNING CENTER/NOAA/NWS
ISSUED AT 2239Z 01 APR 2007

THIS BULLETIN IS FOR ALL AREAS OF THE PACIFIC BASIN EXCEPT
ALASKA - BRITISH COLUMBIA - WASHINGTON - OREGON - CALIFORNIA.

NOTE: AREAS TO THE NORTH OF THE SOLOMON ISLANDS SHOULD NOT BE SIGNIFICANTLY
AFFECTED

... A TSUNAMI WARNING AND WATCH REMAIN IN EFFECT ...

A TSUNAMI WARNING IS IN EFFECT FOR

SOLOMON IS. / PAPUA NEW GUINEA / VANUATU / NEW CALEDONIA / NORTHEASTERN
AUSTRALIA / TUVALU / KIRIBATI / FIJI /

A TSUNAMI WATCH IS IN EFFECT FOR

KERMADEC IS / NEW ZEALAND /

FOR ALL OTHER PACIFIC AREAS, THIS MESSAGE IS AN ADVISORY ONLY.

AN EARTHQUAKE HAS OCCURRED WITH THESE PRELIMINARY PARAMETERS

ORIGIN TIME -  2040Z 01 APR 2007
COORDINATES -   8.6 SOUTH  157.2 EAST
LOCATION    -  SOLOMON ISLANDS
MAGNITUDE   -  8.1

MEASUREMENTS OR REPORTS OF TSUNAMI WAVE ACTIVITY
HONIARA  15CM ZERO-TO-PEAK OBSERVED AT 21:37 GMT

EVALUATION

SEA LEVEL READINGS INDICATE A TSUNAMI WAS GENERATED. IT MAY HAVE  
BEEN DESTRUCTIVE ALONG COASTS NEAR THE EARTHQUAKE EPICENTER AND   
COULD ALSO BE A THREAT TO MORE DISTANT COASTS. AUTHORITIES SHOULD 
TAKE APPROPRIATE ACTION IN RESPONSE TO THIS POSSIBILITY. THIS     
CENTER WILL CONTINUE TO MONITOR SEA LEVEL DATA TO DETERMINE THE   
EXTENT AND SEVERITY OF THE THREAT.                                
                                                                 
FOR ALL AREAS - WHEN NO MAJOR WAVES ARE OBSERVED FOR TWO HOURS    
AFTER THE ESTIMATED TIME OF ARRIVAL OR DAMAGING WAVES HAVE NOT    
OCCURRED FOR AT LEAST TWO HOURS THEN LOCAL AUTHORITIES CAN ASSUME 
THE THREAT IS PASSED. DANGER TO BOATS AND COASTAL STRUCTURES CAN  
CONTINUE FOR SEVERAL HOURS DUE TO RAPID CURRENTS. AS LOCAL        
CONDITIONS CAN CAUSE A WIDE VARIATION IN TSUNAMI WAVE ACTION THE  
ALL CLEAR DETERMINATION MUST BE MADE BY LOCAL AUTHORITIES.        

ESTIMATED INITIAL TSUNAMI WAVE ARRIVAL TIMES. ACTUAL ARRIVAL TIMES
MAY DIFFER AND THE INITIAL WAVE MAY NOT BE THE LARGEST. THE TIME
BETWEEN SUCCESSIVE TSUNAMI WAVES CAN BE FIVE MINUTES TO ONE HOUR.

Duck, Saipan!

Not the sort of "eye" I was expecting to write about this week, but here she is. Our first typhoon of 2007 is expected to hit in about 24 hours.

Unlike the coastal US, our buildings are constructed for these things, which come hard about every two years. Almost all our buildings on Saipan (and all the Marianas) are made of concrete, so we just board up the windows and wait it out. Hopefully no one gets hurt, and we get power back within a week or so.