My Fraught Relationship With The Man-In-The-Box

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Jack in box vector image Courtesy of freesvg.org

I reallyreallyreally do not like inanimate objects talking to me. I avoid Siri, preferring to do my own research than to hear her voice—or to have her record my every Internet search (though I hold no illusions about privacy anymore…). I am not tempted to invite Alexa into my home to find that old Sinatra record for me, thank you very much. 

And back in the day when we actually got into cars and drove places, I always resented the high-pitched voice of that GPS woman, who on occasion directed us to dead-end streets and once recommended that we exit sharply to the right when we were in the middle of a bridge.

I’m not accusing her of malicious intent, but her satellite-guided bumbling was not a confidence-builder. I am perfectly capable of bumbling on my own.

Why then, do I invite the man-in-the-box into my life practically every day? It’s because he’s integral to The Device, which shall go nameless so that I’m not guilty of unintended promotion—or worse. 

Let me sidepedal a bit here and note that I am very receptive to integrative medicine, which brings together the best from East and West. My daily meditation, linking me to the Buddhism of 2500 years ago, has been a great help.

I do try to stick with practices that are evidence-based, and to maintain a healthy skepticism about things that sound extreme to me—Eastern or Western.

When several people whose opinions I respect raved about a physician who practices integrative medicine, I made an appointment.

I wanted to see whether she would offer me new, preferably non-pharmacologic approaches for handling my chronic conditions: specifically migraines that I know have an anxiety component, and mild hypertension.

Well, some of what she suggested made no sense to me. But she recommended The Device, which she felt might help alleviate these issues. And it turned out that she was right.

It wasn’t inexpensive—costing several hundred dollars—but it involved deep breathing, so I felt it was sufficiently safe and akin to the meditation that’s a valued part of my life.

The beloved neurologist who treats me for migraines thought it was a good idea, as it’s a form of biofeedback, which is an evidence-based method to alleviate migraines.

A description: An elastic belt holding a sensor is attached to a computerish small box, as is a pair of earbuds. I snap the belt around my torso and insert the earbuds. Then I listen to the instructions that the little man-in-the-box provides. Note: I am substituting The Device for its brand name. 

Here’s how a session begins:

“Lean back and relax and listen to the music as The Device detects your individual breathing patterns,” he tells me.

If I perform that difficult task to his satisfaction for several seconds/minutes, he says, “The Device has detected your individual breathing patterns. Now breathe according to the guiding tones.” I hear sounds—bom, bom—and I match my breath to the tones. 

Sometimes, as in this morning, he immediately tells me I’ve reached the “therapeutic breathing rate,” which means I’m really cookin’. More often, seconds/minutes pass as he goads me with that familiar refrain: “Breathe in, breathe out, breathe in, breathe out” before I reach that coveted goal.

Once there, I continue breathing in and out in sequence with the tones for another 14 “therapeutic” minutes (not sure why it’s that time length, but it always is) until he says, “The Device is turning off. Bye for now.” Let me tell you, I’m never sorry to part with him at that point.

And then I get to see how well I’ve performed by clicking on the box’s levers. Here’s where I realize my slight touch of OCD kicks in. I’m back in school, and I really want to do well. 

In fact, I usually do. The range deemed acceptable for the initial breathing rate is between 6 and 30 breaths per minute—the lower the better. I’ve never gone above 7.2; this morning’s readout was 5.2, which I guess means I had a pretty restful night’s sleep. 

The recommended final breathing range is 5-10 breaths per minute, and I’m nearly always below that—usually 4.8-4.9. Occasionally, I’ve gotten to 4.3, which is nearly Yogi territory, I think. More about that shortly. 

The Device also reports my synchronization rate (how well I synchronize my breathing with the tones) and my breath detection rate (how well the sensor can recognize my in-and-out breaths).

I’m usually right where I should be with those as well. Except if I cough or sneeze. Or hiccup. Then all bets are off.

But I’ve learned one especially bitter lesson. If my initial inhalations are too long while the sensor is assessing my pattern, once the tones begin, I wind up struggling to match them. And the man-in-the-box knows it. He chides me: “Don’t hold your breath!” 

Try breathing in for longer than you possibly can—and continue for 14 minutes—and you’ll see what it’s like. (Actually, just take my word for it; it’s not something a sensible person would do.) 

The lesson I learned: When using The Device, never-ever breathe in for long, lest the sensor monster constantly remind me of my failure.

In such instances, my synchronization rate would ensure a “needs additional work” message on my school report card.

He (my electronic tormenter) has also on more than one occasion said: “Try to breathe more evenly.” I make an effort not to take offense that he’s dissatisfied with my performance.

And he is oh-so picky about that sensor. “Tighten the sensor,”  he’ll command. Or  “loosen the sensor.”  Even “reposition the sensor.” His standards are high. I scramble to do his bidding. 

I used to strap on The Device just before bedtime, but I found all kinds of reasons not to go through the process then. So it’s now the first thing I do upon awakening—after taking a long drink of water to prepare my dry mouth for the routine.

Sometimes I wonder, as you may well, why I subject myself to this regimen-with-verbal-abuse on a daily basis. Of course, I always have the option of shutting the darn thing off.

But, while The Device hasn’t totally replaced medication, it really has done what the doctor said it might: migraine frequency diminished, blood pressure low-normal, anxiety lessened.

So I’m locked in to this challenge. Plus, in these pandem-icky days, I figure it’s not so bad to give my lungs a bit of a regular workout.

And then I meditate and express lovingkindness for all the nasty thoughts I’ve had about the bossy little man-in-the-box.

Annie

Notes From a COVID-19 Epicenter: Our Quarantine Begins

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COVID-19; image courtesy of state.gov.

This wasn’t the post I’d originally planned to publish. That one can wait for another time. This post is more timely. And since my story may become your story—if it hasn’t already—I thought I should tell it to you now.

I live in a medium-sized community in the eastern US. Yesterday, our mayor requested that we move beyond this new status we’ve just learned about: social distancing.

We’ve now been asked to self-quarantine, voluntarily at this point. We should stay at home, going out only to buy food or medications. We are suddenly activists in the effort to flatten the curve and slow the exponential increase in disease incidence. 

The community officials have been acting very responsibly—closing the municipal buildings and library and encouraging people to conduct their business online. (Woe to anyone without functioning computer and Internet connection, but that’s a story for another day.)

They’ve even stated the number of people who will be permitted to enter the food markets at one time: 50 for the largest; 25 for each of the smaller stores, with only one family member permitted per visit. I’m all for these restrictions, which seem well thought out to me.

As my husband and I are past 60, we are considered part of the vulnerable population. We don’t have the other conditions that would increase our odds of becoming severely ill—such as heart or lung disorders or diabetes—but our well-worn immune systems are better off not being called into combat against this particularly nasty bug.

I’ll note that we’re careful about our health and diet, don’t smoke, and are both gym rats. One of the hardest things about this quarantine is that even though we’d decided it was probably not a good idea to continue going to our gym, the gym announced today that it’s closed until further notice.

That deprives us of the most important man in my life: the personal trainer we work out with together once a week. (I’ve told the trainer that in my husband’s presence.) He has really strengthened us and made us feel we’re up to all sorts of challenges.

I had assumed that under the circumstances, even if I got the damn virus, I would be sick for a week or so and then recover. But I’ve since learned that it’s quite tricky, and even when people seem to be recovering, it can do a sneak attack that brings them to an ICU needing a ventilator.

My purpose in telling you this is not to create panic; I feel amazingly calm myself considering my basic catastrophizing nature. Mindfulness meditation works wonders for me: I don’t dwell on what may happen.

Similarly, I see no point in checking the balances on our rapidly crumbling retirement accounts—or spending more than a fleeting moment pondering potential breakdowns in our food supply chains and the availability of medicines I must take. 

But there are plenty of people who either aren’t getting or aren’t hearing the facts about COVID-19. The messages from the White House and the CDC are conflicting and confusing. Putting out a blanket limit on 50 people congregating in a single spot does not take into account the size of the spot (unlike my local regulations) and how much “social distancing” is possible therein. 

Such ambiguity may lead people to continue taking advantage of not having to be at work to meet with their friends in a bar; that’s definitely not smart. This is not your grandmother’s flu. It’s spreading more quickly than other viruses in the past. It’s also more lethal.

On March 14, our local hospital had 11 cases, and 6 of them (all younger than 60) were in the ICU. Another 40 patients were under observation. Those numbers are increasing rapidly, and they somehow haven’t made it into the state’s official count.

You know those N95 masks many people are talking about, which can be used only once and are essential to protect health care workers as they tend to infected patients? The hospital’s CEO said in an interview that those masks are running low statewide. His hospital had gone through 795 of them by 7 pm in a single day.

He described the past week as something he’d never before seen, even though he’d fought cholera in Haiti after the earthquake, when there were no medical supplies, and “even when we ramped up for Ebola.” He called this crisis “unprecedented.”

The CEO said a number of things that were quite concerning. One that disturbed me the most was that he’s given up on the Centers for Disease Control and Prevention, which had yet to confirm his hospital’s first case.

In his view—and this is something he wants people to know—testing is problematic. It’s more complicated than it’s been described. To be effective, it must be done under strict conditions with a sample taker appropriately outfitted with Personal Protective Equipment (PPE), and differing RNA assays make test sensitivity questionable. 

So at best, the tests are 90% accurate, whereas flu tests are 99.999% positive. He fears drive-through testing that shows someone is negative will give that person “a false sense of security.” He said he told the Governor his concerns. 

There are many experts with differing views; I’m noting his because he’s a highly regarded individual who’s working with labs—not to suggest that his opinions necessarily be used as guidance in individual decision-making. 

Testing in the US has certainly been botched, by nearly all accounts, but many point out, as this Atlantic article states, that knowing how many people have been tested would give us some sense of how far the disease has spread and “how forceful a response to it the United States is mustering.” Hmmmm….

Though our hospital CEO doesn’t want to incite panic, he does want people to take this disease seriously because in infected patients

“things can turn around very rapidly. We had a patient that we were thinking about releasing—he seemingly was recovering—and then, two days later, he was put in the ICU. The flu isn’t like that. People need to know this.” 

He encourages people to be responsible: stay home, avoid malls and theater and group activities for now.

“We need to sort of hunker down at home. Go outside if the weather’s nice in your backyard. That’s healthy and good. But we shouldn’t be out and about.”

That’s what we’re doing. Going into stores for food only when they’re not crowded. Avoiding situations where we’ll have to stand on line. Bringing our rapidly disappearing hand sanitizer with us when we’re out of the house, and swabbing our door knobs on the outside and inside with Lysol when we return.

(We’ve also made some hand sanitizer by mixing alcohol with aloe vera, but both ingredients are no longer available.) 

I heard one virologist say COVID-19 is most likely to linger for up to 9 days on metal and hard smooth surfaces. Clothing and porous surfaces seem not to be a concern. I haven’t found confirmation of this statement, however.

What else are we doing? Agonizing over whether to buy two or three small packages of tissues (8 each pack): they were going fast, and we felt we could use them to open doors once our hand sanitizer was gone. But was buying three packages selfish? 

We’re wiping down our cell phones (Apple said Chlorox wipes are OK) and other surfaces. Lifting weights and exercising at home, and taking walks in the late afternoon when few people are around. And yesterday we toured our small garden, buoyed by the sight of the first crocuses pushing their way through the mesh we’d placed over the hard soil to allow them to get a head start before the feeding faunas’ visits. So those back-aching hours planting bulbs last fall paid off! The appearance of those young green shoots couldn’t have come at a better time.

And we’re washing, washing, washing our hands. I find it so interesting that this devastating organism can be vanquished by plain old soap and water.

Finally, we’re still remembering to laugh. (See my previous post.)

My sister-in-law sent this cartoon today.

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My response was: “Gee, do you know where he got it? I could use some.” 

Do you have stories to tell about how you’re coping? I’d love to hear them. I hope you all stay safe.

Annie

Continue reading “Notes From a COVID-19 Epicenter: Our Quarantine Begins”

How One Woman’s Breast Cancer Experience May Revolutionize Cancer Care

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mammograms for early detection

I love to write about good news. I especially enjoy elaborating on advances in the world of science during these times when science is too often attacked. This story shares some qualities with my recent post about the extraordinary Nobel Prize Winners in Physiology or Medicine. 

Like the Nobel discovery, this one seems destined to save lives and dramatically reduce suffering. It’s the result of one brilliant woman’s using her own status as a breast cancer survivor to create potentially dramatic changes in the detection and treatment of the disease.

My new hero is Regina Barzilay, PhD. She isn’t a physician, yet she seems to be upending medical practice for the better through the use of artificial intelligence (AI).

Barzilay is a professor of computer science at the Massachusetts Institute of Technology (MIT) and a certified genius: in 2017, she was the recipient of a MacArthur Fellowship “genius grant.” 

She and her team, which now includes experts from both MIT and Massachusetts General Hospital (MGH), have created computer algorithms that predict the likelihood of a patient’s developing breast cancer in the next five years. 

The model they designed began with a database containing pathology reports of more than 100,000 women treated at MGH over 30 years. Barzilay and her team then “taught” the computers to provide specific information from mammograms of more than 60,000 patients. 

According to an article in MIT News, 

“Trained on mammograms and known outcomes from over 60,000 MGH patients, the model learned the subtle patterns in breast tissue that are precursors to malignant tumors.”

Barzilay told Susan Gubar, who wrote about this remarkable work in Science Times, the special Tuesday section of The New York Times, that

“machines work more effectively than human eyes. They can register subtle changes in tissue—influenced by genetics, hormones, lactation, weight changes—that we cannot see.” 

Barzilay showed Gubar the results of her own mammograms from 2012, 2013, and 2014. The cancer that was diagnosed in 2014 was, in fact, evident in the two previous views.

I found myself deeply touched by that information, imagining what it must have been like for her to learn her cancer could have been caught and treated two years earlier, and seeing how heroically she turned her personal knowledge into this bold campaign to prevent other women from experiencing similar anguish—or worse.

Gubar reports that

“The enthusiasm Dr. Barzilay brings to this undertaking is fueled by her dismay at current approaches to cancer care. While being treated at MGH, she was struck by the high degree of uncertainty surrounding treatment of her disease.

“Why did her questions go unanswered about how other patients at the same hospital with similar tumors fared with this or that drug or with this or that surgery? Why was there so little information?”

The apparent explanation was that oncologists rely on the results of clinical trials in determining treatment regimens. That’s not surprising; they seek evidence-based medicine.

The problem Barzilay saw was that the trials enrolled just about 3 percent of eligible women, meaning 97 percent weren’t part of the picture. 

Barzilay termed this approach a “primitive practice” that was a “travesty,” Gubar reports, “especially because large volumes of information about patients accumulate in every hospital.” (Emphasis mine)

But a stumbling block to the work she proposed was that the data are written in “free-text” English, rather than in a form a computer could process. That’s when she and her colleagues began building the databases.

In one study, the Barzilay team’s model identified 31 percent of patients as high risk for future breast cancer, in contrast with the existing clinical standard, which identified 18 percent. That difference encompasses a great many women.

Once this work is more fully implemented, the result, Gubar writes, will be that

“New patients will be empowered by learning how tumors with particular characteristics responded to specific treatments. Machines accessing subsets of the population will also make it faster and cheaper for clinicians to identify patients with particular disease characteristics and to enroll them in clinical trials.”

One particularly valuable aspect is that the cancers are detected regardless of the patient’s race—an important consideration in view of the much higher breast cancer mortality rate among African-American women.

According to Gubar, similar efforts are occurring at Google, where AI specialists are examining scans for lung cancer. It seems reasonable to me, as a nonscientist, that this approach is potentially replicable with all sorts of cancers. (I’d welcome hearing from anyone with expertise in AI, cancer, or the intersection of the two fields.)

Barzilay knows buy-in from oncologists is critical to this effort. She sought to learn whether oncologists were reaching out to AI researchers; when she found that they weren’t, she also made one of her aims to enlighten them about these new possibilities.

Writes Gubar:

“Dr. Barzilay and her collaborators want to usher in the day when no woman is surprised by a late-stage diagnosis and when all breast cancers are curable.

“They also hope to solve the problems of over- and under-testing. Instead of a one-size-fits-all practice, the frequency of screenings and biopsies could be customized with sufficient data.”

That could be a huge benefit to patients. For example, at present, the MIT article notes, there is a discrepancy in screening guidelines, with the American Cancer Society recommending yearly screening beginning at age 45, while the U.S. Preventative Task Force says screening should be every two years, beginning at age 50.

And for implications for individual patients, Gubar points to the young women she knows who are aware that they have an inherited BRCA genetic mutation, which can substantially increase their risk for breast cancer (as well as for ovarian cancer).

With great anxiety, they are contemplating prophylactic double mastectomies—although there’s no assurance that such drastic surgery is necessary for them. The numbers of such women are increasing now that genetic testing is so readily available. 

Barzilay’s work can help women better face this difficult decision. In responding to Gubar’s query about such affected women, she stressed:

 “With a CD of their scan, we would be able to tell them their personal risk.”

I wish Dr. Regina Barzilay a long and productive life as she continually refines and expands her invaluable work.

Annie

Here’s Why This 2019 Nobel Prize Is Breathtaking…

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Do any of the following apply to you?

—You’re hard-pressed to find some good news in the public sphere
—You’re troubled about the anti-scientist trends swirling around
—You have, have had, or know someone who’s had anemia
—You have, have had, or know someone who’s had a heart attack or stroke
—You have, have had, or know someone who’s had cancer
—You’d like to live in a place with a higher altitude than you currently can handle
—You’d like to improve your sports performance

If so, you may find the 2019 Nobel Prize in Physiology or Medicine as exciting as I do. And the above list of diseases and circumstances is merely the beginning of what scientists believe will be the impact of the work the Nobel Committee has just recognized.

The three recipients, two Americans and a Brit, pieced together a series of discoveries—their own and some preceding and/or complementing their work—to discern what one scientist called the “thermostat” that enables cells to regulate the amount of oxygen needed to do its work: convert food into energy. The Nobel Committee referred to this mechanism as “one of life’s most essential adaptive processes.”

As the Nobel Prize press release states:

“The fundamental importance of oxygen has been understood for centuries, but how cells adapt to changes in levels of oxygen has long been unknown.”

The “thermostat” the honorees discovered is comprised of a series of molecular occurrences by which cells sense too much or too little oxygen and respond accordingly.

Describing the Breathtaking Work

(From the Nobel press release)

“Thanks to the groundbreaking work of these Nobel Laureates, we know much more about how different oxygen levels regulate fundamental physiological processes. Oxygen sensing allows cells to adapt their metabolism to low oxygen levels: for example, in our muscles during intense exercise.

“Other examples of adaptive processes controlled by oxygen sensing include the generation of new blood vessels and the production of red blood cells. Our immune system and many other physiological functions are also fine-tuned by the O2-sensing machinery.

“Oxygen sensing has even been shown to be essential during fetal development for controlling normal blood vessel formation and placenta development.”

These are the three new Nobel Laureates:  William G. Kaelin Jr., MD, of Harvard University in Boston, Massachusetts; Gregg L. Semenza, MD, PhD, of Johns Hopkins University in Baltimore, Maryland; and Sir Peter J. Ratcliffe, FMedSci, of Oxford University in the United Kingdom.

Concerning the relevance of their findings to major diseases, the Washington Post  quoted Isha Jain, a scientist at the University of California in San Francisco:

“If you think of the main causes of death in the US, three out of five are related to lack of oxygen,” [including heart attack, stroke, and respiratory diseases]. “Understanding how the body senses and responds to low oxygen is pretty fundamental to all these diseases.”

Semenza said he and his colleagues hope that new therapies may increase the passage of blood into tissue with reduced blood flow “in diseases such as coronary heart disease and also limb ischemia, which is a major problem, particularly in diabetics, leading in some cases to limb amputation.”

And then there’s cancer. The Nobel press release explains:

“The oxygen-regulated machinery has an important role in cancer. In tumors, the oxygen-regulated machinery is utilized to stimulate blood vessel formation and reshape metabolism for effective proliferation of cancer cells.”

Semenza told the Associated Press:

“Whereas most of the chemotherapy drugs are designed to kill dividing cells that are well oxygenated, there are no treatments that are approved to treat the hypoxic cells within the cancer. We believe it’s these cells that survive the therapy and come back and kill the patient.”

From “Bench to Bedside”…

Or from lab to life-saving: such action is well under way, the press release reports.

“Intense ongoing efforts in academic laboratories and pharmaceutical companies are now focused on developing drugs that can interfere with different disease states by either activating, or blocking, the oxygen-sensing machinery.”

The first clinical application, a drug to combat anemia, was recently approved in China, and it is now under consideration in several European countries.

Semenza’s work was seminal to the total effort. In the 1990s, he and his group identified genes that were activated when oxygen levels were low to raise the levels of erythropoietin (EPO), a hormone secreted by the kidneys essential to producing the oxygen-laden red blood cells.

The oxygen-sensing mechanism was originally believed to be located only in the kidneys, but both Semenza and Ratcliffe subsequently found, among other things, that it exists in nearly all cells.

Moving from the profound to the less-so, The Washington Post notes that:

“This is the same basic mechanism behind doping, in which endurance athletes try to increase their supply of oxygen-carrying red blood cells.”

Though Semenza’s early article describing that research has now received thousands of journal citations, it was initially rejected by the “top tier journals,” which, he said, “didn’t find it to be of sufficient interest to warrant publication.”

(A note of encouragement to all who aspire to publication in any field of endeavor, don’t you think?)

For those who are interested in the scientific nitty-gritty, the Nobel release provides the road map of individual discoveries by the three researchers and others that yielded this dramatic finding.

Lessons Beyond the Discoveries Themselves

One of the things I especially like about this story is that these men, while working independently over decades, also shared their unpublished data with one another—“sometimes at scientific meetings, sometimes at the bar,” said Kaelin.

No secret patents here; no rivalry to be “the first.” As one made a discovery that he knew was an important piece of the puzzle, he described it to his colleagues.

I’ve no idea whether, or to what extent, this collaborative approach was influenced by their funding sources, but it’s worth noting that a National Institutes of Health (NIH) press release touted the US government’s role in supporting both American scientists’ work, and the American Heart Association stated it underwrote Semenza’s early work. The European Research Council (ERC) supported Ratcliffe’s work.

Two more issues are worth noting. One is that Semenza, who is a professor of genetics at Johns Hopkins, credited his wonderful high school biology teacher, the late Rose Nelson.

“She used to say to us, ‘When you win your Nobel Prize, I don’t want you to forget that you learned that here.’ She just assumed that one of us was going to do that…She was my inspiration, and I think that is the importance of teachers, to serve as that kind of spark.”

The other is Kaelin’s emphasis, as the Washington Post reported:

 “The prize underscores the importance of doing research to follow curiosity and unravel basic biology. He and the other scientists hoped, but did not know, that unraveling how cells sense oxygen could spark ideas for new approaches for human diseases, including stroke and cancer.”

Said Kaelin:

“This kind of research is increasingly under threat. It’s much easier for fundraisers and policymakers to say we will support scientists, but…tell us how it will improve outcomes in five years.

“When you’re doing real science, you have to be prepared to take the road where it takes you—and if you’re doing science, it’s hard to predict where the road is going to take you.”

Will you join me in a virtual round of applause for scientists dwelling for decades on basic research, facilitated by public funding?

Their research won’t always take us where these three eminent researchers have—but when it does, the benefits to us, individually and worldwide, can be immeasurable.

Annie

A Cautionary Summer Tale

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I have a few friends who are medical nihilists (several of them are married to physicians). They avoid medical care whenever possible, rarely see a physician, and when they go, generally ignore the physician’s instructions.

I am cut from a different cloth. I go to the doctor for preventive care, get my flu shot every year, and seek medical guidance if I’ve had a problem for more than a few weeks.

I do have several chronic conditions and a bionic knee and wrist. However, I am fortunately, at this point, in good health. (Cue my late mother’s voice here, making clucking sounds to ward off the evil spirits.)

I tend to be super vigilant about medical matters. In fact, as I’ve written previously, I tend to catastrophize. That sudden pain in my leg? The one that’s probably a pulled muscle? Well, it feels hot, so it could be a blood clot, couldn’t it? (I also meditate, but sometimes the worry forces overwhelm the calmness regimen.)

And, having worked as a medical writer/editor in the past, I realize that I possess just enough medical knowledge to be a danger to myself and others. (I do, however, refrain from prescribing–and for the most part avoid misdiagnosing my friends and family.)

Although it’s gotten worse in recent years, as those around me have died—or narrowly escaped death—this tendency on my part to focus on all things medical has been ever so.

I think I’ve known the seven warning signs for cancer since I learned to read. For those who don’t share my fixation, the first sign is “Any sore that does not heal.”

But the tiny mark on my nose seemed insignificant—certainly not a sore as I understood the term. Occasionally, a little dry skin flaked off and the skin beneath looked slightly pink; then it quickly returned to its previous state. I found it curious, but not at all alarming. This went on for months.

One night, when the spot looked pinkish, I dabbed it with a little cortisone cream that my dermatologist had given me for a previous condition.

Shortly thereafter, I stepped into the shower. When I stepped out, I caught a glimpse of my face in the mirror, and blood was gushing from that tiny spot on my nose—it seemed like several tablespoonfuls.

My dermatologist saw me the next day. “It doesn’t look like anything,” she said, poring over it with her magnifying glass. “But whenever there’s bleeding, we do a biopsy.”

The biopsy was definitive for carcinoma, but wishy-washy as to type. At varying times I was told it was a basal lesion with some squamatization, a squamous lesion, or a “collision lesion” of both cell types. The latter made me envision two small bumper cars packed with differing cells, going at each other at high speed.

One point was certain: the innocuous looking thing had to go. I was referred to a Mohs surgeon for a procedure in which the lesion is removed layer by layer while the patient waits for the biopsy report stating that the margins are clear: the cancer is gone.

At the pre-op visit, the surgeon’s nurse drew a fairly large circle around the lesion with a green marker pen. That should have alerted me to what was ahead; it did not.

The surgeon explained her procedure and then said, “I think we should have a plastic surgeon on standby to close the wound.”

I was puzzled. It was so small—surely a few stitches would do. Then she said, “You have a fine aquiline nose; I think it’s wiser to have a plastic surgeon do the closure.” OK. The plan was that I would see a surgeon she works with on such cases; she’d complete her work, bandage me up, and he’d close the wound later that day. Seemed reasonable.

But when I met the plastic surgeon pre-op, he began describing what sounded like pretty dire procedures. “We can take a skin graft from another part of your body that’s close to the color of your nose,” he said. “Or we can do a flap from your forehead.” All of a sudden, this tiny lesion was wreaking outsized havoc on my face.

I spoke with the Mohs surgeon’s nurse, who assured me that the plastic surgeon gave “worst possible scenarios.” I felt better—for a time. I had agreed to the graft, if needed, because the plastic surgeon said if I didn’t like the results, he could always do the flap. But once the flap was done, no revision would be possible.

Fast forward: the cancer was gone after a single layer’s removal: very good news. The plastic surgeon told me to come right over. He looked at the wound and said, “We’ll take a graft from your clavicle; do you mind a scar?”

I was willing to forgo a pristine clavicle for a chance that my “fine aquiline nose” wouldn’t be seriously disfigured. I will acknowledge that my attachment to it has been more than physical and utilitarian.

I was awake through the surgery, and we all laughed at the surgeon’s stories of his parents’ youthful indiscretions. Not sure why he raised that issue, but it did pass the time and take my mind off the snipping and sewing.

He had warned me the healing would take about a year, so I’m more than three-quarters of the way there. There have been bumps along the way—just recently, one quite literally.

I was walking through a revolving door and, certainly not practicing my mindfulness, stepped ahead before the opening had reached me—like a tiny bird ramming into a window. The only part of me that hit the glass was my nose—straight on.

I began icing it as soon as I could and called the plastic surgeon’s office to see if I should do anything else. He returned my call in minutes—an unusual attentiveness that suggested concern.

“In a battle between a door and a nose, the door always wins,” he said brightly. (He’s a good surgeon, but I didn’t need the wisecrack.) “Do you think it’s broken?” he asked. I said I really didn’t think so; it didn’t hurt that much and was simply quite red. “Keep icing it on and off all day,” he responded. “It should be OK.”

The next day, when I awakened to find the skin graft in place and not beside me on my pillow, I appreciated how fortunate I was not to have damaged myself seriously.

Now that I have a portion of my clavicle attached to my nose, I’ve thought about whether it’s still appropriate to call it a nose. It seems more like a hybrid of two heretofore autonomous body surfaces, finding their way to peaceful coexistence.

It’s a strange phenomenon, but I profoundly recognize that in the scheme of things, so many people struggle with far worse medical conditions for many years. I’m very grateful for my situation and do, mindfully, appreciate every day.

Some mildly annoying lifestyle changes go with this new territory. I’ve had three squamous lesions in less than two years (two were in situ—precancerous), of which two were on my face. Thus, I’ve been warned by both the Mohs surgeon and my dermatologist that although the skin damage happened years ago, I must now take extra precautions: sunscreen (more than 30 SPF) all year round, rain or shine; hats with brims; sunglasses; and long sleeves.

In this 90 degree heat, I get some strange looks, but so be it. A woman of mystery–perhaps a secret agent, who has traded her traditional trench coat for UPF (ultraviolet protection factor) garments.

So ends my cautionary summer tale for you—especially those who are young and carefree. Just one or two bad sunburns can do a lot of damage, and mine occurred before we were worried about losing the protection of the ozone layer.

Don’t be cavalier about your exposure to the sun. And please: don’t ignore any small lesions, no matter how innocuous they may appear, if they hang around for a while.

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One more thing: if you’re even thinking about going to a tanning parlor, fuggedaboudit!

Your thoughts, experiences…?

Annie