1st treatment

We picked up my mom at the Sacramento airport Sunday night, and then checked in to a really nice suite that Angel’s uncle and aunt John and Gail put us up in, right in downtown Sacramento. We’re right next to the drawbridge that crosses the Sacramento River, and right down the street from the state capitol building. John and Gail, if you’re reading this, thank you so much, this place is great. And there are some other pretty nice perks of this place…free breakfast every morning (a really good breakfast, too) and free cocktail hour (two hours, actually) every evening. Come to think of it, we had free breakfast and free cocktail hour the whole time at Ben and Katherine’s house too. Pretty awesome!!

We woke up Monday morning, had a nice breakfast, then hit the road. We first drove down to the UC Davis campus to make sure we knew where to go and where to park for our 4:00 appointment. We followed the directions through the campus, and as we made the last turn to the Crocker Nuclear Laboratory, there was a fire truck, a police car, and an ambulance at the back of the building. That was a great sign, huh?!

Once we made sure we were in the right place, we headed down south a little bit to visit…the Jelly Belly factory! It was a pretty neat tour, but there should have been an opportunity to ask questions. For example, “how can you say that buttered popcorn is one of the top three best-selling flavors when it obviously sucks?” At the end of the tour there was a tasting area where you can try all the flavors you want. They also sell discount bags of Belly Flops, the reject pieces that aren’t awesome enough to deserve the final Jelly Belly stamp. I’ll still enjoy eating the ugly ones!

From there we hit up an olive oil and vinegar tasting, which was pretty neat, then grabbed lunch and took a brief nap in the car before heading back to UC Davis for our appointment. Rounding that last corner this time, we noticed that the emergency vehicles were gone, which was a pretty inviting sign. We waited a while in the lobby before being called back to get the show on the road. We walked through the very industrial-looking building, past the proton accelerator, and around the corner to the small eye patient treatment area. Remember, this is not a medical facility; it’s a nuclear research laboratory in the middle of a college campus.

First, more dilation drops in my eye, and then a crap-load of numbing drops to numb my eyeball and my eyelids. I took a seat in the chair as they prepared to strap me in. Even with the eye and nose holes cut in the mask this time, it’s still a little unnerving having your head locked into such a restrained position, so tightly that my cheek fat was squeezing over the edges of the mask. The bite block was next, then a series of x-rays to make sure I could get my eye (and the tantalum rings) into a position that would match their 3-d plan. Angel and my mom were in the room up to this point getting these pictures, but then they had to leave to another area.

Next Dr. Mishra installed the eyelid retractors. These weren’t highly painful, but a sort of mildly painful, really weird feeling. Back to the emergency vehicles we saw earlier…an earlier patient in the day started feeling nauseous when they tried to put in her retractors, so they let her rest in the waiting area for a while. During this time the patient’s mom got light headed and passed out. At least the proton beam didn’t go crazy and start shooting people!

I have no clue how far my eyelids were stretched, but it felt pretty far. After it was all over I asked Dr. Mishra if she would take a picture at my next treatment. She laughed a little like she thought I was weird for wanting to see that, but she said that she would take the picture. With the eyelid retractors in place I had to rotate my eye as far up as I could to see the flashing red light and hold it there while they did more x-rays. I think I need to exercise my eyeball-moving muscles or something, because it was hard to hold it in that position for very long. Once they verified that my eye was in the right position, someone in another room drew a circle around my pupil on a monitor that was showing a zoomed-in view of my eyeball. That would be how they could tell if my eye was moving too much and they would have to shut the beam off. Angel and my mom were able to watch everything from a set of four monitors showing different angles.

Everyone left the room when the treatment was about to start, and Dr. Mishra talked to me through an intercom system. She told me when the beam would start, and then she gave me several more updates throughout the 90 seconds that the beam was on, so I knew how much longer I’d need to focus on not moving my eye.

When the time was over, they came back in the room and released my head so I could swallow and take some deep breaths. That was it! Only about 20 minutes total. I then got another eye patch to keep on for 30 minutes, just to make sure I didn’t scratch my eye while it was numb.

I felt nothing at all as the beam was on. For all I know they could be trying to kill the tumor with a placebo effect! Just kidding, I’m sure they wouldn’t do that. I didn’t feel any side effects other than a headache. So really, I’m very lucky for having a cancer that can be treated with a proton beam rather than plaque radiation or with chemotherapy. Many other people have had much more difficult challenges. With how easy this is it almost feels like I’m cheating!

Not much to update...

Not much has happened on the medical front since the last post. Angel gives me two eye drops three times a day (pathetic, I know, I’ve never even been able to put Visine in my own eye). The bottle with the white cap doesn’t hurt, the one with the red cap stings real bad for a few seconds. Then there’s the goop she puts in twice a day. Because of these, my left eye vision is 100% blurry all day, all night.

I thought I’d mention a few more things we learned when Angel and I were talking to Dr. Mishra the other day. When this all started, a couple of people (namely Angel and my mom) asked whether the indirect lightning strike from a few years ago could have had anything to do with this eye cancer. When that lightning flashed, it was by far the brightest thing that I had ever seen. Dr. Mishra thought it was very interesting that we brought that up. While she couldn’t say for sure (obviously) that it was causal, she did mention that arc welders (who see bright lights very regularly) are 7 times more likely to get choroidal melanoma than someone who’s not an arc welder. She also said that she’s seen more pilots with choroidal melanoma than she would expect to see. Is it possible that pilots see bright lightning flashes or other bright lights as well? There may be something to this, but maybe not.

She also told us that despite what we had read online, the chances of typical radiation side effects are very low with proton beam therapy. So hopefully no fatigue, no feeling sick, none of that crap. If she has to shoot the beam through my skin, it will feel like a bad sunburn in that spot. If she can’t get my eyelids out of the way, those eyelashes will fall out permanently. If she has to shoot through the important pieces in the front of my eye, I will probably have eye problems (glaucoma, cataracts, etc.) sometime down the road.

We also learned that the loss of vision that I’ll most likely experience won’t be immediate; instead it would be pretty gradual. In fact, it might take as long as 5 years for the full effect of my vision loss to be complete. We thought that was pretty cool because then my brain will have time to adapt as things change. In the end, even if I just have peripheral vision in the left eye, that should be enough information to add a third dimension to my overall vision. But again, most of these statistics are based on the typical choroidal melanoma patient, which is someone in their 60s or 70s. About 2% of patients with choroidal melanoma are around age 30 or lower. So out of the ~1800 people in the US that get it each year, about 36 of them are around my age or younger.

The only other thing that I can think to mention today is an herbal supplement called Essiac. It’s a blend of herbs, believed to have some anti-cancer properties, that was discovered by a Canadian nurse named Rene Caisse (the name is her last name spelled backwards). Angel’s cousin first brought it to our attention, and she had several stories about the effectiveness of Essiac in helping to control, or even get rid of, cancer. Online you can read lots of anecdotal stories about Essiac working its magic.

There are a few scientific studies showing that in cell culture experiments with cancer cells, Essiac has an anti-growth effect. But, there are also a few studies showing that it has no effect. It seems like it really hasn’t been studied enough to be able to say for sure, but I doubt that it could hurt anything. We bought a bottle of it in San Francisco the other day, but I haven’t started taking it yet. Because proton beam radiation damages the tumor cell’s DNA by oxidative damage, it’s not a good idea for me to be taking anything with strong antioxidants while undergoing radiation. I do plan to take it after I’m done with that, however.

Yesterday (Saturday) we drove to the coast with Ben and Katherine. We tried to go to Bodega Bay but a fire had the road closed. So we re-routed and went to Blind Beach, near the town of Jenner. It was a beautiful beach surrounded by big cliffs, with large rock formations out in the water. It was Duke’s first time playing in the ocean and he had a great time.

Angel and I are heading up to the Davis/Sacramento area later today, then radiation starts tomorrow!

Details about surgery, and prepping for a horror movie

When you look at me now, I either look like Ray Charles (sunglasses on) or a cyborg with swollen eyelids, a bloody eye and a huge pupil (sunglasses off).

And I feel like I constantly have an eyelash in my eye, except the eyelash feels like a small twig. It’s really pretty annoying.

Wednesday Angel and I had an appointment at the Mount Zion campus of UCSF. We met three people who will be there during all of the radiation appointments in Davis next week. (1) Dr. Mishra, an oncologist who sees all of the eye cancers passing through UCSF; (2) Dr. Daftari, a physicist who knows a lot about the proton accelerator, etc; and (3) Charlie, an engineer who makes sure that my head is in the exact same position each day of treatment.

We first spent about 20 or 25 minutes with Dr. Daftari and Charlie, making my mask, taking some x-rays, etc. The x-rays are now showing the 4 tantalum rings that are back there, and they are now constructing a 3-d model of my eyeball. Dr. Mishra is primarily responsible for coming up with a plan of attack for zapping this fetus that is growing in my eye. More on that in a moment.

First, the mask. It’s never a very comfortable feeling having your head confined in a very rigid position with no real idea of how long you’ll have to be there. Then add in a bite block and a suffocation mask, and a little bit of claustrophobia may begin to set in. Just joking about the suffocation mask, sort of. Charlie first put my head in place, then screwed in the bite block attachment and asked me to bite into a putrid smelling ball of crap and hold my teeth in it. Placing my lips around the stuff kept me from drooling all over myself. He warmed up the sheet of plastic to soften it up before (gently) smashing it into my face and holding it there until it cooled and could hold its shape. It was while the mask was setting that I probably could have freaked out if he held it there much longer. I couldn’t breathe through my nose, and if I opened my bottom lip to try to breathe I probably would have drooled a nice big puddle. I tried making hand motions as if to ask “how much longer?” but that message didn’t really get across. After he cut out some eye holes and breathing holes, I was laid in a horizontal position to stare into a red light while the x-rays were taken from two different angles.

I asked for a copy of the 3-d reconstruction of my situation, which they said they could get to me on Monday.

After this Angel and I spoke with Dr. Mishra for quite a long time. She is the epitome of an excellent physician - smart, not arrogant, and very willing to take as much time as is necessary to answer our questions. Since she was willing…we asked a lot of questions, and she explained a lot of stuff that we weren’t clear about before.

The surgery – Dr. Char did cut through the outside edge of my eye, which would explain the cut that I saw in my eye! After I was under general anesthesia, they didn’t pull the eye out of the socket, but they did turn it as far as they possibly could to give them as much access to the back of the eye as possible, since that’s where the tumor is. Even with the eye turned very far, the front of the eye (lens, pupil, etc.) is still visible from the outside. From the front they shine a bright light into my eye and the tumor literally projects a shadow onto the back of the eye. The surgeon’s job is to place the rings as best as they can around the tumor (pretty much on top, bottom, left and right of it). To do this, he cut a slit in the sclera (the white shell that makes up most of the outer eyeball) and basically worked the rings between the sclera and choroid all the way to the back of the eye, and then sutured them in place. As you can imagine, it takes practice to do this well, and that’s why Dr. Char is so good at that surgery. This also explains why it feels like someone spent about 1.5 hours beating the crap out of my eye.

She said that my eye will look somewhat more normal in about a week, but it will take somewhere around 4-6 weeks to look completely normal again. Awesome.

Now, back to the image of my tumor. I didn’t make it clear before that the picture DOES NOT show my entire retina. The camera lens was held up against the front of my eye, and my pupil was dilated, but the camera’s lens only had a 60 degree field of view. They couldn’t tell us what the magnification was, but there’s definitely more retina that didn’t make the picture. The size of an average human retina is about 1094 square mm. My eye measures about 8% longer than average, so I’ll guess that my retina is a bit bigger as well, and will guess about 1150 square mm. Based on the measurements of my tumor, it only covers about 9% of the retina’s surface area. Kind of weird that’s it’s killed about 50% of the vision in that eye.

Here’s an updated version of that picture.

I outlined the tumor in blue. The red line is an approximate spot of where they measured the 10.5mm diameter of the tumor. Based on the length of the red line, I roughly estimated a line that would represent 2.5mm in length, shown in green. That’s because Dr. Mishra said she will be zapping the entire shape of the tumor, and an additional 2.5mm margin around the edge of the tumor, in order to radiate any little micro-spines of bad guys that might be creeping outward from the edge. So, to the blue area, add a shell the thickness of the green line. You can see that that will demolish the center of vision, the spot where most of the fine details from the eye are seen. The green line also comes pretty close to the optic disc, the spot where all of the sensory information from the eye is sent to the brain. Damaging that with radiation would be a bad thing, but it would also be a bad thing to miss part of the tumor. Dr. Mishra’s priorities with this treatment are, in order, (1) kill tumor, (2) save eyeball, (3) save vision, the same as Angel’s and my priorities. She’s going to consider only extending her margin 2mm in that direction to try to spare my optic disc, but she obviously needs to make sure she kills the whole tumor first.

Part of her treatment plan is to think about the best angle to hit the tumor from. She’ll have to consider the 3-d shape of my eye and the tumor to make this decision. When radiation time comes they’ll lock my head in place, I’ll bite down on the gag-me stick, and this will keep large-scale motions of my head from happening. Based on the angle of attack that she thinks is best, I’ll be told to focus my eye on a red spot that will be projected somewhere off in space, in order to turn my eyeball in a specific direction. The machine produces a relatively fat beam of protons, all moving forward, parallel to each other. They will make a custom aperture that is specific for my eye and my tumor shape that will block much of the beam, so if you can imagine it, only a certain “shape” of the original beam will pass through the aperture. Since proton beams have very little side-scatter, it will maintain this shape until it hits the tumor. So the entire tumor and the extra 2.5mm margin will be radiated at the same time. The beam will hit the tumor for about 90 seconds each day. They have a camera focused on my eye the whole time, and in case my eye wiggles too much while they’re doing this, they’ll shut the beam down immediately.

Radiation is measured in a unit called a gray (named after some guy). My treatment plan includes delivering 56 gray of radiation to the tumor over the course of 4 days, 14 gray each day. If you’re interested, 1 gray means that 1 kilogram of tissue is absorbing 1 joule of energy from the radiation source. My tumor is obviously much less than one kilogram of tissue. If I roughly assume that the density of the tumor is about the same as water, then it would weigh somewhere around 0.5 grams. If this is correct (Michelle, Paul, help me out here), then the tumor will absorb 1 gray of radiation by absorbing 0.5 millijoules of energy. It will absorb the full dose of 56 gray by absorbing 28 millijoules of energy over the 4 days of treatment. If you’re an over-achiever, you can continue on with the calculations…1 joule is equivalent to 1 watt-second, so you can put these numbers in light bulb terms if you want to.

The radiation from proton beams actually has slightly more biological activity than other radiation sources, so these numbers are a little off. Technically speaking, my dose will be 56 gray-equivalents.

During the surgery Dr. Char also took a fine needle biopsy of the tumor. He first noted that based on what the cells look like under a microscope it’s a low-grade tumor, but he also sent the sample away for further tests, including molecular characterization and gene sequencing. Based on patterns they’ve seen with a bunch of samples collected over the years, this will tell them how likely my tumor is to metastasize and grow in other parts of the body in the future. If it’s the bad kind of tumor, it’s possible that a couple of cells could already be setting up shop in my liver or elsewhere. While my other tests have all come back clean so far, a small population of cancer cells would be impossible to detect at this point. The molecular and gene test results will take around a month to get back. It seems probable that I will need to have some sort of scan done every 6 months or 1 year for a while. If the cancer doesn’t recur over a relatively short time period (maybe 5 years?), it likely won’t recur after that. However, we can never be sure, so it’s possible that they’ll want me to get continued scans for the rest of my life.

Also, the tumor will not die immediately from the radiation. The radiation is intended to damage the cell’s ability to replicate, so hopefully no more tumor growth. It will take quite some time for my body to start clearing away stagnant tumor debris. In fact, they don’t expect to see any change in the size or shape of the tumor for many months…possibly up to a year. They actually don’t expect the “footprint” of the tumor to change at all, ever. What they do expect to see is that the thickness will decrease eventually, which should bring the retina back closer to its original position. The best-case scenario is that I’ll always have the tumor in my eye, but the tumor will not be able to grow or spread. Weird, huh?

Anyway, thanks for reading this long post. My blog has now been viewed almost 1600 times in 6 different countries. I never knew my left eye had such a large following. Thank you all for the interest, and the support. It means a lot to both Angel and I.

A big, red eye

Warning – a couple more gross pictures ahead.

I wanted to revisit a couple of things I mentioned in my last post. First, I noticed a bunch of typos that I’m not going to fix. Second, the image showing the tumor as a big white mass has been updated. I labeled where the center of vision in that eye, as well as the optic disc are. The optic disc is where blood vessels and the optic nerve enter/exit the eye. With the proton beam therapy that I am going to have, the closer the tumor is to the optic disc, the worse my chances of retaining vision in that eye. The diameter of the tumor is just greater than 10 mm, so estimating from that picture it appears that the tumor is only a few millimeters from the most sensitive spot in my eye. This is probably why I won’t be able to see out of that eye after treatment.

You already read about the crazy day on Friday, with the passing out and all. Many of the people who have heard about my vasovagal have mentioned that it happens more often and more quickly to guys. I like to think that in a stressful situation, guys would prefer to stand there and fight. However, since our fight-or-flight response is blocked, we just decide to go to sleep. J

I also have hardly mentioned how much help I’ve been getting while out here in California. Ben and Katherine have been letting us stay at their house, making us feel right at home, and taking care of Duke while we’ve been bouncing from appointment to appointment. They’ve been making us excellent food and not letting us help with the cleanup. I also couldn’t possibly imagine going through this without Angel. You all know how positive of a person she is, and she has helped me keep laughing and looking at the bright side through everything. Angel (along with some help from Google Maps Navigation beta) has also done a thoroughly badass job of navigating Bay Bridge and downtown San Francisco traffic, while I’ve been limited to one eye and blurry vision.

Saturday morning I woke up and Ben had my MRI data loaded onto his computer. We played around with that data for a little while in Matlab. We found a really good transverse slice that shows another view of the tumor in the eye. During the MRI I was told to keep my eyes very still. You can tell from this picture that I was focused on some point in space off to the right. You can also see the tumor in the left eye, as well as the fluid pocket that is next to the tumor.

For some reason, my nose also looks crooked. Maybe this goes back to when we were little kids and I slipped and landed flat on my face at Slide Rock in Sedona? I have no idea how a diagnostic radiologist can look at an entire set of data and see what looks bad and what looks normal. Ben and I found this slice of data because we knew exactly what we were looking for! I'll have to get together with Michelle after returning to Phoenix and try to understand how she does what she does.

Saturday night we took a nice long 2.5 mile walk to Pyramid brewery for some drinks and appetizers, to take advantage of their Save the Air campaign…happy hour pricing if you don’t drive there. Sunday Angel and I went to San Francisco to have lunch (delicious pork tacos) and spend some time with some good friends, Jessica Huang, her husband Barnaby, and their two cute little girls. Barnaby is from the city, so they took us on an excellent driving tour. We got some cool pictures and got to see some views that many tourists don’t get to see. We then had sushi with them at a place in Japantown that was run by all Chinese people. I don’t care who gives it to me though, as long as they have white tuna, I’m a happy man. It was also convenient that Jessica’s mom happened to be out of town for one more night, and since she lives only a short distance from the hospital where Angel and I had to check in at 6:30 Monday morning, they let us stay there for the night.

So, Monday morning was the surgery to get the tantalum rings installed in my eye. Also, we weren’t expecting it but were told that Dr. Char also planned to do a fine needle biopsy of the tumor. He normally does this so that he can look at the cells under a microscope and get an idea of the grade of the tumor. Also, they will send the biopsy away for molecular and genetic characterization, which will help them better determine the later treatment and monitoring steps. The surgery went well, and Dr. Char told Angel afterward that it was a low-grade tumor, meaning that the cells look pretty similar to normal tissue, and are therefore less “crazy” and less likely to metastasize. Recovery after surgery took several hours, and after the anesthesia began to wear off, the throbbing in my eye was becoming more obvious. I got an injection of Demerol to help out with that a bit, and then got our check-out instructions. Angel drove me home as I tried to keep my nausea in check. I was to keep my eye bandage on until the next day when Dr. Char’s office would remove it.

Dr. Char’s job during surgery was to sew 4 small tantalum rings to my eyeball. His goal was to surround the tumor with these rings so that the radiation people know where to aim the proton beam. My understanding is that on radiation day they’ll put me in a very specific position, then will take an x-ray to see where the rings are, and then will aim the beam accordingly. Here’s a picture similar to what I think they’ll be doing…a computer model of an eyeball with the rings surrounding a tumor (http://www.djo.harvard.edu/files/3331_389.jpg). When he says that the surgery went well, I trust that means that he feels like he got the rings in the right place.

After the surgery, even though my left eye was bandaged, it still felt as though I could feel the stitches in the back of my eyeball, as there was a scratching sensation whenever my eye moved. As you know, if your left eye is closed and you move your right eye, your left eye moves along with it. My left eye hurt pretty badly whenever I moved it, so for most of Monday night I tried to keep my right eye either closed or staring at one point in space. You’d have to ask Ben, Katherine and Angel, but I must have made for a pretty creepy dinner guest that night.

This morning was an appointment to get the bandage taken off. Tia peeled it away and said that things looked good. Again, when Dr. Char came in he said that everything looked normal. When Angel looks at it, or when I look at a mirror, I don’t understand how they can say “normal.” But, they’ve seen this many times before so we have no choice but to trust them for now. Here are a couple of pictures to show you my “normal” looking eye.

The pictures don’t really do it justice, but after we got back to Ben and Katherine’s house and I was able to look closely at my eye in the mirror for a while, I’ve realized that I don’t think it was really the stitches in my eye that I was feeling. I think it’s actually a cut in the cornea of my eye, just outside of my iris. It looks like it’s split open and hasn’t sealed shut yet again. I now have medication to keep my left pupil dilated for the next week, in order to keep the eye relaxed instead of continually flexing muscles to open or close the pupil with changing light. There’s also some Neosporin-like medication that I’ll have to put a small glob of in my eye twice a day to keep it from getting infected. For me, having one good eye and one bad eye giving me crappy, blurry vision, means I’ll have a pretty consistent headache for the next week. Here we go ibuprofen!

Tomorrow we have an appointment for a mask fitting and a simulation of the radiation therapy. I’m not sure how similar it will be, but I came across this picture of a Hannibal Lector wannabe (http://www.djo.harvard.edu/files/3330_389.jpg).

I’m gonna stop typing now, as my vision is poor (Angel did offer to type for me, but my thought process doesn’t work in a way that makes it convenient to do it that way). I’m typing this in Microsoft Word with an 11 point font and have the page zoomed into 260% so that I can focus on the letters.

Friday...what a day!

Warning: This post will contain some graphic images and descriptions. Some people may not appreciate looking at or reading them

Thursday night we pulled into Ben and Katherine’s driveway at about 9:00. Duke jumped out of the car and Sammi and Shakey (B&K’s dogs) came outside so they could meet. All of a sudden a herd of deer ran down their street past the driveway. Since Duke loves to chase things that run, he tore off after them. We had to yell his name a few times to make him stop…that was pretty funny.

Well, Friday was a doozy. First thing in the morning Angel and I drove in to San Francisco for the appointment at Dr. Char’s office. Our first impression of that group included 2 observations. (1) Dr. Char knows his stuff. (2) Dr. Char’s staff (especially Tia, Julie, and Monica) know their stuff and are very friendly. Notice the difference between those two statements.

The funny thing I’ve noticed about eye doctor’s waiting rooms is that they are never big enough…it’s almost as though they don’t realize that nearly every one of their patients needs someone else there to drive them home. When Tia was doing my initial exam, the first odd thing she noticed was that when shining a bright light in my eyes, the right pupil constricts…a clear sign of a healthy reflex. The left pupil, however, would open slightly with exposure to the bright light. It was very refreshing how open Tia was with information. Whenever we asked her a question we got a clear, honest answer. This is in stark contrast to someone else in that office.

Tia then took me to an instrument where I was told to focus my left eye at an amber light in the center of the field of view. Small white lights of varying intensity would flash around in my periphery, and I was to click a button every time I saw one. At the end of the test I joked that it was weird they didn’t test the upper half of my visual field at all, but that I was pretty sure I scored 100%. Here’s a map of where the spots were. The dark spots are the ones I did not see.

After dilating my pupils, Dr. Char then closely examined both eyes, and hand drew what he was seeing. I told him I wished I could see what he saw. He replied that I would get my chance. He recorded some notes while we listened, during which time he said that as a young, healthy man, my estimates that my chances of long term survival are excellent, but that my chances of retaining vision in the left eye are iffy. He went on to explain that he has seen some people who he put in the same group as me who are walking around now with 20/20 vision in the affected eye, although he cannot understand why it happened that way. So, there’s a small chance that I’ll retain vision, but it’s more likely that I won’t. I think his analogy was something to the effect of having a flat spare tire in the case that something bad happened to my only other good tire. Maybe that means that I’ll somewhere around an effective 1.1 or 1.2 good eyes.

He also said that he definitely recommends proton beam therapy. “He needs protons” is what he told his assistant. In addition, he recommended a laser therapy as an adjunctive therapy to proton beam radiation. Basically the 810 nanometer laser would heat up cells inside the tumor, and even relatively small increases in temperature can start to kill off some of the bad guys in there. Some of his past research has shown that there may be a trend for better outcomes by combining these two treatments, though the differences were not statistically significant. This basically means that you cannot be 95% confident that adding the laser treatment will give any additional benefit, but it certainly couldn’t hurt.

We had a long wait in the waiting room before Monica performed a few more visualization exams. First, another fluorescein angiogram showed the flow of fluorescent molecules through the blood vessels in my retina, and the tumor, just like the last image I showed. Then I crawled into a ghetto-looking bed and got ready for some crazy images of my retina. Here’s my tumor.

Next was another set of ultrasound images/measurements, this time without the eyelid between my cornea and the ultrasound probe. So yes, that meant getting gooey ultrasound gel squirted onto my eyeball. From the angle in this picture you can clearly see where the tumor is. Normally the retina is just a thin film along the back edge of the eye, forming a sort of half-sphere shape. Since the tumor in partially in the way, the retina is being lifted out of place. Adjacent to the tumor you can see another gap, which is filled with fluid.

The next part, the laser treatment, was not very fun. As I mentioned, the point of the laser treatment was to generate heat in the area of the tumor. Since this can be a source of intense pain, Dr. Char said that it was important to numb the back of the eye first. I now wish I would have had the laser treatment without being numbed. He opened a package to reveal a syringe with a pretty long 25 gauge needle on the end, filled it with a mixture of xylocaine and something else, and with very little warning or time to prepare, he poked it through my bottom eyelid, underneath my eyeball, and into the space at the back of my eye socket. While it hurt as it initially punctured my skin, the rest of the sensation was the strangest kind of strange I’ve ever felt. Even writing about it now makes me anxious and is giving me the shivers. Dr. Char then told me to close my eyes and wait several minutes while he went to attend to the patient in the next room. Angel was told to wait in the hallway right outside the room. I have no concept of time for this part of the story. I very quickly starting getting very hot and feeling very nauseous, so I called out, “Dr. Char?” “Yes?” I heard him reply. The next thing I knew I was having a vivid dream of someone trying to get my attention, and I was trying to turn toward them but I couldn’t move. I then woke up with several people around me and I was sweating profusely. I heard Angel crying in the hallway and asked if she was okay.

Apparently Angel looked at me as soon as I called out for Dr. Char, just in time to see my head roll forward and my body start to convulse slightly. She yelled out that I was passing out. Dr. Char and a couple of others ran into my room and tried to wake me up by yelling my name, and possibly my nudging my shoulder. He yelled out to call 9-1-1. Julie said “Did he say to call 9-1-1?” and Angel replied, “Yes! Call 9-1-1!” I woke from my dream as Julie was talking to the 9-1-1 operator, so Dr. Char told her to cancel the call. Monica used paper towels to sop up volumes of sweat that were coming out of my forehead as she laid my chair back. The next 20 minutes or so I transitioned back and forth from being insanely sweaty to freezing cold. I finally felt good enough to sit up for the laser treatment. It only lasted about 5 minutes, and generated a feeling of warmth in my eyeball but no pain.

I’m still not 100% clear on what caused it, but it was possibly the increase in pressure in the back of my eye socket coupled with the anxiety associated with the feeling of the long needle traveling that distance which activated my parasympathetic nervous system (via the vagus nerve), while simultaneously blocking my sympathetic nervous system (my fight-or-flight response), causing me to simply pass out. This is a so-called vasovagal syncope, an involuntary reflex mediated by my brainstem. Listen to this advice very carefully - if someone offers to give you a numbing agent at the back of your eye socket, I suggest that you hurt this person before they hurt you.

I ended up having an eye patch on for the rest of the day until just before going to bed. Thanks for making it so discreet, doc.

We got all of the instructions we needed for what was to come in the next few days, then headed back to Ben and Katherine’s to relax before having a couple of beers and a glass of wine with an awesome dinner that Katherine made us. We even got to take a short nature walk, where I started getting used to one-eyed vision. It's gonna take a little getting used to. I missed the glass when I first tried to fill it up with water at the faucet.

Keep checking back for more!

More tests, and driving to San Francisco

Okay, it’s now Thursday evening. We are still driving on the way to our friends Ben and Katherine’s house outside of Berkeley. I think we’ve got about 2.5 hours of driving left, which will get us there in just under 12 hours, including a couple of pit stops.

I forgot to mention a couple of things in the last post…when talking to Dr. Low, he cleared up some misinformation that we had. When the retinal specialist first measured the tumor, all he told us was that it was 5mm, but he failed to mention what dimension that was. It turns out the tumor is 9.5mm in diameter, and 5mm thick. I also made it sound like Tuesday was a pretty lame day, but that’s the night that C&S threw me the “Surprise! Jeremy has cancer!” party. So that was a really fun night.

So Wednesday morning my mom met me to get the EKG at my primary care physician’s office. I told Dr. Zwerin and his staff thank you for taking me seriously and for getting me in on such short notice to the retinal specialist. Also, one of Dr. Zwerin’s staff is Lori Haro’s (sorry, can’t remember your married last name) mother in law. Hi Lori! The EKG was normal. Then, I had to have more blood drawn because to get cleared for general anesthesia there were two other liver enzymes they wanted measured that weren’t part of the standard liver panel. That was another hour spent waiting at Sonora Quest.

By about noon Wednesday, the PET/CT still was not approved by insurance, so we went ahead and scheduled the MRI for that afternoon. That was much, much louder than I was expecting it to be. Luckily it was pretty short (~30 minutes). It’s easy to hold your body still for that long, but much more difficult to hold your eyeballs still. Since it was a brain and eye scan, I had to do my best. I also got that data on CD. Here’s one of the pictures.

We got home and started filling out the paperwork for the San Francisco doc’s office, as they wanted it ASAP. My mom and Angel ran to Walgreens to pick up some extra sensitive dental care products (thanks to Patti for the suggestions!) while I ran to Kinkos to fax the paperwork. While trying to get that done I had a crazy flurry of phone calls in about a 10 minute span at about 5:15pm.

1. Maria from Dr. Low’s office saying the PET/CT had been approved after a call from Dr. Low to the insurance company’s physician. I had to tell them that the timing probably wouldn’t work out because in order to drive to SanFran in time to make our Friday morning appointment, we’d have to leave Phoenix by 9am Thursday at the latest. Maria said she’d try to find out if I’d be able to get the scan done in California.

2. Dr. Low himself called to say that the MRI results confirmed what we had hoped…nothing in the brain (yay!!). The optic nerve hadn’t been compromised. The MRI confirmed the diagnosis of a choroidal melanoma that was causing retinal detachment. I still don’t have an answer as to how close the tumor is to the optic nerve. This is important because the likelihood of retaining vision after radiation is inversely proportional to the distance between the tumor and the optic nerve.

3. Maria again, calling to say that the SimonMed staff was willing to come in super early to get my scan started so that we could still be on the road by 9:00am.

4. SimonMed staff confirming that I could check in at 6:45am.

That was a stressful little burst of activity. You can’t eat too many carbs the night before a PET scan, so we went out for a steak, lobster and steamed broccoli dinner. Then we packed our clothes, snacks, and Duke’s stuff for the road trip.

Thursday morning , we woke up early. Angel dropped me off at the imaging place at about 6:30, then went home to pack the car and get the dog. When we were sitting in the parking lot for a minute we saw an old guy wheel in a small, heavy box marked with a radioactive label, which I knew was for me. I think the box was encased in lead, because he had a hard time getting it up the stairs. I got signed in and went in the back for a nice injection of radioactive material. FDG, fludeoxyglucose, is basically a glucose molecule modified to have a radioactive fluorine atom on it in place of one of the hydroxyl groups. I got the injection, then had to lay in a recliner in a pitch black room for an hour to let it disperse throughout my body. I got a decent little nap during this time.

Laying in the PET scanner was much more peaceful than the MRI, because it was quiet, but I’d hate to be any large than I am and have to go in there. Both my shoulders and my elbows scraped the walls of the tunnel as I slid back and forth through it. I couldn’t fall asleep in there because it was too uncomfortable.

I got that data on disc, then Angel picked me up and we hit the road. That pretty much brings me up to date on the blog.

So, what’s going to happen in San Francisco. This is where the perfect timing that I mentioned before comes into play. It’s looking like my treatment is going to be proton beam radiation, rather than the standard plaque radiation. Plaque radiation is where they sew a little shield onto the back of my eyeball and tuck some little seeds of radioactive material into the pocket. The shield is meant to protect surrounding healthy tissue from the radiation. Proton beam radiation is a more sophisticated technology, where a beam of energized protons is basically shot through the front of my eye and is targeted to the tumor. This can be focused very precisely, and the beam of protons has very little sideways scatter. This is becoming a more common treatment for cancers where nearby tissue is very delicate, for example the eyeball.

The main drawback with proton beam therapy is the expense. The proton accelerator itself costs about $150 million. So, there are only 6 of them in the US right now. One is at UC Davis in Davis, California. Dr. Char, who is based in San Francisco, has access to this equipment for his patients for one week, every six weeks. His next week on is September 27^th – October 1^st. Prior to radiation there is a surgery that needs to be scheduled, which he only does on Mondays, leaving September 20^th as the only option. Prior to surgery, an office visit is needed where Dr. Char will review all of my results, dilate my pupils and take a look at my tumor himself. He only does these appointments on Tuesdays and Fridays, leaving September 17^th as the only option. So as I mentioned, if this had to happen, the timing couldn’t have been better.

The surgery on Monday is going to entail sewing some small metal rings to my eyeball, I assume to help guide their aim of the radiation beam. I’m doubtful that they’ll be willing to do it, but I’m going to ask if they can take some pictures of the surgery so I can post some of those as well.

Peace out everyone, I’ll update more later on.

Getting some results and plans...

First, a special thanks to Chad and Stacey for throwing me a pretty awesome party the other night to wish me well. It’s pretty amazing how many people showed up, despite the fact that it was put together at the last minute. Thanks to everyone who was there, and to everyone who wanted to be there! TJ made me realize that in my previous blog posts I never mentioned how I was feeling physically. Good point, I’ve been feeling great, like nothing is wrong at all.

My last post updated through Sunday, but so much has happened since then. Right now it’s Thursday morning, and Angel and I are in the car driving to California, so I thought I’d work on some updates. Typing is going slow, because I’m trying to watch the road as well while Angel sleeps. Just kidding, she’s driving! Those who were at the party that Chad and Stacey threw for me the other night know why we’re heading to California already, but for the rest of you…here’s why!

Monday morning I had a chest x-ray, from two views. The girl had to re-do one of them because my lungs are longer than she thought they would be. I got the data on CD, but apparently they don’t just give you the images in any standard file format, so I haven’t seen them yet. From there we (Angel and my mom were with me J) went to the Sonora Quest lab to have some blood drawn for the liver panel, blood count, metabolic panel, etc. We had to wait at the lab for over an hour, and during that time I was on the phone a lot.

Luckily for me, I’ve worked closely with several well-respected and well-connected physicians for about the last 10 years, namely Richard Herman (neurologist), Jerry Targovnik (endocrinologist) and Laurence Miller (gastroenterologist). They have all been pretty concerned for me since I told them what was going on, and they’ve been very helpful in offering to get me in to a number of places that would offer great care. They also called in some favors from some of their friends. Also, our good high school friend Michelle Lai is a diagnostic radiologist at Barrow Neurological Institute, and she’s also been very helpful in giving me her opinions and putting me in touch with some of her friends.

I talked to Jerry Targovnik while we waited at the lab, who told me that he’d arranged for me to be seen at Southwest Hematology and Oncology. His close friend Jeff Isaacs was out of town, but he arranged for his colleague Boo Ghee Low to see me that afternoon. I called his office and made an appointment for 3:15. Targovnik also told me that everyone he talked to thought I should get to San Francisco to be treated by a friend of a friend, Devron Char. I knew nothing about Dr. Char when I called his office, but it was sort of a cool feeling when his assistant Julie asked for my name and then said “Hi Jeremy, I’ve been waiting for your call. Let’s get you an appointment for Friday morning.” I didn’t yet realize how lucky I was that the timing of everything was working out this way.

After the phone calls were done Angel googled Devron Char and came up with this tidbit: “Dr. Devron H. Char is a pioneer in the diagnosis and treatment of patients with eyelid, conjunctivital, iris, retinal, choroidal, orbital tumors and patients with thyroid eye disease. He has been listed annually as one of the ‘best 400 doctors in the United States.’ Dr. Char has written over 300 medical articles and six books including the basic textbook on ocular oncology. He has served as an editor or reviewer on medical journals in basic cancer research, eye research and clinical eye care. Dr. Char is the founding director of the Ocular Oncology unit at the University of California, San Francisco, Medical Center.”

It was about this time that I started thinking about how fortunate I’ve been to have these connections. It almost seems unfair to the people who have to go through something like this without knowing anyone who can help. This thought has been continually popping into my head.

We made it to Dr. Low’s office for the afternoon appointment. His nurse told me that he had received the results from my chest x-ray, although she didn’t know what they showed. She did, however, give an interesting smirk that made us think she did know the results but didn’t have a very good poker face. We waited another 15 minutes or so with sweaty palms, awkward silence, and some nerves, wondering what the results would show, because at this point we had no idea whether the cancer had spread.

Dr. Low had obviously reviewed all of my info before coming in to talk to us, and he asked what all I knew. I told him that I knew I had a choroidal melanoma in my left eye. He started asking if I’ve recently starting having any pains in my chest or abdomen. My palms were sweating even more thinking about what the x-ray results would be. He finally said that the x-ray showed nothing abnormal in my chest (except some small benign granulomas on the bottom of one of my lungs). Seemed weird for him to ask me that when he knew I was waiting for those results. I guess some people are just oblivious. He also said he wanted me to get an MRI of the brain and a full body PET/CT scan, both of which needed pre-approval from my insurance, but he assured me that he would get them to approve both scans.

So, we went home to wait for more information.

Tuesday was pretty uneventful until the afternoon. Dr. DeSouza (the retinal guy) called to let me know that the liver panel came back with all of the enzymes in the normal range. I got the new patient paperwork from Dr. Char’s office, and was also told that I would need a few things in order to be approved for general anaesthetic. So, I got an EKG scheduled for the next morning at Dr. Zwerin’s office. And then at 5:00, Dr. Low’s office called and said that the MRI had been approved and would be scheduled for the next day, and the PET/CT was still pending approval. Apparently they were hesitant to approve such an expensive test without having pathology results. That, however, would entail a biopsy, and taking a biopsy of the inside edge of the back of an eyeball is something that doctors tend to avoid.

More in the next post…

Long gap between posts

Hi everyone. First, to all of the people who emailed me complaining about how long it's been since my last post, I'm really sorry about that. I've had a lot of stuff going on.

Just kidding, no one emailed me complaining. Hopefully you guys have all gotten the major updates by keeping up with Angel's Facebook posts. I'll be filling in the details with new posts as we drive to California tomorrow.

The waiting game

We got the diagnosis on Friday at about 5:20pm, which meant that the radiology places and blood testing services were closed for the weekend. So, the weekend was mostly about waiting and wondering. And learning.

Angel drove us home from the appointment with no problems, and after we got home we cried a little bit because I'm pretty sure we were both thinking about the worst case scenario. But, we quickly got to the point where we told ourselves that everything was going to be okay. After all, a lot of people who are much worse off than we are have gotten much worse news than we got. And I'm young (relatively speaking), and strong (relatively speaking), so if worse came to worse, that would always work in my favor.

After Angel and I could talk to each other about it while still being able to control our voices (without crying, I mean), I started calling my immediate family members to share the news. Just saying the initial sentence to describe what was happening was harder than I thought it would be. After that it was much easier to fill in the details.

Over the weekend Angel and I learned a lot more about choroidal melanoma. We learned that about 6 people out of every 1,000,000 get it each year in North America. That would be about 1800 people in the US each year. That's around 36 people in Arizona each year, on average. I thought about getting a lottery ticket. We also wondered how many other people in the US had their appendix rupture, suffered an indirect lightning strike, got shingles for their 30th birthday, and then ended up with eyeball cancer. I can't find a support group for those people yet.

We learned that a greater density of people get this cancer in Australia, where there's also a higher incidence of cutaneous melanoma (normal skin cancer), due to their ozone problems. Beyond that, however, it's not proven that UV exposure has anything to do with this cancer. And there are no known causes. I always wear sunglasses anyway, unless I leave them at Chad and Stacey's house for a few days. More people with blue eyes get this cancer than do brown eyed people.

After lots of conversations with each other and with other people, we've come to realize that this is something serious, but it's not the worst thing that could be happening. In our traditional style, we've made lots of jokes. I didn't realize before that Angel didn't really like my left eye that much anyway. My good friend Curtis said something to the effect that he always felt weird looking at my left eye in the past, so he won't miss it. When Angel first typed in the URL of this blog, she typed "bigtroubleiinlittleeyeball.blogspot.com", got a page load error, then said "aww, one too many i's!"

We still had moments this weekend where we got emotional, like when we started looking up the side effects of radiation near the face/head. Dry, painful skin, sores in the mouth, possibly some local hair loss. It's hard to imagine going through some of that stuff and not getting a little upset.

I also had to spend some time reading through my insurance paperwork to see what was going to be covered, what would need pre-approval, etc. Seems like such a stupid system where that's one of the first things you have to consider, instead of just getting well. Then I started to think that at this point in my career, I will be needing to change jobs in the near future. Unfortunately, this is now a pre-existing condition, so if it ever gives me any more problems between now and 2014, it'll be paid for out of my pocket. That is, assuming that provision of the healthcare bill is still around by then.

Overall, we were able to have a pretty relaxing weekend, despite the fact that I still had no clue whether the cancer had spread anywhere else. Also, I've noticed that each time I see the flash in my eye now, it means a little more to me than it did before.

I've gotten lots of phone calls, texts, and emails, and Angel has shown me lots of Facebook posts. We are blown away by the number of people that care for us. I haven't had a chance to respond to everyone, but I appreciate all of the love, thoughts, prayers, etc. It truly feels great to have such a large support network of people who have offered to help us out with anything we need. You can't imagine how great this makes us feel to know that everyone is pulling for us.

The big news

This whole thing started about a month ago, when I started seeing some strange flashes of light in the upper left quadrant of my field of vision in my left eye. A medium sized white light would appear, sometimes a circular shape, and sometimes shaped like a pancreas, and then it would fade away starting at the edges, until it was gone. I'm pretty sure that the last point of light was always in the same spot in space. Each flash would last about 1 second from first appearance until it had faded away. I didn't think much of it at first, but I made a mental note to pay attention to how frequently it happened, if anything about it changed, etc. It started out happening about once every hour.

Over the next couple of weeks the frequency had increased a little bit. A quick Google search made it seem like this sort of thing could be attributed to anxiety, fatigue, sleep apnea, whatever. I was a little concerned, but I didn't think that it was anything too urgent.

Then, about 4 or 5 days ago, I woke up to take our dog Duke out for a walk while Angel took a shower to start our routine for getting ready for work. When we got home from the walk I gave him his breakfast, then headed upstairs to stretch my lower back. I was laying on my back on the floor using my Spinal Stretch device (http://spinalstretch.com/, it's awesome, thanks Angel for getting it for me!) All of a sudden I realized that Duke was nearly hovering over my face, and I hadn't seen him coming. That really spooked me, because I know that I should have seen him out of the corner of my eye. I started experimenting a bit and realized that the vision in my upper left quadrant was not nearly as good as the other side. If I tried to look up and to the left with my right eye closed, the whole corner was a dark, fluttery gray. This realization scared the shit out of me.

I didn't even have a primary care physician, because I hadn't been to the doctor in a very long time. I looked on the website for United Healthcare to find a doctor in the area. After calling a couple who weren't taking new patients, I ended up with a Dr. Zwerin, a general practitioner in internal medicine. I got an appointment with him Friday morning. He did a thorough exam and asked me a bunch of questions about my medical history and my concerns. He ended up telling me that based on his exam I was "disgustingly healthy," but that my story about my eye was deeply concerning to him. He guessed that I had a detaching retina, which is treated as a medical emergency because it can quickly lead to blindness. His office assistant made a couple of phone calls and ended up getting me an appointment 4 hours later with a retinal specialist named Dr. DeSouza.

Luckily, Angel was able to leave work early to go to this appointment with me. During this appointment, a very friendly technician was testing my eyes in all sorts of ways that made me realize my left-eye vision was worse than I had originally thought. When my right eye was covered, she would ask me to tell her how many fingers she was holding up as I looked straight ahead. As long as she held her fingers up above my head, I couldn't see them until she dropped them down to virtually straight out in front of my eye. Because of how light enters the eye through the lens, this meant that something funky was definitely happening on the bottom half of my retina.

I got some drops to dilate my pupils, waited a while, had a couple more tests, then I got in to see the doctor. I lay back in his chair looking at the ceiling, and then he came over with a device to look at my retinas. The light he pointed at my eyes was much brighter in the right eye than it was in the left. He walked across the room to start up an ultrasound machine as he said "Well, it's not good news." Angel and I thought to ourselves that perhaps the retina was farther detached than what we were expecting to hear. He then followed with "It's a malignancy."

I just laid there and stared at the ceiling, because I was speechless for several minutes. I could tell that Angel, who was sitting off to my right, was beginning to cry, but she was doing a great job keeping it in check. She asked the doctor a couple of questions as he started rolling his ultrasound wand around my closed left eye, taking measurements of whatever it was that he was seeing. When we asked him how sure he was, he said "I'm 100% sure that it's a malignancy, and I'm 95% sure that it's a choroidal melanoma." The measurements told him that the tumor was about 5mm in diameter, just less than a quarter of an inch (correction: I now know that the tumor is 10.5 mm in diameter and 5 mm in depth). The tumor is growing underneath my retina, causing it to detach from the underlayers (the choroid and the sclera [http://en.wikipedia.org/wiki/File:Schematic_diagram_of_the_human_eye_en.svg]).

I looked over at Angel to see that she was visibly upset. The first thought in my mind was that I was so sad that she had to hear this news. Thinking about how upset this made her brought tears to my eyes. The doctor kept glancing over at her as he walked back and forth from a table in the room to my chair, so he could look into my eye once more. I could see that he felt bad, and a couple of times he said "I'm sorry, I know this is not what you expected to hear today." My mind was racing, but I couldn't help to think about some essays from a great medical author, Atul Gawande, in which he mentions how terribly many physicians perform when it comes to delivering bad news. I know Dr. DeSouza felt sorry for us, but both Angel and I agree that he did a pretty terrible job of delivering the bad news. I don't blame him for it, I know I couldn't have done any better.

We were escorted to the next room when another technician injected concentrated solution of fluorescein sodium into my arm so they could take some fluorescence angiography images of my retinas as the fluorescent dye passed through my blood vessels. She incorrectly told us that it is a vegetable dye rather than a synthetic molecule. She took a time course of pictures after the injection so they could track how the dye was flowing through the vasculature in the retina and the choroid. Here are the last two pictures they took...one of the right eye and one of the left. You can see the big, bright, highly vascularized blob that shouldn't be there.

There are no scale bars or anything, so there's no way to tell how much of the retina is being shown, or exactly how large the tumor really is.

The doctor came back in to talk to us a little longer. He told us that this tumor is considered a medium-sized tumor for this type of cancer. He went on to tell us that for large size tumors, the general treatment is to remove the eye, a procedure called enucleation. Medium sized tumors generally respond well to radiation, although there is still a small possibility that the eye will need to be removed. And if the eye does not need to be removed, it's hard to say whether the vision in this eye will be spared as a result of the radiation (more on this in the next post). He said that this type of cancer doesn't generally metastasize until its later and larger stages, so there's only a small chance that the cancer has spread up to this point. He said that I will need to see a radiologist to make sure the cancer is still only in the eye, and then that I will need to get started on radiation treatment as soon as I can. He said that no one in the Phoenix area specializes in radiation on the eye, but he knew of a good group in Tucson and one in LA that he wanted me to go to.

He wrote me a prescription for a chest x-ray (PA and lateral) and a panel of liver function tests, to make sure that the cancer hasn't spread, and told me that he would call Monday morning to see whether I've decided to go to Tucson or Los Angeles.

As we waited in the waiting room to see the doctor, time passed so slowly, and then once this news hit, everything seemed to happen so fast. It's just the way that Angel and I are to never be satisfied with enough information. We could have continued asking questions forever, but there wasn't enough time to do so. When we returned to the lobby to pay my $30 co-pay, there was a man furiously yelling at the staff about why he was having to wait so long, and threatening to report them to the medical board. I desperately wanted to punch this asshole in the throat and tell him that the doctor was spending a little extra time explaining to my wife and I that I have cancer, and that was partially why he had to wait a few extra minutes. Instead we just quietly walked out the door to head home.

More later...

My first blog

Hi everyone, Jeremy here. You may be surprised that I'm actually starting a blog. After all, I'm the person who's resisted Facebook for all of this time. Up until now I've had almost no desire to share personal information about myself online, and I also think that Mark Zuckerberg is a big-time douche. But now, I'm going through some stuff, lots of people are asking for updates, and I figured that writing it out might help me feel better. I hope you enjoy the blog.