My clinic is small, and I share an office with my amazing nurses. It is positioned in such a way that I can see patients as they make their way down the hall to an examination room. We typically see patients once they are situated for our viewing pleasure, sitting on an examination table. However, when I see the ambulatory patients walk, I am struck by how seriously impaired their function is. I find myself thinking, “How do they manage from day to day?” How did they adjust to such severe limitations in mobility? At least part of the answer is that they adjusted gradually. I found this out personally. It’s an embarrassing story to relate. I am not sure when it started, because it was subtle. At first it was just an increase in breathlessness going up the 3 flights of stairs to the clinic, until eventually I started taking the elevator. I told myself I was just out of shape and wrote “get more exercise” on my mental To-Do list. Gradually, I started to walk a little more slowly than my usual Olympic walk-a-thon pace. One day I realized that I was avoiding the sidewalk entrance to the building because it was too much effort to step over the 6-inch curb. Eventually I noticed that I was breathless in casual conversation. I also developed pica. Pica is classified as a psychological disorder, although I am quite sure we need to re-think the classification of “psychological” behaviors caused by medical conditions. Pica is characterized by an appetite (more like uncontrollable craving) for substances that are largely non-nutritive. A common type of pica is ice-craving, the medical term for which is “pagophagia.” I had experienced uncontrollable ice craving when I was pregnant, which is pretty common. This time my pica developed so gradually I didn’t recognize it for what it was. I developed an uncontrollable craving for wintergreen-flavored lifesavers. Eventually, I was eating an entire bag of wintergreen lifesavers every day, annoyed that they were individually wrapped. I also developed angular stomatitis (perleche).
By now everyone reading this is thinking, “For goodness sake, it’s so obvious you were anemic!” If I’d gotten my own history from a patient, I’d have figured that out in 2 minutes. But because the symptoms developed slowly over several YEARS, they had become normal to me. This accounts for why, whenever I point out, for example, how edematous a patient’s legs are, they nearly always say, “But, I have always had that.” It can take some talking to convince a patient that pitting edema (extending to the thighs!) is NOT normal. While I didn’t figure out that I was anemic, I did have an idea that I was not OK. In my defense, I was probably in denial because my husband had advanced dementia. It was very bad timing for me to develop a fatal illness while my spouse was dying and our children were 17 and 21. Then one night I tried to run for a plane – in Denver. By the time I got into my seat, my vision was going dark and I thought to myself, “I am quite literally about to die.” I decided to go to the cardiologist.
Except for a chronically elevated pulse and shortness of breath, I appeared fine. The cardiologist did the usual. I had a normal EKG and normal echo. About 3 hours after I left the office, he called my cell and I could hear the fear in his voice. He’d gotten back my blood work. He had already made me an appointment with an MD Anderson hematologist before he called to tell me that my hemoglobin was 7.4 gm/dl. Despite having about half the hemoglobin I needed, I was keeping up my usual activities, practicing medicine, flying to medical conferences and putting in 18 to 20 hour days at work. I asked him about my heart and he laughed. “Your HEART? If there’s one thing we know you don’t have, it’s coronary artery disease – you’ve been living inside a cardiac stress test.” By the time I saw the hematologist (I knew her well because she referred all of her cancer patients with wounds to me), there was serious discussion about a transfusion. I didn’t have cancer. I had just stopped being able to absorb iron via the gut, and the result was a profound iron deficiency anemia. As I read up on iron metabolism through the lens of an anemic doctor-patient, I wondered if I had been absent from class when we were supposed to learn this. Iron metabolism is honestly one of the most complicated processes in the human body.
I did NOT want a blood transfusion, so we agreed to an urgent intravenous infusion of iron. That meant going to the MD Anderson infusion center, where the first person I saw was a patient who rushed up to me in the waiting room and said, “Oh Dr. Fife, don’t tell me you have CANCER?” It’s now five years later and I only need to go once a year. I wait in the infusion center waiting room frantically answering emails on my phone, surrounded by patients who have lost all their hair. I overhear their often nonchalant conversations about horrible chemotherapy regimens and gruesome operations. When it’s my turn, the nurses ask me if I have had any falls, if my nausea is bearable and whether I am coping. I say, “Please don’t be nice to me. I don’t deserve it. I am totally FINE.” And then I lie in a hospital recliner, tasting the iron sucrose running into my vein (it is really odd to think that taste buds can “taste” what is in your blood). And as I lie there, I tell God all the things I am thankful for. The list is long. I am incredibly healthy (my hemoglobin is now 14, thank you). My kids have matured into fun and interesting people, I have purposeful work, my days, although demanding and often frustrating, are never dull. Even when I was worn out caring for my husband, I could lie there and be thankful that I was healthy enough to do it.
Today was my annual infusion, but the nurse gave it to me IV push. I was glad to be in and out in just a few minutes, but honestly I missed the 30 minutes of meditation I used to get during the IV piggyback. I took the photo above as I walked out, promising to do my “thankfuls” later, which is what I am doing now. I challenge you to see how many blessings you can write down on a scrap of paper in 120 seconds. You won’t be able to finish the list in 120 seconds. Put the list in your pocket and think about it as the frustrations of the day begin to mount. As I left the cancer center, I power-walked past a frail man with a walker, laboriously making his way to the parking lot. He smiled as I whisked past him and said to me, “Isn’t it a glorious day?” After nearly 2 weeks of rain, today the sun was shining and the pear trees had blossomed. I agreed with him wholeheartedly – today is a glorious day.