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In the Tall Grass
Neal A. Kline, M.D.
Am J Psychiatry 2005;162:240-241. doi:10.1176/appi.ajp.162.2.240
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My 73-year-old father had been having epigastric pain for months, every time he ate. Right after Labor Day, he had an upper gastrointestinal X-ray series. Then the telephone calls came, one after the other, like machine-gun fire. The radiologist: "It’s no ordinary duodenal ulcer. More like a tumor that has ulcerated as it outgrew its blood supply." An upper gastrointestinal endoscopy showed an almost complete occlusion of the passage from the stomach to the small intestine. I asked whether it was a duodenal mass or whether the origin of the tumor was the head of the pancreas, adjacent to the duodenum. The pathology report was not definitive: "atypical cells." My father was told he had no more than 2 months to live. In effect, he’d starve to death because of the gastrointestinal obstruction. Events were moving very fast: a month ago, we were awaiting the results of a barium swallow, and now death was no more than 2 months away.

Neither radiation nor chemotherapy was advised. What was offered was a Whipple procedure—a pancreatoduodenectomy. Remove the duodenum and all or part of the pancreas, bring up a loop of bowel and anastomose it to the distal stomach, and provide for hepatic and biliary drainage into the small intestine. He had significant risk of not leaving the operating room or the surgical intensive care unit alive and a very limited 1-year survival rate for advanced disease. Given the choice of dying of starvation within 2 months or possibly surviving 1 year with surgery, my father chose the Whipple, which was scheduled for the next day.

Flying from San Diego to Boston, I asked at the hospital information desk where I could find a patient, Herbert Kline. "We have no Herbert Kline." He didn’t survive the surgery, I concluded. Damn! "But we do have a Louis Kline, a Louis Herbert Kline."

In the surgical intensive care unit, I found my father propped up in his bed at about 45°, with tubes and monitors everywhere. He was glassy eyed and unable to respond to questions and seemed to be trying to grab his endotracheal tube attached to a ventilator. I asked a surgical resident how long he thought my father would be in the intensive care unit. He said, "Until he is weaned off the ventilator, which may require a tracheotomy. When the endotracheal tube is removed, with air exchange through the trach, he won’t need to be so sedated. It would be much easier then to wean him off the ventilator."

Returning in November, I found my father in a four-bed ward. He was sitting up in bed. When he saw me in the corridor outside his room, not a flicker crossed his face. As I approached his bed, he said, "Did you see the nurses’ station? They serve cocktails there. That’s why all the patients congregate there. And see the lady in the red beret and red jacket?" He glanced at a woman visiting another patient. "She’s in the Israeli Army. Very snappy uniforms!"

A medical resident brought me up to date: a trach, then off the ventilator, multiple abdominal abscesses and fistulas, multiple computerized tomography (CT) scans, fevers, high WBC counts, but here he was now, despite it all, alert, afebrile, stable. He had a gastric tube to keep his anastomosis "dry" while healing, preventing gastric fluids from leaking into his peritoneum. He also had a feeding tube inserted through his abdominal wall into his small bowel below the anastomosis through which liquid nutrition was introduced. Having been on a regimen of nothing by mouth for weeks, Dad said, "I’m dying for a ginger ale, I’m so thirsty. And I’d probably die if I had one."

He was discharged home at Christmastime. "When I go back to the hospital for follow-up visits, everyone—doctors, nurses, students—everyone knows me, but I don’t recognize most of them. They say, ‘Mr. Kline, you’re looking so well.’ And I think, I may look well on the outside, but I’m not so well on the inside."

In the spring, his serum calcium levels went haywire, going up and up. Hypercalcemia? That hadn’t been on my list of dire eventualities. Medication brought his calcium level down, but with time, it drifted up again. CT scans showed a probable recurrence at the original site, with progressively enlarging metastases in the liver.

In the summer, he was admitted again. I looked him over in his hospital bed. He was wearing pajama bottoms only. He said it was too hot for the top. He didn’t look ill. He was clean shaven. His hair was neatly brushed. His color was good. He had no visible weight loss. The trach scar was well healed, barely visible. The Whipple scar was beautiful if you can call a scar "beautiful." It was thin, white, and flat, running from the margin of his right lower rib cage up to his xiphoid process, then making a 90° turn and continuing down the edge of his left rib cage: a perfect upside-down "V." Like a flock of geese overhead heading north for the summer, after wintering in the south. Dad’s migration, however, would be one way.

At the end of the summer, we went out for Chinese food. Dad didn’t have much of an appetite, but he said he’d try. "This may be my last supper. Lobster sauce and pork strips. That’s what I’d call a Jewish last supper."

Right after Labor Day, he was back in the hospital. His calcium level was high; his breathing was rapid and shallow. He kept his eyes closed, saying he couldn’t see. "I’m not very good at this." And he died.

Death, that crouched lioness, had sprung from the tall grass and taken her prey. With both parents gone—my mother had died a decade earlier—there was no longer any imaginary protection afforded by a generational Maginot Line.

Now Death, in the tall grass, stalks me.

Address correspondence and reprint requests to Dr. Kline, University of California, San Diego, 8950 Villa La Jolla Dr., Suite C-110, La Jolla, CA 92037; neal.kline@med.va.gov (e-mail).




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