Category Archives: Reflections

Bare Bones

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“And why do you worry about clothing? Consider the lilies of the field, how they grow; they neither toil nor spin, yet I tell you, even Solomon in all his glory was not clothed like one of these.
Matthew 6:28-29

“Naked I came into the world, naked I shall go out of it! And a very good thing too, for it reminds me that I am naked under my shirt, whatever its colour.”
E. M. Forster

We come into the world, cold, naked and wet. It’s downhill from there.
Some anonymous cynic

I’ve done two things in my life that might be described as adventurous, daring, courageous or stupid, depending on one’s perspective. The first was jumping out of an airplane at 3000 feet, not once, not twice, but three times. (I was sure I was gonna die the last time because I had to pack my own parachute.) I’ll write about it in a future blog.

But telling people I’ve been to a nudist resort raises eyebrows and prompts some tittering, no pun intended.

Little kids don’t have a problem with nudity. They’ll tear their clothes off without warning, which isn’t a problem unless Mom is in a ZOOM meeting with a two-year-old running around naked in the background. But as we get older, we learn, directly or by inference, that unclothed bodies are shameful and if you don’t agree, you’re a pervert.

Americans can’t disassociate nudity and sex, which isn’t surprising given they descended from the Puritans, a group that was so uptight it outlawed Christmas celebrations. That “nudist colonies” even existed provoked righteous indignation from some and snickering from others.

Public nudity enjoyed tacit acceptance briefly in March 1974. Much warmer than normal weather induced thousands of college kids to run naked across public spaces for the sheer thrill, a phenomenon immortalized by Ray Stevens’ hit “The Streak.”

Now, before I go any farther, I should point out I’m not a narcissist or an exhibitionist. Far from it. Poor body image and self-esteem isn’t restricted to women. I couldn’t look into a mirror from about 7th grade until my late thirties. I don’t recognize the reasonably attractive guy in pictures from decades ago as me. As I’ve gotten older, fatter, and greyer with far less hair, I’ve learned to accept my dad bod.

My interest in outdoor nudity, (naturism to the faithful) was born out of 25 years of life-sucking Midwest winters. I lived in Arizona until I was 11 where we had abundant sunshine, occasional rains, and the rare sun shower, an odd mixture of both. Snow was rare and exciting and usually melted by noon.

Then we moved to Illinois, the Land of Lincoln and the Never-ending Winter, when clouds obscured the sun from November through March. Clouds obscured the sun from November through March; snow a month earlier or later wasn’t unusual. I moved to Michigan for my residency and then stayed in the state to practice for another 13 years.  More snow, less sun and -30° in January. Strolling naked in a warm climate while everyone else froze their asses off sounded better.

I joined the American Sunbathing Association (which became the American Association for Nude Recreation – AANR – in 1995) in the early 1990s. I don’t remember how I connected with them since there wasn’t much of an internet back then and websites were more than a decade away. They didn’t advertise on the backs of matchbook covers like the “Learn to Draw” folks.

I bought Lee Baxandall’s World Guide to Nude Beaches & Resorts, back when we still had bookstores. I discovered that, with few exceptions, naturist resorts are family oriented. Some are permanent residents. Men do not wander around with a cup of coffee in each hand and stacks of donuts on erect penises. Women aren’t an endless parade of Playboy bunnies. Naturists come in a wide range of ages, shapes and sizes. They are just regular people who don’t wear clothes.

There are a few rules when visiting a resort:

  • No lewd behavior
  • No gawking with your tongue hanging out.
  • Don’t take anyone’s picture without consent
  • Carry a towel with you at all times, just in case you sit somewhere
  • Be a decent human being.

I planned to visit a resort outside of Tucson in 1992 during a trip to Arizona for a conference. The now-defunct Jardin del Sol (Garden of the Sun) lay off a dirt road outside of Marana. It was a modest place with a few wooden buildings, a swimming pool, a place to play volleyball and sites for camper hookups. I parked my rental car and checked in with the owner, a short older woman who looked at my AANR membership card.

“You’re here alone?”
“Yes, I’m on a business trip and my wife couldn’t make it.”
She eyed me for a minute and said, “Well, you look all right. The pool is down the hill, and there’s a group having a picnic.”

At that moment a guy in a well-worn white Chevy pickup, who looked and sounded like George Kennedy, stopped and excitedly said something to my host about pending naturist legislation before driving down to the picnic area.

I went back to my car, stripped down to my shoes, grabbed my towel, and headed back. Footwear is essential in the desert; desert sand can become very hot.  Goat heads, the hard, pointed seeds of an obnoxious weed that seems to grow everywhere, prey on bicycle tires and bare feet. And while crawling predators like the scorpion are largely nocturnal, one might run across the foot-long giant desert centipede.

And don’t forget sunscreen.

Thirty years ago, I was uncomfortable around strangers, nude or otherwise, and I wasn’t interested in small talk. I just wanted to sit by myself, work on a sunburn and forget about sub-zero temperatures back home.

I started on a foot path that led away from the pool and stopped at a miniature Boothill Graveyard. The tombstones bore amusing names and the nature of the departed’s crimes, namely violating resort rules (one took pictures without asking). They reminded me of a fake memorial in Boothill:

“Here lies Lester Moore
Four slugs from a .44
No Les, No more.”

Just then an older gentleman, short, bronzed and the spitting image of Buster Keaton, walked up to me.

“Hello, young feller! Can I help you find something?”

“I’m looking for a place to sit awhile and read my book.”

He pointed towards a trellis farther along the trail. “There are a couple of lounge chairs over there. Is this your first time?”

“Yeah, I was born here but I live in Michigan. I miss the sun.”

“Well, there’s plenty here. Welcome!”

I thanked him and headed for the loungers. I put the towel across the seat, lay back and enjoyed the desert, naked as the day I was born, as they say. I stayed for a couple of hours, reading, napping, and baking before driving back to my hotel.

A couple of years later I visited Forest Hills Club in Saranac, Michigan, just outside of Grand Rapids. The resort sits on a heavily wooded hill off a two-lane blacktop and isn’t visible from street level. I drove by it twice before noticing a small sign by a dirt road into the trees; there was an intercom next to the utility gate that blocked the entry.

I pressed the button and a young woman answered. “I’d like to visit for a bit.” The gate opened and I drove up to the site. I showed her my AANR card, and she gave me a brief tour. I went back to my car and took off my clothes and my shoes (no goat heads in Michigan), then grabbed my towel and a textbook. (A textbook? Seriously? How anal-retentive can one be?) I helped her move a large folding table before settling into a lounge chair.

The day was overcast and warm and I lost interest in the book. I lay back in the chair and closed my eyes, forgetting how burned out I was becoming being one of three physicians trying to manage a patient load that demanded five. I imagined spending the rest of my life sitting naked on a beach sipping margaritas and staring out at the ocean.

I haven’t had any further opportunities to indulge, although I maintained our membership in AANR partly to shock a family friend whom we call the Bald-Headed Stepchild. I worked as a traveler for more than twenty years; spending time at home decompressing with Peg was more important that trying to find the nearest resort (there’s only one in Illinois).

If I had my druthers, I’d buy a condo in Mira Vista Resort and try to establish my reputation as a renowned writer-slash-curmudgeon. For now, sitting naked in bed in the morning with coffee and my Kindle while my faithful companion (no, it’s my 15lb Shih-Tzu Baxter, not Peg) eats cookies will have to suffice.

For More Information

American Association for Nude Recreation

AANR: Social Nudism: Behavior Guidelines and Etiquette

Mira Vista Resort

Nude Hot Springs Around the World

Big Think: Nudist Beaches of Central and Eastern Europe

New York Times: Articles on nudism and nudity

World Naked Bike Ride

Featured Image © Can Stock Photo / chrisbradshaw

Writing Exercises

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Disciplined writers commit to writing something every day, but that’s been a struggle. This is my latest attempt.

March 15-16, 2021

Beware the Ides of March.
I admit to being a chronic master procrastinator when it comes to writing, which should not be confused with a chronic masturbator. I am not the disciplined writer who gets up at the butt crack of dawn every day and writes furiously for two, three or more hours.

I’m not a new writer; I’ve been putting pen to paper for more than 50 years. I don’t carry a Moleskine journal, furtively writing everywhere because a newly found voice and sense of outrage is brimming with ideas. My outrage started with an alcoholic stepfather and increased exponentially with the Vietnam War. I’m old and tired and cranky.

I often think of things when I’m driving or out for a walk, neither of which is conducive to putting pen to paper. (Also, my handwriting is so bad I have to ask Peg if she can figure out what I’ve scribbled: “You wrote ‘small Bailey’s’, not small barley.”) I roll things around in my brain, editing and revising until I finally have something to record for posterity.

That, and I’m a poor judge of my own writing. I’m never sure anyone will want to read what I have to say.

I’ve tried to analyze my reluctance with little success, but I can attribute a lot of it to two things: I hate trying to write when the muse isn’t there, because it just makes me frustrated and angry, and I hate being interrupted when I’m in the groove.

Until I alter my habits to something more productive, my days look like this:

I get up after a fitful night’s sleep made difficult by annoying and sometimes terrifying dreams (I was a psychopath being taken to a mental hospital in the last dream I remember). I shower, take my meds from the seven-day pill case I keep in my nightstand, and make coffee. If Baxter is still sleeping – sometimes he won’t get up until 10am or so – I will sit at my desk and try to write or waste time, knowing he’ll be up soon.

When His Lordship has awakened from his slumber, I will take him downstairs and out to pee, then we will negotiate breakfast. Sometimes he is hungry; other times he tries to run back upstairs because he’s just not interested. Occasionally I can entice him with sliced turkey but if he has a case of the fuckits, it’s an exercise in futility. If he does eat, I have to catch him to give him his insulin before he bolts. If I’ve thought fast enough, I put the gate up in front of the stairs.

That being done, I will sit in bed, drink coffee, and play Kindle games or read while Baxter buries, then eats cookies on the bed. I started doing this because if I go directly to my office to work, he yells from the bedroom until I return. When he finally settles down for his all-important early morning or mid-morning nap, I will go to my office and engage in the usual timewasters.

I approach Facebook as the 21st century morning newspaper. My FB friends and acquaintances post news links, often from sources outside the United States. I’ve contacts in the UK, Australia, and New Zealand, as well as one guy in Norway, but he doesn’t appear very often. Reading how the rest of the world sees us is sobering and sometimes infuriating, especially when some asshole here says we shouldn’t have universal health coverage because, “it’s socialism and I don’t want to pay for some illegal’s health care.” Presumably, his own financial ruin, the result of unpaid catastrophic medical expenses, is just dandy.

Then I’ll read the notifications for previous posts which, more often than not, draws me back to running arguments with die-hard contrarians. Common topics include:

  • how Joe Biden is wrecking the country, and how that other guy was so great,
  • people who wear masks are sheep, and coronavirus is a hoax,
  • how the Democrats are coming for your guns,
  • why the national debt is now a problem when it wasn’t during the past four years,
  • poor people are poor because they don’t try hard enough, or they are lazy.

I’m trying to limit myself to thirty minutes as I can spend hours foaming at the mouth.

Next, I’ll check my email and then the ADD kicks in. I get distracted, remembering something I wanted to look days ago, or something I’d promised to send someone.  Last Saturday my lack of progress prompted me to start reorganizing my office. I tossed some shit but just shuffled most of it around.

I’ll give some thought to what I’m going to make for dinner. If I’m really busy I’ll default to takeout. Famous Dave’s on Tuesdays when they have the Feast for Two deal. Popeye’s, El Famous Burrito or Chinese from the Golden Wok on other days.

I have my weekly routines. Tuesday is getting recycling and garbage ready for pickup on Wednesday. Thursday is towel day – washing all the dirty towels. Saturday is for changing and washing the sheets. Somewhere in there I’ll empty the hamper and do my laundry. Peg is particularly finicky about her laundry; for some reason she doesn’t like delicates dried on “incinerate.”

I’ve tried to do the shopping strategically. I’ll do a Costco run once a month, as soon as they open, because otherwise it’s insane. Same with Aldi. I’ll go to Mariano’s nearer to dinnertime when most people are home. Peg and I made up printable shopping lists for Aldi and Costco.

Housework is done as needed. I’ll empty the dishwasher if it’s been run. I vacuum the rug next to our kitchen island as it picks up crap from walking or eating. Getting the Dyson vac we keep in the family room was the best purchase we’d made in a long time. Light, quick and efficient.

After dinner Peg and I collapse on the couch and binge-watch something on Netflix or Amazon Prime until the master realizes it’s around 9pm and starts barking until we go upstairs to the bed.

This all brings me to “The Finite and the Tangible,” a blog post I started years ago and still haven’t finished. Medical school had no definable end in sight. We were expected to acquire useful information from textbooks numbering hundreds, if not thousands, of pages. (Harrison’s Principles of Internal Medicine was about 1,500 pages in 1975. It’s now a whopping 4048 pages in two volumes weighing 13.2 pounds!)  I felt like there was a mountain of books, papers and trash piled into the middle of a school gymnasium and I was the janitor with a whisk broom and dustpan.

Writing provokes the same anxiety and trepidation.

Long ago I learned to derive a sense of accomplishment from simple things like housework, laundry, and cooking. They are finite tasks with tangible results. I don’t have to wait months or years to see the final product. I especially like cooking because cutting things into little pieces is very therapeutic (and, unlike murdering one’s tormentors, legal). I’m a reasonably good cook but I am not a chef by any stretch of the imagination, even though Peg chastises me for doing “cheffy-chef” things like trying to flip a large pancake using just the pan. Hey, practice makes perfect and at least I did it over the sink instead of the bare floor.

A good friend of mine is an artist who, in retirement, has committed to finishing one drawing every day.  I spent the 30-40 minutes writing this when I started, another hour revising the following day, and about 20 minutes just before posting. I’m trying to force myself to write something every day, but it’s still a struggle.

Maybe I’ll ignore the call of the long list of timewasters and go back to “The Finite and the Tangible.” But let me check my Facebook page for just a minute…

The Prostate Saga – Rehab

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WARNING: This post contains material of a sensitive and sexual nature. If you are easily embarrassed or squeamish, you might want to sit this one out.

I saw the Urology Department Physician Assistant the week after my surgery to take out my catheter. She gave me a prescription for 50mg sildenafil (generic Viagra) tablets and told me to take a half tablet every night “to keep the blood flowing” – a prophylactic Roto-Rooter®. I made an appointment with her and the Vacuum Erection Device Clinic for January as “the December clinic had already passed.” I was supposed to talk with the clinic about acquiring a “medically approved” vacuum erection device in January, but I pushed to get it ordered in December since they run upwards of three hundred bucks and I’d met my deductible for the year.

I got a mysterious text message from FedEx alerting me to a delivery from upcrx.com that required my signature. Often “signature required” means either someone is sending alcohol, or the IRS wants to do an audit. Google helped me find University Compounding Pharmacy in San Diego but did nothing to alleviate my confusion.

The package arrived the following week. I scrawled my name on the driver’s tablet and I now possessed my very own prescription “Austin Powers Swedish Penis Enlarger.” I wasn’t supposed to use it until after my postoperative appointment in January, and then only “under medical supervision,” lest I somehow injure myself.

I had an appointment in January with Dr. Fine for a postoperative visit. The PSA level I’d had drawn the previous week was undetectable; I’d get a PSA level done every three months for a year, then every six months if all went well.

He asked about my recovery.

“It’s going fine. The big incision burned every time I moved but that went away in a week and I used the Norco maybe three times. I got by on Tylenol. And I’m back to my pre-surgical level of incontinence.”

His eyes lit up!

“You should really see one of the pelvic physical therapists. There are a couple of people who specialize in male incontinence therapy.”

“I’m fine.”

“You really should consider it; nip it in the bud right now.”

(Like I have the time or inclination to have some dude teach me Kegel exercises, which I’d taught women for decades.)

“Ok, I’ll give them a call.” (No, I won’t.)

Many physicians are hardwired to offer as many labs, procedures, and referrals as possible. That is probably why sleep studies have been such a standard for anyone who is fat, diabetic, hypertensive, and/or chronically tired. He gave me the phone number which I tossed into the trash on my way to the car.

It’s been seven months since surgery; I don’t wear underwear shields anymore and the urgency is almost nonexistent. I may not be able to write my name in the snow but it no longer feels like I’m trying to urinate through a urethra in a death grip.

The following week I saw the P.A.  She had asked me to come in early because she had to go somewhere. Today she was a little frantic and hurried through her instructions.

“You’ll be talking to Jonathan about the vacuum. Stop taking the Viagra while you are using it. Try the Viagra after a couple of weeks. If you don’t see any results after several tries, it’s time to open this little white bag and take the pill that’s in there. If you’re still not getting any results after 2 months, you need to come see me. Here’s an instruction sheet. Now I have to go…”

My next stop was the pretentiously named Vacuum Erection Device Clinic. I figured I’d be in a classroom with several other men discussing our surgical recovery, led by a physician in the requisite white coat giving us a talk on the mechanism of tumescence and how our recent surgery had interfered with function.

Instead, I went to another room and met with the “physician liaison” (read: equipment rep).

“I’ll need to order your device and when it comes in, we can talk about how to use it.”

“Uh, I got it last month.”

“Ok, then. Here’s what you do. Put it over your penis. Pump the vacuum for five or ten seconds, then wait forty-five seconds. Release the vacuum, wait a minute, and then pump it again for five to ten seconds and wait forty-five seconds. Do that for 10 minutes a day. If you have any questions, here’s my card.”

I wasted an afternoon for this?

How an erection works.

The cross-section of the penis looks like a cartoon monkey face. The shaft of the penis contains two spongy cylinders, the corpus cavernosum; a sizeable artery runs through each. A vein flanked on each side by an artery and a nerve runs above the corpus cavernosum. All this is surrounded by a layer of fascia, like a hot dog casing. A third spongy tube, the corpus spongiosum, surrounds the urethra and runs the length of the shaft below the corpus cavernosum while the dorsal penile vein runs the length of the shaft on top. All this is enclosed in loose tissue and covered by thin, flexible skin.

The arteries in the corpus cavernosum normally aren’t fully open, which is why men don’t have permanent erections. When the brain is stimulated, a combination of nerve impulses and chemical signals open the arteries which fill the corpus cavernosum with blood. The engorged tissue presses on the veins, blocking return blood flow and, voilà, an erection is born.

It’s been suggested that men hit their sexual peaks at 18 and it’s downhill after that. Research, however, shows men’s testosterone levels peak in their 30s before gradually declining. Getting an embarrassing, spontaneous erection for no apparent reason disappeared by my late teens.  Sexual function can decline as early as one’s 40s; I started noticing a difference in my late 40s. Other things can affect sexual drive and function besides purely aging:

The nerve bundles required for achieving an erection are often damaged during a radical prostatectomy. Scarring around my prostate required taking out the neurovascular bundle on the right side. The left side was spared but the trauma from surgery is enough to keep the remaining nerves from doing their job. It may take up to two years before being able to achieve an erection with or without ED drugs. If that doesn’t work, the alternatives are injections into the penis or penile implants.

This is my device. It has both battery-operated and manual vacuum pumps which attach to an acrylic cylinder. There are five silicone rings (sizes 5 to 9); the cone is used to slip a ring onto the other end of the cylinder. The ring ejector twists to push the ring onto the penis before removing the cylinder to maintain the erection. The body shield is that circular thing resembling a old-fashioned floppy disk drive and provides a barrier to prevent scrotal skin from being sucked into the pump. The gel is used to form a seal around the base of the pump and to lubricate the penis; without it the penis will drag along the cylinder wall like an anchor on concrete.

Note to self: make sure to grab the correct white squeeze tube: the lubricating gel tube, not the menthol gel I use on sore muscles.

The Vacuum Erection Device, aka the “Austin Powers Swedish Penis Enlarger”

The caveats in the instruction manual were disturbing.

“Vacuum therapy may cause a small “blood blister” on the head of your penis. This is normal and not harmful.”

“The rings may bruise the base of your penis. Some bruising is normal and should not be cause for alarm.”

Wait, what? In what alternative universe is a bruised and blistered penis “normal?”

“If you wear a ring for more than 30 minutes, you may severely bruise or damage your penis.”

So, if that happens, do I just get a new one from Amazon with 2-day Prime delivery?

I looked over the instruction sheet I’d gotten from the P.A.

You were given samples of ED medication to try at your leisure. Please use the paper form you were given (to) track your response and side effects of each medication. The goal is for you to try one tablet every 3rd day followed by (significant) stimulation.

  • Tablets work better on an empty stomach
  • Tablets take one hour to become effective
  • Space out your trials by 2-3 days at the minimum

If tablets do not work, you may still have intercourse with the vacuum rubber bands.

Common side effects – headache, facial flushing, nasal congestion

If you are on Cialis and are experiencing leg cramps – Please stop Cialis immediately as Cialis can sometimes be linked to tendon inflammation, possible rupture.

Oh, goody!

I discovered the vacuum doesn’t work immediately, which was disappointing. One cannot hope to instantly inflate the penis like a balloon that a clown twists into animal shapes for kids at a party. At first it took fifteen minutes to achieve anything resembling an erection, which decreased to around five minutes after three months. The least they could do is make pumps entertaining with indicator lights and an alarm that goes off when one has reached maximum height (or is it length?).

Anyone who played with a vacuum cleaner hose as a kid knows it can inflict some pain if left on a body part for too long. Moving blood into a penis with negative pressure is an uncomfortable process and certainly not erotic. And few things are worse than having a large chunk of scrotal tissue suddenly sucked into the cylinder along with a testicle. The barrier did not help at all; it was too flexible and got drawn in as well.

It didn’t take long for one of the rings to break and the replacements cost twenty bucks each. I ordered a different kind of ring that looked like a flat, silicone bagel (the penis goes through the hole and the surrounding material blocks wandering skin, but it was for a rival brand and didn’t fit my pump. I found another type that looked more like a foam-lined chip clip (or a cigar cutter). I settled on a silicone loop I bought from Amazon.

The battery pump died after a month. The company said they’d send a replacement which never arrived, and I don’t feel like calling them again. The manual pump is equally effective but using it leads to spasms in my right thumb and pain in my right wrist, caused by old nerve damage from two separate lacerations. The recommended forty-five seconds on, one minute off did nothing, even after multiple attempts over three weeks. I finally just pumped and left the vacuum on for several minutes while amusing myself with my Kindle game. (I may not have sexual function, but at least I’m doing my part to delay age-related dementia!) My erections promptly deflated as soon as I released the vacuum, despite the ring. There was never sufficient rigidity to close off the penile veins.

I then tried using 100mg sildenafil without the pump or any kind of stimulation. I got a slight flush but nothing. A few days later I made another attempt. I got distracted doing other things but applied the pump three hours after I took it. I got a reasonable erection which again deflated after taking off the pump and using the loop. I tried the pump again and then manual stimulation which made it last a little longer but still wasn’t anything to write home about. And all this took about 25 minutes, not including the minimum one hour wait for the drug to take effect.

George Burns said, ““Sex at age 90 is like trying to shoot pool with a rope.”

But all is not lost. Men can have orgasms without an erection, although it may take some mental adjustment. If you’re a New Ager into Tantra (and you have a lot of patience), you can have an orgasm using just your mind. Radical prostatectomy removes the prostate and seminal vesicles, meaning there’s no more semen, along with the sphincter between the urethra and the prostate, which normally prevents retrograde ejaculation (semen going into the bladder instead of out the penis). The result is climacturia, the release of urine with orgasm and a common side effect of the surgery. One can prevent this with an adjustable loop around the penis, muscle training or surgery, but emptying the bladder beforehand is the simplest.

More information than you ever wanted to know, eh?

Finally, nothing is more important during post-prostatectomy rehabilitation than a loving and supportive partner. Peg says she would rather have me alive and annoying than six feet under, and for that I am grateful.

Monkey illustration © Can Stock Photo / yayayoyo

The Prostate Saga, Part 2

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It’s a good thing Dr. Fine’s reputation preceded him, or I might not have stayed long enough to meet him. But first, a segue into the genesis of my ire.

When Corporate America took over health care administration, it decided physicians had wasted too much time taking care of patients instead of generating revenue. Large health care organizations began buying up individual physician practices and, in some cases, taking over hospitals. Younger physicians loved this idea: they got a salary, paid vacation and none of the administrative hassles of running a private practice. (I plead guilty, as I joined an HMO for those reasons. I was a poor businessman and I admitted it. The problem was, in many cases, I knew more about business principles than the people signing my paychecks.)

Older physicians balked at being controlled and some of them resisted as long as they could. If you didn’t play ball, The Corporation would find ways to shut you out. If you didn’t contract with the predominant insurers, you became “out of network” and a lot more costly to patients. Other older physicians saw the handwriting on the wall and retired early, the lucky bastards, to stay at home, engage in hobbies, travel or annoy the wife full-time.

We traded autonomy for financial security and ended up with neither.

The Corporation now controlled everything, including your ass, so it could dictate how you did your job. One physician I knew 25 years ago, a hospital employee, said, “I have guys in three-piece suits telling me what to do. And I do it.” Thus, the standard 10-minute appointment was created. No matter how complex the patient, physicians were expected interview, examine, diagnose and treat a patient in the allotted time before moving onto the next one. Or should I say “mooving on”, since patients were now herded through like cattle. (I often threatened to play the Rawhide theme in the hallway during my HMO days. “Head ‘em up! Move ‘em out!”)

If you were a specialist, you got 20 or 30 minutes for consults, even if the patient had cancer. No “wasting time,” like my gyn oncology professor during residency, who spent an hour discussing ovarian, uterine or cervical cancer with women who were still in shock from the diagnosis.

And now, back to our regularly scheduled blog post.

Dr. Fine’s office booked a 30-minute visit at 2:50 p.m. Peg and I arrived about 15 minutes early; she was still in a wheelchair after having foot surgery.  I checked in, sat down and waited. And waited. And waited.

About 40 minutes later a nurse, nursing assistant or whatever, appeared in the door to the inner sanctum and bellowed, “David.”  I got up and wheeled Peg through the open door.

Halfway down the hall, the nurse said, “David, what is your date of birth.”

I told her and she said, “Oh, wrong David.” So, I wheeled Peg back to the waiting room while the correct David was whisked away.

Twenty minutes later she reappeared. “David.” Once again, I wheeled Peg down the hallway, but not as far this time before she realized my date of birth didn’t match what was on her tablet. And, once again, I wheeled a now pissed-off Peg back to the waiting room.

Different women appeared at the magic door, calling names as if they worked in a cheap restaurant, and patients disappeared.

It was now 4:15 pm. I’m normally a quiet, patient type (you shaddap and stop laughing!), but even my patience was wearing thin. The first woman we saw opened the door and called, “David.”
“Which one?”
“Last name Rivera?”
“Yeah, that’s me.”

We were herded into a pen patient room and a few minutes later a very sweet assistant came in to verify my information on the computer terminal (paper charts have all but disappeared). She apologized for the wait and said Dr. Fine would see us soon, but he was running behind.

Peg smiled but said, “We’ve been waiting a long time. Dr. Fine better be a rock star!”

The SYT swallowed and assured us Dr. Fine was indeed was, figuratively speaking, on par with Jimmy Page.

We could hear snippets of Dr. Fine’s conversation with another patient. Another 15 minutes elapsed, then yet another nurse/assistant came in with two books. I don’t recall the titles, but they could be titled, “You and Your Prostate,” and “What You Need to Know about Prostate Cancer.”

“The doctor will be in shortly to discuss your diagnosis.”

Now I was pissed! “I’m a physician! I KNOW my diagnosis; Dr. Ky and I have talked about it and I’m here to talk about getting a surgery date scheduled!” I thought If you’d looked at the record before barging in here, you’d know what’s happened and why I’m here.”

Finally, Dr. Fine entered the room and I understood why he was running late. He greeted us and apologized for running late. “Discussing a new diagnosis of cancer with a patient takes some time and I don’t want them to feel rushed.”

Ok, you earned your rock star status.

He talked at length about Gleason scoring in general. A Gleason score of 6 suggests one’s cancer is likely to grow slowly while a score of 8 and above is likely to be more aggressive and spread quickly. My score of 7 (4+3) put me at intermediate risk and was more concerning than a score of 3+4.  Then he talked about Tumor, Node and Metastasis (TNM) staging and how that relates to overall survival; my cancer stage was T-IIa, meaning no metastases or node involvement. (For more information, go to the Urology Care Foundation educational materials page and download the Localized Prostate Cancer guide.)

Notes from our discussion of prostate cancer and treatment options

We then discussed treatment approaches. I talked about the risks of radiation in my previous post, but the biggest drawback is it turns the prostate to mush. If the cancer recurs, taking out the prostate is next to impossible. Doing surgery first leaves radiation as an option for recurrence.

Surgery removes the prostate completely and, potentially, all of the cancer, but has its own set of risks. Immediate problems include recovering from surgery, including having a catheter in one’s bladder for a week. The surgeon has to cut the urethra (that tube from the bladder to the outside) to remove the prostate, and then sew it back together. One is likely experience some degree of urinary incontinence once the catheter comes out; they recommended getting a large supply of “adult incontinence underwear” along with pads that look like what women wear after delivering a baby.

Surgery removes the seminal vesicles and potentially some nerves along with the prostate, guaranteeing temporary or permanent erectile dysfunction. I would be taking a low dose of the “little blue pill” (sildenafil) every day to “promote blood flow” back into a limp penis. I’d have a checkup six weeks after surgery and then go to the Austin Powers Swedish Penis Enlarger clinic to learn how to use a $300 “medical grade” acrylic cylinder and vacuum pump. For some reason they discourage procuring the much cheaper products available at your friendly neighborhood adult toy store as it could “result in injury.” (Like Ralphie getting his tongue stuck to the frozen flagpole in “A Christmas Story?”)

We agreed to a surgery date right after Thanksgiving. He gave me a card for the Patient Navigator, someone who is supposed to “guide you through the process.” I talked with her once; she told me someone from the hospital “will call you with a surgery date within a couple of weeks. Then someone will call you a week before surgery with questions and instructions.” I used to impart that information to my patients at the end of our visit and didn’t need someone to do it for me.

I saw one of the Urology Department P.A.s (physician assistant) to teach me Kegel exercises, which help control the inevitable leaking bladder after surgery. Women learn Kegels when they are far younger, since they have only one urethral sphincter to men’s three.  I told her I’d been wearing protection for months to which she replied, “Welcome to our world.” The visit lasted only a few minutes. Peg had taught me abdominal core and Kegel exercises to do while driving to client’s houses. She did a better job and for free.

About a week later someone from the hospital’s scheduling department called me while I was driving to a client’s house. My surgery would be on December 2 at 7:30 a.m., a wretched time, as I’d have to be there about 2 hours earlier for preparation (which often takes about 30 minutes). 

“I’m wandering around the Chicago suburbs so now isn’t a great time to talk. How about you give me a call next Monday when I’m home?”

“Ok, that would be fine. In the meantime, I’ll send you preoperative instructions through our website and we can go over them next week.”

 She called and went over my medical history – current and past illnesses; the medications I took; allergies to medications – before going over the same instructions she’d sent the week before. I realize it may seem redundant, but there are people handicapped by a Y chromosome who don’t read or listen and need all the reinforcement they can get.

“Back in the good old days, I used to do all this myself.” 
She replied, “You probably weren’t that busy back then.”

Bullshit. I routinely saw 25-30 patients a day in the office and worked in women with acute problems. I did my own preop H&Ps (history and physical) and dictated it on the hospital’s transcription line. Years later, wrote my reports in MS Word and hand delivered them to avoid hearing, “We can’t find your H&P. Did you forget to dictate it?”

Preparing for surgery

Physicians go through “informed consent” with a patient before surgery or a significant treatment. Ideally, a physician explains what s/he proposes doing, what it is meant to accomplish, the risks and benefits of the procedure (including risk of death, if appropriate), and what might happen if the patient refuses. Then the physician gives the patient time to ask questions, have those questioned answered and, often at the end, sign a permit for said treatment or surgery.

This ritual is supposed to ensure the patient makes a well-informed, intelligent decision while also minimizing the risk of litigation in the event of an adverse occurrence or outcome. In reality, a pissed-off patient can always claim “I didn’t know what I was agreeing to” and some lawyer will take the case. So, many of us believe there is no such thing as truly “informed consent.”

My approach to informed consent for surgery went something like this:

“You need to be at the hospital two hours before your surgery time. They will get you ready for surgery (but it doesn’t take two hours, so you’ll spend a lot of time picking your butt). When everyone is ready, one of the nurses will take you to the operating room, put you on the table, hook up EKG leads and strap you down, so you don’t roll off. (Sometimes we will pick our butts waiting for anesthesia to stroll in.) I will be there before you go to sleep. This procedure is going to take about x hours. You’ll go to the recovery room for about an hour and then sent to your room (inpatient) or sent home (outpatient).

“All surgery comes with some risks: risk of bleeding, infection and injury to something inside. You also have a 1 in 60,000 risk of dying from anesthesia, but you are much more likely to die driving your car, especially in the winter when there are a lot of idiot drivers around.” (For the curious among you, the risk of death from a motor vehicle accident is 1 in 103. I can’t find the odds of dying from stupidity, but the Darwin Award people keep a nice tally.)

If I was tying a woman’s tubes (tubal ligation), I added this:

“You also need to understand nothing is perfect, including tubal ligations. About three out of every 1000 women getting their tubes tied get pregnant, sometimes many years later. A few of those pregnancies will end up in the uterus, but many get stuck in the tube, causing an ectopic pregnancy which can kill you  if not treated. So, if you ever think you are pregnant, you need to see a physician right away.” (I met a woman in Tennessee who had an ectopic pregnancy 13 years after her tubal ligation. She had been bleeding vaginally (and internally) for a few days, not realizing she was pregnant. I found 1300cc of blood in her abdomen.)

Now, that approach was too vague and informal for Ms. “Expectation Management” who thought researching every possible surgical complication was a fine idea, and then expected ME to grill my surgeon on how the team was prepared to avoid them.

I know a lot of the possible complications, which is why I hated gyn surgery! I’m more like Peg’s sister, Michele: Ignorance is bliss.

The day before surgery I had to drink only clear liquids and do a bowel prep. I drank a bottle of magnesium citrate, which is far easier to take than the gallon of NuLYTELY® I had for my colonoscopy prep. But, because a bowel prep can screw up one’s electrolytes, they told me to drink a 20oz bottle of Gatorade four hours before surgery. Yep, 3:30 a.m. Sleep is overrated.

We arrived at the hospital parking lot about 5:30 a.m. and trekked what seemed like a couple of miles to Surgical Registration. I checked in with a woman who was too alert for such an abysmal time. We waited for about 20 minutes, then someone led us on another trek to Pre-Op where I changed into a hospital gown and hopped onto the gurney.

My nurse was an adorable, diminutive redhead with freckles and a pixie cut, too alert and too cheery. She put EKG leads on my chest, a blood pressure cuff on my arm, and poked my finger to check my blood sugar, and started an IV, all while telling me what I needed to do.

“You remind me of my wife.”
“Hey, you brought her here, I didn’t.”

I started laughing so hard she had to retake my blood pressure after I calmed down.

I talked with Dr. Pierce, the anesthesiologist, and reminded him of my paradoxical reaction to Versed (midazolam), a drug used for anesthesia induction and conscious sedation. Dr. Fine appeared a little after 7:00 am for some last-minute discussion and reminders. Surgery would take about two or three hours and I would go home in the afternoon if everything went well.  Then the OR nurse put a bonnet on me, had me kiss Peg and rolled me down to the room. I slid onto the table while the anesthesiologist and the scrub tech introduced themselves and got me ready.
The last thing I remember hearing was, “This might sting a little as it goes into your vein.” Click here if you want to see Robotic Assisted Laparoscopic Radical Prostatectomy .

When I woke up 3½ hours later, it seemed as if only ten minutes had passed. I felt pretty good in large part to the local anesthetic injected around the trocar sites. Even the catheter wasn’t uncomfortable.  I had something to drink and the recovery room nurse had me walk down the hall.  I was home by 3:00 and really happy I didn’t have to stay in the hospital.

The following week wasn’t bad, either. I didn’t have to get up at night because of the catheter. Peg got up at 1 a.m. that first night to empty the bag, but I cut my liquid intake in the evening and emptied it about 11 p.m. which got me through the night. I had six stab wounds for the trocars but only one hurt if I coughed or move wrong, and that only lasted a week. I took three hydrocodone tablets, mostly at night, and used acetaminophen the rest of the time.

My abdomen after surgery
My incisions

The pathology report came back by the end of the week:

Surgical pathology report
Prostatectomy Pathology Report.
A. Right neurovascular bundle margin, excision:
-Neurovascular tissue, negative for malignancy.
B. Prostate, radical prostatectomy:
-Prostatic adenocarcinoma, Gleason score 4+5 = 9.
-The margins of excision are negative for tumor.
-Focal extraprostatic extension, left posterolateral, for a total span of 5 mm.
-Uninvolved seminal vesicles.
C. Bilateral pelvic lymph nodes, excision:
-Six lymph nodes, negative for tumor (0/6).
D. Posterior bladder neck, excision:
-Fibromuscular tissue, negative for tumor.
E. Anterior bladder neck, excision:
-Fibromuscular tissue and focal urothelium, negative for tumor.

So, the cancer cells were worse than the biopsy and it had already peeked out beyond the prostate. Having negative margins means the bad stuff was confined to what was taken out. Surgery turned out to be the more prudent approach.

The catheter came out the following Monday. I had to change underwear frequently for a few days but was back to my pre-surgical level of incontinence by the end of the week. It felt strange being able to urinate like I did before my prostate started squeezing my urethra.

I had an appointment for the Vacuum Erection Device Clinic in January, but that is a whole ‘nother story.

Compared to What?

6 Replies

(Please forgive my absence. The last two months have been a bit chaotic.)

This was too good to pass up.

Number One son, my clone in personality if not appearance, started a discussion on Facebook: So… at what point does the MiniTrue behavior of the current administration become an actionable problem?

A friend of his responded: Ah the ministry of truth telling you to reject the evidence of your eyes and ears.

My first thought on seeing “Mini-True” was Verne Troyer. I remember a few of Orwell’s unique terms – Big Brother, thoughtcrimes, doublespeak and the homeland Oceania – but not the contraction MiniTrue. I asked Peg and she didn’t remember it either.

Number One Son: Ministry of Truth. S’newspeak
The Old Man: Millennial shorthand again.
Number One Son: Jesus dad did you even READ the book?

Yeah, numbnuts, I read 1984 in 1969 when I was a high school freshman. And Animal Farm. And Brave New World, though I’ve never read Lord of the Flies. One my high school buddies called me Piggy because I had “assmar” (asthma).I had an image of Julia I based on a blonde from a beer ad in TV Guide. Years later when I saw the 1956 film version of 1984 with Edmund O’Brien as Winston Smith, Jan Sterling’s Julia came pretty close to what I’d imagined.

I grew up during a time that was similar to what’s going on now but, in its own way, far uglier, although Peg thinks the present is worse. Black people were still being lynched in the South during the 1960s. Detroit and other inner cities burned in 1967 as black people rioted against police brutality, poverty and racism. Martin Luther King, Jr. and Bobby Kennedy were assassinated within a couple of months of each other in 1968, killing our hopes of racial harmony and a return to Camelot.

Our collective stomachs knotted as we watched old men on television randomly drawing birth dates for the draft. We were in a war in Vietnam we could never win, and our leaders knew it.  Fifty thousand US troops died. So did an estimated 1.3 million North and South Vietnamese soldiers, along with 2 million Vietnamese civilians. The American casualties in Iraq, Afghanistan and Syria are far lower, but the faulty rationales for “bringing freedom and democracy to you savages” persist.

College campuses exploded. The Students for a Democratic Society (SDS), founded in Ann Arbor, Michigan organized “teach-ins” (a.k.a. “preaching to the choir”) and antiwar protests. The Weather Underground Organization didn’t think the SDS was militant enough, split off in 1969 and started a bombing campaign targeting banks and government buildings. Diana Oughton, who grew up in Dwight, Illinois, about 15 minutes from where I lived in Streator, died in a Greenwich Village apartment when the bomb she was building exploded prematurely. She was only 28.

The 1968 Democratic National Convention in Chicago was eclipsed by Chicago cops tear-gassing and beating the crap out of protestors. Mike Wallace and Dan Rather, CBS reporters who would become legends, were assaulted on national TV. Chicago Mayor Richard J. Daley, whom columnist Mike Royko called “The Great Dumpling,” made his infamous proclamation: ““The policeman isn’t there to create disorder, the policeman is there to preserve disorder.”

On October 15, 1969, a few million people around the country – mostly young, some older – joined The Moratorium to End the War in Vietnam. Our high school administration had banned wearing black armbands in honor of the day, prompting several seniors to walk out and assemble at the American Legion memorial in the city park. I wore an armband home that day. My stepfather called me a Communist and said the kids at the memorial should have been lined up and shot. I’d never thought of him having any political inclinations and I was surprised as hell. I picked a side that day and I’ve never wavered.

American Legion Memorial, Streator, IL

Six of my high school friends and I read How Old Will You Be in 1984?, a collection of essays from high school “underground” papers around the country. We would all turn 30 in 1984, the age at which we thought as teenagers, adults could no longer be trusted — a sobering thought. (The irony is I now think of thirty as “young and stupid,” and I don’t trust people my age when they have money and power.)

We printed four editions of “The Paper,” our naïve attempt to change the hearts and minds of high schoolers in a blue collar town. Dennis’ dad gave us access to a mimeograph machine; we printed them on pastel paper and sold them for a dime. I still have some of them left, crumbling in a manila envelope somewhere in our basement. It got us mentioned in a much larger collection, The Movement Toward A New America: The Beginnings of a Long Revolution., but not much else.

USA Today ran this opinion on September 6, 2019: “If things are so bad under President Trump, why aren’t we seeing larger protest movement?“  My snarky comment was “Because people won’t look up from their cell phones.” They aren’t willing to risk being teargassed, beaten or shot for what they may view as an exercise in futility. There have been a few symbolic protests and arrests but nothing that has altered minds or policy.

learned protesting doesn’t accomplish shit. My generation wanted a “revolution,” but it didn’t turn out as we’d hoped. Not even close. The only things we “accomplished” were President Lyndon Johnson decided not to run for re-election, and the backlash from the riots killed Hubert Humphrey’s chances of winning. The US didn’t pull out of Vietnam for another 5 years. We got Richard Nixon as President, his war on drugs and his eventual resignation for the Watergate cover-up. Republicans are still fighting the culture wars, even though all of us dirty hippie godless Commies are grandparents and more worried about our 401k’s than sticking it to The Man. (Click here for a story about the couple on the Woodstock album cover, married for almost 50 years!)

Pissing and moaning on Facebook may be cathartic. Signing online petitions to your weasels in Congress might make you think you’re doing something, but it doesn’t. Voting helps but only to a point. Each person can vote for two Senators, one Congressional Representative and the President. I can’t vote Moscow Mitch, Ted Cruz or lunatics like Louie Gohmert out of office. You could elect Jesus Christ Himself as President and as long as the GOP controls Congress, you ain’t getting shit.

Change is incremental and requires fundamental shifts in public opinion. Civil rights, voting rights, gay marriage and legalized marijuana didn’t happen overnight. Bernie’s minions should stop hoping for a “progressive” miracle worker with a magic wand and work towards changing Congress instead of whining about how the DNC “screwed” him in 2016.

Trump’s base will crawl on their knees over hot coals to vote. Millennials and Gen X’ers will comprise more than half of next year’s eligible voting population, almost twice the number of Baby Boomers (whom some of them blame for their misery). They are in a much better position to alter our country’s course because they have more to lose by doing nothing.

In 1969, Les McCann and Eddie Harris performed “Compared to What?” at the Montreux Jazz Festival. Some things haven’t changed in fifty years

“The President, he’s got his war
Folks don’t know just what it’s for
Nobody gives us rhyme or reason
Have one doubt, they call it treason
We’re chicken-feathers, all without one nut. God damn it!
Tryin’ to make it real, compared to what? (Sock it to me)”

We still have a long way to go.

Illustration © Canstock Photo / Satori

Compared to What? By Gene McDaniels. © 1966