Archives of The Cheerful Oncologist, Volume 2

[Our narrator finishes up the week with a hearty “T.G.I.F” and a wink toward the annual spook fest lurking just around the next dark corner…]

I just returned from the local Hallowe’en store, which is a trip to bizzaro land if there ever was one. Who knew that one day the clothes we wore as a teenager would end up as a costume for our own kids? In the spirit of the season of All Hallow’s Eve, I leave you this week with some recommendations for late night reading…in a gloomy house…next to a dim lamp…and the wind howling outside the window…

And who else would supply the story for such a hair-raising setting but the master himself - Edgar Allen Poe.

Just go to this link and find a short story that sends the shivers down to your skivvies. I highly recommend the following:

Berenice

The Fall of the House of Usher (can you figure out what the poem is an allegory for?)

A Descent into the Maelstrom

The Masque of the Red Death (I wrote a post based on this story which can be found right here).

Feel free to recommend your favorite Poe story or poem - and have a Happy Hallowe’en.

“Steady, boys! Steady - wait until they get past that rock…closer…closer…not yet………NOW! FIRE!”

Gee, they make it seem so easy in those old war movies on late-night television. I’ve often wondered how movie soldiers kept from snapping at the moment of crisis. Would I have held my fire like a veteran, or pulled the trigger way too soon, thus ensuring me becoming vulture antipasti?

What, are you kidding me? I’m an oncologist - a specialist at firing away at the bad guys. To me the only crisis in a fight against the Tumor Batallion is if I run out of ammo. Keep those chemotherapy belts coming, boys - we’ll fight it out on this line all summer if we have to.

What a clever conceit! Too bad it’s just an adolescent fantasy. In real life, to take the above analogy further, the bullets launched against cancerous villains tend to spray all over the countryside wiping out Grandmas hanging their wash out to dry as well as one’s foxhole buddies. To put it in plain English, chemotherapy damages normal cells as well as malignant ones. This tends to be a discouraging word when it reaches the big brass at headquarters. One therefore needs to use discretion in letting loose a volley, let alone a naval gun bombardment, when deciding to attack cancer.

In other words doctors are obligated to use “good judgment” in deciding when to begin treatment. Many tumors require immediate if not urgent attention, not unlike a platoon cornered on a Norman field who must fight their way out or perish beneath the hedgerows. Sometimes though oncologists must resist the temptation to start chemotherapy. Sure, every one of us wants to look like we care and that we know what we’re doing, but there are situations where it makes sense to not treat the patient. I’ll give an example that occured recently - a patient with lung cancer I saw whose neck pain was worse than at the last visit. She has already received radiation and chemotherapy to the tumor in her neck, at a cost of moderate toxicity. Now she takes three pain pills a day. Should I start her on second-line chemotherapy?

Ich glaube nicht!. Her pain medicine usage is about the same as always, and her bone scan is only slightly worse than the old scan. My opinion is that it is not worth putting her through the side-effects of chemotherapy. The command therefore is: Hold your fire!

Ahem…I didn’t promise however that I would refrain from using all my weapons - just the ones that are the most dangerous. For your information, in the war against cancer dedicated researchers are producing smart bombs as well as blast-em-all-back-to-kingdom-come chemotherapy.

I put my patient on the epidermal growth factor inhibitor erlotinib, which has relatively minor side effects compared to chemotherapy. In war, this is like a laser-guided missile headed straight to the command and control center of the cancer cell.

This is only the beginning in the long, long march toward more effective treatments, but erlotinib and other targeted therapies do have one thing in common with cancer cells: they don’t fight fair. Good for them - and hooray for bullies, I say.

[Further meditations captured during a week of desultory Rorschach-blogging..]

1. G.L.O.W., or Get Loose on Wednesday was the cry during our college years, when for some strange reason we were unable to survive a full week of academic labor without a boisterous visit to one of the local saloons, as if we were amphibians desperately flopping about in an attempt to return to water. Now Wednesday holds much less sway over our mood - I mean, have you seen how much work you’ve got to do this coming weekend? Better enjoy that latte’ and muffin at your desk while you can, not to mention sneaking in a little internet surfing while the boss’s door is closed.

2. One of the most vivid lectures I remember during medical school was from a wise old practitioner who stated, “Beware of the hateful patient, who can poison one’s mood!” I was shocked to find that what he meant was the “hateful patient” is not one who hates you, but one that you hate. These words were some of the truest ever spoken in my career. Sooner or later all doctors run across patients that are annoying, demanding, in denial, stubborn, rude, even enraged. My response to those encountering such unpleasantness: courage! Doctors are supposed to act like professionals, who don’t let unfortunate circumstances rattle them. As awful as it seems, I think the best maneuver when confronted with exasperating patients is to take it like a tackling dummy facing the entire defensive line. Don’t become hostile - in addition to looking like a boor you will probably alienate your patients. The best thing to do is to sit down and listen. Patients appreciate a doctor taking the time to hear them out.

3. If I said it once I’ve said it a thousand times - never take anything for granted! Sometimes patients who appear to have one disease actually have something entirely different. Sometimes a little shadow on an x-ray does not mean that someone’s cancer has relapsed, which makes the doctor look foolish if he had proceeded to scare the bejesus out of the patient. Sometimes patients just go on living - even when all their doctors assumed the worst. Doctors therefore shouldn’t act shocked when they run across a patient who has lived much longer than expected - it is rude for one thing, and tends to make them look like they really aren’t advocates for the patient.

Better to sail on toward uncharted lands than to assume the trip will end in disaster and stay at home grousing about the injustice of the king while your brother’s grandson ends up being a signer of the Declaration of Independence.

[This week the narrator is compiling observations culled from the events of the day in an attempt to wipe out hedonophobia without resorting to such gimmicks as telethons or knock-knock jokes.]

1. The way I see it, if both my patient and I are scowling then there is no chance that anyone in the room is going to be cheered up. Someone has to take the first step and find some aspect about this current illness that is encouraging, then relay that information in a positive manner. Then perhaps like the sun popping through the clouds a smile of hope will appear on a worried face. That is the way to end an office visit.

2. On a related note, it is easy to be cynical and pessimistic in this modern age, just as it is easy to cut through a neighbor’s flower bed, or ignore a friendly dog, or criticize a child’s efforts, or decide that today would be a good day to stop learning anything new for the rest of one’s life. Anyone tempted to embrace such negativity is falling into a horrible trap. Beware! Better to stand in front of the mirror and say “I feel I am blessed with many virtues, but the only way to know for sure is to use them!”

3. There is nothing more enjoyable for oncologists than to see old patients in the office, for unlike family physicians we don’t always get to watch our patients grow old. I saw a patient today who is nine years out from diagnosis and felt like I had found my long lost brother. How sweet it is to shake the hand of one who has been cured. It produces an indescribable feeling, like being given a brief tour of heaven before being whisked back to earth.

4. When interviewing elderly patients with memory loss, do doctors ever wonder if they are headed for a similar fate? Do they ever daydream about finding themselves perched in front of a television watching daytime ads for malpractice lawyers while being spoon fed pureed green beans? All those years of success in school, all those ‘A’ grades and perfect test scores, all those triumphant debates with fellow residents, all that bestriding the narrow world like a Colossus - is it destined to end in such a pitiful way?

Hey, how do I know? I’m no psychic! But just in case our lives are floating inexorably down the river to the Gulf of Dementia I leave you with this little piece of advice from Jack London:

I would rather be ashes than dust!
I would rather that my spark
should burn out in a brilliant blaze
than it should be stifled by dry-rot.

The function of man is to live
not to exist.
I shall not waste my days trying to prolong them.
I shall use my time.

[This week The Cheerful Oncologist wishes to offer his readers, at no additional charge, a disturbing peek into his world as he reviews selected momentous happenings from each day. These random observations are guaranteed to represent actual emissions from the smokestacks of his mental factories, where deep within teams of Oompa-Loompas scurry about the dusty neurons and axons in an attempt to keep the good doctor’s intelligence quotient from dropping faster than a peregrine falcon hovering over a nearsighted mouse.]

1. Am I less of an American if I don’t drink coffee? I feel so left out when, galivanting about town, I see the happy throngs of customers queuing for lattes and mocha cappuccinos. They are members of a club I had to resign from but long to rejoin. The smell of freshly brewed beans plows through the air, filling the heart with songs of the earth. I have heard the baristas singing, each to each.

I do not think that they will sing to me. In fact, I hear a distinct chortle emanating from the hearty throats of java slingers when I order a meek cup of tea. I sneak over to a forlorn corner of Starbucks and sip it quietly, looking to the world like Wally Cox . My heart pines away for a real mug of joe, an honest cup of coffee like the ones Jack Webb used to down on Dragnet while chasing down forgerers and their ilk. Instead, the ancient ritual of the tea leaves becomes my new morning worship.

Let’s face it - I just want the caffeine without the heartburn.

2. When a patient complains about the cost of a new treatment I remind them that often new agents are initally given at much higher levels before a final dose is established as the most cost-effective and efficacious, and that the reason these more expensive agents get approved by the FDA is because they produce superior outcomes compared with older regimens, frequently with much less toxicity - cf. imatinib for the treatment of chronic myelogenous leukemia for an example.

3. I don’t mind producing scientific articles of support to convince an insurance company to pay for an innovative treatment. Doctors must prove that there is medical evidence showing that a new medicine is worth covering. It does discourage us though when promising new treatments are distributed to patients at a rate similar to the speed at which Uncle Louie picks up the dinner check.

4. Some patients live much longer than the average survival time mentioned in textbooks. I visited with one such patient today and while admiring his longevity could not help but wonder why millions of cancer cells, scattered hither and thither in his liver and other superstar organs, had laid down their spears for a peace conference. I was reminded of Octavius Caesar’s armies, spread out upon the plain outside Alexandria, waiting and waiting for the command to attack Marc Antony. Some day that order will be given and my patient’s life will once again be under siege.

When that day occurs it might be helpful if I gave the Queen of the Nile the bum’s rush from the old commander’s tent and went back to soldiering against this most odious plague of modern times.

[Up next: Tuesday (what, you were expecting Wednesday maybe?)]

Hey all you game show fans out there - how’d you like to play America’s most exciting new show “Who Wants to Be an Oncologist?” Long considered some of our most esoteric, if not peculiar doctors, oncologists are usually depicted mumbling incomprehensible phrases to puzzled patients, poring over greasy charts full of hieroglyphics and scary pictures, eating greasy sandwiches, or staring dreamily out the window while pretending to listen to someone’s wheezy exhaust pipes.

What excitement! What high drama! Given the fact that (thanks to reality television) more and more folks are getting a chance to do something totally detached from the reality of their actual lives, why not give ‘em a shot at treating an actual cancer patient?

The concept is very simple. As your dapper host I will present an actual case to you and you get to choose between two alternative courses of action - in other words, you get to make the same decisions oncologists make every day. What could be more simple? Are you ready to play?

Hit the theme music!

Our case today is that of a 57 year old man with a ten centimeter mass in his right lower lobe on chest x-ray. Chest CT reveals the mass, with no other abnormalities seen. He weighs 289 pounds, has hypertension and a history of chronic bronchitis, and is on disability due to a “bad back.” He has smoked between one and two packs of cigarettes a day for 40 years.

Do you: A. Operate and remove the mass? or B. Order more x-rays?

Answer: C. Get a biopsy for diagnosis! Don’t you want to know what this is first, especially whether or not it is small cell lung cancer versus non-small cell lung cancer? ORDER AVOCAT ET OEUFS A LA MOUSSE DE CRABE IN FLUENT FRENCH.

Biopsy shows squamous cell carcinoma, and all staging scans including CT and PET/CT reveal no evidence of spread.

Do you: A. Operate and remove the mass? or B. Start radiation therapy?

Answer: C. Perform a cervical mediastinoscopy! Just because a PET/CT scan shows no fluorodeoxyglucose uptake in the mediastinal lymph nodes doesn’t mean they aren’t infiltrated with lung cancer, and if they are positive an operation would have very little chance to improve the patient’s long term survival. PERFORM ONE DEATH-DEFYING KICK.

We’ll be right back after these important messages……Hmm, let’s move on. The mediastinal lymph nodes are normal on biopsy, but the patient’s pulmonary function studies (done by the thoracic surgeon, thereby saving you a bit of embarrassment since you forgot to order them) reveal he has severe emphysema, precluding any chance for surgical resection.

Do you: A. Begin chemotherapy? or B. Begin radiation therapy?

Answer: C. [You were expecting maybe A or B?] Begin concurrent chemotherapy and radiation therapy! Did you forget that most experts agree that, based on the results of several recent studies, giving simultaneous chemotherapy and radiation therapy produces superior results compared with doing one or the other, or even giving both treatments sequentially? Hmm, did you?? SWALLOW ONE JUICY EARTHWORM.

Your patient brings you a news article stating that the monoclonal antibody Avastin produces longer survival for lung cancer patients when given with chemotherapy. He requests that you treat him with this new targeted therapy agent.

Do you: A. Begin Avastin now? or B. Wait until he is completed with radiation and then begin it?

Answer: C. [I knew that, wiseguy.] Oops! The plucky newspaper reporter forgot to mention in that story that patients with squamous cell carcinoma shouldn’t receive Avastin because of the risk of fatal pulmonary hemoptysis! So sorry! Also, patients with brain metastases, or on Coumadin, or those with large centrally located lung masses should not take Avastin either. ACT LIKE AN AVERAGE SCHMO.

Well, that buzzer means we’re out of time. We’d like to thank our contestants for playing today and have a parting gift for each of them - a home version of our game, along with a beautiful framed photograph of that little thing that hangs down at the back of your throat. Thank you, and good night.

When patients on occasion express dissatisfaction with one of their doctors I listen carefully to the story, striking an avuncular pose worthy of Marcus Welby while silently judging the severity of the transgression being relayed. If the offense turns out to be a mere velleity, or if what we have here is a failure to communicate I do my best to help them “put it all in perspective”, which is just a cheap euphemism for “Look, can we move on here to more important things like how are we going to keep you alive long enough to attend your daughter’s wedding next spring?”

Sometimes though, when patients are truly unhappy with their doctor I will remind them that medicine is more than an art and a science - it is also a consumer product, and its customers are free to change doctors with as much impunity as changing department stores. This makes me look like a real do-I-play-one-on-television-yes-I-do caring guy, and sometimes patients will change physicians. Hey - that’s their right, right?

Right - except when I’m the one being fired. Heaven forbid I would ever find myself on television, sobbing into the silky suit jacket of Dr. Phil while revealing my inability to accept rejection, but perhaps I can confess to you the gentle reader that it drives me nuts when I get fired. I tend to take it personally, and as we all know doctors need to maintain a certain veneer of objectivity in order provide effective care in times of stress, defined as anytime patients aren’t doing well, and if they were doing well they wouldn’t be in your office anyway now would they?

Right. My latest entry into the Chronicles of the Cashiered occurred when I met a hospitalized patient who had been diagnosed with cancer (a recurring theme in my career). I counseled him about his diagnosis, the treatment options available, the course of action I recommended and the overall goal of therapy. I recall he listened rather impassively, but it was not until he saw me next week in the office that I realized he was seething with anger. Like a flag in a hailstorm I had to take a pummeling from him as he barked out his displeasure with me. After muttering Kyrie Eleison (sotto voce of course) for the fourth time I rallied my spirit and asked him what was it I did that caused such consternation. He looked at me like a country parson who just heard his prize Sunday school teacher let loose an unflattering saloon epithet and uttered thusly:

“You told me too much.”

I struggled to maintain composure while digesting this chunk of criticism. If I understood correctly, my sin was not one of omission, where I failed to take the time to thoughtfully explain this serious illness to my patient, but one of comission. I told him too much about his disease. What on earth did he mean? Years of experience wandering in the realm of the upset patient allowed me to come up with a hypothesis: he was trying to tell me that when we met he was not pyschologically ready to accept his diagnosis and all my blabbering about “cancer” did nothing but slice into him with the force of a thousand knives. Such a gruesome attack however can be repelled with a well-documented defense, used by all the popular kings when confronted with a morsel of rancid news, viz. kill the messenger.

Well, I officially considered myself prostrate on the regal carpet in front of a throne, an arrow triumphantly protruding from between the shoulder blades. Where do I go from here? As I mentioned I can’t stand being fired by patients - one time a patient fired me because I was not wearing any socks. Hey, it was Saturday afternoon in July! Just once why can’t the doc with the overheated tootsies keep cool and look fashionably preppy on his weekend rounds? Is all this sacking of physicians just an example of displacement, for Pete’s sake?

As it turns out, this story has a happy ending. This patient returned to my care and is now on appropriate treatment. Our relationship has not only improved, it has become cordial and all efforts are being made to help him strangle foul, cowardly cancer, that slaps one in the face then runs and hides under the bed and begs for mercy.

Mercy? Mercy? As the Immortal Bard said, “Nothing emboldens sin so much as mercy.” My patient is fighting for his life and as far as his cancer is concerned, it can rest assured that it will be greeted with a hail of bullets when the door is kicked in by the special forces platoon.

Oh, and as to how I convinced him to not fire me? I focused all my energy on getting him to focus all his energy not on the despair of today but on his future, which he finally realized was less than rosy unless he got rid of his tumor. This technique is called reorientation - works like a charm, too - when it works. In the meantime I must work on my psychological skills. I know just what to do, too. The next time I have to be the bearer of bad news I will remember to add the following coda when my unfortunate pronouncement “You’ve got cancer” is met with a critical cri de coeur:

“I can help.”

The most amazing thing happened in the office this week. I made one of my unhappy patients happy.

I don’t mean to imply that he was suffering from some politically incorrect disorder such as misogyny, nor do I wish to suggest that, not unlike a large slab of cheese inadvertantly stored in a warm cupboard, he possessed a rather malodorous personality. I’m sure that ordinarily he was brimming with the milk of human kindness , full of Falstaffian mirth, a man with nothing but the deepest appreciation for the circle of life, etc. When I met him, however, not only had his cup not runneth over with love, I had to fight the urge to pull the nearest fire alarm and dive out the window. As I sat across from him and his scowling family never in a million years would I have thought that someday he would look like a happy camper, let alone a happy camper always be. It could not be denied though - within just a week or two of our meeting he now radiated exuberance. Where before he would shuffle in from the waiting room he now practically skipped about, which is not necessarily an unusual sight in a medical oncologist’s office. After all, we strive to include a little merriment in the workday - keeps us from having to constantly wash our tear-stained clothing. My patient therefore now fit right in with myself and the rest of my staff as we let out a ha-ha-ha, ho-ho-ho and a couple of tra-la-las while struggling to keep our patients from becoming the umpteenth addition to the Spoon River Anthology.

Say, did I mention how I released the happiness hidden within this gentleman? As a public service to all those who work with cancer patients I shall be delighted to reveal this trade secret. Before I do though, let us catalog all the possible remedies that the clever reader may be contemplating were used by the calculating author as he contrived to cure the downcast patient:

No, I didn’t soothe him with purring words of empathy. Counseling patients is important but not always effective.

No, I didn’t overwhelm him with reflective listening, even though listening is more important than talking.

No, I didn’t guarantee that his cancer would respond to treatment. No mortal can predict the future let alone figure out why all those Nigerians want to send me money.

No, I didn’t tickle his funny bone with the latest doctor jokes.

What I did was to remember a very important law from a key medical book that every student considering a career in medicine should read. Law number four, to be specific: The patient is the one with the disease.

The patient, sitting before me with the disease, was suffering from two frustrating symptoms: dyspnea and pain that, unknown at the time, were actually the source of his misery. Myself being the person commanded to solve these problems I therefore placed him on appropriate pain medications, arranged to have his large pleural effusion drained and started his chemotherapy. My patient’s cheerfulness had rotted from the effects of his cancer. If I wanted a happy patient I needed to grab a plow and start sowing.

If there is a lesson in this vignette it is that when it comes to helping the sick, all the fancy office furniture, nattily-dressed assistants, self-congratulatory advertisements - all the gum-flapping-hand-holding-soulful-eye-gazing office encounters don’t compare one bit with the doctor who can solve the patient’s problem. As the father of modern medicine, Sir William Osler put it:

“To know just what has to be done, then to do it, comprises the whole philosophy of practical life.”

Most elegantly put - or as my patients say, “You want me to be happy, Doc? Then make me feel better!”

“Rem acu tetigisti.”

I could a tale unfold whose lightest word
Would harrow up thy soul, freeze thy young blood,

-William Shakespeare

The hour was after midnight. I walked into the night to my Ferrari-like roadster parked under the dim lamps in a joyless square of the hospital parking lot, plenty of time on my hands to reflect on what had just happened.

Time I had indeed. Energy and concentration, however, had gurgled down into my shoes, leaving me about as spirited as a Johnny Reb after Pickett’s charge. Any passing motorist would have noticed how my vehicle traveled down the highway with a distinct lack of exuberance; in fact, I wouldn’t have been surprised if I was pulled over for failure to drive with attitude. The road rushed up from the darkness into my headlights as I weaved past silent neighborhoods. Once home, using a unique combination of junk food and cable television I was able to unwind to the point where gentle slumber, with its special offer of sweet dreams (not available in stores), seemed the perfect bargain. I left the world behind as soon as my pompadour hit the pillow.

Unfortunately for me the world resents being left at the altar of consciousness. It likes to torment those who roam the earth, especially roamers in their right minds, unleashing its Pandora’s box of worries about life in the modern age. Even in dreamland it can hunt down the smiling snorer and change reels right in the middle of the show, right at the part where our hero is flying like Superman to the local lottery headquarters to pocket a check of stupifying size. This might explain why I experienced the following dream:

I was out in the desert when I came across a hiker lying under the vicious sun, obviously suffering from its ill effects. I carried him to a building that conveniently morphed into a hospital as I crossed the threshold. The E.R team instantly began to work on the victim, but as they went to put in an I.V. he suddenly sat bolt upright and said, “You can’t give me any intravenous fluids!”

“Because in my religion we don’t accept anything by vein. It is against our belief!” He lay back down again and began to hum the sextet from Lucia de Lammermoor.

Well, the rest of the fantasy is rather fuzzy, but I seem to recall the staff placing the patient in an icy bathtub and feeding him glass after glass of tomato juice. It was at that point that I awoke with a gasp, squinting into the tomb-like darkness at a familiar green dial. The ghostly numbers announced to the world (which, looking for more opportunities for mischief had gleefully returned post-haste from dreamland) that the time was twenty minutes to five. Silence held dominion over all. Not even one soloist from nature’s feathered glee club had left the nest for the morning concert. This of course allowed me to ruminate without distraction - and ruminate I did, ending any last chance for sleep.

The dream had forced me to confront the fact that I had been at the hospital seeing a patient in consultation who was close to exsanguinating after an operation. Blood was the key element that was missing from the patient, and a blood transfusion was exactly what the doctor should have ordered - except he didn’t. Instead he asked for me. Why, you ask?

The patient was a Jehovah’s witness, and accepting blood is considered a sin in this religion.

Thus my nightmare was simply a reflection of the panic I felt just hours ago as I stood over this patient, looking down at his blood-stained bandages. Luckily I wasn’t dreaming at the time and took advantage of this fact to perform a quick check on my senses. Finding them still in my possession I therefore searched for some morsel of information that would inspire my forthcoming recommendations and soon uncovered a clue. The patient had evidence of platelet dysfunction; why, I could not readily ascertain but it made no difference now. I quickly conjured up a dose of desmopressin and sent the order to the pharmacy tout suite.

It turns out that the bleeding did stop, and the patient stabilized, meaning that he no longer induced waves of sweat-soaked terror in his physicians. This is generally considered to be a good start to one’s day, if you know what I mean.

Irony is found all throughout the field of medicine. The wise physician knows when to stop and marvel at it and when to brush it aside like a bullfighter making his way to the ring. When a doctor is consulted to save a bleeding patient but not allowed to use blood as part of the cure, that is ironic. It is so ironic that if the treatment works one might even call it a feat of magic - and as we all know a magic trick that works perfectly one time may flop the next, spilling cards all over the table. Keep this in mind the next time you or your loved one is confronted with a disease grown desperate.

Our sandals stirred up puffs of tan dust as we started on down the dirt road, walking side by side under the blue and white heat of the summer sky. The brush lining our path buzzed with the sounds of ten thousand winged neighbors exchanging the morning news. After a short time we turned left to enter the meadow, wetting our feet with the remnants of last night’s dew. I turned to my friend and smiled. The lemonade sunlight painted our faces while we hiked up the gentle hill.

By the time we finished our lunch the clouds seemed to become firm, like blocks of granite sliding across a great pale dome. The fields were crisper to our touch as we loped up a steep hill and approached a canopy of pine and birch trees. We walked toward the forest, our conversation interrupted by a pocket of cold air that hit us then quickly dissolved. Our shadows turned on and off underneath the columns of clouds marching over us. My only sensation was that of a hand entwined in mine.

The morning’s sweat was long dried when we finally reached the other side of the woods. We stepped carefully over a giant quilt of brown leaves and black branches, filling the hollow silence with the cracks of our footsteps. Beyond the skeletal trees we saw a broad valley. The sky was clear now as we started down the gray path, and the sun hung weakly above the distant hills. I became lost in my own thoughts.

A wall of wind now flung itself across the hillside. My ears were pinched with cold, and I pulled my hat lower. I was very close to the bottom and could hear the river just beyond the next tangled clump of bushes. Suddenly I realized I was alone. I scanned the horizon and saw my friend far above me, standing on a jutting rock. No matter how loud I cried, my voice was just the rustling of leaves. No matter how hard I ran, my feet stayed rooted into the earth. I took one last look at the face in the distance and felt the sobs of time shaking within me, then stretched toward the sky, filled with a mysterious glory of the coming night.