Friday, June 20, 2014


Several weeks ago I received an invitation to attend a college graduation ceremony. Over the years there have been a number of these, and many more for high school graduations. I view them as announcements or more likely, solicitations for gifts, usually from children of friends or colleagues. Most often we send something but I cannot recall ever attending one. This invitation however was different, coming from a long standing patient who told me during her last clinic visit, she would be sending it. From her body language I sensed no intention to solicit a gift, but a genuine request that I actually attend. Considering our history and this perception, I assured her I would be there, barring a last minute emergency.

At the time of her visit, attending the event seemed like a nice gesture and unlikely to be much of an inconvenience. When the big day finally did arrive, and the reality of the commitment became clear, I developed a sudden case of the proverbial "cold feet". The ceremony was on Friday at 3:00 PM. With six weeks advance notice, it was easy to adjust the clinic schedule to get off early. This last minute shallow act of obnoxious self interest stemmed  from the fact it was a beautiful late Spring day, cool, and not too breezy. It was perfect afternoon with plenty of time to get on the bike. The ride was important, absolutely necessary to be honest, given that I was going on call for the whole weekend starting at 7:00 PM that very evening.

Our story began in 2002 . These were the days when we, Neurology Associates, alternated "call" on a daily basis. I was on the floor and in the Neuro ICU almost every day, rounding on patients I had initially seen on my day of call. I was generally aware of most of  the other serious cases, at least in the ICU. The graduate was admitted in June of 2002 at age 15 with a progressive paralysis of her arms and legs and a MRI scan showing what appeared to be a very bad spinal cord tumor. I was not her doctor at that point. She was being cared for by one of my partners in conjunction with the neurosurgeons.

I recall seeing the family outside the ICU. They were upset, confused and probably angry with the common "why us" and  "this is so unfair" concerns haunting them. She eventually had a biopsy which was inconclusive and she was subsequently sent to a tertiary care hospital for another opinion. A diagnosis of MS was made, which sounds better than spinal cord cancer, but likely more unsettling, given the severity of the attack and the uncertain future of all patients with MS. She improved somewhat but  remained quite impaired. She went back and forth between Macon and Atlanta. She was placed on immune modulating shots three time per week, standard treatment for the disease. For awhile I did not see her.

A year or so later, when I happened to be on call for emergencies, she developed severe visual problems in both eyes. The type of visual loss was typical of another entity, similar to MS but requiring an all together different treatment, steroids, in conjunction with a medication more commonly used for organ transplantation, and most recently a potent rheumatoid arthritis drug. She has been under my care since then, and has required very close monitoring. For many years, she had a number of set backs, making it more difficult to walk, compounded by the visual (optic nerve inflammation) problems. For the last several years she has done quite well with no setbacks and we have been able to cut back on some of the toxic medications as her mobility has improved.

Over this period she has been able to commute to college here in Macon, from her home town twenty miles away. She does not drive, so college has been a project shared by the entire family. She has a wheel chair but can walk short distances with a cane. She most often comes in with her mom or dad or sister. Over the last decade, I have gotten to know them all well. They couldn't be any nicer.

I made it to the auditorium in plenty of time to see the procession of the graduates into the auditorium and onto the large floor. I first covered the entire building on foot looking for the family, but did not see them. There were twenty rows of approximately thirty graduates per row, which multiplies out to a long time if they were all going to "walk". There were a couple of one minutes speeches and introductions for the two main speakers. One of the main speakers was the highest overall achieving student and the other was a highly recognized educator from out of state. Though I would not have likely driven or paid to hear either one, both were quite good.

After the speeches, the names of all the graduates were called and yes, they were all going to approach the stage, go up a flight of steps and walk thirty or so paces across the stage. Though the audience was instructed not to applaud the individual graduates, because the noise would drown out the subsequent name, almost every student announced, prompted a brief loud round of cheering from an anonymous small pocket, well hidden in the large crowd. I intended to pay very close attention to the noise when my graduate was called, so I could easily find the family after the ceremony and let them know I had come.

With not much to do as the first five hundred plus walked  across the stage, I became a little intrigued on how her situation was going to be handled. She entered the auditorium being pushed in the wheel chair and was planted next to the second to last row. She was forty yards from the stage. When her row came forward, she was pushed along aside the rest. When she made it to the stage I noted for the first time, there was a ramp next to the stairs. She was pushed up the ramp to the presenter on the edge of the stage. When her name was called, she stood up, received the diploma and began the thirty paces across the stage on her own. Immediately her classmates broke protocol and began to cheer. Three steps later the entire auditorium joined in and continued to do so, as she maintained her determined, though somewhat impaired, journey across the stage.

I was sitting alone in the top row where I felt I could more easily spot the family. Though curious I was not at all emotionally involved as the events unfolded. When the cheering started, to my astonishment and without  warning, tears ran down my face at record speed, enough of them for me to appreciate their warmth, a sensation I had never previously noted. While she slowly made her way, I did not move and may have not even taken in a breath, fearing, had I done so, she might fall. Frozen, I made no attempt to wipe the tears as they rolled off my face and onto my blue cotton shirt. When the ceremony concluded five minutes later, I looked down and it appeared I was suffering from a prolactin secreting pituitary tumor causing a bad case of galactorrhea (breast discharge), a not so rare condition I occasionally encounter.

Not being able to spot the family among the crowd  I bolted for the door I recalled seeing her enter prior to the ceremony, accurately assuming, as it turned out, she would leave the same way. No one else was there as she emerged through the doorway and we had a very nice greeting. I took her outside and after a short time we found the huge family gathering of aunts, uncles and cousins. There were many great smiles and hugs, and a number of photos taken of the two of us. The family was so happy, in contrast to a decade ago when I first saw many of them, outside of the ICU, worn down and devastated by the life threatening realities she was then facing. This contrast was profound and somewhat intoxicating in a very pleasant way. As I walked to the car, now only an hour or so before taking the weekend call, too late for a ride, I thought "What a wonderful world it is. "