A pleural effusion , fluid trapped between the linings of the lung, had been identified on the CT scan of a 65-year-old man recently diagnosed with lung cancer. ‘Either it’s nothing,’ I told him, ‘an inflammatory response to the biopsy itself, or it’s from the cancer. If the fluid has cancer cells in it, that would change the prognosis.’ Cancer cells in the fluid, a ‘malignant effusion’, would mean the cancer couldn’t be cured. Expected survival time: less than a year. He didn’t speak for a long minute. While I waited, I looked at the patches on his leather bomber jacket. ‘Agent Orange’, one read. Another: ‘Dioxin Kills.’ Another: ‘Combat Veteran’. ‘Where did you get those patches?’ I asked. He stood up, turning around so I could see even more of them. A large round patch covering nearly the entire back of his jacket said ‘Vietnam Veteran’ in gold letters, framing a silhouette of an undivided Vietnam. ‘My son got them on the internet,’ he said. He pointed to one covering his left bicep. ‘What do you think of this one?’
I wasn’t sure it said what I thought it said. ‘What is that?’ I asked.
‘Shit burners,’ he replied.
The patch was three inches by three inches, and showed a stick figure, with a stick figure shovel, poking what appeared to be a broom into a barrel.
‘Out in the jungle you need somebody to burn the shit. Just pour lighter fluid on it and fire it up.’
‘I hadn’t thought about that,’ I said. ‘When was this?’
‘1969, 1970,’ he said. ‘I was the one who did it.’
‘Nobody else wanted to do it?’
‘People didn’t like it.’
‘But you weren’t afraid of it.’
‘Of course not,’ he said. ‘Go out in the jungle with a barrel and a case of beer, smoke weed all day.’
‘And get it done.’
‘It was no problem,’ he said.
Sixty-six is the median age for cancer diagnosis in men. Many of the patients we treat at the Veterans Administration Hospital, or VA, served in the Vietnam War. This man wasn’t unusual in displaying the emblems of his life almost fifty years previously; that time still felt present to many of the men in the clinic. And his view of his current situation wasn’t unusual either: the cancer didn’t appear to upset him. For many of my patients, illness and its treatment – no matter the suffering, anxiety, grief – couldn’t be as difficult as what they’d already survived.
‘Well, now you’re here,’ I said to him. He sat back down, but didn’t speak. ‘We need to get an X-ray. You lie on your side and that way we can see how much fluid is in there. The radiologist can try to tap it with a needle.’
He didn’t say anything.
‘Questions?’ I asked.
He stood up and stuck out his hand. When I took it, he squeezed firmly. ‘Just keep me alive,’ he said. ‘That’s all.’
A 70-year-old man with prostate cancer had previously opted to have a prostatectomy at a non-military hospital. Now, many years later, he was being treated at the VA and he came to me to be considered for radiation treatment of the ‘surgical bed’, which is where the prostate used to rest. His PSA level – the tumour marker in the blood – had indicated a possible recurrence. ‘I saw that you had the operation at a private hospital,’ I said. ‘Why not at the VA?’
‘I wanted to be away from all things military,’ he said. ‘I went to Vietnam October 1967. I stayed for one tour. Then I was home October 1968. I wanted to forget about Vietnam.’ He looked at his wife, who gave him a smile, then he continued: ‘You see some guys going to AmVets meetings or wearing Marine Corps hats.’ Many of the patients wear these hats, sold in the hospital gift shop, which is called the ‘canteen’ like the store at a military base. He shook his head, looked down to his lap. ‘But I didn’t want anything to do with it.’
‘But you’re wearing the hat now,’ I said. He was wearing a blue baseball hat with ‘US Marines’ embroidered in gold over the eagle, globe and anchor insignia.
He thought for a moment, looked to his wife, then back to me. ‘I guess I changed,’ he said. ‘My third day in country I was asked to write a condolence letter. That was my job, to write letters. It was a suicide. He was 21 years old.’ He put a finger on his lower lip, on his magnificent beard, and gave it a rub. ‘In writing to the family, I couldn’t say what the circumstances of the death were.’
‘Did he count as a casualty?’
He looked across the room for a moment. ‘He counted as a casualty.’
I thought about it. ‘Do you think his name is on that black wall in Washington?’
‘His name is on the wall.’ He took a deep breath, exhaled. ‘I checked.’
‘The letter said nothing about the suicide?’
‘Nothing,’ he replied. ‘We weren’t allowed to say that. I wrote, and my commanding officer just signed it. Sign, sign, sign. Thirty-six letters in 13 months.’
‘You must have done other jobs, too,’ I said. ‘You didn’t just write two or three letters a month.’
‘It was an administrative job. But still, I wasn’t ready for it.’ He thought of something. ‘My second day in country, I was brought to a large room. It was where bodies were collected before being sent back home. There were two guys walking around the room, stuffing rags in all the holes.’ He shook his head, put his thumbs inside the shoulder straps of his overalls, looked into his lap. Then he looked up, still shaking his head from side to side. ‘We were 19, 20 years old,’ he said.
A 66-year-old man with long, thin-braided dreadlocks, wearing a forest green nylon tracksuit, had returned for a follow-up appointment. ‘It’s been five years since you were treated for prostate cancer,’ I said.
He looked up. ‘Five years?’
‘Unbelievable,’ he said.
‘You can go. We’ll do the same thing next year – PSA blood test, see you right after.’ I put a hand on the door. ‘Anything else?’
‘What about my PTSD?’ he said. ‘The doctors don’t know how to treat PTSD in older men. There’s no experience. As a younger man, I had my youth to protect me – drinking, to close off your mind, or drugging, out on the streets. But an older man can’t drink so much, he can’t be out drugging. It wasn’t even known, before the Vietnam vets showed up with it.’
‘That’s true,’ I said. ‘It wasn’t recognised.’
‘Where am I supposed to go? My psychiatrist, he’ll put a hand on my arm and say “I know how you feel.” What do you mean you know how I feel? You weren’t even born yet, during Vietnam. How the fuck do you know how I feel? The doctors they got are babies. They don’t know what’s going on. I was illegal in Vietnam: I had my 18th birthday, 10 December 1967, at Khe Sahn, Hill 18.’
‘We’ll see you in a year.’
‘Sometimes these appointments are so far ahead of time, I forget,’ he said.
A 75-year-old man with prostate cancer, after being told what the treatment involved, decided he would go ahead with it. ‘I go to appointments in Behavioural Health,’ he said. ‘This won’t interfere with those appointments?’
I sat in the chair next to him. ‘This department can accommodate,’ I said. ‘Just let the therapists know. They take care of the schedule.’
He looked at his wife, then back to me. ‘Behavioural Health is interesting,’ he said. ‘People ask, “Do you like to kill?” I say, “Who’s asking?” They sent my mom a plaque saying I was dead. That’s how deep I was in the bush.’
A man treated for cancer five years ago had returned for a follow-up visit. Looking at his PSA, I said he could carry on with his life and forget about us for another year.
‘Oh, man!’ he replied. ‘You’ve made me so happy.’ He was thin, and his wide smile expanded his cheeks and face. ‘You see, I deal with a lot of anxiety. I think about the ’Nam every day. My wife says, “Why don’t you think about something else?” My shrink says she needs to understand me. It’s always in the back of my mind.’ He waved his hand in the air behind his head.
Sometimes notes from other clinicians can help us to see a patient more clearly. In the medical chart, I read that this man had talked with his psychiatrist about a long-recurring fear in which he and his sergeant were attacked by US soldiers by mistake. He didn’t want to discuss it, the psychiatrist had written. ‘Loud noises bother him, and he is always checking his back. He goes to group twice a week.’
I clicked on the clinic note from PTSD group therapy. ‘Veteran was extremely tearful at group therapy,’ the note said. ‘He recalled Vietnam and the things he was asked to do there and the people he killed.’
The man picked up a tissue and wiped his face. ‘When I was getting prostate cancer treatment, five years ago, the parking was contentious.’
‘I think the parking is still contentious,’ I said.
‘Back then,’ he said, ‘I just put on my roller blades and I would skate down here, along the path on the river.’
‘It was peaceful. I made it peaceful.’
‘We’ll see you next year.’
A 70-year-old man in the middle of treatment for oropharynx cancer reported some throat pain, which he was controlling with as many as four tabs of oxycodone per day. ‘How does radiation work?’ he asked. ‘You’ve got the pressure gauge connected to the source and you calibrate the radiation based on the reading?’ He was wearing a black T-shirt with a map of Vietnam in the old political geography, the former provinces spelled out and allocated different colours. In the several weeks he’d been under treatment, he talked about the years he spent alone in the woods after returning from Vietnam, eating berries and a deer he killed fresh every week. He lived in a cabin without plumbing or electricity, but had collected, by his count, thousands of books and had educated himself by reading: ‘Especially books on herbal medicine, sustainable agriculture or intercourse.’
‘The radiation source is electronic these days,’ I said.
‘I was an ordnance and supplies officer,’ he said. ‘I guess it’s all declassified now.’ His duties included checking on the safety and efficacy of nuclear weapons. He described missiles with special markings – black crosses on a yellow stripe on their tips – and remembered different-sized shells with distinctive markings.
‘Really?’ I said. ‘Nuclear weapons?’
‘We had to be ready for anything. You got the Chinese to the north, and if they decided they wanted to surround Vietnam, we needed that option so that we could fight our way out – lay waste to everything with one button.’
‘Huh,’ I said. ‘Well – anything else, this week?’
‘I don’t have enough oxycodone,’ he said. Oxycodone carries a high risk of abuse, for which over-prescribing doctors are at least partly responsible. ‘I need extra for a survivalist camp I’m building in the woods.’ In his lap, he held an issue of Bass Angler magazine. Its cover showed a young woman in a bikini holding up a seven-foot fish by its mouth.
‘We can’t give you more right now,’ I said. ‘If your pain during treatment isn’t controlled, that’s one thing. But we can’t supply back inventory for survivalist camps.’
‘All right,’ he said, not upset.
‘Forty years ago in the Orient was when I got turned on to martial arts and holistic medicine. I was in the woods for 28 years. Technology passed me by. Cell phones and computers, I didn’t know. But I’m smart. I worked on laser-guided missile systems. My IQ is 139. I don’t drink hard liquor. I drink light beer and non-alcoholic beer, because my mouth is so dry.’ Head and neck radiation treatment causes dry mouth in many patients. ‘I walked to town the other day and I went into the convenience store. But I got nervous in there. And I’d learned from my reading, just walk out, and next time try to go ten feet in.’
‘So that’s what I did, I just walked right out.’
A man who had been treated for prostate cancer some years ago now had worrying PSA results. The cancer had returned.
‘I’ll have to tell my daughter,’ he said. After a pause, he continued: ‘She said she wants to go to cosmetology school. I tell you, that perturbed me.’
‘Why’s that?’ I said.
‘She knows I want her to go to a real university. That’s what I did. It was a struggle. Why did I do all this stuff so you can go out and do hair? She learned that stuff from her mom. I used to try to tell her mom she don’t know the world the way I know the world. She’s a foreigner – Trinidad. But just as dumb as American girls.’
‘Did you go to college before or after you went to Vietnam?’
‘One and a half years college, then to Vietnam for three tours, then returned to finish college.’
‘That had to be different.’
‘Students, professors – they didn’t know what I knew: flashbacks, sleeping with a knife under my pillow.’ He shook his head. ‘One time, middle of the night, I grab my wife and I rise up and do this –’ He took his arm and swung it up and down in a stabbing motion. ‘She said, “You need help.” I said, “You’re right.” You think something’s wrong with you. But I started to learn what I’d been through. And it’s nothing that’s wrong with us. It’s what happened to us and what we’d been through.’
‘My other daughter, she says she wants to go in the FBI.’
‘And I got a son, he’s in college in Chicago, for engineering.’
‘It’s something, how children can turn out differently.’
‘Different mom. That one, before I go to Vietnam we weren’t sure what was going to happen and I say, “If you mess on me, it’s not going to be good.”’
‘It wasn’t good. After that, I say, “No more American girls.”’
A 64-year-old man with lung cancer had finished treatment three months before. ‘The scans look good,’ the nurse said. She handed me the reports, printed from the computer chart. ‘I didn’t tell him the results.’
In the examination room the man sat in the vinyl lounge chair. He was tall and thin, wearing glasses and a navy blue baseball hat with gold letters spelling out ‘Purple Heart’ in a curved line along the brim. The patch on the front of the hat said ‘Vietnam Veteran’. I asked the man how he was feeling. He smiled and said he felt fine.
‘You had a chest CT scan – did anybody tell you the results?’
He raised his eyebrows.
‘They’re fine,’ I said. He opened his eyes wide. ‘The scans look good.’
‘I was hoping you wouldn’t say something else,’ he said.
‘You’ll get more scans, months from now. There’s still something on them – opacities or grey spots where there’s supposed to be air in the lungs – but a CT scan can’t detect the difference between a persistent tumour and scarring, or an inflammatory reaction in the treated lung, which is a normal response. So how do we tell? We get more scans, over time.’
Lung cancer could come back anywhere, so I examined his whole body. I asked him to follow my finger tracing lines in the air and then felt his neck. Behind and below his left ear, the space felt hollow. ‘Is this new?’ I said. ‘I don’t remember this from before.’
‘That’s my lazy W,’ he said. ‘Shrapnel, from Vietnam.’
‘I’m glad you’re here to tell me.’
‘I wasn’t supposed to go,’ he said. ‘I’m my mother’s only son. I was on a plane to Germany, filled with other guys who weren’t supposed to go. Instead of going to Germany, the plane turned around.’
‘Did that really happen?’ I said. ‘That wasn’t written about.’
‘There were a lot of things weren’t written about Vietnam,’ he said. ‘We killed children. I had to. My buddies exploded in front of me, when they took cookies and Cokes from the children. So we mowed them down, all those children right in front of us.’ He brought his arm in front of him and he traced the line of fire, years and miles away, across the empty space. ‘I felt so bad,’ he said. ‘I had guilt. For years I had guilt. I couldn’t live with myself.’ He looked down, shook his head. Then he looked up. ‘But when I held my first granddaughter in my arms, I thought this is what God wanted for me.’ He held his arms out in front of him, his biceps shaking.
The room was quiet for a moment.
‘Any questions?’ I said.
‘I’m just trying to get this weight back on. I’m down to one-forty-nine. I used to be one-eighty-five.’
‘It’s not a big deal,’ I said. ‘We’ll see you in four months, with a new CT scan.’
He smiled. ‘That sounds good.’
A 65-year-old man, treated for prostate cancer some months earlier, had returned for a follow-up. He mentioned his chronic back pain. ‘I fell off a cliff,’ he said. ‘My backpack broke the fall. The rest of the platoon was still at the top of the cliff. The medic ran down to me, and just as he arrived, I stood up. He said, “If you had stayed down, we would have had to call the helicopter to medevac you out. Now that you stood up, you fucked yourself. Let’s go.” I stayed in the jungle another six months. When I got back, I couldn’t get the VA to agree that this was an injury sustained while I was in the army. My dad was a vet from World War Two and he told me to go to the VA office and tell my story until the VA covered the back injury. After 35 years they agreed.’
‘What happened to the medic?’
‘Jones? I don’t know. I guess he went back to Fresno, California.’
A 71-year-old man, sent to radiation oncology for treatment for advanced lung cancer, was wearing a Vietnam Veteran baseball cap. Different metal pins were stuck around the base of the hat: ‘Marksmanship’, ‘Rescue’. ‘What did you get this one for?’ I asked, pointing to one that said ‘Jungle’.
‘I was 19 years old,’ he said, ‘in training in Panama. They blindfolded me and took me in a helicopter to the middle of the jungle. When they let me out, they gave me a compass, a knife and a chocolate bar. You had to find your way back.’
I shook my head. ‘Wow,’ I said. ‘As you watched the helicopter leave, I wonder if you thought, “I’m 19 years old. Why am I here?”’
He shook his head, didn’t smile. ‘I wanted to do it,’ he said. ‘I didn’t think about anything.’
The nurses, who talk with the patients long before I do, often relay details the patient doesn’t tell us. The nurse told me this man used to have blood in his urine. ‘I don’t think this has anything to do with why he’s here to see us,’ I said to her. But I checked with the patient. Did he see any blood in his urine?
‘Not recently,’ he said.
‘What do you mean?’
‘Not since the 1970s, when I got back from Vietnam. For two years, every time I urinated, it looked like straight blood was coming out. The doctors at the VA in San Diego ran all kinds of tests but they never found anything.’ Then he thought for a minute, before continuing: ‘They said it must have been something I picked up in the jungle.’
‘How long would you go out into the jungle?’ I asked.
‘The whole time,’ he said. ‘Thirteen months.’
‘What about food?’ I asked.
‘We ate what we found out there,’ he said. ‘I was in charge of a group of guys, anywhere between six and thirty men. Our job was to find the enemy.’
‘Did you find the enemy?’
‘Most of the time, no,’ he said. ‘Usually by the time we found their camp, they’d have scattered. So that was something we ate. We’d eat the food they left behind.’
‘And you never spent any time outside the jungle, in a place with showers or phones?’
‘Once a month,’ he said. ‘We’d go back to get our pay. After a day we’d go back out again.’
I hadn’t realised it, but I had been leaning forward in my chair. I sat back. ‘We’re going to get you started in the next few weeks,’ I said. I told him about the treatment programme: daily radiation for six weeks, with chemotherapy once a week. Most patients found swallowing painful during radiation, I said, and most patients became fatigued. Sometimes, the combination of radiation with chemotherapy could lead to more serious problems, such as injury to the heart or lungs; during the course of treatment, some patients would need a hospital admission, for pneumonia, dehydration, sepsis, or some unexpected problem. ‘Rarely,’ I said, ‘complications from treatment can lead to death.’ I paused for a moment. ‘Any questions?’
He shook his head.
I stood up to leave, then I turned back to him. ‘When they dropped you off in Panama,’ I said, ‘after they took off the blindfold, how long did it take you to get back?’
‘Two and a half weeks,’ he said.
‘I think you’re going to get through this.’