I have played sports throughout my life. Baseball, football, basketball, tennis, soccer, badminton, table tennis, running, cycling and even a short, and impressively painful, stint as a rugby winger.  I would much rather play sports than watch sports.  My wife may refute the last comment when she finds I’m watching an American, English Premier League, Spanish La Liga, or Italian Serie A soccer match, or when watching my beloved ESPN top 10 plays from the day before.  Overall, however, I am more of a participant than a spectator.

Coaches are important individuals in the life of any athlete. Ideally, they should be good role models teaching the fundamentals and advanced skills necessary to be a successful participant in any given sport, while emphasizing sportsmanship, fair play, and maximizing the athlete’s physical and mental preparation.  Coaches are larger than life to many young athletes, and often have a profound impact on their charges, sometimes positive and sometimes negative.  I vividly remember all of the coaches who I played for throughout my life, and many of them were loud, profane, almost cartoonish caricatures of a guy wearing a whistle around his neck, commanding and wheedling his players to work harder.  I say his because I’ve never had the good fortune of playing for a female coach.  I am happy and encouraged to see more women coaching from the youth level to college, and in some sports, at the professional level.

Coaches are people who should mentor, teach, encourage, cajole, and inspire the athletes playing for them. I recall fondly several of the coaches I had over the course of my life, and they are people I still admire, respect, and emulate to this day.  Conversely, I also remember the negative experiences of those who were verbally abusive or who denigrated, humiliated, or demeaned the efforts of their players.  These are individuals I do not respect, but I did learn from the negative examples they represented, and I always strive to demonstrate the polar opposite of their bad behavior.

I have a patient who epitomizes the positive values of a coach. He is colorful, articulate, bombastic, energetic, excitable, enthusiastic, encouraging, and inspirational.  He is an assistant football coach and head track and field coach at a moderate-sized high school in a large city in the Southern United States.  He always has a twinkle in his eyes and one corner of his mouth tends to turn upward in a sly grin like he knows he’s about to spring a practical joke on you.

I first met the coach more than a decade ago. I’ll provide a spoiler alert by telling you he is still alive as I write this piece.  However, it’s been a long, painful, and dramatic journey in his personal battle with cancer requiring multiple surgical procedures, a variety of chemotherapy cocktails, and radiation therapy.  I have personally operated on him five times, and he has undergone two additional operations in his home city for acute problems requiring urgent surgery not allowing him to travel to see me.

The first operation I performed on him was a right hemi-colectomy, meaning I removed the right side of his colon (large intestine) and reattached the small intestine to the transverse colon. This operation was for a colon cancer causing pain and bleeding.  It was clear at the time of the operation the cancer had spread to lymph nodes near the tumor and all of these nodes were removed as a standard part of the operation.  Once the patient recovered from this operation, he received six months of adjuvant chemotherapy.  At a clinic visit with me three months into his adjuvant chemotherapy treatments, he matter-of-factly stated in his slow Southern draw, “I hate these poisons, Doc.”

I understand the sentiment. Nobody is excited about the prospect of receiving cytotoxic drugs to kill cancer cells present in their body.  Temporary or permanent side effects from damage or destruction of normal cells is an inevitable consequence of these treatments.  Disregarding the side effects, the coach never missed a beat and continued to prowl the sidelines during football season and the infield during track and field season.  His wife told me despite the fatigue and the loss of sensation in his hands and feet during chemotherapy, he remained effervescent and positive as he encouraged his students.

Things were going great for twenty months after he completed chemotherapy. I was seeing him every four months and checking blood tests and CT scans.  The twenty-month mark was not a happy visit because his serum tumor marker test, CEA, was elevated and his CT scan showed two liver metastases in the right liver not present on the scan just four months earlier.  I walked into the exam room and he immediately knew something was awry.  He let out a protracted sigh, glanced at his wife, and said, ”Go ahead, Doc, lay it on me.”

So I did. I laid out the results calmly, answering questions from the coach and his wife during the conversation.  I showed him CT images of the two tumors in his liver and we discussed options.  The first option I mentioned was surgical removal of the liver tumors, and as soon as I moved to option two discussing additional chemotherapy he waved his hands and proclaimed, “Stop! Stop! Stop!  We aren’t talking more chemotherapy here, Doc.  Cut those things out of me.”  Fair enough.  For completeness sake, I managed to sneak in a few comments regarding chemotherapy, but I appreciated he was not interested in hearing it.  I knew we could rejoin the dialogue about more chemotherapy later if needed.  Instead, we spent twenty minutes discussing the details of a right liver resection, including the downtime while he recovered, and the fatigue he would experience during rapid regeneration of his liver.  He mock glared at me and chirped, “You know you’re messing with my football season, right?”

A week later, I performed a routine right hepatectomy on the coach. The operation went flawlessly.  He was up speed walking in the halls the next day, and by day four demanded to be released from the hospital.  He was eating a normal diet (normal for the coach since I caught him with a contraband double cheeseburger and French fries sneaked in by his wife) so I had no reason to keep him in the hospital.  I saw him in the office two days later.  He was healing well and he planned to return home the same day.  I admonished him to take it easy for a few weeks and allow himself time to heal.  He shot me a look I interpreted as, “Sure Doc, whatever you say,” and headed out for his drive home.  My suspicions about his compliance with physician’s instructions was confirmed the following week when his wife sent me an email including several pictures of the coach prowling the sideline during the Saturday night football game a few days after I had seen him in the office.

Well then, so much for doctor’s orders.

Despite himself, the coach recovered uneventfully and did well for another year. As the next football season approached, I saw him in clinic for a scheduled visit.  To my considerable disappointment, I was forced to walk in and inform him and his wife he had two new tumors in the enlarged (hypertrophied) left lobe of his liver.  I have never witnessed a more pure expression of exasperation on another humans face.  He kept quickly turning his face from me to his wife and back again until he finally exclaimed, “Well, what are you going to do about it?”

Before I could answer his question he held up his hand like a traffic cop telling an automobile driver to stop and stated emphatically, “Skip the chemotherapy talk, can you take them out?” The two tumors were near the lower edge of the left lobe of the liver, so I responded in the affirmative.  It was possible to remove these two tumors with wedge resections.  His response was immediate, “All I need to hear.  Let’s do this thing.”

So we did. The next week I performed an operation made slightly more difficulty by dense adhesions, or intra-abdominal scar tissue, of his left liver to the abdominal wall and diaphragm, but I successfully removed the two small tumors.  An intraoperative ultrasound examination of the liver failed to show any additional tumors.  Per his usual post-operative routine, he was up doing laps the night of surgery and was out of the hospital three days after the procedure.  I mentioned a few days later at our first post-operative visit he should refrain from full-time coaching duties and, expectedly, he rolled his eyes and stated, “Yeah, right.”  I had to try.

Another football season was completed. and when I saw him in the winter before track season started, his CT scan revealed a new liver tumor, and also a single right lower lung nodule. This was a relatively rapid recurrence of his malignant disease, so I forced him to sit through a discussion of options, including chemotherapy.  To both the coach’s and my surprise, his wife spoke up and remarked calmly, “You know, you really should consider some chemotherapy.  This stuff just keeps coming back.”  The look of extreme exasperation returned, but fortunately, this time was directed at his wife.  A remarkable staccato conversation took place going something like this (I am paraphrasing because I was laughing too hard to remember it word for word).

“Woman, are you trying to poison me?”

The wife, “No, but you are being a stubborn mule!”

The coach, “You know I have no time for this chemotherapy crap and feeling down! If I’m a mule, I’ll be doing some kicking!”

The wife, “Don’t lay any of your whining on me man. Man up and take it! And if there’s any kicking, somebody may lose some balls!” (Figuratively or literally? This was not specified).

The coach (looking at me), “Doc, are you hearing this? Did you put her up to this?”

I managed to regain my composure and a modicum of professional demeanor, and informed the patient I had not previously conversed or conspired with his wife against him. The surgical fellow and medical student who accompanied me into the patient’s exam room stood by with stunned expressions on their faces.  They weren’t sure what to make of this couple or my interaction with them.  They did not know them as I did.  This couple had been married for over 30 years and had a wonderful bond and harmony.  Despite the bad news I had delivered, both the patient and his wife were hopeful.  We had a calm and rational discussion of options and the patient agreed to see his medical oncologist at home and initiate systemic chemotherapy.

I called the medical oncologist and explained the situation and we agreed the patient was in excellent shape, active, and would be a candidate for second line chemotherapy used to treat patients with metastatic colorectal cancer. The patient initiated treatment the next week.  He returned in three months and the liver tumor and lung tumor were both smaller by approximately one third.

When I walked into the room to discuss the findings with him, for the first time in our relationship he looked haggard and beaten down. He shook his head from side to side and told me, “Doc, this stuff is wearing me out.”  I get it.  His mood brightened when I told him the tumors were smaller and no new tumors had appeared.  As usual with this patient, before I could finish discussing all the results, he started asking when I was going to schedule an operation.  He had already undergone three cancer operations and I knew he had significant adhesions in his abdominal cavity from previous surgery.  Nonetheless, he had two tumors in locations where surgical resection was feasible.  I let him recover from the effects of chemotherapy for another month and then performed a somewhat unusual operation.  I made an incision at the site of the scar under the ribs on his abdomen, and after entering the peritoneal cavity I began to dissect through the heavy scar tissue.  After about an hour of work his liver was completely exposed.  I performed a standard intraoperative liver ultrasound and confirmed I could detect only a solitary tumor at the top of the left lobe.  Once again, it was possible to perform a wedge resection to remove this tumor and take only a small amount of normal liver.  Then I did something unusual.  I had discussed this with my thoracic surgical oncology associates before the operation, and they agreed, while unorthodox, opening the right side of his diaphragm and removing the small tumor at the surface of the right lower lobe of the lung would spare him a chest incision.  Opening the muscle of the right diaphragm readily exposed the lung tumor, which was removed without difficulty.  We left a temporary chest tube in to make sure there was no air leak from the lung and to drain any fluid accumulating in the right chest cavity.

The patient was a little slower to recover after this fourth round of surgery. The chemotherapy had weakened him yet he was walking as usual on day one, but at a slow and measured pace.  Nonetheless, he was out of the hospital four days after the operation.  At his first clinic visit, I felt compelled to discuss completing another three months of chemotherapy, knowing he would have no interest in complying with the suggestion.  The mere mention of chemotherapy earned me a third look of exasperation from the patient, and plenty of eye rolling from his wife who said, “Good luck convincing him to do that.”

So we returned to a follow up routine. Six months later I received a call from a surgeon in his home city who informed me the patient had come in to the hospital with a complete small bowel obstruction.  The patient had a fever, severe abdominal pain, vomiting, and an elevated serum white blood cell count, so the surgeon appropriately took him to the operating room and found a short segment of small bowel was twisted, cutting off its blood supply.  The surgeon removed this section of nonviable small intestine and anastomosed, or reconnected, the two ends of small bowel.

Fortunately, we had a period of over two years before lurking cancer cells reappeared in lymph nodes along his aorta. I found out about this during a follow up visit when the patient mentioned his medical oncologist had noted his serum CEA level was elevated and had obtained a PET scan.  This scan showed three lymph nodes near his aorta were highly active, suggesting they contained malignant cells.  The medical oncologist then treated this area with a combination of low dose chemotherapy and radiation therapy.  In checking the CT scan we obtained, I could see one enlarged lymph node.  It was not clear if this still harbored cancer cells because his CEA blood test was normal, so we opted to watch.  A few months later his medical oncologist called me and asked if I would consider removing the one lymph node because it was still active on a repeat PET scan and had increased in size.  Surgical removal or para-aortic lymph nodes for colorectal cancer is an unusual approach, but this man had already survived many years with stage IV disease, and the solitary lymph node was the only evident site of active cancer.  The patient and his wife returned and we discussed a surgical approach.  In his usual glib and cavalier style, he instructed me to proceed at flank speed.

A couple of weeks later I performed an operation that was as difficult as I anticipated because of dense scar tissue throughout the belly cavity. Once I moved all of the small intestine out of the way, it was possible to palpate the abnormal lymph node easily.  I removed the enlarged, cancer-bearing lymph node and several lymph nodes in the area.  It turned out to be a good decision because one of the lymph nodes adjacent to the obviously abnormal lymph node bore a microscopic nest of viable cancer cells.  This operation took almost four hours to complete because of the extensive adhesions.  As a result, for the first time the coach was in the hospital for a full week recovering from the slow return of normal contractions and activity of his bowel.

I didn’t even bother discussing chemotherapy with the patient during his hospitalization knowing his opposition. His medical oncologist adopted the same approach.  The coach and I agreed to a follow up visit three months after his latest operation.

Two months after his operation, I received an unexpected call from the coach. He called my secretary who paged me and asked me to call my patient, “urgently.”  Anxiously, I called his cell phone fearing I was going to hear his cancer had recurred yet again.  When he answered, he said brightly, “Hey Doc! What are you doing and where are you?”  This may seem to be a peculiar personal question, but not from this patient.  I explained I was just completing inpatient rounds and he said, “Well come on down to the lobby, I want you to meet some people.”  Stammering, I asked dumbly if he was in the building, and he laughed and said, “Duh!”  Asking a stupid question, I deserved a “Duh” as a result.

I took the elevator down to the lobby where my grinning patient was surrounded by a flock of about two-dozen high school students. He explained he was teaching a health class at his high school and wanted to impress upon his students the importance of cancer prevention and proper screening for early detection.  He decided to load them onto a school bus and take a road trip to a cancer center.  No forewarning for me or anybody else, just a spontaneous “Let’s get it done” approach by the coach.  He asked if I could spend a few minutes talking to his students.  I winked at him and replied, “I can do better than that.”

I spent the next two hours escorting the coach and his students to various areas of the hospital and asking surprised colleagues to explain briefly a bit about what they did in the care and diagnosis of cancer patients. We visited my laboratory and my colleagues showed them some of the interesting research tools we use to study malignant disease. As I escorted the coach and his gaggle of students to the lobby he turned to me beaming and gave me a hug and a kiss on the cheek.  The students began laughing and informed me he had a habit of doing that at the school, too.

The surgical adventures of the coach were not finished. A little over a year after the surprise high school student visit, he had a new liver tumor appear on CT scan located deep in the remaining lobe of his liver.  This time I knew I couldn’t remove it and leave him with a volume of liver adequate to survive.  However, radiofrequency ablation to destroy the tumor with heat was feasible.  The tumor was near a large blood vessel, the left hepatic vein, draining blood out of the remaining left liver.  It was also close enough to the diaphragm my radiology colleagues and I felt it would not be safe to place the needle through the skin using ultrasound or CT guidance.  So a surgical approach was indicated.  I performed this operation, and after a grueling two hours of dissecting his liver millimeter by millimeter free from scar tissue I was able to locate the two centimeter diameter liver tumor with ultrasonography. I treated it with a radiofrequency needle, destroying it completely.

Four months after this fifth cancer operation, the same surgeon in the patient’s home town called to inform me he had once again performed a long and difficult operation for a bowel obstruction on the coach. Surgical procedures do not come without immediate, acute, or long-term risks.  This time the surgeon did not remove any small intestine; the obstruction was caused by a hair pin kink in the bowel where it was stuck to the retroperitoneum.

Cancer is an unpredictable opponent. The coach has been treated with most of the types of therapy we use to manage cancer in our patients.  He has never regained normal sensation in his hands or feet as a result of toxicity from some of his chemotherapy treatments.  Despite the pain of recovering from numerous operations, the side effects of chemotherapy, and the chronic diarrhea and discomfort he developed after radiation therapy, the coach is cheerful and still leads his teams on the field.  His wife has told me in sidebar conversations he is beloved by the students, teachers, and administrators at his school.  He is a constant source of inspiration and positive energy.  When I saw the coach a few months ago for a routine follow up visit, I was pleased to inform him no evidence of cancer was found based on his imaging studies or blood tests.  He nodded, and in a moment of reflection calmly stated, “You know, Doc, this cancer thing has been a long, tough game.  The outcome is still uncertain.  But one thing is clear.  Nobody can say you and I didn’t play our hearts out.  We left it all on the field.”

I don’t recall ever hearing a more eloquent or meaningful statement. The coach is a testament to indefatigable human spirit, optimism, hope, and grit.  He is a shining example of all a coach, and a great human being, should be.