"The Color of Dust" In 1967 and ''68, in the hills and valleys of Quang Tri Province, US Marines established positions along the demilitarized zone that separated South Vietnam from the communist North. The Marines did not know the terrain--the jungles, ridges, and ravines of the Annamite Range, where a sixty-foot tree canopy and dense undergrowth limited visibility to just a few yards. There, in the far northwestern corner of South Vietnam, the cold, steady monsoon rains, called the crachin, from the French word for "drizzle," continued for months. The land and climate were suited for the ancient military strategy of the Vietnamese, used in turning back the Mongols, the Ming, and the French: violent, close-quarters combat. Hundreds of Marines and thousands of their Vietnamese allies died in month after month of intense fighting. In the Situation Room in the White House basement, President Lyndon Johnson followed the Battle of Khe Sanh on a sand-table model. When the Marines finally withdrew in July 1968, the North Vietnamese, bloodied but still formidable, seized control of the area. Nothing had been achieved.
The medical oncologist at the VA called. "Mr. A is back in the hospital," he said. "They''re calling recurrence, on the brain MRI, in the left temporal lobe, exactly where he was treated with radiation last year." "Not good," I said. "We can see him." I could picture Mr. A in front of me, with his handlebar mustache, its tips twirled into points.
He always wore a white T-shirt, a black leather vest, and an army-green "boonie" hat with the sides turned up to display three small enamel pins: one with the "M.I.A." logo, white letters on a black shield; next to it, the eagle, anchor, and globe insignia of the Marines; and a miniature South Vietnamese flag, with its yellow and red horizontal stripes. He had a welcoming, wide-open grin that he flashed easily and often, and that made him less daunting to talk to, especially in those moments--we''d had many of them--when we discussed matters of life and death. Eight years earlier, he''d been operated on for an early-stage lung cancer. A year after that, he developed an inoperable recurrence, which was treated with radiation combined with chemotherapy. Since then, each of his surveillance CAT scans had looked alike--there was a small chance that he had been cured.
After together reviewing the images from the five-year scan, I walked him and his wife out of the exam room. "We''ll see you next year, with new scans," I said. "I''m blessed," he replied. "Every day." He nodded to his wife, who had continued walking down the hall. That''s when I first noticed the gold chain he wore, with three small gold trinkets. When he saw what I was looking at, he said, "This one''s a bayonet," and he showed me the little figurine. "And this one''s a map of the island of Puerto Rico," he said, turning over a second trinket.
The third piece hanging from the necklace was a three-dimensional representation of the eagle, anchor, and globe. "You have the same pin on your hat," I said. "Marine Corps," he said. "It''s why I got PTSD." After a pause, he continued, "I was nineteen years old, just out of high school. I was bad . baaaad. After my girlfriend broke up with me, I didn''t care about nothing.
" "That''s who they wanted." He nodded. "On the plane over there, we were hugging each other, crying, yelling. We knew we were going to kill or be killed. When it was time to land, the airfield was under attack, and the plane was diverted. That''s when we knew this was a real war going on." "Unbelievable." "Right when the hippies said, ''It ain''t our war,'' and Muhammad Ali said he wasn''t going.
I was only in country a month when a grenade went off in my face. We came upon an NVA camp. The guys were placing satchel charges, to blow it up. I was moving a woodpile, and when I picked up a stack of wood, I heard click." "How many guys were you with?" "Platoon. We got out of there. One guy was giving me a bear hug." He lowered his voice to a whisper.
"I said, ''Motherfucker, don''t give me a hug, let''s get out of here.'' VC was all around. We could hear them. "For the next thirty years, liquor was always on me. I was freebasing cocaine, walking around the house with a machete. ''Get me my rifle,'' I said to her." He motioned to his wife. "We have to go," she said from down the hall.
"What about work?" I said. "Got high on the job," he said. "I worked at a chemical solvents plant." I shook my head. "Now it''s nineteen years clean," he said. "Free of alcohol, drugs, and work." He smiled. "I''m leaving," his wife said.
She was at the door, ready to exit the clinic. He nodded toward her. "She gave me an ultimatum. I went in the psychiatric hospital, got therapy for PTSD. She saved my life two or three times. I couldn''t go to the Wall before that. I saw my cousin''s name on the Wall, broke down crying. Even now, if I get sad, I find a place to be alone in the house to cry.
" He took a breath, gazed past me. Five years previously, he''d been in the radiation oncology department every day for six weeks, receiving radiation treatment for lung cancer. I had not known that a grenade had gone off in his face, or that he''d walked around the house with a machete. "I''m blessed," he said. One morning, six months later, Mr. A woke up with problems finding words. Was it a stroke? His wife took him to the closest hospital--not to the VA, where he''d been treated for cancer--and a brain scan revealed what looked like a brain tumor in the left frontal temporal region, the neuroanatomic area responsible for language. A neurosurgeon removed the tumor, and a week later, the pathology report returned: lung cancer metastasis.
After this type of surgery, the chance that the metastasis will return in the very same area in the brain is at least fifty percent. Cancer care guidelines recommend radiation to the surgical region to reduce that risk to about ten percent. Just after Mr. A was discharged from the hospital, his wife passed away. He skipped his follow-up appointment, and his attendance became unpredictable--consistent with his years-long approach to medical appointments, many of which he missed without explanation. This was not unusual at the VA, where many of the patients led complex lives, or lived in ways accountable to no one, whether by affected pride or bona fide iconoclasm. For the past five or six years, Mr. A had followed medical recommendations most of the time--enough of the time, apparently: he was alive more than five years after a diagnosis of recurrent advanced lung cancer, which fewer than twenty percent of patients survive.
Yet by the time he made it to a rescheduled appointment in the radiation oncology clinic, almost six months had elapsed since the brain operation. Updated scans of his brain and body showed that the tumor had not returned, either in his brain or anywhere else. When I asked him about what had happened--the emergency rush to the other hospital, the urgent operation--he wasn''t sure of the details. In particular, I wanted to know about the radiation--where and when did he receive it? "You would remember it," I said. "It''s usually just one day of radiation treatment, with your head locked into an immobilization device--not like with us years ago, to the chest, daily radiation for six weeks." "I remember that," he said. Although he''d presented with word-finding problems, since the operation and the intervening several months, his language fluency had returned to almost normal. "That''s what I mean.
" He smiled and shook his head. "The brain, I really don''t remember. I wasn''t feeling so well. Then my wife died--she used to take care of all that stuff." When we finally tracked down records from the other hospital, we saw that in fact Mr. A never did receive radiation after the brain operation. It was an example of a common problem, for patients at the VA or any hospital: when the care becomes fragmented, pieced together from too many physicians, too many hospitals, with no synchronization of the overall plan or goal, important parts can be missed. As he''d still not received the recommended treatment, he was referred to the university hospital across the street for a specialized radiation procedure called stereotactic radiosurgery, which was not available at the VA.
"The data to support radiation in this situation say treat within six months," said my colleague who saw Mr. A. "He''s now almost eight months out from surgery. It''s also atypical that he developed brain metastases but no metastases anywhere else, almost five years after his chest was treated. I don''t know if he''d still benefit. Plus, his language fluency has returned to just about baseline. Why put him through the risk? Maybe, this far out, he''s proven he won''t recur." "Maybe he''s in the fifty percent who don''t recur, even without radiation," I said.
"Right," he said. "We could watch it. If it comes back, we could treat it then." It came back three months later. In the left frontal temporal lobes, exactly in the region of surgery, a surveillance MRI showed "enhancing nodules," as the neuroradiologist described them: on the images, white flecks against the gray of the brain, adjacent to the surgical region. "I had hoped we might get lucky," said my colleague from the university hospital. "Still, it''s not so bad. We can treat him now.
" Stereotactic radiosurgery is typically given over just a few hours. Most of that time the patient waits, with his head immobilized to the treatment table, while the treating physicians select the appropriate radiation dose an.