After a snowboarding accident left me with a shattered leg, the ensuing three months of confinement and immobility finally came to an end. My knee had healed remarkably well. What a thrill it was to simply walk around my house, up the stairs and down the stairs and through the door to the outside world! When I started hiking again in the mountains, I assumed that this challenging chapter in my life had ended and that I would resume the life I had known before the accident. I had no idea that a time bomb ticked away inside my knee.

One day in the fall of 2007, nine months after the surgery, I noticed some little red papules throughout my body, as though I had the measles. The rash looked like those that occur sometimes after viral infections, especially in young children.

I was not aware of having had any kind of infection in the past few months. In fact, I rarely got infections. The inevitable stream of bacteria and viruses that have doused me in my medical practice over the years have served to keep my immune system actively producing plenty of antibodies to fight off innumerable pathogens.

In a few days, the diffuse rash morphed into lesions resembling something called guttate psoriasis. “Guttate” is a Latin word that means teardrop. The affected patches of skin consisted of individual red, scaly lesions in the shape of teardrops. The lesions covered my arms, legs and torso. I felt like a leper as I stared with both fascination and horror at my naked body in the mirror.

I watched helplessly as the lesions progressed into what clearly looked like psoriasis—an autoimmune disease.

Using my skills as a medical detective, I reviewed in my mind all the possible causes of autoimmune diseases, one of which is heavy metals. The metal plate in my leg immediately came to mind. I needed to determine what metal the orthopedic surgeon had screwed into my leg.

The man who had so skillfully repaired my shattered leg had a good reputation for his excellent surgical repairs. I had referred dozens of patients to him over the years, all with good outcomes. The follow-up appointment with him was both helpful and disappointing. He revealed that the plate in my leg was stainless steel, a material that was being phased out for implants because of the potential to cause serious immune reactions. Titanium, known to be more inert, has since replaced the stainless steel hardware.

Stainless steel is an alloy composed of several different metals, one of which is nickel. Nickel makes up about 10% of the surgical steel.

Nickel is a heavy metal that causes pathological immune reactions in approximately 15% of the population. When I questioned the surgeon why he used stainless steel, he said that there was no titanium on hand at the time of my surgery.

Although I knew that my immune system tended to be overly reactive to many foreign substances that didn’t belong in my body—the result of prolonged exposure to toxic chemicals while working in a medical clinic in the early 1990s—the thought never occurred to me to question the materials that would be used in my leg before the surgery.  Both the excruciating pain, along with the pain medications, had clouded my thinking and prevented me from being my own advocate.

During my appointment with the orthopedist, I took off my clothes down to my underwear and asked him to look at the unsightly lesions that covered my body, questioning him if he had ever seen anything like this in his practice as a result of stainless steel implants. He glanced briefly at my body and then looked away. He assured me that he had never seen such a condition before. He spoke adamantly that the psoriasis had nothing to do with the metal plate in my leg.

I asked if it was possible to remove the plate since the leg had healed so well and no longer needed the plate to hold the bone fragments in place. He strongly advised me to leave the plate in place and repeated with utmost certainty that the psoriasis had nothing to do with the stainless steel plate.

At that moment, I realized that of course the surgeon had never seen a condition like mine related to stainless steel. Unless the patients had done a lot of research on their own, how would they ever make the connection between the metal in their bodies and their autoimmune diseases?

Since only a handful of doctors in the US have training in environmental medicine, I wondered why I even bothered to ask the orthopedist if there was a relationship between nickel and autoimmune disease. And why ask when I already knew the answer? The role of heavy metals in causing disease is basic knowledge in the field of environmental medicine—the kind of medicine that I specialize in, along with general family practice.

Discouraged, I returned home and made a plan for myself that included an anti-inflammatory diet and supplements, lots of sun exposure on my bare skin, and Epsom salt baths to mitigate the effects of the psoriasis.

I wore long-sleeved clothing when I saw patients to avoid frightening them with the scary-looking lesions. Fortunately, my face, hands and feet were spared the psoriatic sores.

After about six months of enduring these plague-like lesions, the psoriasis gradually began to fade and eventually disappeared entirely—to my great relief. I assumed my body had adapted at last and had made peace with the stainless steel. The reprieve was short-lived.

Something Brewing

In early 2008, one year after the snowboarding accident, I began to feel a vague, nonspecific malaise and persistent fatigue. Occasionally my heart burst into a rapid beat, accompanied by an irregular rhythm, known as atrial fibrillation. At times I felt sweaty, as though I had a low-grade fever. These episodes lasted for only a few minutes and occurred infrequently, yet a nagging fear crept up my spine as though something serious was brewing. Nothing abnormal showed up on standard blood tests, as I might have predicted. Nor did environmental testing of my house provide any clues that could shed light on my symptoms.

The months passed while my fluctuating symptoms remained the same. Thoughts of the stainless steel plate in my leg returned to the forefront of my consciousness. I wondered if the malaise I felt was related to yet another autoimmune reaction to the nickel. I began my search for a test that could determine if that was the case.

The Melisa test appeared to be what I was looking for. Melisa stands for Memory Lymphocyte Immunostimulation Assay. The lymphocytes are a branch of the white blood cells that make antibodies, whether it’s to foreign invaders like bacteria or viruses, or, when gone awry, to one’s own self.

The procedure for testing involves putting drops of the patient’s blood into individual test tubes that contain a small amount of the substance in question. For testing surgical steel, one tube contains chromium, another molybdenum, and the last contains nickel, all components of stainless steel. The lab tech mixes the blood with the metal in each tube and incubates the mixture for five days.

After the incubation period, the lymphocyte reaction is measured by how active the lymphocytes are and how quickly they are multiplying which would, in turn, determine the level of reactivity to the metal and the amount antibody formation in the patient’s blood.

In my search for a place to get the Melisa testing done, I learned that there were no labs in the US at that time that did this kind of testing for metal hypersensitivity. The labs were located in Europe. I contacted a lab in Germany and got instructions about how to ship my blood overnight to their lab. But it wasn’t until several weeks had passed that I was able to get my blood drawn and send it for testing.

Around the time of my search for answers, summer was approaching, along with my 60^th birthday in June. My friend Lenya Reese—the same friend who had been on the mountain waiting to meet up with me when I had the snowboarding accident—invited me to accompany her and some of her rafting buddies on an eight day raft trip through the wilderness and red rock canyons on the San Juan River in southeastern Utah. She thought it would be a fun way to celebrate my birthday and welcome in the next decade of my life. I gratefully accepted. But, at the same time, I noticed that my response to the invitation was not as enthusiastic as was typical of me when it came to adventures in the wilderness.

The River 

As the day of our trip approached, I felt increasingly more fatigued and dragged my feet with the preparations. Typically, the anticipatory excitement propels me to get organized weeks before leaving on a trip. This time I waited until the day before the trip to get my gear organized. On the day of departure, I felt so exhausted that I thought about canceling, but the image of being on the river in the wilderness in canyon country kept me going.

Our rafting group camped at Sand Island campground outside Bluff, Utah. We put our boats into the water the following morning. We planned to raft a stretch of the lower San Juan River and end up eight days later near Mexican Hat, Utah. From the take-out point at the end of our trip at Clay Hills, the San Juan River continues on to Arizona where it ultimately drains into the Colorado River.

The first day on the river, my energy returned enough for me to feel dumbstruck exhilaration at being surrounded by the beauty and wildness of this primordial and magical world. The vastness of geologic time spread before us, manifested in the stark red-colored sedimentary rock towers sculpted into a multitude of arresting shapes, overlying strata of igneous and metamorphic base. The farther the river cut through the canyon, the more ancient the rock formations became, with the rim of the canyon towering higher and higher above us. My little red inflatable kayak looked like an insignificant pixel in this grand and timeless sweep of land.

Sparse desert vegetation dotted the arid landscape. Tiny clusters of colorful flowers stood out like precious gems, including the brilliant red scarlet trumpet, the faded yellow flowers of the snakeweed plants, and the stark white of bulbous flowers hanging from the prehistoric looking yucca plants.

The mighty desert river snaked through the canyon with an ever-changing mood—sometimes serene and gentle, other times raging and roaring. Most of the time the river was an opaque, brownish muddy color from the churning of the current, but it could also be a bluish green color with slight translucence.

By the second day, my energy began to plummet, accompanied by feelings of being extremely overheated. I noticed that the seven other people on the trip were not complaining of the heat and appeared to be quite comfortable. At every opportunity I jumped into the water to cool off and I kept my cotton T-shirt damp at all times while we were on the river. When we beached our rafts and kayaks to break for lunch or for hiking up side canyons, I hunted for shade, and if there was none, I kept submerged in the water along the embankment. Fortunately, the nights were cool, sometimes even chilly.

By Day Three I noticed that my heart pounded, making me aware of each forceful contraction. In fact, I could watch the rise and fall of my heart beating under my T-shirt when I lay down. I assumed that I had become sensitized to the heat for some reason and that my heart was beating forcefully in order to cool me down. That night in my tent, I lay awake all night unable to sleep from the pounding of my heart. Meditation and deep slow breathing were of no help. Feelings of foreboding crept into my consciousness.

On Day Four my heart started to race. Normally, as an athlete, my heart rate remained around 50 or 60 beats per minute and my blood pressure averaged 90/60. But now my heart beat in the high 80’s and episodically reached 100 beats per minute. I spoke to my friend, Lenya, also a healthcare provider like me, and discussed my symptoms with her. Our presumptive diagnosis was heat stroke. We decided to treat it symptomatically by doing everything possible under the current circumstances to keep cool. She invited me to travel in her raft as a non-paddling passenger so I could rest. My empty little kayak, tied to the back of Lenya’s raft, bounced around in the currents.

Another night of sleeplessness followed.

Day Five arrived, accompanied by a tremendous pressure in my head which felt like my head was going to explode from what I presumed was dangerously elevated blood pressure, while, at the same time, my heart beat erratically.

Only Lenya knew of my symptoms because I didn’t want to frighten the rest of the rafters, especially since there was nothing that could be done for me and no way for me to be evacuated. Given the 2,000 ft. cliffs on each side of us, there was no way to make radio contact. And even if we were able to go straight through to the take-out point at Clay Hills in one long push, there would be no one there to pick us up in that remote part of the wilderness, far from paved roads with traffic. Our pick-up person was not scheduled to be at Clay Hills until day eight.

Yet another frightening and sleepless night.

On Day Six, the symptoms were so severe that I realized I was going to die—right there on the San Juan River—from either a hemorrhagic stroke or a heart attack. I spent much of the day making peace with this idea. At every stopping point, while the others went on little hikes up side canyons to see petroglyphs or explore for Anasazi ruins, I went off by myself and lay on the ground to communicate with the Great Spirit.

I remembered a saying that I had heard, “There are no atheists in the trenches,” and I could attest to that assertion.

I reminded myself that life was a terminal condition and, if I had to die now, how fortunate to die in this magnificent setting in the wilderness.

I reviewed my life and felt good that I had led a life that was fully engaged and authentic, deeply meaningful, and guided by the heart. I was passionately in love with life. Now it was time to let go.

My son, Barrett, was wise and compassionate and had all the inner resources he needed to thrive, I told myself. My patients knew how to do a good job taking care of themselves and had learned many of the skills they needed to figure out what was wrong with them…as well as what was right. They would be just fine without me.

I had no unfinished business. I was ready to let go. I hoped the passing would be quick and not drag out into prolonged suffering.