"Big deep breath...in through your nose, out through your mouth."
Today's gonna be a good day. It's Friday!!!! Our first case is a "double dip," an EGD--short for esophagogastroduodenoscopy, an endoscopic exam of the esophagus, stomach, and first segment of small intestine--and colonoscopy combo, evaluating a chief complaint of abdominal pain and rectal bleeding. No big whoop. The patient's a healthy 51 year old female; no medications, no allergies, no medical problems, just a little rectal bleeding noted after the endometrial ablation she underwent two weeks ago to alleviate her heavy menstrual periods. "After the surgery, I couldn't 'go,' so I inserted half of a glycerin suppository, and that's when I noticed I was bleeding from my rectum. Maybe I tore a little hemorrhoid?" Sounds reasonable, especially since she's so thin, healthy, and asymptomatic. Aside from having a maternal grandmother who died from colorectal cancer, there's nothing too remarkable in her history. This'll be a piece of cake.
"Big deep breath. You'll start feeling really sleepy in just a few seconds. You're gonna feel that oxygen blowing in your nose a little harder as you're drifting off to sleep, OK? See you when you wake up."
It's 7:40 a.m., but here in the GI suite, the propofol is already flowing as freely as cheap wine at a house party. After only 80 milligrams of this wondrous milk of anesthesia, my patient's snoring like a true champ. "Wow, she's a lightweight! This case is gonna be a cinch." The scope goes in at 7:41 and comes back out two minutes later. "Her EGD's normal," says my gastroenterologist colleague, Dr. Selleck*, as the procedure nurse and I spin the stretcher around in the opposite direction for the colonoscopy. Everyone in Room One's in a good mood, chatting excitedly about our weekend plans...did I mention it's Friday? We get our patient positioned, and I push a little more propofol as Dr. Selleck performs a standard pre-colonoscopy rectal exam.
"Oh, FUCK!," he blurts out, his tone unexpectedly grave and serious. "Something's not right. She's got a mass in here." Praying it's only a thrombosed internal hemorrhoid, we all watch silently as he passes the scope a few millimeters into our unconscious patient's anus, collectively groaning, "Oh no..." as the olive-sized, ulcerated tumor comes into view. "It's cancer," he says quietly, his voice heavy with compassionate despair, "and it's a bad one." I deepen the anesthetic, and we proceed with the remainder of the exam.
Because the tumor is situated so close to her anal sphincter, it can't simply be cut out without affecting continence. "Depending on whether this is squamous cell or adenocarcinoma, she might be looking at a permanent colostomy," he remarks as he takes a few endoscopic biopsies of the now bleeding tumor. "She reported having rectal pain, which is indicative of a more invasive and very likely unresectable tumor. She'll need a rectal ultrasound and CT scans for staging, and we'll go from there." I felt myself starting to become a little undone: "A permanent shit bag? Are you kidding? She's only 51! Jesus Christ! I'm not sure I'd even want to live with an irreversible colostomy." The procedure nurse, a 31 year old woman, nodded in agreement. "Well," Dr. Selleck said, "at least you'd still be alive."
"Hey there, you're just waking up. Big deep breaths for me. We're going to recovery now, and when you're awake, Dr. Selleck will come talk to you about your results."
Mercifully, the propofol sedation lingered long enough to allow for a peacefully sleeping patient with a no-questions-asked transfer to recovery. I don't think I could have handled it if she'd been awake. People waking up after their procedures always want a confirmation that everything went all right. I was exceedingly thankful that it wasn't me having to deliver such devastating news, especially because I'd already determined that if it were me and I was looking at forty-plus years with a permanent colostomy, I'd probably let the cancer metastasize and die in hospice.
Just a couple of nights ago, I awoke from a terrible nightmare. It was Thanksgiving, and I was sitting at a long dinner table in the house of someone I barely knew, a conservative woman who appeared to be very wealthy and kept talking incessantly about Jesus. I didn't know anyone else at the table, but they all looked uptight. No one was having any fun. I felt a sense of awkward discomfort, like I was in the wrong place at the wrong time, and I didn't know how I'd gotten there. I ate what was offered, but otherwise kept my mouth shut. Looking across the dining room into the foyer, I could see a bunch of twenty-somethings dressed in garish Halloween costumes clamoring down a large staircase, prompting the hostess to get up and investigate the commotion. Somehow, I knew that they were renting rooms upstairs. That's when I saw Pocahontas and a big fuzzy bumblebee pointing their shotguns, and I knew we were all going to be robbed. There was no time to escape, and that's when I awoke.
What's it like to wake up as your normal self one morning, only to be informed a few hours later that your days are numbered by a disease, that your body's been invaded by a cancer that will probably leave you disfigured? Although our patient took the news pretty well, her husband was visibly shaken. Instead of heading home with his wife after her uneventful colonoscopy, he was accompanying a newly diagnosed cancer patient to the hospital for CT scans of the abdomen, pelvis, and chest to see if the tumor had already spread to other parts of her outwardly perfect body. Interestingly, the patient disclosed that she'd suspected it might be a cancer. Perhaps her calm demeanor wasn't from the propofol after all; evidently, she'd been discreetly preparing herself for the worst possible scenario.
I've had a really hard time shaking yesterday's disturbia. I'm turning 50 in a few days, a birthday which nowadays means, "Congratulations! It's time for your screening colonoscopy!" I'm relatively certain that mine isn't going to be normal, either, given the fact that I was diagnosed with Crohn's disease when I was 19, and have endured a lifetime of gut-related misery that I've just learned to live with. I don't like taking medicine, and I don't "do" sick very well. That's been good motivation for eating a healthy diet and keeping myself in excellent physical shape. I value my independence and my intactness. I like my body the way it is, the way it was designed to work. Anesthesiologists are known for our tightly toned sphincters, making it even less of an irony that I find the idea of being surgically altered so unappealing. As yet, I'm undecided about whether or not I'll submit to a colonoscopy.
Last night, I kept thinking about that dream I'd had, and how uncannily it paralleled my patient's cancer. Like a malevolent uninvited dinner guest, her malignancy had been lurking unnoticed for God knows how long, serendipitously discovered because the rough-edged surface of the glycerin suppository fragment she'd used to treat her post-surgical constipation disrupted a friable time bomb that was ticking away patiently, aggressively straddling her sphincter. It also occurred to me that continuing to sit at a table full of Jesus-talking conservatives is very much like what I do for a living. The practice of medicine necessarily involves a controlled level of hypocrisy. I've given anesthesia to people having all kinds of procedures that I personally would never consent to, with the understanding that although I'm obliged to inform them of risks, benefits, and alternatives of the anesthetic, it's not my place to judge what's right or wrong for them. For some of us, quality of life is what's important; for others, it's sheer quantity. Just how much surgical disfigurement or chemical alteration one is willing tolerate in order to stay alive is a reflection of one's perception of quality, the metaphysics of which are complex and uniquely individual. No two definitions of quality are the same. From an acquired disease perspective, quality of life becomes a matter of adaptation. In contrast, my sons have lived their entire lives with the cruel genetics of cystic fibrosis, and all the pills and therapies and hospitalizations that go along with it. They've never known life without concomitant disease or what it's like to be completely healthy. For them, adaptation hasn't exactly been a choice.
Doing what I do, and knowing what I know, am I a hypocrite or am I simply being non-judgmental? Isn't acknowledging that what's right for me isn't necessarily right for everyone else, and vice-versa, the hallmark of self-determination and autonomy, the most inviolable principles of both medical ethics and humanity? Is supporting others who are sick, but not wanting there to be anything wrong with me really such a paradox? Would any of my feelings change if I suddenly became incapacitated or terminally ill? And, now for the question of the moment: Should I have that colonoscopy?..."Big. Deep. Breath."
*name changed
Physician, Heal Thyself! (a related post)
Today's gonna be a good day. It's Friday!!!! Our first case is a "double dip," an EGD--short for esophagogastroduodenoscopy, an endoscopic exam of the esophagus, stomach, and first segment of small intestine--and colonoscopy combo, evaluating a chief complaint of abdominal pain and rectal bleeding. No big whoop. The patient's a healthy 51 year old female; no medications, no allergies, no medical problems, just a little rectal bleeding noted after the endometrial ablation she underwent two weeks ago to alleviate her heavy menstrual periods. "After the surgery, I couldn't 'go,' so I inserted half of a glycerin suppository, and that's when I noticed I was bleeding from my rectum. Maybe I tore a little hemorrhoid?" Sounds reasonable, especially since she's so thin, healthy, and asymptomatic. Aside from having a maternal grandmother who died from colorectal cancer, there's nothing too remarkable in her history. This'll be a piece of cake.
"Big deep breath. You'll start feeling really sleepy in just a few seconds. You're gonna feel that oxygen blowing in your nose a little harder as you're drifting off to sleep, OK? See you when you wake up."
It's 7:40 a.m., but here in the GI suite, the propofol is already flowing as freely as cheap wine at a house party. After only 80 milligrams of this wondrous milk of anesthesia, my patient's snoring like a true champ. "Wow, she's a lightweight! This case is gonna be a cinch." The scope goes in at 7:41 and comes back out two minutes later. "Her EGD's normal," says my gastroenterologist colleague, Dr. Selleck*, as the procedure nurse and I spin the stretcher around in the opposite direction for the colonoscopy. Everyone in Room One's in a good mood, chatting excitedly about our weekend plans...did I mention it's Friday? We get our patient positioned, and I push a little more propofol as Dr. Selleck performs a standard pre-colonoscopy rectal exam.
"Oh, FUCK!," he blurts out, his tone unexpectedly grave and serious. "Something's not right. She's got a mass in here." Praying it's only a thrombosed internal hemorrhoid, we all watch silently as he passes the scope a few millimeters into our unconscious patient's anus, collectively groaning, "Oh no..." as the olive-sized, ulcerated tumor comes into view. "It's cancer," he says quietly, his voice heavy with compassionate despair, "and it's a bad one." I deepen the anesthetic, and we proceed with the remainder of the exam.
Because the tumor is situated so close to her anal sphincter, it can't simply be cut out without affecting continence. "Depending on whether this is squamous cell or adenocarcinoma, she might be looking at a permanent colostomy," he remarks as he takes a few endoscopic biopsies of the now bleeding tumor. "She reported having rectal pain, which is indicative of a more invasive and very likely unresectable tumor. She'll need a rectal ultrasound and CT scans for staging, and we'll go from there." I felt myself starting to become a little undone: "A permanent shit bag? Are you kidding? She's only 51! Jesus Christ! I'm not sure I'd even want to live with an irreversible colostomy." The procedure nurse, a 31 year old woman, nodded in agreement. "Well," Dr. Selleck said, "at least you'd still be alive."
"Hey there, you're just waking up. Big deep breaths for me. We're going to recovery now, and when you're awake, Dr. Selleck will come talk to you about your results."
Mercifully, the propofol sedation lingered long enough to allow for a peacefully sleeping patient with a no-questions-asked transfer to recovery. I don't think I could have handled it if she'd been awake. People waking up after their procedures always want a confirmation that everything went all right. I was exceedingly thankful that it wasn't me having to deliver such devastating news, especially because I'd already determined that if it were me and I was looking at forty-plus years with a permanent colostomy, I'd probably let the cancer metastasize and die in hospice.
Just a couple of nights ago, I awoke from a terrible nightmare. It was Thanksgiving, and I was sitting at a long dinner table in the house of someone I barely knew, a conservative woman who appeared to be very wealthy and kept talking incessantly about Jesus. I didn't know anyone else at the table, but they all looked uptight. No one was having any fun. I felt a sense of awkward discomfort, like I was in the wrong place at the wrong time, and I didn't know how I'd gotten there. I ate what was offered, but otherwise kept my mouth shut. Looking across the dining room into the foyer, I could see a bunch of twenty-somethings dressed in garish Halloween costumes clamoring down a large staircase, prompting the hostess to get up and investigate the commotion. Somehow, I knew that they were renting rooms upstairs. That's when I saw Pocahontas and a big fuzzy bumblebee pointing their shotguns, and I knew we were all going to be robbed. There was no time to escape, and that's when I awoke.
What's it like to wake up as your normal self one morning, only to be informed a few hours later that your days are numbered by a disease, that your body's been invaded by a cancer that will probably leave you disfigured? Although our patient took the news pretty well, her husband was visibly shaken. Instead of heading home with his wife after her uneventful colonoscopy, he was accompanying a newly diagnosed cancer patient to the hospital for CT scans of the abdomen, pelvis, and chest to see if the tumor had already spread to other parts of her outwardly perfect body. Interestingly, the patient disclosed that she'd suspected it might be a cancer. Perhaps her calm demeanor wasn't from the propofol after all; evidently, she'd been discreetly preparing herself for the worst possible scenario.
I've had a really hard time shaking yesterday's disturbia. I'm turning 50 in a few days, a birthday which nowadays means, "Congratulations! It's time for your screening colonoscopy!" I'm relatively certain that mine isn't going to be normal, either, given the fact that I was diagnosed with Crohn's disease when I was 19, and have endured a lifetime of gut-related misery that I've just learned to live with. I don't like taking medicine, and I don't "do" sick very well. That's been good motivation for eating a healthy diet and keeping myself in excellent physical shape. I value my independence and my intactness. I like my body the way it is, the way it was designed to work. Anesthesiologists are known for our tightly toned sphincters, making it even less of an irony that I find the idea of being surgically altered so unappealing. As yet, I'm undecided about whether or not I'll submit to a colonoscopy.
Last night, I kept thinking about that dream I'd had, and how uncannily it paralleled my patient's cancer. Like a malevolent uninvited dinner guest, her malignancy had been lurking unnoticed for God knows how long, serendipitously discovered because the rough-edged surface of the glycerin suppository fragment she'd used to treat her post-surgical constipation disrupted a friable time bomb that was ticking away patiently, aggressively straddling her sphincter. It also occurred to me that continuing to sit at a table full of Jesus-talking conservatives is very much like what I do for a living. The practice of medicine necessarily involves a controlled level of hypocrisy. I've given anesthesia to people having all kinds of procedures that I personally would never consent to, with the understanding that although I'm obliged to inform them of risks, benefits, and alternatives of the anesthetic, it's not my place to judge what's right or wrong for them. For some of us, quality of life is what's important; for others, it's sheer quantity. Just how much surgical disfigurement or chemical alteration one is willing tolerate in order to stay alive is a reflection of one's perception of quality, the metaphysics of which are complex and uniquely individual. No two definitions of quality are the same. From an acquired disease perspective, quality of life becomes a matter of adaptation. In contrast, my sons have lived their entire lives with the cruel genetics of cystic fibrosis, and all the pills and therapies and hospitalizations that go along with it. They've never known life without concomitant disease or what it's like to be completely healthy. For them, adaptation hasn't exactly been a choice.
Doing what I do, and knowing what I know, am I a hypocrite or am I simply being non-judgmental? Isn't acknowledging that what's right for me isn't necessarily right for everyone else, and vice-versa, the hallmark of self-determination and autonomy, the most inviolable principles of both medical ethics and humanity? Is supporting others who are sick, but not wanting there to be anything wrong with me really such a paradox? Would any of my feelings change if I suddenly became incapacitated or terminally ill? And, now for the question of the moment: Should I have that colonoscopy?..."Big. Deep. Breath."
*name changed
Physician, Heal Thyself! (a related post)