Saturday, October 27, 2012

Big Deep Breath

"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)

21 comments:

  1. Oh, boy. This one is tough for me. I've aways had a major fear of cancer—even before either of my parents died of it and they both now died of it. I don't know why that fear of cancer has been with me for as long as I can remember. Maybe it's because as a kid (I can't remember how old, but single digits) I had polyps on my bowels. They turned out to be benign, but back then there were no colonoscopies so I bear a large scar that reminds me that if they had been malignant I probably wouldn't be around to write these words.

    Being a natural-born worrier, I've often thought about whether I'd want to go through a cancer treatment if the result is to live a life that, for me, although probably not for everyone, would be a life of indignity. Probably not. I'd probably take the option, as you suggested you might, of letting it metastasize in a hospice. Although, I'm not sure that I can predict now how I would react if and when the situation arises.

    As to are you being hypocritical, I don't see that at all.

    You're a doctor/anesthesiologist. You're not there to tell people what they should think (as much as they might benefit from you doing so).

    From what I've been able to learn about you in our online interactions, you seem to be a very accepting person. A doctor's job, as I see it, is to tell his or her patients what their diagnoses are, what their options are, what the potential risks are, and what the likely rewards are. It's then up to the patients to choose from among those options the one that's right for them.

    Being an accepting person, you recognize that "right" is in the mind of the patient, even if that is different than what is right for you. You are doing what you are trained to do in order, as best you can, to help the patient fulfill that choice, even though it might not be the right choice for you.

    ReplyDelete
  2. It is tough, Joel, because one's perception of health and wellness, as well as the quality of his/her life, is so incredibly subjective. I don't see myself as being "preachy," so it's not like I'm failing to practice what I preach. It's just that I don't think I could live happily, being incapacitated or grossly disfigured, e.g. having tubes coming out of me or missing certain body parts.

    ReplyDelete
  3. "Right" not only changes from person to person, but also changes for each person as they mature. I don't know if you read my post "A Virtual Stone". You should. A medical choice was forced on my brother at an age when no one should be forced to make that choice. At the time I couldn't fathom EVER stopping. Now I get it.

    ReplyDelete
    Replies
    1. Karen, I just read it and left you a comment...what a moving and poignant tribute to your brother.

      Delete
    2. http://bakinginatornado.blogspot.com/2012/09/a-virtual-stone.html

      Delete
    3. Thank you very much. That experience taught me never to pretend that I know what I'd do in someone else's shoes. What I might do is fluid, not rigid. That's why important medical decisions are so difficult. There's so much room for future regret.
      I think your sons are very lucky to have a Doctor for a Mom. I know that anything that can be done, you'll get done. I'm not sure you can ask for more under the circumstances.

      Delete
  4. Wow. The things you deal with, my dear. You're right. It is all about adaptation. When my father-in-law found out he had cancer the news was devastating. Our lives all changed. His and my mother-in-law's lives were turned completely upside-down. He battled the disease for three years before succumbing to it, and all the things he did in those three years -- going to see grandkids' soccer games, plays, concerts -- he really made the most of it and continued to make memories for everyone, including himself. Though those years were hard, at least he did have those three years and he made the most of them.

    ReplyDelete
    Replies
    1. Janene, sounds like your father-in-law found just the right combination of attitude and adaptation to live fully and happily, in spite of his disease.

      Delete
  5. Flaming heck. I really felt it for that patient even though she guessed what might be wrong. I just can't imagine how I'd feeling being checked out and then being told I had cancer. It's the bad word that nobody wants to hear.

    I would say that you should have the colonoscopy screening otherwise it will be playing around on your mind BUT saying that, I'm always telling others to be screened and checked out but when it was my turn, I didn't return for my check-up for 6 years - hypocrite, don't like all the fuss, the prodding, poking, going places they shouldn't go etc.

    The decision is yours to make because at the end of the day if ever the worse was to happen God forbid, would you be happy to know that you did nothing to stop what could have been stopped if you had intervened, or would you regret it?

    You have a way of really bringing it home to me, thanks. HAPPY BIRTHDAY in advance - just in case I miss.

    ReplyDelete
    Replies
    1. RPD, I think what bothered me most is how close that patient and I are in age. If she'd been a lot older, it might not have upset me as much. It's all relative, I guess. Both my husband and I are due for screening colonoscopies; guess it's time to get them out of the way. Glad you enjoyed the post, and thanks for the birthday wishes!

      Delete
  6. I'm so sorry your patient got the results she did. And for the pain you all felt. Cancer is frightening. So I understand why you wouldn't want to have the test. But I sincerely hope you are able to take a "Big. Deep. Breath." and go for the screening. Knowledge is usually better than being in the dark. And it may let you kick some uninvited guests out of your dreams.

    ReplyDelete
    Replies
    1. Gina, I will probably suck it up and have the screening test. So many colon cancers can be identified and treated early through screening, before they become invasive or life-threatening. I suppose my own colonoscopy might make an interesting post :-)

      Delete
    2. I think if anyone can make that a must-read riveting post, it's you :)

      Delete
  7. Kris, I don't know how you do it. I quit being a therapist because I couldn't stand to listen to another person talk about their problems. What you have to face is so much more challenging and intense. I have no idea how I'll react if I find out I have a terminal illness. It's not something I ever think about. Dying is one of those "I'll let you know how I feel when it happens" sort of things. I imagine my reaction will be as unexpected as everything else has been in my life.

    ReplyDelete
    Replies
    1. Doing my job involves a healthy level of denial, Marty, but because of my sons' illness, I believe I'm all the more compassionate. It's also helped solidify the fact that death is an inevitable and inescapable part of life, a reality that people naturally want to reject.

      Delete
  8. It always hits closer when you are close to the same age.... Yeah, its a tough case, and makes you reevaluate your own life in new light. Its hard to say what any one person would put up with to live, especially what I would. I know all my priorities have recently changed, now that I've found my fiance, so all my old ideas are different, as I'm no longer perpetually single with occasional doses of psycho women. Either way, heart goes out to the patient, and we'll all see how we turn out in the end ourselves.

    ReplyDelete
    Replies
    1. It's crazy, Dan...I give anesthesia to people twenty years younger than me who look 30 years older because of poor lifestyle choices (smoking, overeating, not exercising, poor stress management, etc). It's hard not to be frustrated by people who don't care at all about their health, especially those who are still young. Yes, love changes everything, doesn't it?

      Delete
  9. Of course you're not a hypocrite! (or so I believe). You're not a doctor in your own life, anymore than I'm a therapist in mine. We're human. We don't always do what we suggest to our patients; we have our own fears, opinions and prejudices. And thank God we do -- if not, we'd be predictable and boring as hell. That said, I also feel hypocritical at times. And I'm dreading colonoscopies already. Hell, I squirm when my gynecologist sticks his finger up my ass! -- which he started to do two years ago.

    Thanks for a brilliant, fascinating and thought provoking post!



    ReplyDelete
    Replies
    1. June, I have to say this...I am very glad your gynecologist performs a rectal exam. I didn't mention that in this post, but had the gyn that did this woman's uterine surgery a couple weeks ago performed a rectal exam (which is standard!), that cancer would have been identified sooner. And you're right about our personal lives being separate from what we do for a living. I think it gives us perspective that we wouldn't otherwise have.

      Delete
  10. Thanks for telling me about the finger invasions I so hate. That poor woman...my heart goes out to her.

    ReplyDelete
  11. Oh I hate hearing stories from the OR like this one. So sad. I think that there are many people who, like you, would oppose the idea of end stage appendages like tubes, colostomy bags, etc...however, rarely admit to it due to obligation or guilt in regards to their families. Great post, as always!

    ReplyDelete