Tumours and Transformations

Text taken from The New England Journal of Medicine: http://www.nejm.org/doi/full/10.1056/NEJMp1716548?query=featured_hematology-oncology

Dr Scott Winner, MD

It happened 21 years ago, near the end of a night on-call. Around 5 a.m., the emergency department physician paged radiology and requested an ultrasound on a 41-year-old male with right upper quadrant pain. I walked down the hall and entered the exam room. A man lay on his back on a gurney and a woman leaned on the bed’s railing. An ultrasound machine and a small black stool were beside the bed. I introduced myself.
“I’m Dr. Winner. I’ll be doing your ultrasound. Where’s your pain, sir?”
“Right here.” He pointed below his right ribs.
“Okay. Let’s get started.”
I shut the door and flipped off the lights; the room darkened. As our eyes adjusted, I said to the woman, “So are you his better half?” Her lips turned up slightly and she nodded yes. I pulled up the patient’s shirt exposing his abdomen.
“How long have you two been married?”
“Nine years,” the man replied.
I squirted acoustic gel on his skin. He arched his back and said, “Whoa! That’s cold.”
“Sorry about that. I should’ve warned you.”
He sneered at me. I changed the subject.
“So, do you have kids?”
The patient turned his head toward his wife. She stared at him. I regretted asking. The patient looked back at me and said, “Our 2-year-old son died 2 weeks ago.”
“Oh…I’m sorry.”
The woman folded her arms on her chest.
“What, uh, what did your son die of?”
“He had cancer of the liver. Hepatoblastoma.”
For a moment, the three of us sat together, silent and breathing. The only sound in the room was the low hum of the machine.
I leaned forward, picked up the ultrasound probe and placed it on his belly. Bowel gas and blood vessels flashed on the screen. I moved the probe in search of his liver and said, “Okay, sir, take a deep breath in and hold it.” He did so, and his liver came into view. My breath stopped. For a few seconds, I just stared, then I angled the probe up, down, right, and left. The husband and wife were watching me.
She asked, “Do you see something?”
“You can breathe, sir.” He exhaled, and I pulled the probe off his skin. The screen went blank. Gazing at the machine, I said, “I’m just getting started.”
I fidgeted with the machine settings for no particular reason. I shifted in my seat. I placed the probe back on his skin and studied his kidneys, spleen, pancreas, aorta, and gallbladder. All were normal. I moved the probe back to his liver. There were masses everywhere. I measured some of the lesions and saved the images. I did not talk or look at the man or woman as I worked. I couldn’t. I knew something intimate and heartbreaking. This patient had just watched his child die of a liver tumor. And all the while, they had been dying together — father and son.
I put the probe down and covered the man’s skin with a clean, white towel.
“I’m finished.”
“What did you see?” the patient asked.
“Sir, you have, uh, your liver has lesions in it.”
“Is my gallbladder okay? They thought it was my gallbladder in the emergency room.”
“Your gallbladder is normal. You have liver masses.”
“You mean like cancer? You think I have cancer in my liver?”
“We’ll need to get a biopsy to prove it, but yes, sir, I do. I’m sorry.”
The woman reached between the bed rail bars and touched her husband’s bare waist with the back of her hand. I asked them if they had any questions, but neither answered. I stood up, paused, and left the room. The orderly was waiting in the hallway; I told him the patient was ready for transport. I called the emergency department doctor and gave her the results of the study. I went back into the hallway and saw the man being wheeled away, his wife’s silhouette walking behind. They turned a corner and disappeared.
My shift ended, and the morning crew arrived. One of my physician colleagues asked me about my night. My patient’s ultrasound films were still hanging on the viewbox in front of us. I showed him the images of the patient’s liver masses and started to tell him about the couple’s 2-year-old son, but my voice cracked. My colleague gently placed his hand on the nape of my neck. We stood there, shoulder to shoulder.
I left the hospital and drove home. I undressed and stepped into a hot shower. I put my head under the water and let it soak my scalp. When I closed my eyes, I saw vivid images of the father’s tumor-laden liver.
I was raised to believe that hard work and effort could solve any problem. The Little Engine That Could was my favorite childhood book, and I internalized the book’s mantra — “I think I can.” I was never the smartest kid in class, and it took me two attempts to get accepted to medical school. When I graduated and earned my M.D., my father gave me a framed quote by Calvin Coolidge, which read in part, “Persistence and determination alone are omnipotent. The slogan ‘press on’ has solved and always will solve the problems of the human race.” My response to setbacks and suffering was to try harder, to work harder. I did not know how to pray or meditate. On the Sunday mornings of my youth, my mother went to the Presbyterian church on West Water Street while my father and I slept in.
Prior to that night on call, I had seen many sad cases, among them a teenager shot in the head, an orthopedic surgeon sitting and sobbing next to his sick child, and a fetus dead in the womb. To cope, I occupied my time and mind with exercise, work, and tasks while the sadness of these cases dissolved somewhere inside. But for the father and son with cancer, there was no room, no space within me.
In the days following my experience with the patient, I tried to persist and press on, but I had entered an unknown world, one that I did not understand. My long-held beliefs and ways of being seemed inadequate. I went for a run but found myself walking and ruminating. I lost interest in studying medicine. After reading my 3-year-old daughter a book at bedtime, I stayed with her until the cadence and sound of her breath assured me that she was safely asleep.
A week after that night on call, a week after my center of gravity shifted, I am at work thinking about the father with cancer. I check the medical record for the pathology report of his liver biopsy. The result: adenocarcinoma. My gut aches. I notice that he is an inpatient in room 221. I think about visiting the patient, although I have no earthly reason to do so. There is no procedure to perform, no note to write, and no checklist to complete. But this is an impulse, one that I don’t understand and can’t ignore. I take off my white coat and hang it on a chair. I walk to the stairwell and climb. Looking down, I notice depressions on the surface of each step from all those who walked this path before me.
I arrive on the second floor, walk by the nurse’s station, and enter the hallway. Human voices rise and fade away as I travel. I’m searching for something. I find the patient’s room, and my pace slows. The door is open, and I enter his room. A few steps past the threshold, I stop. The physical world fades and thoughts fall away. What I encounter is ancient, transcendent, fearful, beautiful. The patient rests in bed. Family, friends, and the chaplain surround him. They all hold hands, heads bowed.

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Rohit Joshi

I am a doctor who helps people deal with cancer with diagnosis and management of the illness (chemotherapy, biological agents, immunotherapy and hormonal agents).

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