Thursday, March 13, 2008

Not acceptable

I've been reading the Stoic philosopher Seneca lately. Don't ask me why. It was one of those $5 books you can get at Borders. But certain parts of it have made an impression on me. As we move deeper into this secular age, it's interesting to read outlooks from the pagan age. Thinkers such as Seneca encountered the same injustices and moral quandaries as we do today, and it's edifying to see how difficult issues are resolved from a pre-Judeo-Christian perspective. At it is least for me.

Anyway, Seneca said "what can happen to somebody can happen to anybody". I wrote about a patient last November who was 28 and presented with perforated cecal cancer (T4N2). He started Folfox chemotherapy in Jauary and things seemed to be going well. He regained lost weight, returned to work, and was starting to look forward to the rest of his life. Then his CEA bumped up to 45 and the medical oncologist ordered a CT scan. The right lower quadrant showed a concerning mass/phlegmon that seemed to be invading the lateral abdominal wall. The liver looked clean and he was non-toxic. I told him, frankly, that I was worried about recurrent disease, given that the intial presentation involved a perforation and spillage of tumor cells throughout the abdominal cavity. Naw, it's probably just an abscess, doc, he told me. I nodded my head grimly. I hope so, I said. But let's prove it.

So I explored him today and I encountered carcinomatosis. Knobbly tumor implants were everywhere; abdominal wall, omentum, superficial liver capsule, serosa of bowel. Palpating the undersurface of the abdominal wall was like running your hands along a wall imbedded with marbles. Cancer is unmistakable. It's hard and frozen and all wrong amongst the soft suppleness of the liver, omentum and bowels. Your heart breaks. You get all geared up for an operation like this, anticipating a possible major en bloc resection, and then it all comes to a halt. There's nothing to do. Not today. So I bypassed a segment of bowel intimately involved in the main tumor mass, sent numerous biopsies, and then closed up shop. It took me a while to gather myseslf for the post op family talk. It went as you would expect. Devastation. Grown men and women crying. A wife stoically trying to keep herself together. Nothing cuts like the unabashed wail of a mother grieving her son.....

He's 28 years old. He has a young child. Why is he the one who gets the short straw? Is there a cosmic reason? What solace can be sought from a buffet selection of religion, philosophy, new age mysticism, and whatever else? Why should something like this happen? Life is very short indeed. You never know when your time is going to come. I understand that. But that doesn't mean I have to accept such a structure at this point in my life. I'm not ready for that. Seneca says that "we are all chained to fortune" and that "when the order to return the deposits comes, the sage will not quarrel with Fortune, but will say, 'I am thankful for what I have held and enjoyed'". The essence of stoicism. I'm not sure that does it for me either. After all, Seneca, apparently, was Nero's right hand man...

9 comments:

Sid Schwab said...

It's a horrible combination: colon cancer at a young age, which in my experience is a very bad actor, and perforation, which is nearly 100% incurable. It is indeed awful to go in with a shred of hope and find what you describe so well. And the "why?" I think Seneca is right.

rlbates said...

So very sad. Nothing more to say. Just sad.

Bongi said...

i did almost the same operation this week, but my patient was well into her 70s. her daughter was the one wailing.

acceptable or not, we have no choice but to accept it.

DrWes said...

Very moving post. Thanks.

make mine trauma said...

As far removed as I sometimes am from the patients I assist on, (I seldom become intimately involved with them or their families) it is always heart wrenching when finding an abdomen seeded with cancer. And, to have to break such news to the family, I cannot imagine.

Kacey said...

It doesn't matter whether you are 28 or 82 --- when hearing the positive words of a death sentence --- you are never ready. We (even fundalmentalist Christians) want another day, before we must go into that dark night. There is always the question, "Why?" And, then the alternate answer, "Why Not?" I suppose it comes down to , "If it can happen to somebody, it can happen to anybody."

JP said...

Very moving, indeed. As a biologist, I never cease to be disturbed by that singular moment when the antelope's legs stop kicking as the lion's mouth patiently holds, or when the struggling cricket gives in to the widow spider's advance. But a human life, and a young patient at that... I don't know how you doctors do it.

A, a fourth-year medical student said...

As I med student I've only observed such cases but I agree they are devastating. I carried the pre-op hope of the patient to be cancer free into the OR and then to see the implants on the laparoscope cameras...you're right about the wrongness the implants have.

Surgeons, I think, can be forgiven for being a bit sharp at times as they are the ones that so often have to give bad news after they were the only ones that could go look for it.

Surgeon in my dreams said...

Buckeye, I have just today happened upon your website. I've been here way too long since I am supposed to be busy on other matters, but I WILL be back. Your writing style - I love it. You're definitely going in my "Favorites".