Sunday, July 27, 2008

The lesion

There wasn’t anything unusual about her at first glance. She seemed like the typical grandmotherly 68 year old lady that I see every day. She lived alone. Her four kids were in the area and she saw her grandchildren most weekends. She had been a homemaker most of her life. She lived comfortably off her husband’s pension and her own social security. She was in the hospital for “weakness and fatigue”. The internist had run a battery of tests, sent bloodwork, consulted half a dozen specialists. The investigations were unrevealing. Her heart was ok. She had some mild cortical atrophy. She was a little anemic but the upper and lower endoscopies were negative. She looked thin and wan when I walked into the room to introduce myself. She seemed to sink into the crevices of the hospital bed with a defeated resignation. Her voice was tepid and quiet and I had to pull the chair up close to the bed to hear her.

I had been called with regards to a “lump” on her back. How long has it been there, I asked her gently. She looked away, pausing for a moment. It’s so embarrassing, she said. I should have seen someone sooner. I neglected myself. She couldn’t look at me. She kept staring at her hands folded across her lap. It’s ok, I said. Would you mind if I took a look?

I helped her with the buttons on the hospital gown. At the tip of her shoulder blade was a giant gauze dressing. As I moved to peel back the tape holding it in place, a foul, festering odor was released. The gauze was heavy with moisture. I'm so sorry, she said. I know it smells. It's fine, I said. Underneath the dressings was a tennis ball sized fungating mass, serum seeping from the ulcerated surfaces. She slowly shook her head with her eyes closed, wrinkled hands folded across her mouth like a steeple.

-How long has it been there?
-Two years, she whispered. I thought it might just go away.
-Does it hurt?
-No. Only sometimes. If I bump it. I ought to have seen someone sooner. I was so busy taking care of my husband. He was ill, you know. I didn't want to think about anything else. I didn't have time....

For two years she functioned as a caretaker for her deteriorating husband. She fed him, bathed him, cleaned him when he soiled himself. Everything was directed toward him, all her energies, everything outside herself. Is this a deeper form of love, this extreme self denial? I had to sit down. I couldn't say anything. I covered her back up. We sat in silence in that dim little hospital room for a good five minutes. This quiet, frail little old lady. No one in the family knew what she had quietly endured. She had downplayed her husband's decline. Denied all offers of assistance. Always kept the lesion carefully concealed and perfumed. And now she was done hiding. She was here.

-You must miss him, I said after a time.
-You have no idea, she said, looking at me finally. And suddenly, I thought I saw a glint of determination in her eyes, the very drive that had gotten her through the past two years.
-But I want to get better now, she said. I just hope it isn't too late.

A core biopsy revealed a poorly differentiated malignant melanoma. After lymphoscintigraphy confirmed that the right axilla was the primary lymphatic drainage basin, we proceeded with a wide local excision and concommitant sentinel node biopsy. Melanoma, as opposed to other skin cancers (squamous, basal cell), has a tendency to spread to the regional lymphatics. The thicker the melanoma, the higher the chance of metastasis. As I began the axillary dissection, my heart dropped as I encountered clumps of matted, enlarged lymph nodes. The lesion itself was excised uneventfully, a twenty minute procedure, and just like that it was gone.

When I saw her in the office a week later for drain removal and a discussion of the final pathology she wasn't alone. All four of her daughters accompanied her. The two flanking her sides both held her hand. There was a rosy color to her cheeks that was lacking a week before. She smiled. She seemed at ease, finally. Surrounded by her loved ones, the burden of concealment cast off, comforted by her new-found transparency.

The most important factor in melanoma staging is thickness, usually discussed in terms of millimeters. Her melanoma was 5 centimeters thick, an exponentially thicker lesion than what we typically encounter. But the margins were clean and her wound had healed nicely. What about the lymph nodes, one of the daughters asked. Amazingly, all the lymph nodes were negative, I said. Some of them were enlarged but this was secondary to reactive inflammation rather than metastatic spread.

And then that little exam room became the warmest, most festive place in northeast Ohio. There was crying and laughing and squeals of delight. My patient's eyes glistened with tears, her shoulders shuddering. I tried to modulate the excitement somewhat (still a big lesion, poorly differentiated, etc) but not too much. Now was a time for good news and optimism. The pathology on the lymph nodes was entirely unexpected; I never would have guessed it.

It seemed the rest of the family was committing to my patient in the same fashion that she had done for their father. She was moving in with the eldest daughter. The girls were taking care of everything. Things were going to get a lot easier. Never again would she have to endure anything on her own. She hugged me on the way out, even gave me one of those embarassed quick pecks on my cheek.

When I'm in a room with a patient, I try to keep my emotions in check. You don't want some doctor breaking down in front of you, turning into a blubbering sack of goo. Sitting here on a Sunday writing this story allows a different perspective. For some reason I have a hard time letting go of this particular patient. She had something to teach me; and the further I get from the actual events, the more I seem to understand. I'm still quite young, and have a lot to learn. I'm grateful for the opportunity to interact with human beings in the intimate setting that the doctor/patient relationship affords. I think we all carry our own lesions with us throughout life, whether it resides on our back, or our leg, or deep within the recesses of our hearts. We all have them. There's no shame in that. And it's a good thing to know that the burden can be lessened the moment we decide to reveal it, the moment we decide we don't want to endure it alone anymore....

24 comments:

Vijay said...

Wonderful story & well written. Thanks for sharing.

Phorun Medipoxy said...

Wow. Very moving post. Thank you.

Theresa said...

Wonderful post. I feel the same way you do: if a patient's story moves me, if it stays with me for some reason--then I know it holds a lesson of some kind, for me or for another patient I might encounter. There is so much to learn from the people we meet in this work. GREAT story, thanks for sharing.

Health Train Express said...

Buckeye, you are undoubtedly a superb caring physician and surgeon. Not a technician. I would be priveleged to have you as a surgeon. My last post may have seemed a bit harsh, after reading it, it comes out in print a bit differrently than face to face. I wanted to share with you what happened to me as I have seen it happen all to often to gifted surgeons. Keep on caring and working hard.
I came across this great video from Stanford on Medcast.


Health Risks of Type A Personalityl
Wes Alles, PhD, director of the Stanford Health Improvement Program, discusses the health consequences of Type-A behavior. Alles explores a number of strategies for how to relinquish this behavior and adopt a less stressful lifestyle. The talk is part of a series from Café Scientifique, an international network of community meetings for the public on the latest ideas in science and technology.
This video cast sponsored by Stanford University on “Medcast” is also delivered by podcast subscription on iTunes.

http://deimos3.apple.com/WebObjects/Core.woa/Browse/itunes.stanford.edu.1339720424

Not sure if the link will work, you may have to copy and paste it into your browser url.

You can also subscribe to medcast via itunes podcasts.

Hope you enjoy it, he says it much better than I could ever do.

Keep on going, just hit the brakes every once in a while, and learn to say NO every once in a while.

I have you linked on my blog.
gml
gml

Bongi said...

beautiful. when you said to her that she must have loved her husband you made contact with her humanity, looking beyond the ugly smelly lesion on her back. you met her where she was and made a difference.
p.s it seems you also made a difference with the knife.

rlbates said...

I'm so glad there are young surgeons like you.

Kacey said...

I wish I knew for sure that all my doctors have the inner vision you do. Sometimes we feel that after sixty-five, medicine has given up and relagated us to the certainty of death. Bless you....from the other side of Ohio.

Jessica Bond said...

You must be some awesome surgeon. I am very moved by your post. It is clear you are living your purpose in life.

Thank you - we can all learn from your post.

DrCris said...

First post of yours that I have read, and I loved it. Tears.

It reminded me of a similar patient, who nursed her husband through dementia and general medical decline before finally presenting to have her breast cancer attended to.

As an octogenarian, hers was the indolent cancer you would expect, and she had a simple surgery and a good recovery. But my touchstone with her was her enduring grief over her husband.

Anonymous said...

I hate to be the party pooper, but melanomas tend to come back even if completely excised. I'm a dermatopathology fellow.

Yet I hope to be wrong.

tom said...

A true human being is what you are, surgery is what you do.

The Happy Hospitalist said...

I echo the dermpath fellow. 5 centimeter melanoma that hasn't spread would raise very caution flags for me. You just haven't been able to prove it with today technology. Yet. Great story by the way.

Ming said...

Yup, i gotta agree with the dermpath guy. I'm a path resident. Ulceration also makes the stage higher. was there a skin graft at the end?

T. said...

What a completely beautiful and beautifully written story. Thank you! I can only pray that the surgeons I come into contact with will have your compassion and humanity, whether I'm providing anesthesia for them or coming to them as a patient.

Buckeye Surgeon said...

Dermies coming out of the woodwork! I grant that that the prognosis is grim. However, we do have to keep moving forward. What's the next step? High dose interferon? Any adjuvant ideas?

Bongi said...

the question about prognosis is not the point here. i think her prognosis is probably poor, but she will die without the smell of that lesion. she feels more acceptable and more human. buckeye may not have given her life eternal, but he did restore her humanity. hats off to you, buckeye.

Devorrah said...

This may be the best blog post I've ever written. Thanks so much for sharing it.

Kelley said...

Great post. I love reading your blog, as I'm originally from NE Ohio, and love to see the "local references," but this post was just phenomenal, and helped me to remember why I want to make the sacrifice to go to medical school (the reason BEYOND the flashy procedures and sharp scalpels). Thanks so much for sharing.

walt dandy said...

Very nice. I agree about the prognosis. Whether she shows up with a brain met in 6 months is beside the point. If that is the case you gave her 6 months with the weight of the world off her shoulders, and that is a hell of a gift my friend.

Buckeye Surgeon said...

Thnaks WD.. I like your list of favorite books in the profile.

Enrico said...

I was reading the comment thread, top-to-bottom** and if Bongi hadn't posted his second comment, I sure as hell would have. The prognosis isn't the point--the woman put her entire being on hold and Buckeye's rapport allowed her the freedom and safety to address herself without guilt or shame. I hate to be the king of the obvious for the *path types, but tissue surrounding the lesion is called the patient.

(**I read this post this last week but I SWORE I commented--sorry if Blogger gobbled it up--"what everyone else said" :) You have a great gift for sharing, in print and in person.)

Kathy said...

Really interesting post and subsequent comments. I wonder if the patient or family members will ever see it and what they might think if they did? What struck me most is Buckeye's humanity. Patients need this, and I speak as one who has had cancer in the family several times. We've had great human being doctors, and I am very grateful for that. Still I want my doctors to level with me and so I hope Buckeye continues to guide this patient and family with information about the reality of the situation. I liked seeing the question to the dermpath types about what next. Humility and a willingness to ask for advice is a nice quality in a surgeon too. Glad to have happened on this blog as I tried to find information about a recently diagnosed hernia for myself, on the heals of a lot of caregiving for my teenage daughter.

Anonymous said...

I'm a nursing student doing some research and came across your page.
I admire your tenderness and sharing.

Stacey Gordon said...

Rad Tech/mammo tech here...Stumbled across your blog while researching HIDA scans... This story resonated with me, probably because I am a cancer survivor as well. Knowing both sides of the machine, I call it...
It is nice to know that there are some physicians out there that think like you do.
They are hard to find...
Thought I'd share, for what it's worth, from the opposite end of the spectrum.. being 35, an athlete and diagnosed with breast cancer: http://southgeek.blogspot.com/2011/01/heroes-and-tigers-and-saints-oh-my.html