Archives of The Cheerful Oncologist, Volume 2

Every so often the local paper runs out of fresh ideas for “human interest” stories and assigns a cub reporter to write on some stale topic such as weight-lifting grandmas, or the ineffable joy received from pursuing a hobby so bizarre that only a smattering of aficianados, some of them obviously non compos mentis, actually partake in it.

I usually ignore such pablum, but today’s little refreshment was a story about folks who work the last shift of the day - the graveyard shift. Although the article was meant to be amusing, filled with cliches about police officers and bodega clerks peering into the inky, scary blackness night after night in order to earn their paycheck, the reporter could not disguise a certain amount of smug elitism in pondering why anyone compos mentis would stay up all night instead of sliding in between the flannel sheets with a teddy bear under one arm.

Yes, why would anyone choose to flip their normal day-night schedule upside down? Do you think it could have anything to do with this strange obsession some individuals have with earning a paycheck? Could it be that they have been “asked” by the boss to doff the pajamas, don the uniform and disavow doss for a nobler cause?

Reading the article brought back memories of my first experience working the night shift. After all, health care workers from janitors on up to the chiefs of cardiothoracic surgery have toiled away enough midnight hours that if laid end to end could span the Neolithic Period. After my sophomore year in college, during a grueling search for a summer job that would be commensurate with my skills and elegant manner, I lucked out and was hired by a large hospital as an orderly. What a fortunate break this was, since I was a pre-med student yearning to get a taste of what life in the chaos and glory of medicine would be. The only problem was that the position was for the 11-to-7 shift, which meant I would be sleeping away the prime fun-time hours of the summer. I didn’t hesitate though - I gladly took the job. Before one could say “geeky ice-cream vendor” I was patrolling the halls of a post-surgical ward in my white outfit, complete with white belt and shoes. I was the night orderly, there to help little old ladies hit the commode with at least 50 percent accuracy, there to take the complaints of the noisy and take the pulse of the quiet (just in case someone had decided to embark for the happy hunting ground).

No offense, but we were a strange crew, those of us who loved the hours when Dracula could be found sipping a carotid milkshake. I of course had no choice on which shift I could work, and tried to bribe the daytime orderly for a switch, but he was a professional [translation: this was his real job - cf. Maslow’s Hierarchy of Needs: “Esteem” -Ed.], and wasn’t about to sacrifice years of conniving to get assigned daylight hours for a few wampum. The nurses, who actually chose to work that shift, seemed to enjoy padding down the dark halls like a drowsy cat, waking patients up in order to give them their sleeping pill. I didn’t share their enthusiasm and in-between taking vital signs and answering call lights I learned to sleep propped up against a metal desk. It wasn’t too hard once I figured out how to keep my head from snapping forward like a crash-test dummy hitting the wall.

Here I was - a wannabe doctor - in a real hospital, with real patients snoring in their Procrustean-style beds. I roamed the place with a cup of fossilized coffee, just waiting for the chance to jump and provide real service with a smile to all those huddled masses who yearned to be free from constipation and other weighty matters - yes, it was the orderly who was charged with the responsibility of eliminating all eliminations egressing from the patients. Lucky me - within the week I knew what the term “Code Brown” meant, si usted comprende.

Actually, the job was so full of routine and quiet times it quickly became boring. After a week I had yet to see even an intern make an appearance on the floor, not even to flirt with a nurse. Of course, the nurses I worked with were not exactly coquettes sending out pheromones of enticement. I found myself sinking into listlessness, and began to have second thoughts about turning down that career position Uncle Pete had dangled in front of me. Just when the floor became as quiet as a…well, you know, I met a patient my age who shocked the hell out of me and like a living nightmare, became the biggest challenge I would face that summer. What awaited me behind the closed door of room 214 was the first trial I would face in my quest to become a real doctor.

My new patient - my doppelganger - was admitted with a phencyclidine overdose.

Next: The Graveyard Shift: Part 2 - Angel Dust and Sharp Objects

All in green went my love riding
on a great horse of gold
into the silver dawn.

four lean hounds crouched low and smiling
my heart fell dead before.

e.e. cummings

This spring two of my favorite patients have been simultaneously forced to take intense chemotherapy treatments, replete with side effects ranging from the mildly annoying to the deadly, in an attempt to save their lives. They did nothing to deserve the cancers now fiendishly shaking the hourglass representing their time left alive. Their diseases were not caused by any specific demerit in the scorecard of life - smoking, drinking, lack of exercise, poor diet, periodic irritability and/or unpleasantness [if that is a risk factor for cancer it’s a miracle the blog host is still alive -Ed.]. For whatever reason they just got cancer, and now have come to me, the medical oncologist, for relief. They want to live, therefore they have asked me to kill the tumors within them.

This scenario is not unheard of in the world of cancer treatment. In fact, it is an everyday occurance - mundane, and of little general interest to the intelligent (not to mention good-looking) readers of this small planet in the galaxy called Health Care Blogs. So why do I mention it?

The reason why I squeeze these meager observations from the recesses of my mind is because I simply cannot believe what has happened to my two patients. The chemotherapy I carefully designed and delivered to them both has failed. Unless a salvage treatment is successful in destroying the cancer, all is lost. This is brutal. Even condemned prisoners get to live for years on death row until a final judgement is cast but my patients will never see the next New Year’s Eve unless something miraculous happens. What kind of modern medicine is this when state-of-the-art treatments don’t work when by all rights they should? They say we’re making progress against cancer but every time a patient with it dies I feel the nighttime stars dim, and sense a gray wind clutching the tops of trees and houses until they collapse.

Perhaps in a thousand years there will be a brief lecture given to second-year medical students about the Dark Ages of medicine, back when what used to be called the Internet was in its infancy, and scientists had still not completely deciphered the human genome, and cancer was still allowed to grow into a visible, palpable tumor before even being diagnosed, and the parents of sweet, bubbly infants had no idea what diseases their babies were destined for, and patients were allowed to desecrate their bodies with tobacco and a bizarre diet consisting of fat and refined sugar with little feedback on the consequences.

Wouldn’t today’s doctors like to sit in on that lecture, and chortle with satisfaction? I certainly cannot say whether I will be aware of the advances in medicine that are destined to occur hundreds of years from now - that is one of the limitations of being a mortal. It would be nice, however, to witness the eradication of one or two heinous cancers before my name appears on a granite marquee.

When things don’t go as expected for my patients I often feel like a car mechanic who, when asked to fix the brakes on a stalwart vehicle, does so with enthusiasm only to find out later that the repair job failed and the car went careening off a cliff, with all lives lost.

There is no better motivation to keep searching for the cure, than to see patients with potentially curable cancers wither “like an untimely frost / Upon the sweetest flower of all the field.” Let every child whose path in life leads to a career in cancer research be blessed with brilliance, diligence and divine insight.

As we pick up the story, our main character had just found himself trapped in his office by a feisty pharmaceutical representative eager to perforate his eardrums with a long-bow full of crisp, well-rehearsed questions designed to match the creases of her black suit.

The product in question: who cares - that’s the MacGuffin!

The time: just minutes into the post-meridian, when hungry patrons of all types are filing into the hospital cafeteria and piling the vittles high on their plates.

The mood: The oncologist - a rather pathetic look of phony interest covering a morass of boredom and tummy-grumbling. The office staff: lip-smacking mixed in with silent snickering. The Big Pharma rep: unbearable sprightliness.

I usually don’t eat the lunch provided by drug reps - not that I hold a grudge against pungent steaming aluminum pans of mostaccioli or garlic chicken, or bags of potato chips large enough to use as sleeping bags, or chili. It’s just not what I race down the hall for when I’m ready to re-load the old metabolism for the afternoon’s labors. Speaking of the daily schedule, I certainly don’t find any joy in getting stuck in a long-winded presentation while my patients are thumbing through the July 1982 edition of Family Circle, wondering what happened to their doctor. Depending upon the layout of the office, I can sometimes slither out the back way during a sales call without encountering the reps. Today, however, unless I was ready to squeeze through the laboratory window, which would have started a four-part harmony of tongue-wagging from patients observing my exodus, I was trapped. Therefore stiffening the sinews, if not summoning up the blood from its cowardly hideout, I marched forth and greeted the salesperson with about as much enthusiasm as when one picks up the car from valet parking.

It is interesting to see the different tactics used by pharmaceutical salespeople. From my own experience I have encountered all types of reps - those pushing hard-sell tactics and those using the soft sell, reps who are overloaded with facts, reps who know every doctor, celebrity, and celebrity-doctor in town, and those who ooze with unctuous gratitude everytime I give out a box of samples. My tete-a-tete today was with what looked to be a recently retired cheerleader who had taken up the cause of better health through costly medications. The product in question was one I did use, so I listened respectfully to her recitation of the latest abstracts from Anderson (or was it Uzbekistan)? As the precious minutes ticked off I began to plan out my end-game - why not simply raise the right hand and swear solemnly by the gods of chemotherapy that I will to the best of my ability preserve, protect and defend her product from a lack of use?

That seemed to be a sincere and generous way to end the meeting, but unfortunately I had not the strength to force the moment to its crisis. Mr. Undecisive, I blurted out the one thing that did not need to be said in order to release my fetters and allow me to get on with the rest of my frightfully busy day. Always trying to play the preux chevalier, I asked:

“Do you have any literature you could send me?”

It is always a pleasure to learn of the latest advances in my chosen field, and I am truly grateful to the long years of research and development that goes into every new chemotherapy or biological treatment. I also humbly acknowledge the role played (although in my opinion a small one) by the pharmaceutical representatives whose mission is to disseminate information like Johnny Appleseed strewing whatever it was he strewed. When it comes to saving trees, however, drug companies seem to have a mortifying lack of interest in conserving this vital natural resource. I know this all too well, because ever since I queried that drug rep I have had to climb a six-foot ladder to get over the Great Pyramid of Giza of medical propaganda that is piled on my desk. I’m thinking of taking a speed reading course. Maybe I should just buy a larger trash can.

I let out a soft breeze of relief as I guided my jalopy into the doctor’s parking lot: another harrowing trip on the crash-test roadway known as my route to work had come to an end without me being extracted feet first by the jaws of life. I don’t intentionally wish to impugn my fellow commuters, but when I see little old ladies diving into mailboxes to get out of harm’s way, and emergency vehicles illuminating the highway like strings of carnival lights, I begin to wonder if folks are truly paying attention to the road. Most mornings by the time I reach the hospital my right leg looks like it came from a Mr. Universe contest from continuously pumping the brakes. This is not an inspiring way to start a long day at a job requiring patience, concentration and a lapidary expression of optimism.

Hey, let’s face it - there are some days when all I want to do is sneak in the back door, quietly see a few patients, peruse the latest antics of some of my fellow med-bloggers while nursing a quick cuppa, and get the heck out of town. On that morning as I trudged into the office my secretary turned and gave me the kind of smile usually found in medieval paintings on the queen’s lips as the king is trundled off to the scaffold.

“We’re having lunch brought in today from Xanthoma Subs and Grinders - would you like to order something?” She cautiously offered me a smudged black-and-white menu. Before I could decipher the ingredients of a sandwich called “The Elvis” my mind began to thaw out. Wait a minute! Food from the outside world on a Tuesday can mean only one thing - a pharmaceutical representative was coming. I was going to be “detailed” by Big Pharma today! Big Pharma? Ay Carumba!

It’s not that I don’t appreciate receiving information about a drug company’s new treatment, but in the field of medical oncology I feel the product sells itself. No matter what spin is put on it, the drug either stops cancer from growing or just sits there in dumb admiration as the silent hordes ravage the host. A promising new cancer treatment doesn’t suddenly become more effective just because a fleet of zeppelins bearing its logo are released across the country. I had already reviewed the drug and looked forward to this sales pitch with as much gusto as Richard III looked forward to a picnic on Bosworth Field.

Tables were set up in the back and around noon a man wearing a pink and green shirt waltzed in through the rear entrance and delivered several greasy bags. My staff hovered over the delectables, creating a tableau vivant that could have been immortalized by Titian, if he had remembered to bring his brushes. Lacking the necessary enthusiasm for appreciation of the feast, I started to sneak out until I heard the voice of my secretary, warbling with kissy-face small talk, coming down the hall toward me.

Too late - the sales pitch was about to begin. I elevated my jowls into a smile and prepared a face to meet the face I was to meet.

Next: The Sales Pitch: Part 2, or What Kind of Fool Am I?

The sudden death of a patient is devastating to doctors. It is beyond sad, or depressing - it is a viscious slap across the mouth, a painful screaming, a well-placed sledgehammer blow to the abdomen. Some oncologists, especially those instilled with empathy, may even consider such deaths as a failure on their part. This is ironic, because cancer patients usually don’t suffer sudden death like victims of a heart attack. They certainly can die from such events as strokes or pulmonary emboli, but typically they pass away after a predictable decline in function. The slow inevitable loss of a loved one, however, is no less tolerable than a sudden death and in some ways is crueler since it prolongs the sorrow of caregivers and relatives. I don’t care what has been published - in my world, where patients fight for their lives each day, there is no such thing as a good death.

With all the unhappy outcomes oncologists have to deal with both professionally and personally though, nothing brings them to their knees faster than a treatment-related death. By this I refer to a patient dying not from their cancer but from a complication of chemotherapy - usually an infection leading to failure of one or more vital organs. I write this today because over the weekend a patient of mine with metastatic cancer developed pneumonia after his first chemotherapy treatment, and rapidly went into septic shock. He now lies helplessly in the intensive care unit, and I would be a fool if I thought he was going to survive this blow. The buzzing swarm of “what-ifs” now torments me as I try to counsel his family.

Such a loss makes me think, even at the risk of sounding pretentious, of how Lt. General Lloyd Fredendall might have felt after the battle of Kasserine Pass in 1943. The unexpected loss of either patients or soldiers is a tragedy. It must not, however, weaken the will to fight on. Unless doctors can look to future struggles with a thoughtful determination to succeed, they may not get sacked, as Fredendall was by Eisenhower, but they will have nothing to be proud of when they look in the mirror.

Last night I went with my friends to the village carnival, where I saw a colorful tent with a sign over the door announcing “Fortunes Told.” I decided to amuse myself and went through the dusty flaps. Inside a cheesy actress dressed as an old woman sat at a small table. I could hear snickering behind me as I presented my palm for her scrutiny. Faded posters of flowers, mostly lilies, hung from the walls around us. The scent of sandalwood undulated overhead as she traced a few lines down to my wrist and looked straight at me.

“You are going to die before the new year begins,” she announced - and then bolted from the tent through a fold in the back.

I sat there like a mannequin for just a second too long before guffawing and hollering for an ambulance, much to the delight of the crowd.

The next afternoon as I drove to the office of my oncologist, I sensed that the trees appeared greener than usual. The sun was at a particular slant in the sky that seemed to cast an artificial glow all around, as if the world was suddenly in another part of the universe. Walking from my car to the office, I figured I was just experiencing a fillip of paranoia after my visit to the soothsayer - after all it had been almost three years since I completed chemotherapy. Still, her words were not exactly reassuring - of all the foolish comments she could have made, her prediction was particularly cruel to anyone who has had a serious illness. It was just my stupid luck, I thought, as I waited in the exam room. I looked around and noticed some new photographs the doctor had taken - this was one of his hobbies. A large framed shot of white irises overlooked the sink.

“I wanted to show you something,” my doctor said as he sat down on a stool next to me. I caught the faint essence of his cologne. “I noticed that your tumor marker was slightly high last fall, so I re-checked it at your last visit. Now it is much higher. I think we need to get some scans to see if there is any evidence of return of the cancer.”

He continued to speak to me, but I felt myself sliding down a chute backwards, screaming silently as the roar of a hurricane blasted my ears.

* * * * * * * * * *

Sometimes I feel like the gypsy in the circus wagon, cursed with the gift of clairvoyance, forced to reveal unhappy secrets to those whose lives are a glorious unfurling in the morning sun, but a forlorn withering by nightfall. A rising tumor marker in a perfectly healthy cancer patient is one of the most distressing developments ever conceived. It is a harbinger of adversity, a black mountain on the distant horizon that is the gathering storm, an unlucky card laid down by Madame Sosostris. Medical oncologists, however, play more than one role in this drama. They are also charged with the responsiblity of staring Kismet in the face and daring it to continue; they are given the task of conjuring a reversal of fortune for anyone suffering the oracle’s doom. Someday - not in my lifetime, but soon - a miracle is coming, and then the doctors’ laughter will be matched only by that of the people whose lives have been given back to them. That will be a sound worth waiting for.

As much as I fear and loathe the spectacular event known as cardiopulmonary resuscitation, or the code, it still holds me spellbound. I sometimes wonder if they still run codes the way I used to back in the day. [Some introduction. The slacker obviously has no clue how to write a compelling lead. -Ed.] I admit I haven’t read much on this topic since I last ran an official code, which was during the Reagan administration. I’m sure that if I took the time to do a little research it would become as obvious as a dystonic reaction that improvements in cardiopulmonary resuscitation are discovered regularly. I might even discover what those funny thingamajigs are that I see all over public places like the airport. I’m beginning to suspect that these are not really portable microwave ovens.

I could use a refresher course in CPR, but the thought of it sends porcupine quills up and down the spine as I recall my previous attempts at trying to revive the dying. I would hate to sign up for a course, plop down on the floor next to a Resusci-Annie and suddenly get flashbacks of a previous code and start screaming for giant needles, molasses, plumber’s helpers - anything to help save a life and therefore avoid having to inform a family that their beloved “didn’t make it.”

Hey, wait a minute - this could be the source of my gloom! I seem to have recovered the memory of walking ominously down the hall to a little room found in every E.R. - a room where family members wait to hear how their loved one is doing. During my residency it was called “The Quiet Room” which was an outstanding example of medical euphemism due to the fact that after an unsuccessful code the howling of bereaved relatives could be heard throughout the hospital. Outside of a personal tragedy, there is no worse feeling on earth than to have to break bad news to a heartsick spouse or parent. It makes me want to vomit just to think of it, but isn’t this considered to be the first step toward healing old traumas?

Sure it is, and any reflection done on the difficulties in dealing with patients who suffer cardiac arrest will ultimately lead to a deeper understanding of fear and its effect on making medical decisions. Such understanding will lead to self-discovery, and soon a peaceful rebirth of the true human nature of the self will heal all the old wounds - Q. E. D.

Ain’t that a brilliant piece of thinkin’?

The only problem with all of this omphaloskepsis is that I still am haunted by the last code I ran during my senior resident year. It was night when it occurred, at a time when the halls are mysteriously quiet and the distant garble of the late late show can be faintly heard coming from the rooms of the gomers, who never mind that their television is left on until morning. Of course I was lounging on the bed in the “Resident On Call” cubicle, savoring the last few morsels of a magnificent bedtime snack when the alarm went off. The usual suspects crashed into the patient’s room that night - an unkempt intern, several anxious nurses, a sleepy anesthesiologist, and two friends of mine who happened to be working on another floor. I ran the code, which ended with the demise of the patient (despite our heroic efforts). I was at the nurses’ station finishing up my note in the chart when I heard a series of cries reminiscent of cats being tossed off of a merry-go-round. These noises turned out to be the gasps of the participants who had lingered in the room just long enough to witness the previously deceased patient jump from the ferryman’s boat and swim across the Styx to rejoin his comrades now gathered around his bed. The noble resuscitators took up their tools of the trade and began to work once again on our poor nearly departed soul.

When a runner informed me of what had happened I reacted as if I had just seen a triple-layer cake explode in the oven. “It can’t be!” I thought as I ran down the hall but sure enough, the patient had a pulse and, depending upon which hysterical team member interviewed, either a normal blood pressure or one found only in Octupus vulgaris. Thus I was the only resident in the history of the training program to end his “Cardiac Arrest Note” with the following words: “Addendum: after pronouncing the patient he was noticed to have regained a pulse, and resuscitation was re-started.”

Egad.

Forgive me, O Lord, for all my sins of comission and omission - but this is ridiculous. I should have been a pair of ragged claws scuttling across the floors of silent seas rather than to have to endure such an unfortunate alignment of the stars. Just as a trapeze artist sheepishly ends his career after continuously falling into the net during matinees, I bid farewell to my role as the leader of the Cardiac Gang. I’ll let the stars of the Emergency Room run the codes, and I shall be content to contemplate my little corner of the universe where mitosis proceeds unbridled and esoteric concoctions are created in an attempt to halt the advance of the invader immortalized in the sky.