Archives of The Cheerful Oncologist, Volume 2

“Survivor Recounts Lobotomy at Age 12″

A 56-year old man underwent a transorbital or “ice pick” lobotomy as a boy in the early 60’s after being diagnosed as “schizophrenic” by Dr. Walter J. Freeman, the neurologist who “brought the lobotomy to the United States, first performing it in 1936.”

Brought the lobotomy to the United States? Is this an example of finding a market for your product whether customers need it or not? “According to medical records, Freeman diagnosed [the patient] as a schizophrenic - a diagnosis that would not have held today,” his current doctors say.

Oh, great - let’s all go out and hire a sales staff to push a new procedure on the unsuspecting public!

Over the years, lobotomies were done on about 40,000 to 50,000 people in the United States in mental institutions and hospitals. About 10,000 of those procedures were transorbital or “ice pick” lobotomies.” (Yes, your mental image is correct - the doc jams an ice pick above the eye through the orbit and into the frontal lobe of the brain).

By the way, it’s a good thing physicians changed to medical, not surgical treatment of psychiatric illness in the 1960s, or most of my 6th grade class would have ended up as extras in One Flew Over the Cuckoo’s Nest.

“According to estimates in Freeman’s records, about a third of the lobotomies were considered successful…but the majority of patients did not do well - some died, many were paralyzed and in the cases in which patients were well enough to leave the hospital after the procedure, many were left childlike and devoid of personality.”

I suppose if I was a cynic I would remark that lobotomies and cancer chemotherapy share some characteristics, namely that they can have low response rates and are fraught with the possibility of disability or death. The difference is that the damage from chemotherapy can be avoided by choosing less risky treatments such as hormone therapy or targeted therapy, or proceeding with an alternative treatment such as surgery or radiation therapy. Also, research continues in every country on Earth in an attempt to find and develop improvements in anti-cancer therapy, whereas I am not certain that anyone was able to refine the delicate particulars of the “ice pick” lobotomy.

Oh, and one last contrast between the two therapies- no matter how sick one gets from their chemotherapy, with today’s modern supportive care the odds are overwhelming that one will recover. Unless Dr. Victor Frankenstein is still in practice, I don’t believe one can send a lobotomy back to the store for a refund.

Gee, that Kevin, M.D. sure takes long vacations!

I have enjoyed posting stories of interest on his blog, in my characteristic highly dignified manner.

Here’s an example of the latest news:

“Dark Chocolate Helps Counter Heart Damage from Smoking”

Maybe I should comment on the medical news on this site…just for giggles…

Dr. Kevin Pho, who runs the popular medical weblog Kevin, M.D., has jumped the fence for a well-deserved holiday. In his absence he has asked a few of his fellow bloggers to fill in, which I personally interpreted as carte blanche to turn his website into a Mardi Gras of shenanigans.

The results can be found at Kevin, M.D., and I would like to thank Kevin for the opportunity to add a little mischief into the lives of his esteemed readers. After all, you know what they say about laughter…

“Courage is not the absence of despair; it is, rather, the capacity to move ahead in spite of despair.”
-Rollo May

Last week a patient of mine with breast cancer who was fortifying herself for a long course of adjuvant chemotherapy asked me a poignant question. For some reason I found it easy to answer her and it was not because I am necessarily blessed with a Lincolnesque ability to comfort the stricken. In this case I was just thinking fast. I listened to the question and then suddenly got an idea - I answered her by posing another question:

“It’s not ‘How do I get through this?’ but rather ‘How do I not get through this?’”

She looked at me with pleasant expectation just as I realized I had pulled this answer out of the old mental filing cabinet without pausing to take along the appropriate supporting documents. I could see the words beginning to form on her lips and, never one to be shy, jumped in front of her to ask myself the follow-up question that she was about to reveal:

“What on earth am I talking about?”

Perhaps I mentioned previously that we oncologists learn early on in our training to think on our feet. Given the dire straits our patients find themselves in, combined with the confusing jumble of detailed information they must assimilate, we eventually all become experts at providing accurate information (as well as hope) to the distressed. It’s a simple task, really - just say all the right things at exactly the right time without upsetting patients or their families. Oh, is that all? Not only is this a daunting task, just try doing it extemporaneously in the midst of a chaotic office visit. Oncologists therefore who spout snappy epigrams as I do must be cautious in their use, so we don’t end up awkwardly shaking pom-pons of encouragement when the team is down by twelve touchdowns, if you know what I mean. In this instance after hearing my patient’s question I suddenly discovered my own version of the answer: not the typical there-there-you’ll-be-all-right pat on the head, but a paradoxical way of addressing this issue of how one does survive the emotional trauma of receiving chemotherapy. I tried to convince her that it is more difficult to not get through treatment, and laid out my argument as follows:

“Remember, taking adjuvant chemotherapy is obviously different than taking treatment for an incurable cancer. You’re going to take chemotherapy to kill any microscopic tumor cells remaining inside you, but officially you’re in remission after your surgery. This means that you will almost assuredly recover from the physical side effects of chemotherapy, but what about the emotional side effects? When you asked me ‘How do I get through this?’ I’ll bet you mean ‘How do I get through this without becoming disillusioned, or bitter, or angry, or consumed by hopelessness?’ You’ll never fall prey to those destructive emotions because you aren’t struggling with the three things that in my opinion can poison one’s recovery from this ordeal. They are isolation, fear and hatefulness.

“Going through chemotherapy is a lonely time. No one, not even your oncologist (unless a cancer survivor also) can understand what it means to sit in that chair week after week. That is why you must send out a clarion call to your family, neighbors and friends that you need them by your side. Sharing your feelings with those who care about you makes your suffering all the less. Use them for rides when you don’t feel like driving; let them cook for you and water your garden. No one should have to go through this alone.

“Fear of the unknown - of chemotherapy side effects, the ability to continue working, whether or not you are going to live to see your children grow up - mangles hope and deadens joy as easily as if you were a condemned prisoner waiting out the night for a date with the gallows at dawn. It is my job as your doctor to fill this void with knowledge, to inform you of what to expect as your treatment goes along and assure you that you will make it through. It is unacceptable for any patient to be frightened because their oncologist did a lousy job explaining the details. My responsibility is to do everything I can to rid you of fear.

“Lastly, becoming angry or even hateful at the unhappy twist of fate that has befallen you is like choking yourself and then crying out “Somebody help me!” Giving in to hatred removes you from the rest of us and places you in a bleak, far off land where guardian angels never bother to visit. Fight with all your might against the syrupy promises that hate uses to entrap the disheartened.”

I wasn’t sure if she was particularly enlightened after listening to my pep talk, but remembering that the secret to counseling patients effectively is to counsel them constantly, I ended our conversation with this well-worn request:

“Write down your questions as you think of them, and let’s talk again soon.”

Welcome to the first Literary MedBlog Showcase, where the nominees for “Best Literary Medical Weblog” for 2005 get the chance to display their writing talent and familiarity with the King’s English. Each of the six stories showcased starts out the same, then is finished by the specific blogger. According to the rules, each story must contain a line from a holiday song (formerly known as a Christmas carol). My offering, complete with the required hidden line from a well-known carol, along with a few other tidbits from a certain poem by Clement C. Moore, begins thusly:

It was a dark and stormy night.

I struck the match and the flame burst into bright orange-blue life. It danced on the end of the matchstick as it neared the ragged edge of the cigarette dangling between my chapped lips. Soon the smoke that lazily trailed from the glowing end of the cancer stick filled the entire elevator. My fingers plucked it from my mouth and I exhaled, mindlessly watching the plume of wispy grey ash travel towards the cylindrical fluorescent bulb that poured antiseptic yellow light onto us. The elevator ungracefully jolted to a halt and the doors swished open. The man with a goatee in a long white coat and black patent leather shoes shot me a dirty look as he stepped off.

“We’re in a elevator in a hospital,” he derisively muttered, enunciating “hospital” as if he was introducing a new word into my vocabulary. “What kind of idiot smokes in the hospital?”

The elevator doors swished shut, but not before he noticed the solitary finger of my right hand poised in the air. At him.

He looked offended. I didn’t care.

The elevator lurched back into motion as I chuckled to myself. His expression was certainly more amusing than the duties that awaited me. Reluctant to acknowledge that I was near my destination, my tired fingers apathetically dropped the cigarette and I watched the sole of my left shoe squash it, along with its orange flame. The elevator doors swished open. I then looked up and noticed that just above the illuminated number “7″ someone had scribbled a graffito announcing with great enthusiasm that “Wanda”, whoever that was, possessed an extraordinary talent for performing what gentlemen would call a “risque act.”

Thoughts of Wanda and her intriguing approach to dating must have distracted me, for as I exited the elevator I crashed into a diminutive woman carrying a tray of Christmas cookies, sending them flying through the air. The resulting explosion was impressive, resembling a 4th of July rocket bursting in perfect symmetry as several dozen red and green stars floated up then down onto the hard linoleum floor. I tried to help the poor woman up without attracting attention but as luck would have it just as I sent her on her way (sans Xmas treats) I heard a familiar voice chortling behind me. I turned and what to my wondering eyes should appear but the hospital gossip himself, standing there with a silly grin on his face. I whistled and shouted and called him by name.

“Don!”

“We now are gay?”

A parallel thought occurred to me as he gave me a smirk: Dash away! Dash away all! I didn’t run off though, but instead offered him a piece of a shattered cookie. He laughed like he’d had a bowlful of Jell-o that morning and then turned like a jerk and laying a finger inside of his nose, trotted on down the hall - the round-bellied little creep.

Suddenly I felt as if hot coals had been pressed against my ears, and longed to sit down. Today was supposed to be my day off, and it had started out promising enough, with me nestled all snug in my bed, just settling down for a long snooze after a rather late night at the casino. When the phone rang at a quarter to noon I was still several layers deep into a complicated dream involving a physics final exam, a missing cheerleading outfit, and King Kong. It took a couple of hundred rings before I was able to raise my aching head high enough to find the phone.

“I know today’s your day off,” the strident voice said, “but we need you this afternoon. George called in sick and you’re the only one available to fill in. You’ve got to come in now.” I’m not certain what my reply was but I believe it included some serious accusations about George’s relationship with his mother. I must have consented because I soon found myself toweling off from a cold shower. After dressing I lighted my first cigarette of the day and with a little help from Mr. Caffeine and a stale Pop-Tart I soon was driving on in to the hospital.

Now after my incident with the Cookie Lady and that louse Don I felt embarrassed as I wandered down the bright corridors, trying to avoid eye contact with anyone else. I squinted against the pulsating bank of ceiling lights which gave the luster of mid-day to objects below. My head began to pound. Before reaching the corner I ducked into a restroom, locked the door and fired up another Marlboro. As dry leaves before the wild hurricane fly, so did great double-helices of smoke twirl upward from me - and right into an inconveniently placed smoke alarm. Just as the blasted thing went off I ran over to the window and threw up the sash, then dashed out the door and down the hall.

I could see my destination up ahead, a rather plain glass door with the number 101 painted on it. As I neared it I nervously fingered another cigarette and stopped. A passing nurse gave me a dirty look, and I glanced down, only to notice that my clothes were all tarnished with ashes and soot. I must have spilled my cigarette all over me when that alarm rang. The urge to smoke then overpowered me, and I did an about-face and locked myself inside a nearby mop closet. Approximately five minutes and one asphyxiated mouse later I emerged looking like a smoldering firefighter. The coast was clear so I headed into Room 101 and closed the door behind me.

From the seats of twenty formica desks, twenty faces stared back at me - some twinkling, some merry, some rosy and at least two with noses like cherries. They were mostly middle-aged folks, with a few thirty-somethings mixed in, and they had one thing in common with me: they all looked like they wanted to be anywhere but in this room. I silently sighed and with a final exhalation went straight to my work.

“Good afternoon. My name is Rudy Blitzen and I will be your leader for today’s session. Welcome to day three of our Stop Smoking Now and Forever! class. If you have any questions about today’s material just give a wink of your eye or a twist of your head, and I’ll explain. Now let’s go to work.”

That’s all folks! Be sure to visit the other blog sites as mentioned in yesterday’s post. Now let me exclaim ere I drive out of sight, “Happy Christmas-Hannukah-Kwaanza-Eid al-Adha-Diwali to all, and to all a good night!”

Edward George Bulwar-Lytton, call your office!

Tomorrow the following medical bloggers have a treat in store for their readers. Look for a short story from these literary-minded blogmasters:

intueri

The Examining Room of Dr. Charles

Barbados Butterfly

Bloodletting

Random Acts of Reality

The Cheerful Oncologist

Hint: one of us resides in a distant time zone and just might have already posted the story! Read them all tomorrow and compare each writer’s unique style and twisted imagination…

“I’m on Highway 17 about twelve miles south of Columbus and just had a flat tire.”

“Dad seemed confused this morning and now we can’t even wake him up.”

The above situations all have something in common, and it is not just that they are distressing. They all are followed by a question, which can be asked in many different tones, but is always composed of the same five words:

“What do we do now?”

Of the four problems mentioned the last is the one I encounter in my profession, and as one might guess the development of mental status changes can challenge even the most experienced physician. Before revealing how I would attempt to solve this crisis I might take a moment to explain what the first three problems have to do with the case of the comatose father. After a vigorous bout of head-scratching, (and thanks to our highly evolved intelligence), one might suddenly realize that the first three predicaments represent a certain pattern. For example, the highway crisis can be solved by one person in most cases - either by the driver or his rescuer if the driver hasn’t a clue how to change a flat.

The second crisis, however, is unlikely to be corrected by just one individual. After a storm bulldozes through a city it takes dozens of workers clearing trees throughout the night to restore electricity to the hundreds of darkened homes. A team of professionals is required to solve a dilemma as big as a power outage.

This makes perfect sense - some problems can be corrected by one person and others require teamwork. What then of the rain shower now pummeling the abandoned Yucutan beaches? Is there a way to stop the skies from emptying on young lovers? Can we ever hope to control the weather? And why do stars fall down from the sky every time you walk by?

Ahem…let’s not get distracted. The ruined tropical vacation is a perfect example of a problem that cannot be corrected no matter how many entreaties are made, or goats sacrificed. Some facts of life just cannot be changed, although they did finally take “Hee-Haw” off the air. What makes the conundrum of the obtunded slumberer unique is not that his malady is difficult to diagnose. Au contraire, it should be easy to find out the cause of his hibernation - it is the solution that represents the sticky wicket. Those of you who have been paying attention undoubtedly have realized the connection between the first three crises and that of our patient, namely that unlike the others, this problem seems to have three possible outcomes. It could be solved by one individual working alone, or only by a team of health care angels toiling throughout the night - or it may be clearly insuperable. Examples of each respective cure include the solitary caregiver reducing narcotic or sedative usage to correct the effects of overmedication, or the team of specialists called in to remove a subdural hematoma or begin radiation therapy for brain metastases. The worst of all possibilities is if the patient has slipped into an irreversible coma due to a cerebral hemorrhage or some other catastrophe.

Not that I need more tension in my life, but when it’s me standing over the obtunded patient, I do get excited and wonder what on earth the final answer will be - is there a simple solution, or is the patient doomed to drift off to the heavens as we all stand hopelessly by?

In the example above the crisis was precipitated by the patient’s calcium level rising from 9.8 (normal) to 19.8 (Holy-Mother-of-God-Batman!) in one week. Hey, at least I found out quickly what the cause was by reviewing a standard blood test. Fortunately for the patient this complication can be corrected - first by one person writing the proper orders in the chart, then by the team of pharmacists, techs and nurses who give the treatment promptly and skillfully. In my patient’s case after receiving treatment he awakened from his visit to the Sleepy Isles, and all was well - for now.

I say for now because whether I like it or not, being an oncologist is all too frequently like lying on the silky sands overlooking the turquoise waters of the Gulf of Mexico - and hearing the distant rumble of approaching thunder.

“God grant me the Serenity to accept the things I cannot change..”.

Last week I had one of those days when I felt not only popular but like a true celebrity. Everywhere I went people wanted to see me, to talk to me, to get me to sign my name for them. I almost wanted to put on a faded T-shirt, boots and a ratty old stocking cap and, like some overrated movie star, stroll down the boulevard, ready to deck any unfortunate papparazzo who dared to come within my reach.

That, ladies and gentlemen, is what is commonly called a pipe dream. In reality I was just another working stiff running around the office who happened to be an oncologist, and having identified myself as such, was now fair game for any and all nurses, patients, family members, colleagues, technicians and morticians who wished to exercise their right to demand satisfaction from me for a host of troubles.

Trouble…trouble…trouble - oh, we got trouble! Right here in River City! With a capital “T” and that rhymes with “C” and that stands for cancer!

Ahem…pardon the musical interlude. What I am trying to convey is the sense of angst doctors feel when they are bombarded with the suffering of the ill. Sometimes we get hit with such a missile barrage of problems we come to a stop in the middle of the hallway, listening to one tale of woe after another as we attempt to come up with solution that doesn’t immediately identify us as clueless or even worse, insensitive.

Unfortunately there are some complications of cancer that cannot be resolved no matter how hard we try. Not to be flippant, but death is a major complication of cancer. [No! Really? What a brilliant deduction, Sherlock! -Ed.] Even in this time of nascent hope as the promises from translational medicine become reality, death still finds its way into the sickbed as easily as the rays of the moon. Fatigue, although more readily tamed these days, continues to lurk around every corner, eager to weigh down the innocent. Blessed are the physicians therefore who follow our prayer and accept the limitations of medical care, and who possess the serenity to move on from the disquietude of futility toward more humble, but more readily attainable goals. To put it in the vernacular, docs are as worthless as teats on a boar if they ain’t at least tryin’ to help the patient.

“Courage to change the things I can…”

There are some adversities from cancer that can be alleviated, and when skillful physicians spot them they attack with as much force as St. Patrick did when he decided to collect snakeskin luggage. Of all the disgusting symptoms of cancer, none upsets both patient and doctor as much as pain. Pain is unacceptable at any level and in my opinion must be suppressed at all costs - even if the antidote leads to side effects such as sedation. I’d rather have my patient asleep and free from pain than wide awake screaming in agony. The same can be said for nausea, which can be successfully treated with modern antiemetics. All it takes is one tenacious caregiver to make a difference in someone’s misery.

I guess as long as we’re out hunting for things to change we might as well include the bete noire of ignorance. Oncologists have the power to slice through the irritating and humiliating haze of ignorance by performing one simple act: speaking honestly, yet kindly to patients and their families. Taking the time to analyze the medical record, carefully interview and examine the patient and construct a thoughtful plan of action isn’t enough - we must become adept at communicating with patients, otherwise they live with the awful fear that comes from not understanding what lies ahead.

“And Wisdom to know the difference.”

Here is where the prayer becomes the perfect inspiration for anyone besieged with a serious illness, or anyone who finds themselves, as I have, in a career spent trying to throw life preservers to the drowning. If only we could acquire such wisdom as to not waste our days worrying about things that frankly cannot be reversed. If only we knew how to unlock the gift contained with this peaceful saying.

Well, what are we waiting for? This isn’t a contest, or a quiz, or a lottery. Re-read the first line: “God grant me the Serenity…” This is a prayer, and prayers are how those with faith find relief from desperation. Therefore the next time we find ourselves wishing for strength to cope with adversity, we might try repeating this prayer and then believe that these gifts will appear when we need them the most. This is the secret weapon of the steadfast, incorruptible healer.

tergiversate: to use evasions or ambiguities; equivocate.

Anyone who thinks doctors do not work under pressure obviously has never been sick. How soon we forget the last time we sat in an exam room or in the Emergency Ward and, just like on a soap opera, nervously waited for the physician to come in and tell us that “everything was going to be all right.” What rippling confidence he had as he put his arms around our shoulders! How relieved we felt with the first glimpse of his immaculate smile and his crisply ironed lab coat as he pronounced the phrase we so desperately needed to hear! How calm and collected he was all throughout this crisis! What a sweet surprise it was to be invited to his flat that night for an elegant dinner prepared by his lovable housekeeper!

Yes, what a wonderful conclusion it was - unfortunately it had nothing to do with us because this blissful scene was from an old T.V. show we watched last night. In reality doctors don’t have scripts to follow, or directors to prod them to a better performance, not to mention a pre-written happy ending followed by a word from our sponsor. On the other hand, in real life physicians are continuously doing an improvisational act in front of a very attentive if not critical audience, and with no intermission. Seriously, when was the last time you interrupted your doctor in order to get a snack? See what I mean? Patients, especially the very ill, tend to hang on every word emerging from the doctor’s mouth.

Not that there’s a problem with that. It’s just that when communicating information to patients and their families physicians are often expected to understand the illness fully (omniscience), to have implemented the correct solution to the problem (omnipotence) and to be able to determine in advance what the outcome will be (precognition).

Gee, the last time I checked there was only one individual with all three of those powers and it wasn’t that dude with the red cape and the big “S” on his chest, let alone a humble doctor. Asking physicians to summon more powers than they were endowed with leads to this dilemma - should they play along with this role of a lifetime, or admit that they are less than perfect, thereby exposing themselves to the scorn of the anxious assembled all around them?

Let’s consider the options. We could choose to react to pointed or hostile questions that we haven’t a clue what the answer is like a gang of bandits cornered in a warehouse, firing back in anger. This manuever has about as much a chance of winning over the crowd as shouting “Heil Hitler!” during the playing of the national anthem before the start of a WWE match. Getting all defensive about the fact that despite treatment grandpa isn’t recovering from his brain metastases doesn’t strike me as a judicious let alone constructive use of one’s skills and energy. Then there’s always the “I don’t know” angle, whereby we assume a pose of mystical, Gandhi-like quiescence and look off toward some distant peak as we confess the limitations of humanity. This certainly might get one off the hook but does not exactly inspire confidence in our leadership of the crisis.

Therefore, when faced with a touchy situation or a clinical mystery that has us stumped, we bearers of the caduceus sometimes resort to circumlocution, to perphrasis, to taking evasive action like a submarine diving beneath the thermocline to escape a Russian torpedo. As a Method actor might say during rehearsals, “What’s my motive for this behavior?” Here’s what the director might say:

“You’re trying to avoid a confrontation. Doctors in general do not like to get into fights with their clients.”

“You’re desperately trying to focus on the good news; for example just think of all the money she’ll save on groceries by losing her appetite.”

“You’re afraid of being labeled an insensitive louse by the patient’s heavily tattooed family.”

“You’ve convinced yourself that your patient will improve despite any setbacks such as the fact that she just died.”

I know it has been said before, but let me repeat it for all: doctors have to learn to become good actors if they ever want their practice to flourish. The truth, aside from being something in the movies that folks are accused of not being able to handle, hurts when it is composed of unfortunate news. Sometimes doctors have to provide counseling in such a manner as to not create a wailing morass of distraught relatives who become a whirling dervish of misinformation and despair. You may call it tergiversation, but we pros call it diplomacy. Think of it as that old joke about the fellow who said, “Don’t just come out and tell me our cat died! For Pete’s sake break it to me easy - say that the cat is on the roof, and then the next day say it won’t come down, and the next day say it slipped and fell onto the rocks! By the way, where’s Grandma?”

“She’s up on the roof.”