I don’t believe in Cancer Cures

pexels-photo-69224I met Audrey the first week after I graduated from Medical School.  I was now called Doctor, and the title felt shiny like a bright new copper penny, but also heavy and uncertain.  She came in through the Emergency Department as white as a ghost and short of breath.  Her blood count was very low and she had no white blood cells.  A Bone Marrow Test quickly determined that she had AML (Acute Myeloid Leukaemia). Audrey was a slim almost waif like older woman who wore dark red lipstick and an elegant neck scarf, even when she was forced into the thin blue cotton patient gown.  When we, “The Team”  walked into her room 24 hours later and told her that she had “Leukaemia” she looked at us straight in the eye and stated  “I don’t believe in Cancer Cures”.  The attending Hematologist was perplexed, and left the room with me remaining present and looking nervously at Audrey.  She asked me what I thought.  I told her that I thought we could make her better, and if we did nothing she was going to die.

And that was the start of our Patient Doctor Relationship. She decided to stay in hospital and be treated.  I was the intern rotating on the Hematology/Oncology service so I saw her every day of that month. The 31 long days from when she started her chemotherapy to the final day that she got to go home.  I would pop in to spend some time with her when I was on call in the hospital, and she would always save me some small treat if she was well enough to notice my presence.  Many evenings she was not well enough but would look at me and put on a  ghost like smile. I sat in her room with my books and studied when she slept.

The day I finished that rotation was the day Audrey got to go home.  She had had her post chemotherapy bone marrow test and all was clear.  She was in remission.  Giggling she said she was as “high as a kite”  as she put back on the dark red lipstick. She had a tiny package to give me.  There was no card, and I unwrapped it carefully.  Inside  was an small enamelled  fish charm to put on a necklace or bracelet.  I thanked her. Time passed and I kept the charm safe.  It sat on the bracelet that  my granny gave me when I turned twelve.
At the end of that internship year  Audrey came back through the Emergency Department.  Low blood again and no white blood cells.  Her leukaemia had entered again into an acute “blast” stage.  There was nothing more that could be done. She was dying.  I had seen patients die before, but never one that was so connected to me.  I was just learning how to have empathy without feeling every moment of pain personally.  And besides I didn’t want to lose that ability to feel the pain of my patients.
I couldn’t go in the room to say goodbye to her. I stood outside the door numbed with pain nervously fingering my little enamel fish.  I couldn’t even cry because it would have seemed unprofessional.  She died before I could say goodbye.  She didn’t suffer to my knowledge.  After she died I went in the room because the nurses asked me to pronounce her death.
That was 30 years ago…

Brief Encounter

pexels-photo-26168I remember being called from the ICU to come assess someone on the medical ward. A young man from one of the local university residences had a high fever, a weak blood pressure, and now he was breathing fast. When I saw him, he was too breathless to speak more than 1 or 2 words at a time. There were a few purple spots on his arms and legs. Those were new. An IV drip with a powerful antibiotic coursed through his left arm. He was shivering. We brought him to the ICU, waiting in case he tired to help with his breathing, and using medications to support his blood pressure, hoping it wouldn’t cut off the circulation to his limbs or his kidneys.

He was growing Meningococcus in his blood by the next morning, the deadliest form of that dreadful bacterial infection. I got a report and a pill. “You were exposed,” the nurse from occupational health said. “The vaccine that will be offered to the whole residence wouldn’t be effective in time if you got sick.”

Thankfully, the patient recovered in a matter of days, and got back to school the next semester. No other cases were reported. He had a less common strain that had a vaccine at the time; the more common strain, type B, had no vaccine until quite recently. But the immediacy of treating a potentially deadly disease, having to take medication lest I get sick and even worse, potentially further the spread of that lethal infection, stayed with me for a while.

The blessings of modern science, public health, and systemic hygiene, mean the worries of a sudden encounter with unseen lethal forces like smallpox, diphtheria, and pertussis, are largely a thing of history. I had a brief encounter, and the young man lost a semester of school but recovered. Unless we are vigilant about vaccinations, we as a society could lose a lot more.

I cried…(2/2)

pexels-photo-39811Then the question came; how long do you think she has? A sister and a brother are on their way here tomorrow. I don’t know for certain, so much variability, but it could be a day, maybe two, I answered hopeful. I walked over to the bedside and checked her pulse, slow and weak. Then, I noted her breathing was changing, there were some apneic spells. I looked over to the daughter who seemed to know. Is she getting close, she asked? Yes, she is, I answered.

I stepped aside to allow them access to their mother’s bedside as the daughter moved to close the door to the room. She grabbed my coat sleeve and said she wanted me to stay. She indicated the bedside. I went to their mother, pulled the blanket off, and held her cool hand, noting the paleness and the cyanotic nailbeds. The son and daughter are next to me as they ask why the colour changes and I answer that her body is shutting down. She is getting closer.

They step outside the room to call their families to come and I am left alone with this brave valiant woman. I note that her breaths are further apart now. It seems like many minutes go by but likely only a few seconds before they return with everyone, tears streaming down their faces. I cannot feel her pulse, the right carotid is no longer pounding, and her breathing has stopped. How long has it been I wonder as the daughter asks if she is gone.  I wait a few seconds before turning to them all and announcing by nodding my head that she is gone. The daughter was nearest to me and she hugged me as I said I was sorry for their loss. As I left the room, I quickly patted the son’s arm as well. That’s when it started.

I could not hold back the tears quietly falling down my cheeks, much as I tried. The nurse and the support worker were coming up the stairs and down the hall; did I want a stethoscope to verify my diagnosis of death? No, that won’t be necessary. I know, I felt it. I made my way downstairs to the office, wiped my tears, and sat down to do the paperwork. The nurse came to see if I was alright. The son came downstairs and asked me if I was ok, too.

I am fine, I said. It has been a long time since I was at the bedside while someone is dying and I had forgotten how special this moment is. I expressed my appreciation; their family had allowed me this privilege after knowing me but a few minutes. You have a heart, the son said, as he hugged me and thanked me. Thank you, I said and meant it.

On my way out of the house, I saw the daughter again. She seemed to be coping well. She hugged me again, saying we are so used to doctors being so standoffish and strict. Thank you.

I was putting on my boots when the son came over and encouraged me to drive home safely. And the same to you. Walking to my car, the freezing rain, the cold, the slippery roads did not matter. I did not feel like I usually did after a call; I felt like I had just lived something very precious.

I cried…(1/2)

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My family will tell you I cry easily. Bets are on when I watch a movie with them as to which scene will start the waterfall. But it was not a movie that made my cry the other night.

I am a coroner and I have attended thousands of deaths: at home, on the roadway, in the hospital, in the forest…but I do not cry there. Sometimes it is harder than others not to. I am expected to be the voice of reason and calm in often chaotic scenes. I do not disappoint; I do not cry there.

I am a family physician and I have attended upon thousands of people over more than thirty years: in their homes, in the office, at the hospital, and even on airplanes. Rarely have I come to tears with a patient, only after they have left will I allow the sadness of the news given to flood my mind. I am expected to be strong, calm, in charge, and I should know what to do; have a plan. I do not disappoint.

I practice palliative care in the home and at hospice. I attend deaths to say goodbye to the departed and the families; the latter needing the most attention. I offer words of empathy and sympathy; I remain calm. I try to lessen their distress but not their loss.

The other night…she arrived with her daughter and her son just before 4 o’clock. She is comfortable, the nurse told me, just letting you know she has arrived. I assured her I would be in later. It was 6:30 when I met them. The weather was turning nasty as I entered the hospice.  The door to their room was open, I noted, as I took off my boots. The daughter locked eyes with mine, offered a smile, inviting me in. I didn’t bother taking off my coat as I walked in and introduced myself. We shook hands and I met her brother sitting in the chair nearby. So, tell me about your mom, as I glanced quickly at the older woman settled in the bed and sleeping comfortably.

She told me much about her mother, how she had lived on her own, a full life before dizziness changed things. She invited her to come live with her a while as she recovered from the inner ear problem hampering her independence. Soon after, she realized that something was wrong, she was just too listless. After taking her to the local hospital, she was admitted and eventually, she was diagnosed with cancer that had spread to her brain. Treatment followed but it was not working and she was getting weaker. They said she was palliative earlier this month. I kept her at home as long as I could, the daughter said. But, she is not eating or drinking anymore. The nurses put in two ports for pain and seizure medications, and we needed help. We are all ready for hospice.

I listened to the story of this mother and grandmother who had obviously been cared for with much love. Her daughter was impressively well organized in her thoughts as she provided details; her brother added some details as well. They seemed to be working very well together; their mother was fortunate, I thought, as the son walked over to their mother, got a sponge swab wet with water and cleansed her lips and inner cheeks with ease while speaking to her gently. I observed the reaction from their mother, barely a moan, she was deeply asleep. She seemed to be breathing with some effort now.

 

 

“We are lucky”

I looked up from the photo that he’d handed me, trying not to convey my shock. His eyes were earnest and he sat forward in his chair, waiting for my response.

Those are my parents.” He said. “We took that picture when we found them.”

There was little that could have prepared me for this moment, sitting across from a bright, kind, and unfathomably resilient young man, looking at a photo of the corpses of his parents.

In an instant, everything disappeared but the need of this person in front of me to feel validated, connected, and human.

For some reason, it was important to him that I see his parents.

And my job, as his Doctor, was simply to help him. The patient scheduled before him had not shown up and I had spent the hour in extreme frustration. Now, I fought back tears as I looked at this young man. My chest tightened and I had to remind myself to breathe.

In my previous discussions with this patient, I had learned about the horrors he had survived: watching his family killed one by one in front of him as he hid behind bushes, pulling his sister – barely alive – to the safety of a nearby church and leaving her there without knowing whether she would survive; fighting through horrors, hunger, and the wilderness to reach another country – and refuge. He was thirteen years old when he fled Rwanda.

He’d finally made it to Canada and was now a full time graduate student, in contact with his sister back home, and haunted by unspeakable terror. He was trying to survive – to study, to date, to make friends – all the while wracked with guilt and overwhelming gratitude blended into one dissonant, weighty mass.

What could I possibly offer by way of comfort?

“Do you have any pictures of your family?” I asked at his last appointment. “Yes,” he had replied. “I have one. Would you like to see it?” I had answered that of course I would and today, he pulled the photo from his pocket.  I expected to see the smiling faces of the family he’d so lovingly described.

“My parents.” He nodded towards the photo. “That’s my mother.” He added proudly, pointing to one of the skeletal remains lying uncovered amongst others on a long, flat rock. He and a woman he confirmed to be his sister, stood smiling beside this pair of bodies in the dim light of what looked like a cave.

We identified them by their jewelry.”

“My mother was wearing her ring, and my father had special cuff-links that they found beside him in the ground.It was three years later that they found them.”

I thanked him and gave him back the photo, telling him how glad I was that he and his sister had found their parents’ remains.

Yes,” he said. “Thank you. We are lucky.”

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A Little bit of serendipity

She was the daughter of a childhood friend who I hadn’t seen in twenty years.  She bounded into my office, full of energy, laughing as she excitedly told me about her day.  As a 10 year old, she loved the fact that her doctor was mommy’s friend from when SHE was ten.

“What’s up guys?” I asked her mom and my 10 year old charge.

“Oh, I just wanted to check in with you about something.  I’m sure it’s nothing but just thought I’d double check.  Lisa has been having some nose bleeds that take a while to stop and today she seemed to have trouble swimming –she got tired quickly and said she couldn’t really breathe. I’m sure it’s just a cold”

“I feel fine!” protested Lisa, as her mom told me the story

“Sure you are, and stop putting things up your nose!” I said teasingly, as I helped her up on the table.

Of course she just had a cold, or at worst was a little anemic. I knew this kid didn’t exactly have the greatest diet. I asked about other bleeding including from her gums (yes-she doesn’t floss!) and whether she had started her period (NO!).  I quickly did my physical exam, looking for enlarged glands, open sores in her nose, and listened to her chest,  while chatting with her mom about her current pregnancy.

Out of the corner of my eye, just as Lisa was about to hop off the table, I saw them.

Petechiae.

Just a few scattered on her chest.  I lifted up her pant legs and pushed up the sleeves of her arms and there they were-bright red pinpoint spots.  And on her thigh- a large purple bruise.  A few more when I looked at her back.

“Where’s that from?”

“Oh you know Lisa, always bumping into things”, her mom shrugged.

“Well most likely she’s fighting off an infection and it’s viral given what I’m seeing and hearing” but I would like to do some blood tests.

“Mom, no!!!” Lisa whined as her mom took the requisition from me.

Her mom glanced at me with a raised eyebrow, knowing I wouldn’t make her get a needle if I wasn’t a bit worried.

“I’m sure it’s fine, but Lisa, I do need you to do this” I said. Promises of visits to the toy store were made and the tears soon stopped.

I forgot about the blood test as the week went on. Until Friday. And I saw it.

Leukemia


That was 8 years ago and I’ve left that practice and moved provinces. I’ve lost touch with my friend and her daughter but I know through mutual friends that Lisa is doing fine.

I’ve frequently thought about that visit and wondered, what possessed me to order blood tests that day instead of waiting and bringing them back to see if the symptoms resolved?  That’s what I had always done before and normally would do. It would be the standard of care.

I never did blood tests on kids and subject them to unnecessary needles.

How is it that a friend who I had lost touch with, showed up briefly in my life, for me to diagnose and help her daughter with cancer, only to go our separate ways again?

Serendipity. That’s how.

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Happy Passover/Easter

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Reflections at Passover/Easter

Like so many second generation Canadians, my grandparents chose Canada and Canada took a chance on them back at the turn of the last Century. We are a Jewish family. My grandparents were fleeing the last days of Czarist Russia and the Pogroms that targeted poor Jewish villagers, just because of their religion.

Once safely in Canada they started their new lives with a commitment to education, charity and service. They were poor immigrants to be certain, but they were rich in their good fortune as new Canadians. I tell my friends and sometimes my patients, that I have won the lottery twice in my lifetime. The first win was when those same grandparents made the hard choice to uproot themselves and move to Canada, (Winnipeg, no less). The second lottery I won was when my parents said to my sisters and I that we should study anything we were interested in at University and that they would do what they could to help us financially. So, I chose medical school as my path to a fulfilling career, embodied by service to others and lifelong learning.

Over 30 years of General Family Practice, I continue to feel lucky. I share the best and the worst moments in my patient’s lives. I can encourage and comfort. I can support healthy behaviours and discourage unhealthy ones. I can laugh and cry with you. Yes, I do cry, sometimes with you, but more often after you have left my office. I cried today. I cried for the children of Syria who, unlike me, were simply unlucky to be born in Aleppo or another war torn city. I cried for my patient who will lose everything she holds dear, because of her addiction. Yet, I can support my patient, offer her comfort and the promise to be there every step of the way in her recovery. I wish I could offer more. I wish the children of the world had the good luck that has blessed my life. I wish I had a magic wand to mend all the broken hearted patients I encounter day in and day out. I wish that this Passover/Easter season, we can all take time with our loved ones to count our blessings and commit to making a difference wherever and whenever we can.

Together we can be the change.

Happy Holidays

The sound of no heart beating….

Still on the theme of organ donation, both from the viewpoint of the medical team, family and recipient. #save8lives #trilliumgiftoflife #beadonor

Healthcare and Humanity

pexels-photo-165746The sound of a needle driver (what we use to suture) opening and closing is barely audible.  In fact, if you ask most surgeons, they’ll tell you it’s silent.

But standing in the operating room alone that day, no radio on in the background, no nurses talking, the vital signs monitor off, the anesthetist gone…it was the loudest sound I had ever heard.

Each time I went to sew– open click, grab thread, close click, needle pass through the skin, repeat–the soft click made me cringe.

The noise seemed an affront to the baby in front of me. And I couldn’t stop thinking of him as a baby.  A baby that would never be a toddler. A child. Adolescent. Or adult.

A beautiful baby–stuck forever in this moment–an infant.

Open, grab needle, close, pass through skin, repeat.

I was a junior resident on a pediatric cardiac surgery rotation. In…

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His Final Gift

FullSizeRenderWhen my father died many people approached me to tell me about the small things he had done to change their lives..  They were apparently insignificant things as I never knew about them exactly.  Not accomplishments that would come up in general conversation, a curriculum vitae or at the end of an illustrious life, an obituary.  They were things like providing tutoring before a big exam, and other favours of that nature.  They were cumulative and I would hear repeatedly about these small gifts.

His final gift. He had Parkinson’s, and his world in the last couple of years of his life became increasingly restricted. His mobility suffered and at the end he suffered a fall resulting in a massive cerebral hematoma (traumatic stroke)  and brain death.  As a result he was able to give his final gift.

I signed the consent for organ donation as they turned off the life support.  I guess I wondered what would happen, but was a bit too numb to completely understand.  Time passed and I heard nothing.  His old gold watch for a while was his only tangible presence and I wore it 24 hours a day. It was like  having a childhood lovey, a talisman.  Eventually I had to relinquish it to my brother as it was not mine to keep; his final gift to my brother.

A letter came to me a year or more later from “Trillium Gift of Life”  . The letter was forwarded from the woman who received his liver.  I was a bit shocked that someone ended up with the liver of an elderly man, but I guess it was a good liver.  She was writing to thank us for his final gift.  She had just welcomed her first grand daughter into the world.  The year before she had been dying of liver failure secondary to “Primary Biliary Cirrhosis”.  She knew that her daughter was newly pregnant, but also knew she likely only had a few weeks left to live.  When he died he gave her back her life as well as gave her grand daughter a nana, bubbi, granny or whatever that special person is called in whatever culture.  His final gift of love.