WHEN LIFE GIVES YOU ONIONS

Have you ever read that spoof-newspaper, The Onion? Sometimes it just cracks me up. Like in this article about big-league baseball contract negotiations. Have a great weekend, everybody.

IN CASE YOU WERE WONDERING

Just in case you were wondering where I got the name, The Wounded Surgeon, I must admit, I didn’t make it up. There is a series of poems, The Four Quartets, by TS Eliot, which contains this beautiful and apt image:

The wounded surgeon plies the steel
That questions the distempered part;
Beneath the bleeding hands we feel
The sharp compassion of the healer's
art

More recently, a book of literary criticism called The Wounded Surgeon was written by Adam Kirsch. In it, Kirsch explores the lives and writing of six modern American poets, Elizabeth Bishop, Robert Lowell, John Berryman, Randall Jarrell, Sylvia Plath, and Delmore Schwartz. The title just struck a cord with me, somewhere in between poetry and real life, between the aphorism, "Nothing new under the sun," and "Hey, I was just about to say that!"

When we're born, our parents give us a name. Seems it's taken me all this time to realize that the best ones are already taken.

JUST LIKE DAD

Last Sunday my eight-year-old daughter said something really smart. It was bright, funny, even a little political and competitive. My sister, surprised, told her, “You sound just like your Daddy.” We all laughed. It was something my husband would say, we could almost hear him saying it. My daughter answered, “Yeah, my Dad’s a good role model.”

I chimed in on this post-Italian Ice conversation. Our whole family was taking a stroll after dinner and I was a few steps behind them walking with my Dad, her Pop-Pop. “You know, my Dad was a pretty good role model, too.” I explained, as much to her as to myself. I thought how my entire life I have emulated my father. Quiet like him, humble, steady under pressure, a good student, faithful, kind, goofy sense of humor. Even professionally, I became a surgeon, just like him. “Yes,” my daughter answered. “I guess all fathers are good role models.”

I gave her my sad face, like I felt left out from her list of heroes. “No, Mommy, you’re my role model, too,” she explained. “You see, I want to be a doctor, just like you, but I want to talk just like Dad!”

THE DREAM OF A COMMON LANGUAGE

My husband turned to my nine-year-old son at dinner. “This summer,” he proclaimed, “we are going to learn Italian.” Why would he decide to take on such a feat? It couldn’t have been the food. We were sitting at an overpriced strip-mall Italian restaurant, disconcertingly named after the Native American name of our town on Long Island and some neologism combining the word pasta with the word cafeteria.

I doubted that it was the ambiance. There was a strange trompe l’oiel mural covering one wall depicting an open air piazza in Rome or one of the hill towns of Italy. The remainder of the dining room contained fake brick, wood laminates and artificial plants. It was a study in illusion.

I once listened to a patient ramble on in Italian about his latest hospital adventure. I had greeted him with the few phrases of Italian that I knew from our honeymoon in Italy or had learned from the housekeeping staff at the Brooklyn hospital where I used to work. He mistakenly assumed I was fluent in Italian, and began his discourse.

He told me of a recent hospital admission during which he felt he was treated rather gruffly by some of the associates in a large gastroenterology group. First they mistook him for his roommate, then they continued to call him by the wrong first name, then they said they didn’t know why he was bleeding. He felt alienated and dismissed. I shook my head, and let him continue, giving up on my attempts to steer him toward an English version of his story, just enjoying the lilting cadence of his emotional words. Then I answered him, and he smiled, realizing that my answer was in English, but that I had understood everything he had blurted out in his own native tongue. I examined him, reassured him, and he thanked me as he walked out to the receptionist to make a follow-up appointment.

I brought his chart back to my desk and for a moment let myself dream of a common language.

CERVICAL CANCER VACCINE APPROVED

As anticipated on this blog, the FDA has approved the use of Gardasil, the vaccine that protects against human papillomavirus, in 9 to 26 year old girls and women. Strains of this virus are believed to cause 70% of cervical cancers and 90% of genital warts. Click here for today's New York Times article on the subject.

HUMP DAY

Nope, can’t have sex yet, just looking for a way to describe my first Wednesday back at work. Raining and gloomy. Traffic snarls. Another fund drive on public radio interrupting my commuting pleasure. A distant colleague, well-known in the hospital where I did a colonoscopy today lost his wife to lung cancer on Saturday. She had worked in his office the past couple of years, since his recent cardiac problems required stents and then bypasses, and a careful eye on his schedule. The endo nurses had gotten to know her as she would walk over to the hospital from his office with cases to book. They say at the wake he looked really crushed. They speculated that he probably thought he would be the first to go. Two adult children at home and a grandchild that they would mind while their children attended college nearby. Now he’s a widower. Sometimes there are just no words.

The office has been busy, but quiet, especially with my compadres out of town at the ASCRS annual meeting. One of my patients got into a rainy day fender-bender when some chuckle-head backed into her car in a parking lot. The weather channel is predicting five more days of rain.

Home now, and Blogger has the hiccups, and is down for maintenance. The Yankees-Red Sox game got rained out. It has not been rescheduled as yet. Guess I’ll catch up on some reading. Safe home everybody. Be careful in the rain.

THE MOST IMPORTANT SOMEONE

The large pharmaceutical company Merck, perhaps still reeling from the troublesome recall of their immensely popular anti-inflammatory, Vioxx, has launched a public awareness campaign for cervical cancer. It’s called “tell someone,” and is penetrating the print and television media with splashy ads, including tear out colorful postcards in Spanish and English and 60+ second television commercials outlining the importance of screening examinations (Pap smears) that can detect cervical cancer at very early, and precancerous stages.

Cervical cancer is the third leading cause of cancer-related mortality in women worldwide. This year an estimated 10,370 women will be diagnosed with cervical cancer in the United States and approximately 3,710 women will die from this disease. Ninety-nine percent of cervical cancers are caused by a virus called the human papillomavirus (HPV). This virus is sexually transmitted and rampant. It is suspected that more than 80% of sexually active adults are infected with or carriers of this virus. Recently published studies demonstrate the effectiveness of an HPV vaccine which Merck will introduce to the market amidst this public service media blitz. Speaking of media, in the time since I was diagnosed, I have seen TV news coverage, news magazine coverage, and even blogs about cervical cancer and HPV, and the controversy surrounding the new vaccine. Glaxo-Smith-Kline, another pharmaceutical giant is working on a vaccine of their own.

In the 15 years since I have graduated from medical school, there have been few medical developments of such magnitude. In surgery, the pendulum has swung from radical mastectomy past lumpectomy and axillary dissection to lumpectomy with sentinel lymph node excision in the treatment of breast cancer. The introduction of laparoscopic surgery continues to influence surgical practice, with more and more minimally invasive procedures developed and perfected each day. But a vaccine to prevent cancer? That is big. Really big.

But while I'm "telling someone," who is the most important "someone" to tell? Obviously too late for me, and for anyone like me, already diagnosed, in fact already treated for cervical cancer. Who will a vaccine that can decrease the risk of this cancer help the most? Editors of The Lancet medical journal wrote a piece this past January exploring this question. The studies on the drug included young women in their teens and twenties. The studies have shown maximal effectiveness in the young women who were not sexually active and who tested negative for HPV. Effectiveness has not yet been proven in men nor in children, although studies are ongoing.

It has been more than 30 years since the model of a cancer causing virus was first proposed. It has taken that long for a vaccine to fight that virus to be developed, and may take a few more years to understand the epidemiology behind eradicating it or at least protecting people from its worst consequences. In the meanwhile, my philosophy will be "Tell Everyone," and the most important "someone" that I need to tell is outside swimming in our pool. She's only eight, and just got home from school, so I have some time to let the FDA and the political pundits work on some of the controversies. It won't be long, though. Indeed, she has already been subject to more than her share of "serious conversations" in the past few weeks. That's how I know that my daughter (and I) will be able to handle this one, too.

INSURANCE RUNS

If you have lost your life
Without noticing it
Somewhere in your
forties
Or misplaced it perhaps in childhood,
That casualty does not
appear on the schedule. . .

From “A Schedule of Benefits,” by John N. Morris

This poem appeared in POETRY magazine in 1981 and caught my eye from the pages of The POETRY Anthology, I’m not really sure why…probably just the mood I’m in. Honestly, I didn’t mean to put the evil eye on Posada when he sat out a few games due to back spasms… looks like he avulsed his hamstring muscle his first game back. Guess that puts me ahead in the race to get back to work.

SIGNS AND SYMPTOMS

Saw Dr. Abu-Rustum at my first post-op visit yesterday. I made the appointment at their satellite facility in Commack. It had a similar setup as the Manhattan Outpatient Center, large, comfortable waiting areas, with wings of exam rooms and treatment areas. I understand they do surgical consultations and follow up appointments, as well as chemotherapy and radiation treatments at that facility. Sitting in their spacious waiting area, I grew once again very grateful for the relatively early stage during which my cancer was found as well as the rather straightforward nature of its treatment.

Dr. A smiled when he saw me, and apologized for the delay. It was over an hour since my scheduled appointment time before I got in to see him. His face grew more and more concerned as I told him of the fever of last week, the symptoms I had, many of which, chills, sweats, pelvic pressure, were now gone. He nodded at the bloody drainage that I am still experiencing, and mentioned that the pulling sensation at my wound when I urinate was very common, described most often by women having hysterectomies in the face of endometriosis where the ovaries are preserved. In a panic I asked, “Is this going to happen every month?” He assured me no, that once the post operative inflammatory response of the endometriosis calms down, when everything heals, I should not be having these symptoms again.

I confessed to him that I had tried to go back to work last weekend, but that my associate was uncomfortable with such a short recovery period. He laughed and said, “Good, I like that guy…I like his thinking…smart guy.” He was not as entertained one bit by my experience with his own office, and found it particularly vexing that he had not gotten the message that I had called with concerns. It was evident that he was not keeping up with my blog! He grew anxious to examine me.

I will spare you the details of the examination. Suffice it to say that he remains concerned about the fever, the drainage, and the healing of the vaginal cuff (the upper part of the vagina which was sewn closed after amputating the uterus). He believes that there was a collection of blood, lymph, and fluid building up inside (fevers, sweats, pressure), that has now “broken through” to decompress via the vagina (bloody drainage). He now has me on two antibiotics, three times a day, and an antifungal chaser to take on day 10 to guard against any yeast infection.

He limited my activity to walking and going up and down stairs, but no lifting, no situps, no swimming or riding a bike, stay off my feet when possible. Absolutely no sex, no douching, no tampons, nothing per vagina…really, it is very fragile, it will rupture, he warned. (Yeah, as if…!)

No, I can’t go back to work just yet, he said, because I know what you’ll do…and I don’t want you standing hunched over an OR table for 3-4 hours, or spending a morning doing 3 or 4 or 5 or 7 colonoscopies, not yet, you’re still healing. Finish these antibiotics and if everything gets better, you can go back to work. He scribbled a sentence on his prescription pad… “Dr. B—may return to full work on June 5, 2006.” Is that OK with you? I didn’t answer.

He tried to cheer me up. “Well, it’s OK with me, in fact longer than that would be OK with me, but any less than that…not OK. And if your fever comes back, I need to know.” I smiled a smile reserved for such occasions. “I’m not kidding, “ he scolded. “Please don’t go through the regular channels to try to reach me. You call the page operator at Memorial and tell them ‘This is Dr. B—and I need to speak with Dr. Abu-Rustum.’” I kept smiling, maybe even a little nervous laugh. “Seriously, M, you are my colleague. You are a surgeon. And if you think something is wrong, I need to know.”

I stopped smiling. Now I was getting upset. He sensed this. “Listen, M, you’re going to be all right. You're not septic, OK? Just a localized infection, draining, which is good. This will get better. You just have to be patient, give it some time. You are still healing. I can still see the (absorbable) stitches we used. You have to let things heal.”

I thanked him, waited for his nurse to fill out my disability forms, then went to my office to break the news to my office manager.

HOME AND AWAY

The Yankees had an amazing 5-4 win today in 11 innings against the Mets. Mariano Rivera got his first save in a while, coming in to strike out the side in the bottom of the 11th. This follows a heartbreaking loss to the Mets, where just last night, Rivera came in with the game tied and gave up the winning run in the bottom of the ninth. Which just goes to show you, anything can happen.

The Yankees have been hampered with injury this spring, just this week getting bad news about Carl Pavano, Shaun Chacon, and Tanyon Sturtze, all pitchers in what’s turning out to be a fairly meager pen. This added to a hand injury to right fielder Gary Sheffield, and a broken wrist on left fielder Hidecki Matsui. Just before yesterday’s game, manager Joe Torre added backup outfielder Bubba Crosby to the disabled list for a hamstring strain.

Former Ace pitcher Randy Johnson continued to struggle through his fifth straight horrible start last night. I was intrigued for a moment, before the start of the bottom of the second inning, after Johnson had warmed up, that catcher Jorge Posada stood from his catcher’s crouch, walked into the dugout and took himself out of the game. Recently, Posada had gotten some clutch hits, including a walk-off homer in the bottom of the ninth to win against the Texas Rangers 14-13. It is well known that throughout his career, Randy Johnson has preferred pitching to one catcher over another, and that Posada was never one of his favorites. Did Johnson ask for the change? Is he in any position to ask for such a favor? Did Posada tuck his ego under so early in the game to help a struggling Johnson or was Johnson just not listening to him, not hitting his targets, shaking off his signs, and Jorge just got fed up? Did Posada hit the bench for himself, or for the team?

These were the questions I asked myself, having grown up during the Yankees “Bronx Zoo” era, when egos loomed large, and personalities clashed in concert with on the field struggles and triumphs. No doubt the vignette held additional interest to me, considering my own experience at work yesterday morning.

I hit the office early, dressed to the nines, ready for action, ready to attend to any work that had piled up on my desk, then make some rounds. Two full weeks out from my surgery, I thought taking call this weekend, with a pretty low census (if any) in the hospital, and no major cases slated for Friday, our usual operating day, may be a nice way to ease into things, feel like I’m doing something, without spending hours on my feet in the OR.

The boss thought differently. When I called him to get the list of patients he would want me to see in the hospital this weekend, lets just say he “shook off the sign.” He said, not in so many words, “Look, M, I’ve been talking to some people, and I just don’t feel comfortable with you coming back this soon. Two weeks is too early. I’ve talked to GYN’s who do this operation and women who have had this operation and some people are out 8-9 weeks. I understand you aren’t even driving yet… I just don’t think I can take the chance of having you come back too soon…you’re a surgeon, you know what can happen, you can get an infection, herniate, bleed. I’m just not comfortable. It’s too soon. Take another week. See your doctor, get a note from him that says when it’s OK for you to come back, then maybe I’ll be more comfortable. Right now, I just would feel horrible if anything should happen to you.”

I don’t know if it was being shocked, embarrassed, or stupid, that I had no response, defense, or retort to his argument. I wanted to say I’ve been busting my ass to get well so quickly, to have as little effect on my productivity, our practice, and our patients as possible. I wanted him to know that one of the reasons I had my surgery in the city with Dr. A, was because he believed he could get me back to work in less than half the time predicted by my original GYN. I wanted to cry didn’t he realize I’ve used up all my vacation time and can’t afford to take any more time off. I wanted to sing, “Oh, put me in coach. I’m ready to play—today!”

But I didn’t. I just acquiesced, saying of course I didn’t want to do anything that would make him uncomfortable or put him in a difficult position. I packed up my things, called my husband to pick me up, and went home. I called my doctor’s office to see if I could get a note that would clear me for work on Monday, but they balked and advised me to wait until my post-op visit next week to discuss it with Dr. A. I changed out of my suit and into sweatpants. I surfed the internet to bone up on short term disability benefits in New York State. I slid into a deep, deep funk. After Posada left the game, I went upstairs to listen to the rest of the game in bed, and slammed the off button on my clock-radio when Rivera gave up the losing run in the ninth.

The official story is that Posada is out with back spasms, and I’m starting to believe it, because he sat out today’s game, too. With both teams hurting, it will be interesting to see which of us will get to come back to work first.

RAW EDGES

First, the acknowledgements: K—thanks for the wine. B—thanks for the journal. C—thanks for the New Yorker clip. S&M (ooh!)—thanks for the plant. Harper-Collins—thank you for the Milosz. T—thanks for sharing your boo-boos, making mine feel smaller and easier to heal. A—thanks for calling to check. Sis—thanks for your watchful waiting. Bros—thanks for keeping J sane. Mom—thanks for being there. Dad—thanks for letting me be a surgeon. J—thanks for letting me be a poet, and loving me anyway. G&C—thanks for letting me be the best mother I can be, even when I’m horrible to you.

Everyone, thank you for the flowers and cards, for the posts to my blog, for reading my blogs at all, for your thoughts and prayers, for helping A in the OR, for offering to help in any and all ways. All of you have been instrumental in my continued recovery.

L—the nurse from Dr. Abu-Rustum’s office called last night, bless her heart. She seemed a little more concerned this time about my malaise, although by last night I was, indeed, feeling much better. She asked about my temp. I told her I took it, only because G was trying to fake out of school sick and I had the thermometer out to check his temp, and mine was actually normal – 98.6F on the nose. Additionally, the wound had dried up, no further drainage, and the wound edges, although still red, are just kind of pouting, granulating, perhaps not perfectly apposed, perhaps hypertrophying and forming a keloid, as L suggests. Regardless of this cosmetic issue, the depths of the wound feel fine. A little “Healing ridge” around it, not too tender, except when I sneeze, no further pain with urination, in fact, not much pain at all. OK a little wave of excruciation just before a BM in the morning, which have been showing up just fine each morning since I stopped taking Percocet!

There’s another raw edge, no doubt, that I don’t have access to as yet, and won’t for another month (J’s counting, I think). The top of the vaginal “cuff” that gets sewn or stapled shut as they amputate the uterus, may bleed, from what Dr. Abu-Rustum said. He said it may get worse as I become more active, and may even resemble a period, but then should go away as the weeks go by. So far, a little spotting, but nothing unusual.

But speaking of periods, there’s one more raw edge, all that rough, friable endometriosis that’s splattered throughout my pelvis and on my ovaries. I do believe that this tissue is trying to go through the same cyclical changes in a way that my uterus used to, responding to hormones still being produced by my ovaries. So the promises that after a hysterectomy at least I wouldn’t have to worry about having my period are largely false. Since my ovaries have been preserved, good for another 10-15 years and 100,000 miles of hormones, I’ll most likely still get many of the worst parts of my period – mood swings, PMS, water-retention, bloating, abdominal, pelvic and back pains, everything but the bleeding.

So yes, I’m feeling much better, these last couple of days, but forgive me when I get back to work next week, if I seem a little “edgy.”

LOW GRADE

Patient: Doctor, it hurts when I do this.
Doctor: (in his best Grouch Marx voice) So, don't do that!

Two hours after phoning my surgeon’s office his nurse called back. She wanted to know why I was taking my temperature. I said because I feel like crap and my wound is red. I tried to go over the four W’s, but she wouldn’t hear of it. “What’s your temperature now, right now,” she commanded. I stuck the thermometer in my mouth, but held the receiver up so she would hear it beep. “You’re taking it orally?” “Mmmhmmph,” I attested. When the beep came, my temp was only 99F. I felt humiliated and alarmist. She asked me how much water I’ve been drinking, and said it seemed sufficient. Then she told me to stop taking my temperature. That it wasn’t so important to monitor it, but to take it only if I felt “feverish.” That with my ovaries out (which I corrected her that they aren’t) that I was going to feel different and that a slight temperature elevation in the morning was normal. She said to keep an eye on the wound and if the redness spreads or my temp goes above 100 again (both sceanarios unlikely, since I can hardly see the incision and she told me not to take my temperature) to call her again tomorrow. I said I would and thanked her for her time, growled for my husband to make me some lunch, ate half of it, drank some water, opened the mail, read a book with my daughter, home with an injury to her foot, took a nap, took a shower and wrote. And no, I didn’t take my temperature.

FEVER II

Last night, the right pole of my wound started to pus out. Wound edges red, discharging a scant amount of purulent drainage. I cleansed and dressed it with sterile gauze, and this morning, no real change. My temp is steadily 100.3 - 100.5F, still low grade, but went to bed with chills and sweated all last night, really the last couple of nights. Worst part...today it hurts to sit. Really, pressure in my rectum when I sit on my butt. So I'm either constipated and impacted, or I have a pelvic abscess, or both.

Luckily, I'm a proctologist. Who thought I would ever get to say that!? Saturday night, I visited the office. Probably a bad move, overall, because I tried to tend to a bunch of stuff on my desk and got myself totally aggravated. That accomplished, I raided our sample closet, and went home with a treasure trove of fiber, laxatives and suppositories that should keep me pretty clear. Saturday, using a glycerin suppository, I was able to deliver a few solid nuggets. Then yesterday I drank some lactulose and cleaned out my colon COMPLETELY. Honestly, I was seeing some residue of stuff I don't even remember eating. Which is why I don't think I'm impacted right now.

Pelvic abscess? Going to have to defer to my surgeon for that...made a call out to him this morning, but line is busy. Will keep trying, and let you know.

FEVER

Wind. Water. Wound. Walking. And I forget, is there a fifth? Four elements of concern when a patient is spiking a postop fever. Mine isn’t high 99.9F, but the fact that I’ve been trying to take more Ibuprofen and Acetomenophen (Advil and Tylenol) rather than Percocet, may be masking it, since both are strong antipyretics, and fight fever at the same time that they fight inflammation and pain.

So lets look at these. I can almost eliminate wind and walking, as earlier causes of post op fever. Getting mobilized and walking around in the hospital and here at home have prevented the complications of atelectasis and deep vein thrombosis. I don’t have any shortness of breath, chest pains, leg swelling, palpable cords of clotted veins, or calf pain.

Water. A urinary tract infection? Been drinking lots of water and fluids to stay hydrated. Urination has been uncomfortable, but more around my incision and in my pelvis, rather than burning about my urethra when I pee. I can almost imagine the bladder adhering to my healing wound and pulling on it each time it empties. But the urine itself is clear, no blood, no cloudiness, so more than likely, it’s not a UTI.

Wound. Hmm. Well the laparoscopic incisions, one inside my innie of a belly button, and two 5mm wounds on either side seem OK. The problem is I can’t really see the other, largest incision. It’s hidden under the most adorable curtain of fat and flesh and stretch marks that I ‘ve had a problem getting rid of since having my babies. When I lie down, it redistributes to almost flat, but I can’t see it lying down, and when I stand up, well I guess I have to hike it up to see the incision underneath. Still covered with steristrips, with a little old blood on them. No drainage, or fluctuance, a little firm at either pole, and some ecchymosis (bruising) between the umbilicus (belly button) and the larger incision. The length of the wound, as expected, is numb, anesthetic, but pulling my fat up to look at it smarts. So maybe it’s the wound. Guess I’ll stay in bed tonight and let the kids take care of me and keep an eye on it on the weekend.

ENDOMETRIOSIS – or How My Minimally Invasive Procedure Became Major Pelvic Surgery

I failed to mention yesterday that often when patients (and their surgeons) survive Post Op Day 5, they’re feeling much better by Post Op Day 6. As am I, watching the Yankees, hopefully, eek into first place by, hopefully, beating the Red Sox. Finally found the right amount of pain medication to allow me to spend a little more time on my feet and thus get rid of those pesky gas pains.

I don’t remember much about the hours right after my operation last Friday, but I do remember Dr. Abu-Rustum’s kind face smiling as I opened my eyes in the recovery room. “You’re going to be fine. Operation’s all done,” he said, “but we couldn’t do it through the scope – lots of endometriosis, everywhere. We made a small Pfannensteil incision, and once we got exposure, everything came out fine.” I, still being in that morphine-induced state of overall well-being, nodded my head, happy to be alive.

Endometriosis is the abnormal implantation of tissue like the lining of the uterus throughout the abdomen and pelvis, commonly involving the lining of the pelvic cavity, the outside wall of the uterus, the ligaments supporting the uterus, the fallopian tubes and the ovaries the surfaces of the bladder and the rectum. The most common symptom of endometriosis is pelvic pain, painful periods, painful sex. Some forms of female infertility are caused by endometriosis. Since the endometriosis is so much like the inside of the uterus, it responds the same way to hormones secreted by the ovaries throughout the menstrual cycle, producing blood and proliferative tissue, and because it has nowhere to go, scar tissue every month, making everything inside sticky and stuck. That’s what they found when they went in laparoscopically, and in the end, that’s what made them convert to an open procedure.

11 o’clock, or just after, looks like the Yanks are going to lose this one after all. And they fall behind the Red Sox by a game as a three-day long thunderstorm sweeps into town. They say by midnight, it will be raining cats and dogs. Oh well, you can’t always get what you want.

POD #5

A hump-day like no other. Post-operative day 5 is always the one that surgeons fear. And when the surgeon is the patient, that fear is doubled. After the assault of any major surgery, the body undergoes endocrine, immune-mediated (inflammatory), cell-mediated, metabolic, and nutritional responses to injury that culminate on or around Day 3, and reach homeostatic balance by Day 5. Day 5 is the day that many surgery-related complications will present. Wound infections, dehiscience, evicerations, small bowel obstructions, anastomotic leaks, stump blowouts…the first hints often show on POD#5.

Probably why I feel so horrible today. Every time that I laugh, cough, urinate, especially urinate, I feel like they’re doing the operation again, with me wide awake. Like my pretty healing bikini-line Pfannensteil incision is being torn open again and some ungodly retractor like a Balfour or O’Connor/O’Sullivan is being used to hold the edges wide open and apart. Ouch. And we won’t even discuss the gas pains… in shockwaves, from my pelvis to my eyes it hurts. No relief. Am I doing too much, or not enough? What should I eat? High Fiber, to make the BM’s softer, or Low Fiber to not produce so much gas? Take more pain medicine and walk around more, or stop taking pain medicine because of its constipating effects? Dunno.

Maybe I should just be happy. Cancer’s out, and you can’t die from gas pains. It’s Post Op Day 5 and I don’t have any of the major complications listed above. The Yankees have another chance to beat the Red Sox tonight. My vote for Taylor went through. I watched “Love Actually,” last night and remembered how cute Hugh Grant and Liam Neeson are. Yeah, I should just be happy.

JIGGETY--JIG

Perhaps no “Jiggety—jig,” but definitely “Home again, home again.” And it is good to be home again, although my stay at Memorial was uneventful, and everything is going fine, this homecoming was better than I’ve ever known, and a comfort like none other. Oh, I’ve come home before. Home, from college, tired, from work, even refreshed from vacation. But this homecoming was different. More knowledge than any one year of college, more tired than from any job, including my current one, and well, still on a vacation of sorts, certainly fast using up my vacation time and working hard to be more rebuilt, rejuvenated, and refreshed than on any other vacation I’ve ever taken. I know that I will never take for granted tucking my kids in at night, or the comfort of sleeping in my own bed. And tonight – the Yankees vs. the Red Sox. Jiggety—jig.

BOWEL PREP

I will spare you the gory details. Suffice it to say Fleet Phospho-Soda is not like any soda I've ever had, and my favorite clear liquid is... Luigi's Real Italian Ice!

It is so nice to hear from everybody again. Thank you for writing, for posting, for sending, for calling, for praying. I can't think of anybody to single out named Denise, but I wanted to post this poem I read today (while eating Italian Ices) and dedicate it to you, my friend. It's been much too long.

Letter to Denise
by Hayden Carruth

Remember when you put on that wig
From the grab bag and then looked at yourself
In the mirror and laughed, and we laughed together?
It was a transformation, glamorous flowing tresses.
Who knows if you might not have liked to wear
That wig permanently, but of course you
Wouldn’t. Remember when you told me how
You meditated, looking at a stone until
You knew the soul of the stone? Inwardly I
Scoffed, being the backwoods pragmatic Yankee
That I was, yet I knew what you meant. I
Called it love. No magic was needed. And we
Loved each other too, not in the way of
Romance but in the way of two poets loving
A stone, and the world that the stone signified.
Remember when we had that argument over
Pee and piss in your poem about the bear?
“Bears don’t pee, they piss,” I said. But you were
Adamant. “My bears pee.” And that was that.
Then you moved away, across the continent,
And sometimes for a year I didn’t see you.
We phoned and wrote, we kept in touch. And then
You moved again, much farther away, I don’t
Know where. No word from you now at all.
ButI am faithful, my dear Denise. And I still
Love the stone, and, yes, I know its soul.

Thank you, friend, for being so faithful, and for putting up with my meditations. And yes, we'll be "in touch" again soon.

A ROUGH WEEKEND

It was a difficult weekend for my family. I could see it in their faces, hear it in their tone. This is the week, six years ago, that my mother died. As we spent Sunday together, I could feel each person, my Dad, my brothers, my sister, even my husband going through his own personal history of her last days with us. The phone calls, the drive for us from Erie, the hospitals. In one, in Brooklyn, my Dad had practiced as a general surgeon his entire career. After my residency, I even worked there, first assisting on bigger cases, and fulfilled a dream my Mom always had for me – operating with my father. It was the last place my children, then just two and three years old, would see my mother alive.

The hospital where she was transferred next was a big Heart Hospital on the North Shore of Long Island. Here they were equipped to do everything, which is of course what we wanted them to do, since none of us were ready to say goodbye. My Dad and I, well trained that surgery can save, let them cath her, let them crack her chest, let them try for hours to patch the shredded fibers of her heart. Then she died. Nothing will ever be as painful.

My youngest brother, 36, had a pacemaker placed yesterday. The cardiologist came out of the procedure and told him in a heavy Indian accent, “Both your nodes are dead! Boat of dem!” I think he knew this, my brother. He’s had vague complaints since my Mom passed. Trouble sleeping, chronic fatigue, pains in his shoulder, palpitations. He was visiting her grave a year and four months later and took a day off from work to rest, still tired all the time. The next morning, running late for work, his subway stopped working a distance away from his office. When he got to the surface, he was carried by a wave of people coursing North. He turned to see his office building crumble to the ground.

Nothing will ever be as painful. I’m sure I thought this when Dr. Abu-Rustum gave me a date for my surgery, and I’m sure my brother thought about this when he scheduled his electro-physiologic studies/pacemaker placement. It’s a rough week for my family, anyway. And May 5th is the day my mother died. In the Catholic Church, saints’ feast days are celebrated on the day they died. I always believe that things happen for a reason. I remember explaining to my children how my mother died. I told them that her heart broke a little each time her children moved away. And that she died so she could be with all of us at once, no matter where we were.

AFTER SERIOUS SURGERY

There is some e mail that I don’t get to open right away. Offers to redeem my Marriott Rewards points at exotic new resorts, to lower the rate on my mortgage…the ones about cheap Viagra from Canada I don’t open at all. Regrettably, if things get really busy, as they were on Friday, I don’t even get to read e mail that I want to open. Like my poetry email, for example. At least two of the major publishing houses, and many of the internet resources for poets published frequent, if not daily newsletters and/or started sending daily “Poem a Day” e mails in celebration of the 10th Annual National Poetry Month this April. I’ve been getting so much poetry e mail, I set up a separate screen name on AOL just to accommodate it all. And, with April, which was busy enough, coming to an end, I was keeping pretty up to date with it…even uploading some of the Podcasts to my daughter’s iPod for later reference and entertainment.

Until Friday. After two relatively straightforward anorectal cases, my boss and I hunkered down for a long, difficult case. A young (51 year old) man with a very low rectal cancer, now six weeks following preoperative chemo/radiation therapy needed surgical resection. The operation involved removing over a foot of his colon and rectum, mobilizing (freeing up) his splenic flexure, connecting (anastomosing) his colon to his anus, and forming a temporary ileostomy. Seven hours and a couple of pee-breaks later, the tour de force was complete. My back was killing me, my associate’s hand was cramping, and the fifth anesthesiologist of the case was asking us whether we prefer our massages before or after a huge case like this. We both just looked at him. I saw this patient today on rounds, he looks great, just extubated early this morning, all the puffiness from the massive fluids used during the surgery to keep him hydrated starting to resolve. I told him, “Don’t worry, I got the number of the truck that hit you.” He grabbed his sides as he started to laugh, ouch.

Only last night I opened an e mail from the Knopf Poetry Center, dated 4/28/06. It was part of their “Poem A Day,” program and it contained this poem, by June Jordan:


FIRST POEM AFTER SERIOUS SURGERY

The breath continues but the breathing
hurts
Is this the way death wins its way
against all longing
and redemptive thrust from grief?
Head falls
Hands crawl
and pain becomes the only keeper
of my time

I am not held
I do not hold
And touch degenerates into new
agony

I feel
the healing of cut muscle/
broken nerves
as I return to hot and cold
sensations
of a body tortured by the flight
of feeling/normal
registrations of repulsion
or delight

On this meridian of failure or recovery
I move
or stop respectful
of each day
but silent now
and slow


My question is, after serious surgery is this how the patient feels, or the surgeon?

For a download of this poem, and a Podcast of Toni Morrison reading it, click here.

PRE-SURGICAL TESTING and THE MODERN LIFE OF THE SOUL

Thank you to all those who have come to visit me at The Wounded Surgeon. I am overwhelmed by the response…and you know who you are. In the past week I’ve visited with an angel on ice skates, an orthodox Jew, a nurse whose husband is being treated for squamous cell carcinoma of the tongue. Neighbors and cousins, a classy lady who sells wine, a writer, a priest, and the surgeons…oh the surgeons, one, an inventor, another who offered me food (“It’s a Jewish tradition, in times of need we throw food at people,”) another who’s entertained me with pictures and stories of Holy Week in Peru, one I’ve lived with, and one who I’ll love forever.

Great news from Memorial Sloan Kettering Cancer Center. They just completed a gazillion dollar renovation of their operating suite, and apparently it’s just that – sweet. Twenty-something OR’s fitted with state of the art technology for minimally-invasive surgery, beautiful family waiting areas, and (all my pals in the OR will salivate like me) over 300 lockers in the staff locker rooms. And they do their first case in the new suites on Monday.

All this from the ebullient nurse practitioner who took my history and did a physical at MSKCC on Wednesday at my Pre-Surgical Testing appointment. Kudos again to everyone at Sloan, who made me feel wonderful and special and whole, even as they were taking my blood, doing and EKG, or shooting a chest xray. The NP actually knew my history before she took my history…soup to nuts, she even told me what my hemoglobin was the morning I had to return to the OR for bleeding! When I mentioned my surprise at her strangely complete fund of knowledge, she explained that she always reviewed records completely before interviewing a patient. She thought at first it would cut down on the amount of crying at these interviews, but now has accepted that people will cry no matter who told the story. She had joked with the patient before me that it was actually her job to get people to cry while she wrote their H & P. She cried anyway. I assured her in my most authoritative surgeon’s voice that she was NOT going to make me cry. No way. Instead we dished about how kind Dr. Abu-Rustum was with his patients and how penetratingly blue Dr. Weiser’s eyes are.

My sister and I made a day of my trip to the city, visiting the Edvard Munch exhibit, The Modern Life of the Soul at the Museum of Modern Art. His work is haunting, deep, and sad. The figures in his work wander through a vibrant, boldly-colored landscape featuring orange skies, moonlit waters, or monstrous green shrubs. Their clothes are somber and dark. Their faces (the ones lucky enough to have faces) stare zombie-like, expressionless, except for the rare expression of sheer terror (The Scream, 1893) or angst (Jealousy, 1895). My sister thought she saw a smiley face hidden in the shadows of a rock, and insisted that it was intentionally the only smiling face in all of Munch’s work. I told her she was nuts and we’d better leave or I’d be late for my appointment. As we left, we had a plebian discussion over whether the word modern means contemporary or only work from the early 20th century, and what happens when modern art becomes centuries old? Can artists get kicked out of the MoMA for being too old fashioned or traditional?

During the train ride home I wondered how Munch would have painted today’s modern soul. Two guys in Rangers jerseys got in. Sad and dejected – check. More people in dark suits boarded – check, check. Not a smiley face in the bunch. Perhaps today we are just as zombie-like and faceless, still dealing with Munch’s century-old principal themes of (lost or frustrated) love, anxiety, and death, just now with iPods at our hips and cell phones to our ears.

My family picked me up at the Stony Brook train station. My son couldn’t wait to tell me about his baseball game. Before I tucked him in, he read me a bedtime story about a little house in the country that watches the country turn into the city around her, until she is finally rescued by the great-great granddaughter of her original builder and brought back out into the country on a flat-bed trailer. I kissed him goodnight. I tried to apologize for missing his game. I wanted to tell him how proud I am that he can read as well as he can pitch. I secretly thanked him for rescuing me, and bringing me back out to the country where I belong. He was already asleep.

I got into bed, and finally let myself cry.

WHERE I HAVE TO GO

Occasionally there are moments of clarity and purpose. Moments when I realize that I am exactly who and where I need to be. Prior to one such moment today a patient unraveled before me saying that she would gladly take my cancer as her own. At first I took this as a deep gesture of devotion from a doting patient. I felt like Sally Field at the Academy Awards, “You love me…You really love me!!!” Then came the moment. My patient’s red eyes welled with tears, and she rolled into a litany of her woes. A widow in her forties, she was now fifty-six. Her second husband is in his eighties and frail, but has been a good companion. She is in chronic pain, which none of her doctors can seem to cure. She is restless and tired, hoards Ambien like treasure, and takes pain medicine like candy. She is unhappy, desperately unhappy, and she is addicted to drugs. She does not love me, although I have no doubt she would like me to have a full and happy life, she does not love me. She wants to die.

In revealing all this, I can tell she feels better already. She describes her young granddaughter, for whom she would like to scrape through a few more years, just to watch her grow. We joke about the new bar-coded, state issued prescriptions mandated just this month that will eventually, hopefully, mean the demise of her secret stashes. I make her promise to see her gynecologist who she hasn’t visited since her hysterectomy, to make sure that she doesn’t have what I have. She feels better as she leaves, and promises also to badger my office staff during my upcoming medical leave, for progress reports.

My patients don’t love me. They can’t. But they need me. And I need them. My work, my patients… it is where I have to go.


Read The Waking, by Theodore Roethke.

AT ANY MOMENT A GREAT MOMENT

A nice, easy day, actually home in time to catch the Yankees home opener. And what a game! The Yanks took an early lead, then lost the lead, then fell behind, walked seven gazillion times then won it on a bottom of the eighth three run homer by Derek Jeter (sigh). The offense was strong, and Jeter, Bernie, and Mo had great games, Damon got a warm reception, a couple of hits and RBIs in his new home, Sheff hit a homer after almost taking off Larry Bowa’s head with a foul down the third base line. Very fun to watch. Unseasonably warm early spring afternoon. Feeling stronger, and resting well. And, as Michael Kaye paraphrased, “The great thing about watching Yankees baseball…at any moment, a great moment.” Happy spring.

CHANGE THE WORLD

Back in the OR today. The same OR where less than three weeks ago angels were tending to me and a young, confident gynecologist was facing a known but terrible consequence of trying to do the right thing. I wrapped some presents for the scrub angels, the circulating angels, the ER angel, and my anesthesiologist. I brought in three dozen Dunkin Donuts for the rest of the staff and shivered a little as I walked between the PACU and OR#2.

If I could change the world,
I would be the sunlight in your universe.
You would think my love is really something good.
Baby, if I could change the world.

I entered OR 4 where my partner was operating. Eric Clapton was crooning off someone’s iPod near anesthesia. I went out to the sinks to scrub, came back in, suited up, then stepped up to the table and called for a clamp, another one, then a retractor. Now Clapton was singing “Tears In Heaven.” Can a place feel new yet familiar, a motion be automatic and perfect?

I must be strong, and carry on,
‘Cause I know I don’t belong
Here in Heaven.

I once said out loud but to no one in particular that I would follow Eric Clapton anywhere. Little did I know that today I would follow his voice home.

POST OP VISIT

Did a few colonoscopies this morning. Feeling a little stronger each day. And it felt nice to see some of my hospital friends…nurses, techs. They all wanted me to know how worried they were while I was out, and how good it was to see me again. No patients to see in the hospital, so I went home and took a nap until it was time to head to the office.

After work I had an appointment with my GYN. She seemed warmer now, more relaxed. I told her about my second opinion visit at Memorial and how I was planning to have the surgery with them. She didn’t seem too offended, and said she understood that it was worth a try to go someplace where they would at least try to do it laparoscopically. She warned that I should try to get an early time, and explained to my husband how important it was to have a big operation like that early in the morning when the surgeon and staff are rested and fresh.

I asked her if she would still be my gynecologist afterwards. She said of course, although there wouldn’t be all that much to do until my ovaries are ready to check out. My husband asked the burning question, “Can we have sex?” and after he got over the embarrassment of making sure my doctor didn’t think he was including her in the equation he got the thumbs down sign. “ I don’t think she’s ready yet,” she said. “I still see a little bleeding.”

She gave me a hug and wished me luck. She revealed that she was going to be away the weekend of my surgery. At an all-inclusive singles club in Turks and Caincos, or somewhere warm. My husband thought of setting her up with my brother, the only other person he knew with the confidence to go on vacation alone.

We took the kids out to dinner—Chinese food. I stopped to pick up some thank you gifts for the nurses at the hospital on the way home.

OPENING DAY

Back to work today. Not easy. Tiring easily, and not concentrating so well, but good to be in circulation, talking to patients, joking with my staff, discussing cases with my colleagues.

The Yankees start their new season tonight. Another thing to add to my ever growing list of things to thank God for…baseball season.

GREEN EGGS AND SPAM

In the chill of an early spring Saturday morning, my son and I snuck out of the house to find a store that would sell us eggs and food coloring. It was April Fool’s Day, and rather than replace eggs with plastic ones with funny sayings on them (my daughter’s idea), G and I had a more colorful idea. We would emulate the great Dr. Seuss and make Green Eggs and Ham, or spam as the cupboard would allow.

By the time we got home, my daughter, C, was awake. She, an eight-year-old aspiring chef wanted in on it…any excuse to make Daddy breakfast, and to scramble eggs. She got out the whisk and the bowl and showed her brother G how to break an egg with one hand. He was too busy with the colors, and thought a pink pile of eggs would go nicely with the green ones. I manned the frying pan, cooking up their colorful scrambles, while C made some toast, and G softened a stick of butter in a ramekin, coloring it to match the eggs.

So this is what I’m missing on Saturday mornings when I commute to our satellite office in Nassau County. Perhaps it is time to reclaim some of my Saturday mornings to spend with my family. The kids went to wake up their Dad. I made a pot of coffee. Daddy smiled at his family’s efforts, complained that the eggs were just a little salty for his taste, then gasped as he poured sky blue Half and Half into his coffee. The children’s laughter was like music.

HEALING WELL

Dr. Abu-Rustum did a thorough exam. I don’t know why I thought he might not. Was it because I felt so fragile, had barely moved since St. Joseph’s Day, was still bleeding just a little bit? It was a gentle, but thorough exam, and as he moved the speculum around to examine what was left of my cervix he muttered a tiny, soothing, “I’m sorry.” I reassured him he wasn’t hurting me. He told me that the biopsy was surely a generously-sized cone, and that I was healing well.

Back in his office, the doctor explained in clear and pertinent detail, the staging of cervical cancer, the reason for such a big cone (corroborating my GYN’s stance that she was going for a therapeutic excision), and the likelihood that the bleeding was from tiny but vigorous cervical branches, exposed when the healing tissue/eschar sloughed off, like a scab falling off prematurely. He reiterated that he thought I was healing well, that I should make a full recovery, and that my cancer would be cured by a total hysterectomy. He showed us a chart with fractions of percentages describing the slim chance of cancer in the tissue surrounding my biopsy, the almost negligible chance of spread to regional lymph nodes, and the minimal expectation of cancer spreading to the ovaries or recurring in the vaginal cuff.

An expert in minimally invasive techniques, he rose to my request that he attempt a laparoscopic assisted vaginal hysterectomy, agreed with my GYN that the chances of conversion were higher in me due to adhesions from my previous c sections and the narrowness of my pelvis, but encouraged me that even open, though a pfannensteil incision, that my recovery would be swift. “Two to three weeks, at the most,” he said. “I just can’t see you lying around for six to eight weeks…after all, you’re young, you’re thin (hubby elbows me), and you’re a surgeon.”

For the first time in over a month, I was healing well.

SECOND OPINION

Memorial Sloan Kettering Cancer Center is an amazing place. My first understanding of it was as a General Surgery Resident, when I was doing a rotation at MD Anderson Cancer Center in Houston (another amazing place). I was tagging along with a GI Surgical Oncologist named Doug Evans. Never, I thought, have I met a surgeon so well read, so in command of the literature…and not just the way he pushed it around a copy machine…he actually knew what to copy! Anyway, he used to always talk about the guys at Memorial, and their latest work like I would talk about the Yankees and their latest homestand – far away, and heroic.

As a Colorectal Surgery Fellow I cultivated my own command of specialist literature, and found that more and more of the studies that I was reading were coming out of MSKCC. I followed the career of another Doug, Doug Wong as he continued his groundbreaking work in ultrasound staging of rectal cancers and minimally invasive treatment of early staged rectal cancer from Minnesota to New York at, you guessed it, Memorial.

As a young attending surgeon joining a practice on Long Island, I didn’t feel any closer to MSKCC than during my years in training, until my uncle got colon cancer. Suddenly everything I had ever learned and anyone I had ever known took on immediate importance. If I couldn’t take care of him myself…where would be the best place for him to be treated? I knew the answer was Sloan Kettering. I gave him Doug Wong’s name, but they couldn’t get an appointment with him for weeks. We put our trust instead in a young surgeon named Martin Weiser. He took great care of my uncle, did a laparoscopic sigmoid colon resection, and had him home and recovering in 4 days.

Almost a year later, I ran into Dr. Weiser at a course we were both attending on Pelvic Floor Physiology. I thanked him again for taking care of my uncle. He confided that my uncle underwent one of the first laparoscopic colon cancer surgeries performed at Memorial and he had such a great outcome they put his picture and his case on the cover of the hospital’s annual report!

I have since sent many patients of my own to Sloan Kettering for second opinions, and some of my most challenging cases, like very advanced or recurrent cancers, that I thought would be best cared for at a tertiary care center with a multidisciplinary approach I have sent to Dr. Weiser.

But never would I have imagined I would be referring myself there.

For weeks I’ve been rolling this diagnosis of cervical cancer around in my gourd. Looking at the slides with the pathologist, discussing it with colleagues, family, friends, and my doctors. I’d done the research, heard the recommendations, considered my options. Who am I now to take my little early stage, microscopically invasive, and completely curable cancer to the Mecca…to Memorial.

Then again, and my friend Nance convinced me of this, how blessed am I to live so close to such a quality institution? A reputable Cancer Center where the best minds care for cancer patients every day. A place where I have sent my own patients, my own family. How could I not take advantage of such a resource? Why not?

My husband said as he met me at the 3rd floor registration area, “People must have to take a personality test to work here…” It did seem so, everyone, from the doorman to the front desk to the registrars, the aides, the nurses, so calm, so welcoming, so warm.

And there, around me, I saw people, all ages, all stages, all different types of cancer, most with help, some alone. And strangely, it made me feel…OK. It made me finally understand how very, very fortunate I am. To have my husband beside me, someone to practice being old with, my beautiful children, our loving families, my friends, a rewarding career, and this cancer…thank God they found it early!

SUNDAY'S, TOO

“What did I know, What did I know,
Of Love’s austere and lonely offices?”
--Robert Hayden

Stayed in bed almost the entire weekend…feeling absolutely horrible. Drained, achy, depressed. Frustrated with myself, too, at how week I feel. My husband says it’s because I did too much the last couple of days. He’s probably right.

I went to Mass today. Father says I look kind of bushed. I almost passed out, spinning around to give everyone the sign of Peace, then came home and rested some more. Appointment for second opinion tomorrow.

DOUBLE DIGITS

Had an appointment with my Primary Care Physician today. Told her the whole story, and she just shook her head. Said my hemoglobin was up to 10.1 now , but that my WBC’s were still elevated. Probably from the physical stress of the sudden blood loss and second surgery, my system was in overdrive.

She also told me to take another week off, and not to feel guilty about it, that I absolutely would need it to continue to recover. I slumped out of her office and proceeded to feel horrible for the rest of the day. Taking my vitamins, eating healthy, drinking lots of fluids, but still very shaky.

Made a series of phone calls today to confirm my appointment at MSKCC, and to be sure I had all the slides and information they would need to make their best recommendation.

MARCH MADNESS

Thank God also for College Basketball. On modified bedrest over the last few days I have watched over forty hours of NCAA Men’s Basketball. It’s great recovery entertainment. You don’t have to think too hard, you get to watch beautiful, young, healthy bodies subject to seasoned coaching and expert strategy perform natural feats of wonder, skill, and speed. This season was especially exciting, as many of the top-seeded teams won and then lost games, in the final few minutes, or in overtime. This week, my Alma Mater, Georgetown, fell to the mighty Florida Gators.

I guess what I’m really avoiding talking about is that I met with my Gynecologist today about the biopsy results. She is recommending a “simple hysterectomy,” in other words, removing my uterus, but preserving my ovaries. She believes this will take care of the cancerous tissue and remove the most at risk organ. The part that is throwing me off is that she is adamant that I take 6 weeks off to recover afterwards, and would not recommend a laparoscopic assisted/ vaginal approach, mostly because of the difficulties she had during these first two operations “bringing the cervix down” through my narrow pelvis.

I am really miffed, and still shaking as I think about the events of the past week, the past few weeks. I am achy, although less so each day, don’t feel like I’m bouncing back like I should. She was real flippant about things, said that I should be resting and not doing much really until Monday. She recommended a second surgical opinion prior to the hysterectomy, and gave me the name of a GYN oncologist nearby, who has taken care of her own mother for uterine cancer. I told her I was going to Memorial to see a GYN ONC there.

BAD ATTITUDE DAYS

I woke up the next day very achy and despondent. Why me? Why now? All the gratitude, all the joy, and all the faith that had filled the last two days, seemed completely depleted. They were replaced by questioning, anger, and depression. The wake up call was there. My cousin’s sister-in-law, a nurse from MSKCC called to get some information so she could intervene in arranging a consultation with her favorite GYN ONC surgeon there.

Despite all the help, all the comfort supplied by my family, I felt very isolated, very alone. Like no one could feel how I felt. Like nobody cared. Which, of course wasn’t true. Had dinner in my bedroom with my bros and sister. Said Grace with the kids over the walkie talkies…

The next morning, I couldn’t believe how achy I still felt. Still hurts to cough? This is unbelievable. How much Iron should I be on? How much water? How much Gatorade? What were my electrolytes? Didn’t anybody care???

I called my PCP’s office. Had her order some labs to be drawn before our appointment on Friday. Then I called work to tell them I’d be out for at least another week. My boss, not feeling well himself, and shouldering the burden of my abandoned half of the practice, told me to take a look at my contract “While you are lying there,” to determine how I wanted to handle this disability. I took the liberty of taking his tone and his comments the wrong way and let myself feel hurt and indignant by whatever he was implying. I found out from my office manager later that he has no intention of paying me for any medical leave or disability term, and that I should take all my vacation time now, if I want to get paid. The syrupy sweetness of her voice could not hide the stress and anxiety she was feeling managing my absence.

My husband, meanwhile was working on issues of his own. Saving my life, raising the children, and running out of his blood pressure medicine all finally took their toll during my second Bad Attitude Day. He exploded at the condescending tone of my voice as I dictated which forms needed to go where to get the children enrolled in a private school next year. His BP was 180/110 and his head was about to shatter with ache.

In one fell-swoop, things started to get better. We went out to get his prescription refilled, and he brought me to the lab to have my bloodwork drawn. As the medicine kicked in, he grew calmer. I took his arm in the parking lot at the outpatient lab, my first trip out of the house since the day I bled. This lab, just 100 yards and across the street from my own office, where the bleeding started. I leaned on him as we took those first few steps out of the car. He laughed, and said, “ Look, were practicing being old!”

THE MISSION

When I got home Sunday night, I asked my Dad to call out all the troops. I was no longer going to go it alone, now I needed everyone to know, and everyone to remember me in their prayers.

So today, I got many, many calls, from cousins, aunts, and uncles. It still hurts to breathe heavy or to cough. I should have brought home my incentive spirometer. I think if I am going to be in bed much longer, I should wear anti-embolic stockings or something.

The call that really touched me today was from one of my aunts, who is very devoutly religious. She told me that she was praying very hard for me, and that Jesus would help me feel better, because I have a mission. She reminded me that I have patients that rely on me, that I am a kind, skillful, and compassionate doctor, and that I do God’s work each day. My children, my husband, are part of that mission, too. Jesus will make me better, because I have a reason to live. So many people suffer, she said, and they search for their mission in life. I am already blessed with a mission, and for this reason, I will be saved.

And I started to feel better.

i thank You God for most this amazing

I will never forget the moment that I opened my eyes to the dawn unfolding outside my hospital window. A wall of glass, facing east, revealed the sky, changing in slivers from night into day. My throat was sore, but I was…breathing. I am alive, I thought, thank you God, I am alive. I thought of my husband, my children, my family, my friends, and was deeply merry. I thought of the secrecy, the discretion, since I’d learned of my diagnosis, how bad, what stage, what next, how long? I didn’t know, so I didn’t want to alarm anyone. I was ashamed and trying to tackle this all alone. But now… here I am… lying in this bed…alive… only by the very Grace of God. I must tell them. I must thank Him. Tears streamed down my face as I started to pray and a poem by E. E. Cummings danced with my prayer, and I thanked Him.

THE ANGEL ON THE HILL

When we got to the Emergency Room, I was happy to see a friendly face. I was at the Hospital On The Hill, and thanks to the magic of downsizing, the struggles of single-parenting, and corporate and personal obsessions with multi-tasking, the nurse who triaged me was a friend. I had known J since my first days as an attending at that hospital, six years ago. She was a member of the Endoscopy Unit with whom I would do colonoscopies each week. She used to talk about her adventures in the ER, where she often took shifts to support her two teenaged children. When the Endo Unit was consolidated into an Endo Room, J was cross trained as a circulating nurse in the Operating Room, so I would still get to see her almost every week.

It was now evident that the angel taking care of me that night would be working through J. She quickly got me triaged, had my husband register me, got me into an exam room, showed me where all the pads were, found my doctor, assisted her with my exam, and when it was decided the bleeding would be best dealt with in the operating room, stayed with me until they rolled my stretcher into the room. “You shouldn’t be alone right now,” the angel said, piling warm blankets on me and changing my diaper (the bleeding was now too heavy for pads).

I was trembling, not with fear, but with crystalloid, liters of IV fluids “wide open” filling the veins in my arms. In truth, there was no fear. I was a surgeon. I had faith in the power of timely surgical intervention, and felt that we got there “in time.” I had faith in my doctor, the nurses, the ER, the OR, and in God. The angel He had sent was letting me know, now through the suddenly calm eyes of my husband, “Everything’s going to be all right.” I wanted to answer him, but I was weak, and so cold. And then, suddenly, warmth, between my legs, filling the diaper, the warmth of my own blood.

THIS IS NOT MY PERIOD

Friday was St. Patrick’s Day. I bantered with anesthesiologists about great restaurants in Philly, and becoming a girls’ lacrosse coach, but really, I was not feeling well. I had four cases scheduled and helped my associate with another two, but they were all pretty light cases and I couldn’t wait to go home and rest.

I was bleeding. Really all along, since my biopsy. It had turned a blackish brown and lightened some mid week, but by Friday I was noticing a redder tinge and heavier flow. I called my doctor and she returned my call while I was doing my second to last case. She asked if the flow was like a period, and reminded me that irregular periods was the initial symptom that we were working on when we found this. I agreed, that it was not any heavier than a regular period, promised to call if it gets any heavier, finished my cases, passed by the office, then went home to rest. I put my feet up, ate some corned beef and cabbage, and went to bed. I was on call, but only got a call or two that night.

The next morning I got a call at 6 am. One of our patients in the hospital was vomiting and sick. The housestaff had taken care of making sure he wasn’t having a heart attack, but I decided to go in early to make sure he was OK. He was, and after we decided the nausea was some of the after-effects of anesthesia and pain medicine, I let him go home as we had planned.

I then proceeded (late) to a full morning of patient hours. The satellite office where I spend almost every Saturday morning is about an hours drive from the hospital. Seven new patients, and some established and post op visits. I was rushed, stressed, and irritable, although I tried hard not to show it. I was also still bleeding, but was more annoyed that I didn’t have enough pads with me than that it was soaking through the ones I had.

Later that night, my husband, my son, and I were in my office, fiddling with a new computer they had bought me for my birthday. After apologizing for bothering him on a Saturday night, I had the office IT guy on the phone for an hour, trying to install a new driver and port for an old reliable printer. That finished, I went to the bathroom to pee and passed a clot the size of a fist. I told the boys they’d better get me home quick, I needed to lie down, and to call the doctor.

I LIGHTEN UP

Had a great day on Thursday, and my husband really helped. Did three colonoscopies, then picked him up to drop off some forms at the Catholic School where we want the kids to go this fall. They’ve had an OK run at public education, but they’ll do better, they both will, in a smaller, more controlled environment.

We went to lunch in town, before I was scheduled to start my afternoon patient hours. I explained how guilty I used to feel taking time for lunch, but now felt justified, as I had added an additional day of patient hours and planned to fill days I wasn’t operating with office procedures, making for a six day work-week. Besides, we said in unison, just like Terrence and Philip, “I have CAN-SA.” Morosely we joked about my diagnosis, how we should have kept that life insurance, and whether this would ever amount to a good parking spot!

I went to the office, and was sobered when I had to tell a 62 year old woman who complained of bleeding hemorrhoids that she had a large rectal cancer just above her hemorrhoids that was the more likely and more critical source of her bleeding.

I decided to call an old colleague of mine. We were chief residents together, and we still kept in touch via e mails and IM’s. This was a sensitive issue, though, and I wanted to talk to him and hear his voice. He warned me to get out of my comfort zone, to treat this diagnosis with the attention it deserved. He urged me to get a second opinion. He mentioned surgeons he knew at Fox Chase Cancer Center, near where he practices, or recommended I find someone top notch at Memorial. One thing I can say about gynecologic cancers, he said, is that they should be attended to by specialists. GYN oncologists operate more like us, more like general surgeons, than general practice OB/GYN docs. You don’t have to be at a place where you’re known, in fact, that can jynx you, being taken care of in the community where you’re well known. You’re going to be fine, because you are a strong, good person, but I am so sorry to hear that. I guess we’re all getting old, but please have it taken care of by the best you can find, and a specialist.

At least he didn’t say “At least they got it early.”

AT LEAST THEY CAUGHT IT EARLY

I remember hearing on NPR the end of an interview with a woman whose husband was stationed with the US Military Troops in Afghanistan. She talked about how she would shrink each time someone would say, “Well, at least he’s not in Iraq.” The comment did nothing to console her, although she kindly assumed that’s how it was meant. Instead it embarrassed her, belittled her, and sometimes made her really angry.

I think I know how she feels. Seems each time I tell someone of my diagnosis, I get the same response, “Well at least they caught it early.” To myself, and sometimes even out loud, I answer, “Yes, thank God.” Although I’m not yet sure that I believe that…one that they got it early, pretty sure that they didn’t get it all, and definitely not thankful yet that I HAVE CANCER!!! Doesn’t anybody believe me, can’t anyone bear to let me mourn this abnormal uncontrolled process going on deep inside, microscopically invading normal tissue, the normal tissue that once housed my beautiful two children? OK. So (hopefully) I’m not going to die from this, but do I have to be thankful…already?

I shared my frustration with my husband. “You know what’s more annoying,” he asked, only half kidding I think, “is when people get so wrapped up in themselves they can’t see when someone’s just trying to be nice.” Ouch.

STAGING

All the world’s a stage,
And all the men and women merely players.

--Shakespeare, As You Like It

I looked at the cells through the microscope. They looked “happy enough” as my friend the pathologist described them as he helped me review the slides from my cone biopsy. Regular, smooth, ordered, each dotted with the small purple nucleus of normal cells. Then he showed me some scarier looking areas…not so happy. Jagged, irregular (mitotic) nuclei, looking all revved up and angry, big bloated dysplastic cells looking just about ready to burst with pink cytoplasm, and glands, functional components of cervical tissue choked with abnormality. A very few, rare, he said in his final report, were actually invasive through the glands. He showed me these areas and reiterated how magnified it all was under the scope. And then he printed out a copy of his report.

UTERINE CERVIX, CONE BIOPSY:
RARE MINUTE FOCI OF SUPERFICIALLY INVASIVE
SQUAMOUS CELL CARCINOMA IN A SETTING OF EXTENSIVE CARCINOMA IN SITU WITH BULKY
ENDOCERVICAL GLAND INVOLVEMENT. HIGH GRADE DYSPLASIA, BUT NOT INVASIVE
CARCINOMA, IS PRESENT AT THE ECTOCERVICAL MARGIN OF EXCISION.

TNM
staging: T1A1, NX, MX.

So that was it. I had cervical cancer. An early form of it, from what the biopsy had captured, but carcinoma in situ/severe dysplasia at the margins, which to me was a concern, and most likely an indication for more surgery.

I told my husband, showed my boss, did some research on the internet, rolled the diagnosis around in my head for days, and counted on seeing my doctor in about a week to hear her recommendations. For whatever reason, I kept it all inside…talking to very few people about it at all.

SEX AND THE O.R.

My gynecologist pushed back the curtain in the Ambulatory Surgery holding area with a flourish. “My favorite line, do you watch Sex in the City,” she asked, then went on, “is when Stephanie is telling Carrie in the car that she has breast cancer, talking about the lumpectomy that she’s having, she says ‘Tuesday we’re going to get the little fucker out!’” she giggled. “That’s how I think you should be thinking about this, get this out, get on with your life, do what you have to do.”

I was not done kicking myself, “Could this have been prevented by more frequent Pap smears?” she and I both knowing I had let four years lapse since having an annual exam. “Yes, could be, could be,” but she was not prepared to join me in the self-flagellation. She then went on with my post-op instructions. The anesthesiologist came in, gave me some Versed, and they whisked me off. I vaguely remember getting positioned on the table.

HAPPY BIRTHDAY TO ME!!!

Had a fabulous dinner at a swanky local steakhouse. My son got all dressed up -- shirt and tie he tied almost all by himself. A pharmaceutical rep, hosting a dinner in the cigar room, paid for our dinner! My dad met us at home for cake and coffee. The kids had me open little presents -- an exercise ball and a memory stick for the digital camera. Then we got on line to order my big present -- a new computer to use at work. It should be delivered the week I get back to work following my procedure.