I saw two very sad cases last week. The first was a woman in her 30s who had metastatic inflammatory breast cancer. The disease had infiltrated her spine so badly that standing for greater than 20 minutes puts her at risk for compression fractures of the spine (and thus, paralysis). There was nothing surgically we could do since the cancer had spread, and although she will start radiation and chemotherapy, she will die from her breast cancer prematurely. Surprisingly, her attitude about her disease and life was...cheerful. I can't explain it, and I won't try. I can't recall exactly what she talked to me about, but there was not a hint of melancholia. She understood her life in a way that I cannot yet comprehend.
On Friday, I scrubbed into a fascinating and involved surgery with the intention of removing a lung. It was breath-taking (excuse the pun). This was a young man in his 50s with squamous cell carcinoma of the lung. We began with a mediastinoscopy, an incredibly technical procedure to stage the lymph nodes of lung cancer. With a small incision above the suprasternal notch, we dissected into the pretracheal space down to the carina. The lymph nodes we sampled were negative for cancer, so we proceded to a thoracotomy, accessing the chest cavity to resect the cancer. This involved cutting the latissimus dorsi and serratus anterior, spreading the ribs, and seeing a lung in vivo, expanding and contracting. People go to Hawaii or the Grand Canyon or the Himalayas for a beautiful view; this was equally stunning. But then I saw the cancer, perverse, a purple angry splotch, hard as a rock. The anesthesiologist deflated one lung selectively and we went in, identifying the extent of disease.
The findings were shocking. The tumor had become so pervasive, it spread to the inferior pulmonary vein and into the pericardium. We got an intraoperative consult from another surgery attending, and he agreed with the seriousness of this disease. The cancer has spread too far. We could not resect it surgically. We thought we could cure this man, and now, after opening him up, we realized we can do nothing. Cutting out what we could would worsen his outcome, giving him only one lung without denting the relentless progression of cancer. So despite this four hour ordeal, we reinflated the cancer-infested lung, reset the ribs, sutured up the muscles, and left without changing anything.
Through this surgery rotation, I've seen immediacy of treatment: taking a scalpel to the problem and cutting out the pathology. But here, we've hit an impasse, unyielding, and I don't know how to negotiate the emotions, the feeling of futility. Everyone dies, and on a bell curve, some people are going to die young. Cancer is as reasonable a reason as any. But to cut someone open with the intent and belief that we could dissect away the evil, and to find that there's no recourse but surrender - I struggle to find the words. Yesterday's poem was such an attempt.
On Friday, I scrubbed into a fascinating and involved surgery with the intention of removing a lung. It was breath-taking (excuse the pun). This was a young man in his 50s with squamous cell carcinoma of the lung. We began with a mediastinoscopy, an incredibly technical procedure to stage the lymph nodes of lung cancer. With a small incision above the suprasternal notch, we dissected into the pretracheal space down to the carina. The lymph nodes we sampled were negative for cancer, so we proceded to a thoracotomy, accessing the chest cavity to resect the cancer. This involved cutting the latissimus dorsi and serratus anterior, spreading the ribs, and seeing a lung in vivo, expanding and contracting. People go to Hawaii or the Grand Canyon or the Himalayas for a beautiful view; this was equally stunning. But then I saw the cancer, perverse, a purple angry splotch, hard as a rock. The anesthesiologist deflated one lung selectively and we went in, identifying the extent of disease.
The findings were shocking. The tumor had become so pervasive, it spread to the inferior pulmonary vein and into the pericardium. We got an intraoperative consult from another surgery attending, and he agreed with the seriousness of this disease. The cancer has spread too far. We could not resect it surgically. We thought we could cure this man, and now, after opening him up, we realized we can do nothing. Cutting out what we could would worsen his outcome, giving him only one lung without denting the relentless progression of cancer. So despite this four hour ordeal, we reinflated the cancer-infested lung, reset the ribs, sutured up the muscles, and left without changing anything.
Through this surgery rotation, I've seen immediacy of treatment: taking a scalpel to the problem and cutting out the pathology. But here, we've hit an impasse, unyielding, and I don't know how to negotiate the emotions, the feeling of futility. Everyone dies, and on a bell curve, some people are going to die young. Cancer is as reasonable a reason as any. But to cut someone open with the intent and belief that we could dissect away the evil, and to find that there's no recourse but surrender - I struggle to find the words. Yesterday's poem was such an attempt.
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