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Wednesday, October 28, 2009

THE C-WORD

The fingertips of my right hand have been trained, over the past few years to pick up subtle irregularities in the examination of a patient.

The sensory information gained from these soft pads of palpatory precision, communicate via amazing electro-chemical pathways along my nerves, to send a message of alarm or calm to that central processing unit in my skull.

As doctors, we usually begin our examinations by using these sensitive fingertips of ours to feel pulses.

It's probably the first thing one learns to examine. I remember practicing on my fellow students after our first clinical skills tutorial, and bragging about who had the lowest heart rate and could thus claim supreme athletic fitness.

Such a simple thing, feeling a pulse.

And yet, at it's most basic of functions, it is an ultimate determinate of life, or death.

Lub-dub, lub-dub.

A rhythmical, cyclical affirmation of life, beating a constant reminder into my fingertips that, "Yes doctor, I am alive, don't give up on me yet."

Except that this time, the pulse lied...



She was logged in the book as "???oesophogeal cancer???"

That question mark prefix:

Mostly an indication that the diagnosis is still being worked up.
Often a symbol of hope that our suspicions are unfounded.

I drew the curtains, armed with my cheery and hopeful, yet concerned bedside manner.
The one I've developed over the years to try and lessen the terrors of being in a state hospital and the threat of a disastrous diagnosis.

But I was no match for the enemy that confronted me.

I was physically shocked. My years of service have brought me face to face with the destructive forces of disease and trauma, yet I have never been this physically moved.

There it was.

Present.

I did not need to touch her to know what I instinctively felt.

Cancer.

I could hear it cackling at me, callously thrilled to have so viciously ravaged her body.

So confident in its permanence that it willingly revealed itself, showed its hand, tortured me with its unquestionable impending victory over her life.

She lay there, motionless, except for the slow sad movements of eyes sunk deep into the despairing depths of her skull.

In a defeated and very small voice I introduced myself to her.

She responded after a few seconds with only a painful exhalation.

Touching her made me shiver with horror.

Her skin, like old leather that has been trodden on and left outside to be battered by the rain and sun, was stretched unwillingly over her skeleton. I looked at it listlessly collecting in the hollow that used to be her abdomen, and watched it tiredly continuing on its journey over her chest - her nipples the only hint of the breasts that fed the three children huddled around her bedside.

Her arms and hands were like the branches of a dead tree...thin, dry, reaching hopelessly into space.

I knew then that I had no weapons against such an advanced and evil adversary.

I could feel her spine when palpating her abdomen.

I was sickened.

And before feeling it, I saw her abdominal aorta pulsating, valiantly carrying on the physiological fight, regardless of the inevitable surrender.

Why did this lady only present to us at such a late stage?

Because she is poor? Because she doesn't speak English?

Why did the initial slow deterioration of her life not warrant ear-splitting sirens summoning sympathy and support and treatment?!

But it was too late for all of that. The cancer had metastasised.

Any further medical intervention would have been cruel and inhumane, and would only prolonged her torturous demise into death.

I gently informed the family of the very poor prognosis, and let them know that she would most definitely stay in hospital for the night while we tried to find a placement home for terminal care.

When her husband left, he bent over the skeleton that used to be his wife and kissed her forehead. He then turned to me and placed an old washrag and a bar of soap in my hands.
"This is her washrag." he said. "I'm the one who washes her every day with this washrag. Can I leave it here? Will someone wash her while I am away?"

Choking back the tears all I could manage was a nod of the head.

I handed over the washrag to the nursing staff, and finished my shift, dejected.
By the time I arrived the next day, she was gone.

But what remained with me is cancer's destructive power and our frightening inability to conquer this terrifying disease.

6 comments:

Illegally Blonde said...

This is the one that I cried about in a status update earlier!? Again, the tears! Not fair. Not fair. Not fair. But it does beg the question...why had her husband, who so carefully washed her every day, not sought medical help for his wife. Yes, he may have waiting in long queues? It is true, she may have been denied whatever medical treatment she needed ( if the state's resources were not sufficient to provide it, like poor mr Soobramoney)but...there are state hospitals, and the doc angels like you are there, at work, everyday! Poor or not...people get to hospital when things are that bad, don't they???????????????????????

Ketan said...

Hi Dr. S!

It was liver mets?

I've had to face fewer such situations. But they always are bad!

I remember at a first-aid center in a very famous temple, I had tried to resuscitatate a 45-year old man exactly 2 min after he had died! It was terrible. His wife and teenage daughter and son were watching all that from outside.

I did not have the heart and authority to declare him dead at that point. So, he was sent to the main hospital. He was to undergo a coronary bypass a week later, and despite warnings of not exerting, he had chosen to stand in a long queue in hot Sun, only to gain audience of the idol in the sanctum. I felt extremely sorry for his family, but for him somehow I felt an anger. It was his utter foolishness that left his kids orphaned now. Usually, in an average Indian family, it is the male who is the only source of income, and I could sense all that horror in his family members' eyes. It was very bad, to say the least.

I'd been an atheist for very long, but I couldn't help but feel an anger rising at the very concept of God.

Just a bit more common sense, and the family could've lived on happily ever after. :(

I feel very pained, when I see people suffering despite all the progress made by science, when it's much easier to be happy nowadays. Not that I'm unaware of the glaring conditions of deprivation many people live in. But then, there are those who choose to smoke, binge on alcohol, get into a fight, kill others, when possibly they could've gone about their own affairs, trying to make the best off their lives. And you know, this foolishness is not just restricted to those afflicted with poverty. Even those well endowed indulge in all kinds of foolishness, only making their own and others' lives miserable in the process!

I know, a large portion of my comment wasn't even connected to your post, but these are some of my ideas that keep on coming to my mind.

I just hope, with further progress in science, we would be able to make cancer lot less painful than it is today! And also that these treatments would be affordable. With my being interested in pharmacology, let's see if I could do something! :) Though, in all honesty, it would be more because cancer is an intellectual challenge, rather than out of humanitarian concerns.

Moving post, quite as usual!

Have a great day!

Geraldine said...

It is so so cruel, being human and being aware of our existence,but also of our mortality. What saddens me is when that life is so full of hardship and sadness that it almost more cruel to have even begun in the first place.

My dear dear friend, who passed away from breast cancer earlier this year, used to refer to it as The Fucker. And I totally agree.

Dr S. said...

@geri: "the Fucker" is the most appropriate freaking name ever. It encapsulates it all, it's just one godawful FUCKER.

@Ketan: Liver mets, peritoneal mets every-mets. AND, because it was so difficult for her to swallow from the dysphagia caused by the Ca, she was slowly starving to death as well.

I feel for that poor family, having lost their breadwinner....I wonder if the proprietors of the temple will aid them financially now that he is gone...

@Illegally blonde: The Back story is that this family had been seen a few weeks earlier and diagnosed with the cancer. However, getting an appointment for furhter investigation and specialist follow up took forever due to the ridiculous shortages in staff, facilities and clinic time in the state sector. Which is why everything was just all the more tragic. Thank you for calling me an angel...that means a lot. Sometimes I just feel like the Grim Reaper, or a messenger of bad news....x

Ketan said...

Well Dr. S, I was posted over there as an intern, and I did not get to follow the MI case, but I do not think he would have been compensated.

Actually, it is not legally binding on the Temple authorities to compensate him since he had chosen to stand in the queue against strong medical advice. And well again, to the extent I could gather the workings of the Temple's trust that oversees the finances, I do not think he would have been compensated.

Moreover, considering the cost of living, and especially, of education of two teenaged children, no financial aid could ever prove sufficient.

You have any idea of the most common predisposing cause for esophageal cancer in SA? Is it gastroesophageal reflux, or smoking, or something else?

Did that lady, in your knowledge, have any of the predispositions, or was it totally sporadic?

TC.

Ketan said...

Well Dr. S, I was posted over there as an intern, and I did not get to follow the MI case, but I do not think he would have been compensated.

Actually, it is not legally binding on the Temple authorities to compensate him since he had chosen to stand in the queue against strong medical advice. And well again, to the extent I could gather the workings of the Temple's trust that oversees the finances, I do not think he would have been compensated.

Moreover, considering the cost of living, and especially, of education of two teenaged children, no financial aid could ever prove sufficient.

You have any idea of the most common predisposing cause for esophageal cancer in SA? Is it gastroesophageal reflux, or smoking, or something else?

Did that lady, in your knowledge, have any of the predispositions, or was it totally sporadic?

TC.

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