You are the angel of death And I am the dead man's son... And who is the master of the fox hounds And who says the hunt has begun
(Pink Floyd, “Free Four”)
"What was the name of the hospital where you had your breast abscess drained?"
She looks away, "I'd rather not say...it was in Joliet...where I live...I'd rather not say."
"OK, well, what did they do for you at that hospital?"
"Well, they stuck a needle in me...twice...and they drained it...they gave me some pills..."
"When was that?"
What? The anti-biotics?"
"The middle of...uh...when was that?...the middle of November."
"And when was the surgery?"
"Right then...the middle of November."
"OK, let me put this in perspective, when did you first notice that your L breast was larger?"
"When I was nursing...when I just finished nursing my little baby..."
"And when was that?"
"Um...July...the end of July."
"OK, so 7/92 you first noticed the swelling...and then what did you do?"
"I waited awhile 'cos I had so much...with my little girl..."
"What's her name?"
"Tanesha, Tanesha J."
"That's a pretty name. When did you go to the other hospital?"
"So, after 9/92, you waited until New Year's Eve to come to the emergency room of Cook County Hospital?"
She looks away again, "Yes, well, I was busy with my baby, and I thought it would maybe just go away with the pills they gave me..."
"Do you have a family history of any type of cancer?"
"My sister...she just died of leukemia...she had chemotherapy...it was awful...it made her thin and sick and she lost all of her hair...and she died anyway...she died August 3rd."
"I'm sorry to hear that...was she older or younger?"
"She was one year younger...she was 35."
"Man, that's a shame, she was very young."
"And my Auntie, she died last year she had breast cancer in her whole body."
"So, you've had a lot going on lately...with your family and your new baby?"
"Yes, I just want to get back to my baby."
"OK, well that's all the questions I have for you now...I'll see you a little later."
"Yeah, she's 36 yo BF, who noticed a swelling of her L breast after weaning her kid. She went to another hospital, she wouldn't say which one..."
"That's important information...you've got to be more persistent...more aggressive..."
"I know, she just won't say...it’s not like I didn't ask...she just said she didn't want to say...it seemed maybe like she didn't want the other doctor to get in trouble because she kept asking me if I thought he had treated her right..."
"OK, just go on."
"OK, she, um, where was I? So, she went to this hospital and had the abscess drained and was on 2 courses of Abx...this was 9/92 to 10/92...and then she waited until now...2mos. later to come here..."
"What do these people think? Does she have a family history of breast CA?"
"Yeah, her aunt died 1yr ago from breast CA...her younger sister just died from leukemia, too."
"OK, go on, the physical?"
"Well, her L breast is about 3x the size of her R, and that's pretty big to begin with..."
"How 'big' is it?"
"It’s like this," I make the size of a basketball over my chest.
"Come on, that's psychiatrist stuff...gesturing like that... how many centimeters?"
"I didn't measure, its big..."
"OK, OK, go on, any fevers? chills? night sweats?"
"No, no, she denied that, but while I was examining her the wound dehisced a little and drained some serosanguinous fluid..."
"Shit. I'll take a look at her...we might have to take her to the OR later. Take care of those CTs that you didn't get yesterday. Now, Dave, listen to me, I don't care if you have to sit in radiology for 2 hrs, you've got to get those films, no excuses."
"But I checked twice...they're supposed to be in the Fantus file room, but they're not there...they've checked twice..."
A nice down comforter of snow covers the city, when the flakes are at a distance they are calming, gently floating, but even so, they speed up and splatter on my cold glasses and face...trudging through the snow...yesterday was filled with malice, destruction, and weariness...when I stepped out of CCH I smelled burning plastic and a cloud of smoke billowed purposefully upward until it reached the low-lying ceiling of clouds...it definitely stretched past Damen and Ogden...the source was somewhere north of the Eisenhower...at about Racine...then I was off!...my sister and I were in Dr. Wax and I had just found the Spacemen 3 disc, “Sound of Confusion,” and a disc by Damon and Naomi, 2 members of Galaxie 500, called “More Sad Hits”...just then the power goes off and we have to leave without the discs...SNOWSTORM...driving up Lake Shore Drive onto Sheridan road...sliding around the curve...I withdrew from further action...when nature clusters the best response is passivity...the Romans...if they were to stumble on their front stairs in the morning...would go back to bed.
"Hello, yes, hello, is Mr. Chow back yet?"
"Is there any way I can reach him? It’s important that I talk to him today concerning a copy of a CT for a Pt going to surg on Mon."
I didn't even know it was possible to make a copy of something that is lost. The surgeons probably lost it anyway. They're always taking films without checking them out and then no one else can find them. Man, the more that resident yells at me the less I take him seriously...fuck it...I'm going to take 10 minutes and get a cup of coffee.
"You can't just keep pretending that you don't have cancer! You have cancer! You need treatment! It’s not going to just go away!..."
"You know, I'm not trying to make him mad, but the other morning he got real mad...I know I have cancer...I'm just afraid of the chemotherapy...I saw what it done to my sister...all thin and wastin' away...no hair...I want treatment...just not chemo...I need some time..."
"I don't think that he's mad at you, he's just frustrated...doctors get frustrated when they know what has helped other patients...you know, for cancer there's a lot that doctors can't cure, that they can't make go away...and the treatment we want you to have is based on what has helped other pts and it is all rather cookbook...we know what kind of cancer you have and we can look in a book and see what is the best treatment for you..."
"I know, I know, but can't I just have the antibiotics and come to clinic every week like he first said?"
"That was before we knew you had cancer...when we thought you had an abscess...antibiotics won't do anything to your cancer."
"At the other hospital they said I had a clean bill of health, that's what they said, 'We've taken your biopsy and you have a clean bill of health, it’s not m-m-menign."
"But then they found out that you had cancer, right?...they told you you had cancer?"
"Well, yeah, but first they told me I had a clean bill of health , and I was happy...I told my family...they was happy...then they told me I had cancer and I couldn't understand how they could say I had a clean bill of health and 2 weeks later say I have cancer...I know I have a tumor, and all tumors are cancer, right? but cancers can be m-menign or malignant..."
"Well, tumor means an abnormal growth - it can be benign, which means it won't spread throughout your body - or malignant , then it’s a cancer and it can spread to other parts of your body...you have a malignant cancer and it has spread to your lungs and to the lymph nodes, that drain fluid from your breast, in your L armpit...Mrs. C, you know, you have a bad cancer, it’s not going to go away by itself or with antibiotics [God, sometimes this kills me when her eyes start to tear up, she definitely understands, but then denial kicks in] and it will continue to spread throughout your body..."
"Well, say even if I was to have the chemo and radiation? I still might need a massmectomy, right? Why go through all that chemo if you still might take my breast?"
"Mrs. C, we know that the cancer has spread at least to your lungs and that it is in the skin of your breast, we don't know about the rest of your body (you'll have your bone scan as an outpt) and surgery would only remove the cancer in your breast and not from the rest of your body...that's what the chemo is for...right now we aren't worried about saving your breast - we don't even know if we can cure you of your cancer - we are just talking about prolonging your life...you have a bad cancer and it is probably going to kill you eventually...now, since you have cancer that has spread in your body, we can only treat that with chemotherapy and radiation...has anyone explained to you how chemotherapy works?"
"Well, in cancer the cells grow unchecked - they just keep growing, even where those cells are not supposed to grow in the body, and the chemotherapy kills, or at least slows, those growing cells, but the side effects are from the chemotherapy affecting not just the cancerous cells, but also other healthy cells in your body that are grow fast - like hair, skin, and the cells that line your stomach and intestines - and so the side effects show that the chemo is doing what it is supposed to be doing - to kill the cells in your body that are growing quickly, both the cancer and other cells, too."
"OK, I just need time, I mean, they tell me I've got a clean bill of health [I hate it when she smiles when she says that] and then I've got cancer...I'll just wait and see if this biopsy heals up and if I swell any more...and if those cancer cells are growing fast maybe I'll heal even quicker?"
"No, no, not really, because, you see, the cancer cells are no good, they don't work like normal cells, they don't grow in a normal pattern, they are very chaotic...no goal in their growth...and they won't stick together right...in fact, we are afraid that your wound might not heal at all, because of the cancer in your breast."
"Oh...it might not heal at all?...But you don't know with me, right? I might completely heal up? I might have a miracle and heal right up and then I'll come back and show you where the cut was and it will be all healed up nice...what would happen then? how would you treat me then?"
"Well, you know, we can never say what will happen to an individual for certain...science is based on numbers and percentages...there is no certainty in science - only probability...all we can say to you is what is most likely to happen based on other women with breast cancer...and that is that your breast probably won't heal right...if you have a miracle, we'll deal with that then...but that's not what we think will happen...and you know, Mrs. C, we can't tell you what to do with your body, we can just give you our recommendations based on other people with similar cancers, and that's for you to have chemotherapy and radiation therapy...you have a bad cancer and it has already spread in your body...it’s common for people to have problems absorbing that they have cancer - you know, for it to sink in - we call that denial, that you are having a hard time accepting your illness."
"Yes, denial...I just need time for it to sink in...I'm scared from my sister's leukemia...and I've got my new baby...I just can't deal with all this so fast...first I have a clean bill of health...then I need a massmectomy, but its menign...then I have cancer...and you want me to have chemotherapy..."
"We'll give you time, you go home to your family and your little daughter and you think about it...talk with your husband...I can tell you've thought a lot about it already..."
"Yes...I didn't sleep at all last night, I was up worryin'."
"Well, it’s important that you think about all this, but if it gets to the point where you really want to sleep and get some rest, just ask the nurse for something to help you sleep and we'll write an order for some sleeping medicine...OK?...Now, when you come back to clinic you can always decide if you want chemo, and you can always call us if you have any questions or if you just want to talk about your cancer. We just want to make sure that you realize that you have a bad cancer and that it is probably going to kill you, but with the chemotherapy and radiation we can at least slow the cancer and keep you alive a little longer and prolong your survival. We don't want you to deny it like at the other hospital, we just want to make sure that you understand...so that you can make a good, informed decision about whether you want chemotherapy or not...we also want to make sure that you have time to think about all this before we ask you again if you want that treatment."
"Thank you, I'll think about it, but you wait and see, I'm going to have my miracle...you wait and see...I can't wait to see the look on your face when I come back and my wound is all healed up!"
"OK, OK, Mrs. C, you keep your hopes up...I'll see you in clinic in 1 & 1/2 wks. I'm glad to have met you and I hope everything goes well for you at home...I'll see you in clinic, just promise you'll come to clinic..."
"Oh, I promise."
"Next time, you just go to the room, the uh..."
"The CT room."
"The CT room and they just get the film from a file and..."
"they get it from a tape and make a copy..."
"Tape?...there's no tape, they just..."
"No, there's a tape...I was there...the technician looked up the tape # in the file and she got the tape and made a copy...I know how to get a copy now...and here it is"...he keeps talking, but all I can think of is how I've been becoming more and more withdrawn from everyone around me all this week.
Teaching Point: The next week I got really sick. Sunday night I had a high fever and woke up covered in sweat throughout the night. The next morning I had a hell of a time getting up...I went through the old well, I won't shave - I'll sleep 5 more mins, then I won't take a shower - that's 5 mins more...eventually I got up and got dressed, then I sat down and felt like shit...I called in sick...I figured I had a flu, what with the high fever, the muscle aches, the overall malaise...I mean, it hurt behind my eyes...every time I moved my eyes...but then the next morning: my throat hurt every time I swallowed and I looked in the mirror and it was all pussed out...it was strep and I started Pen VK, 250mg, QID, on an empty stomach...so I was out all week...the services switched while I was out, so there was a whole new bunch of residents when I came back to the hospital...on Wed, the day Mrs. C was supposed to come to clinic, Mr. R had to be taken up to the OR, he had esophageal CA that had eroded into his stomach, when we opened him up his stomach was distended - stretched tight like a balloon - and it was full of stinky blood, augwh...anyway I was in the OR retracting all day for the surgeons and I told Goldie that Mrs. C was supposed to come to clinic, but she didn't see her, so I don't think she ever came to clinic...