Family Feuds and Cancer Survivors

I make no claim to have battled the Emperor of All Maladies, I have merely doggedly walked under the feet of the insurgents who attempt to stand in the way of the Emperor's tank as it rolls into the square. I loved and resented the experience, captured by their vision and passion, I may even make a career of anti-tank mines myself.

Its a fascinating family dynamic. At its head is the Matriarch, simultaneously commanding, inspiring and terrifying, all the while deeply proud of her brood and how far they've come. The fatherly and jovial Uncle at the height of his career, confident in his inside knowledge of how the whole machinery works, with only occasional sexually inappropriate jokes. Then there's Diva, the sometimes moody and generally demanding teenager. The Adopted Child, sweetly cerebral but easily the brunt of the family's jokes. The Distracted Godfather, now moved on to faster moving races, still an efficient and skilled surgeon but detached from family functions. Last comes the Runt, once dotted upon but now pressured to prove that she can play with the big kids. As a family they can be inspiring, compassionate, blood-thirsty, passionate, and heartless all at once. If you succeed they applaud you loudly, taking credit for having painstakingly formed your skill. If you fail, they step back disgusted at your weakness, sure it is no fault of theirs.

It is one of those rotations in residency that seems like an initiation, a gauntlet designed to prove your worth at every turn. Having survived you now breath easier, knowing comrades have fallen before you, switched to other specialties, left without mental health intact.

Despite the incredibly melodramatic picture I've painted, I'm grateful to the Emperor and the Insurgents for lessons learned...I can say that from the other side.

Good news! You have lymphoma!

Well, I have some good news and some bad news... The bad news: you cancer, but the good news is that its lymphoma!

I recall standing next to my attending at the gyne oncology clinic as an elective medical student in complete disbelief at the words that had just come out of her mouth. The poor patient dissolved into tears. She had been pacing back and forth with too much back pain to sit in the chair next to her husband, a result of massive lymph nodes pressing on her psoas muscles.

A hideously awkward discussion ensued where the attending (sickeningly upbeat and logically) explained that lymphoma had a drastically better prognosis than ovarian cancer, so it was a better cancer to have really. The whole time the poor patient's husband tried to refrain himself from punching said attending in the face. Or maybe that's just the fly-on-the-wall little medical student's interpretation of what happened. My attending then did a smooth punt and turf to medical oncology despite the sobbing patients request for answers.

I remember feelings of helplessness washing over me, overcome with empathy for this hurting woman and anger towards a frankly ridiculous attending. It was in the midst of a frigidly cold elective in Ontario during which I was supposed to be impressing people but felt achingly lonely and completely incompetent for the entirety of the rotation.

Last night I had a vivid flashback on call at the Death Star. The emergency physician called me to see a woman with "new onset metastatic ovarian cancer" who had recent growth of parotid (jaw), neck and axillary lymph nodes (and of course, a mass in her pelvis). It felt like a case of: "patient has vagina, please see in consult." She was young, and as I spoke with her and her husband the fear was palpable. A single tear slipped down her cheek as she answered my questions. The truth was, the chance of her having ovarian cancer was slim to none as further investigations confirmed, gyne oncology was not the service that could help her. Unfortunately Dr. DoucheBag McEgo was the internal medicine Sr resident and it took three heated discussion, four hours and a (useless) consult with hematology for him to admit the patient. My blood was boiling with Dr. McEgo's passion and determination to turf this lovely patient to anyone but his team.

Hours passed, internal med finally saw her but as I walked by to see another patient, her husband grabbed my arm, looking for answers. What's going on? Does she have cancer? Is she going to die?

Leaving the post-partum lady with a fever and the palliative patient with metastatic uterine cancer who now had a lung full of fluid, I sat on her stretcher and laid it all out for them. Yes, right now it looks like lymphoma, but there's treatment for this. The husband curled up in fetal position crying. My heart broke a little...maybe a lot, but it felt like I was actually doing something useful. Not turfing, not fighting to get rid of patients, but being present in the pain, messy as it is. I'm not scared of tears anymore and I'm no longer just a witness to it all.

Full Circle

February 14th, 2008 Vancouver was enveloped in its standard winter cloak of gray clouds and cold rain. Although, even that I was only aware of cycling in the drizzle to work in the dark mornings for 6:30am rounds, leaving as light left the sky in the evenings. Exhausted and drained from another day at the Death Star. There was a haze in my eyes and my head ached, I was on call that night and groaned inwardly when the oncology fellow paged me to go to Emergency to see a patient.

She was a woman in her early 50s, who after a long post-operative recovery from ovarian cancer debulking surgery had now developed an abscess. She was febrile and in significant pain, accompanied by her husband. She was also a physician, as was her husband a fact I knew from her lengthy admission to the service.

The most amazing thing happened that night. Though her own pain and fear, she focused on me as a person. How is residency going? What type of practice are you considering? What are you struggling with? What do you love about the specialty? I stood next to her stretcher in the emergency department, examining her, explaining the CT scan she would get and the antibiotics she would be on, all the while completely floored. Here was my patient, a physician no less, taking the time to recognize my humanity, something no one else had taken the time to do that whole year. I remember the night vividly.

September, 2010 Why don't you see the next patient? She's a doc so make sure she's okay seeing residents first. And there she is as I walk in the room. A warm smile on her face, her arms tanned from the sun, positively glowing despite a recent recurrence and chemotherapy. Hey! I know you, February 14th. Were her first words to me. You saw me on the night I was readmitted to hospital!

I couldn't help but recount to her how she had recognized the person-hood of a junior resident in the middle of the night in the emergency department and in doing so had renewed my faith in a healing vocation. We can't cure her cancer, but nothing about her suggests a dying woman, she is living and vibrant, full of hope and laughter. And so I come full circle.

Doctor in Denial

There comes a time in every kid's life when they realize something about themselves that has become too obvious to deny. This has happened on many levels for me, and now, there's no denying it, its been four years, lets face it, I'm a doctor. No more denial.

The challenge comes when trying to find a new blog title though, something that portrays a journeyer, some humility, faith, a learner, open-mindedness, and yes, something related to obstetrics and gynecology. A list of hilarity ensued:

Hippocratic Acrobatics

Chicken Soup for the Vagina [lets get all spiritual]

Vaginal Soup for the Soul [that's going too far]

Vaginal Surrender: Gynecology on its Knees [an attempt at the humble part gone oh so wrong...]

Vagina Smagina [not quite profound enough]

Confessions of a Passionate Nomad [sounds like a travel blog, although a friend once told me she could see me 'saving the world, one vagina at a time'...]

Confessions of an Aspiring Mid-wife [might get doula-wacked, better watch out]

Dr. Mister the Gynecologist [insert inside joke here]

God, Boob-juice and Hysterectomies [stop while you were ahead]

Eventually, after several episodes of gut wrenching, eye-watering laughter, here's the new title, comments welcome.

Informed Consent, the Lion King and Cholestasis

So...what you're saying is that there's a risk of stillbirth so that's why you recommend getting labour started now?

This was after a thirty minute discussion on cholestasis of pregnancy which is associated with a 1-3% risk of stillbirth at term. The poor woman came in as itchy as a bed bug infested child, going a bit nuts scratching her skin off. There's no need for an urgent induction, but we do tend to recommend proceeding with a birthday party if the baby is already fully cooked in there.

Well, this is a miracle baby you know, it was an IVF pregnancy and we're really quite nervous about it...but...its just...well...

Understanding where people are coming from is crucial, we get taught to ask how people feel about treatments, what their perceptions are yada yada yada, but I couldn't quite get inside this woman's head.

We had tickets for the Lion King this weekend, couldn't we have the baby next week instead?

Then it all made sense. We're not in Uganda any more kid, there's more important things than life and death you know, there's the Lion King. [Insert irony here.]

Off to Amsterdam Again

My time is drawing to a close. I’m going to miss things. I’ll miss the carpenters saying good morning and greeting the chapatti lady as I wind through the neighborhood, past plantain trees, scattered maize and jack fruit trees on the way to catch the matatu every morning (I live behind a petrol station you see). I’ll miss the milky chai, fresh pineapple and mango breakfasts. I’ll miss my chats with Veronica every morning in Kisenyi before we start our surveys as we sit in her somewhat derelict hair salon, the world passing us by on the dusty street outside. She loves reading, and although she has no books, she budgets to gets the local Luganda paper every morning and as she sips her chai she translates the stories for me.

She this man! Ah! He was to marry this woman, but then at the wedding day, this woman here came into the church and said that he was already married to HER and had three children! These people…

The last page of the paper always has an update on the soaps. Most are dubbed Brazilian soap operas (not quite sure why), sheer cheesy hilarity to watch. Apparently everyone says I look like the character ‘Ina’. Veronica points at the pictures as she explains:

Shona, have to seen it yet? On TV? Well you see this man, he is in love with Ina but they forced him to marry this woman, see? Can you see even the tears in his eyes? Oh it is so good this show.

She’s an amazing woman, she’s 55 and has had seven kids, four of whom are alive. In addition to being village chairperson, it sounds like she helps support about 10 grandchildren. Two of her children are working in Iraq and she wants to send her other daughter as well, the money is good she says. It blows my mind. They mostly work in security and when they are there everything is provided, their salary goes directly into a Ugandan bank account. Perfect scenario, no? Except for the getting blown up part I suppose.

I’ll miss the vitality of life, the gratefulness for each day that people have. The vivid colours of clothing, the smiles in response to my attempts at Luganda, the very grittiness of life. As my mom says of life in the developing world, the colours are brighter and the pools are deeper. It strikes me also that heartache is closer to the surface, each moment of life is more precious, it can come and go so quickly after all.

I’ll miss my Ugandan family, the sometimes profound, sometimes hilarious dinnertime conversations. They are middle class Ugandans who are deeply generous, taking in all sorts of strays in need (mzungu and Ugandan alike!) I’ll miss groundnut sauce…but I suspect I won’t miss the matoke (steamed and mashed plantains) for every meal. After some deliberation, I don’t think I’ll miss the Lugandan gospel music piped through the household sound system at 7am every single morning. I vaguely recall initially finding it a lovely part of the whole Ugandan experience… naive rookie!

I may even miss the tachycardia-inducing bodaboda rides. The first day I was sure I would not die, instead I would be smeared on the road between a matatu, a large truck and a bicycle overloaded with plantains, maimed for life. After that it turned out to be a fun part of the daily routine.

I’ll definitely miss not being on call…two months with no call has been soul restoring. Although my soul has been restored by much more than that. I’ve found passion for my vocation again, or it has found me. Instead of pulling myself out of bed each morning to do something interesting that I feel privileged to do, the work itself pulls me out of bed and drives me through the day. I feel empathy again, compassion, my jaded attitude has dissolved in the mud of Kisenyi and in the eyes of the women who have shared their stories with me. I’ve lost the sense of overwhelming helplessness in the face of human need and again am ready to hurl myself indignantly at injustice.

I’m reminded of a quote that a physician read out to our class on the first day of medical school, as we sat packed into our seats in Libin theatre, naively full of apprehension, dreams and ready to take on the world.

Do justice,
Love mercy,
Walk humbly.

Of course, these were familiar words, as I was raised on them.

A Love Affair

I’ve been having a love affair with Jinja.

Who’s Jinja you say? Fine, I’ll admit it, not a person but a place. The source of the Nile. It was the third weekend I had been up there, the first time for rafting, the rest to kayak.

The kayak skirt tucked tightly around me, my red Spice playboat responding to every movement of my hips as we paddled along. I feel a bit guilty, you know, with the water shortages in this part of the world, that I should be inhaling so much of the Nile into my sinuses…so wasteful.

My teacher David and I had spent hours working on my rolling, you know, the second 180 degrees that gets your head OUT of the water. As I feel I have a gift for easily accomplishing the first 180.

We now paddled down the river to approaching rapids. The sky was bright above us, the sun beating down, but ahead huge dark clouds loomed. Like a prairie thunderstorm on a steaming summer day, we could see a sheet of rain approaching in the distance. The clouds flashed like fluorescent bulbs, trying to flicker to life and I heard deep grumbling in the distance. I cursed myself for not having invested in a waterproof digital camera as the light show was breathtaking.

It was exhilarating. The pounding waves, spray and foam of the rapids, David convinced I was capable of turning my kayak backwards and surfing the wave. Of course I was, but it took few runs to maximize the percentage of time my head was out of the water.

Then the storm hit us, pelting down, the rain seemed to have the force of a waterfall. Powerful, overwhelmed equally by beauty and adrenaline.

An affair I won’t easily forget.