Monday, February 13, 2006

How Do We Move on From Here?

The wound smelled like something had died. The odor was overpowering. Sadly, your rectum was removed thirteen months ago and the wound is actually larger than when we started. After more than a year of two visiting nurse visits a day to pack it with various materials in an attempt to heal, prevent infection, and promote tissue growth, this enormous opening where your rectum used to be has simply become part of your world. You adjusted to the colostomy so well and handle its inconveniences with great aplomb. The discomfort of that massive opening and the difficulty sitting in a chair notwithstanding, you still complain so little.

You’ve overcome HIV, keeping your virus essentially asleep with excellent adherence to your antiretroviral medications. The diabetes is also under excellent control, and despite your third grade education, you have internalized the years of teaching and try so hard to be good. You even beat acute TB and underwent nine months of multi-drug treatment, never missing a beat. What fortitude!

The cancer seemed to have been beaten back in 1990 according to your medical records from a hospital in another state. You underwent surgery, chemotherapy, and radiation---you defeated cancer and lived to tell the tale, having received an HIV diagnosis not long before that. You were amazing.

Then, about fourteen months ago, you reluctantly allowed a rectal exam, and there it was, eating away at what was left of that most private and vulnerable area. We hoped that you would heal well, that the cancer was completely removed (a difficult promise to make), that your recovery, although arduous, would be complete, or at least complete enough to allay some fears, at least for a while.

But now, after thirteen months, the fibrous tissue (caused by the large quantities of previous radiation) does not allow this wound to close. About a month ago, I accompanied you to yet another appointment with the amiable surgeon, and he allowed me, as usual, to don gloves alongside him and examine your surgical site up close. A yellowish mass hung in that cavernous and fleshy space, and I watched as he expertly removed it with a small disposable scalpel, dropping it into a formalin container for immediate transport to the lab for biopsy. He looked at me and shook his head—neither of us liked the look of that unnatural-looking tissue. The biopsy was positive for adenocarcinoma.

The biopsy behind us, an MRI does reveal a mass, unidentifiable and not completely quantifiable, but it’s there. At the wound specialist’s office today, I peeked into the wound alongside the nurse as she cleansed and repacked it. That yellowish color deep inside there is disturbingly similar to the color of that mass removed by the surgeon not that long ago. It screams “cancer” as I inspect it.

How do I communicate to you the gravity of this finding? How do I tell you that the wound will most likely never close? How do I find the words to say “I’m sorry” and “I’ll stand by you no matter what”? You have been through so much, shouldered such burdens, patiently accepted each test, each surgery, each probing scalpel, each exam. How do I convey to you that this road will not ease up, but will necessarily become even more arduous? Chemotherapy is an option, complete with hair loss, abnormal blood counts, nausea, discomfort, and even more appointments. You will have to suffer even more indignities, more exams, additional doctors, new treatments.

If this is hard for me, how is it for you? How will you cope? Will your preoccupations and worries get the better of you?

I stared into this gaping wound today as if into an abyss, like looking into a hellish crystal ball with a window to your future. The tea leaves do not sing of sunny days and an end to your suffering. The prognosis cannot be good, but my ability to support you on this journey---my inner strength---it cannot waver. If it does waver, it is out of love and a deep respect for your humanity, and the difficult road which you will ultimately walk alone.


tscd said...

It's so hard to give bad news to people. We get into this profession to help people, but often we end up breaking hearts.

Unknown said...

How horrible for that patient, and you as well, having to be the bearer of bad news. I had a patient with a similar wound and even though it wasn't cancerous, it still took his life.. What a battle patients go through on a daily basis!! It makes us appreciate our own lives even more. Wonderful post!