Remission

Doctors insist people are kept alive for as long as possible. Invasive intervention, as it may be called, can save lives, gripping the dying by their fingers and violently force them back to a life of intubation, mechanical ventilation and occasionally brain death.

Grappling Life

It is against our nature to let people pass, to do nothing. Once we investigate a patient's illness and find an incurable disease, that patient's story becomes the caring doctor's failure. The entire arsenal of medical therapy, oncology and surgery is unavailable to this patient. This is the psychology of medicine.

A new perspective is gaining popularity, which is welcomed by patients and their caring doctors... this is the view, as Professor MHK once told me: letting nature take its course.


However, cure is occasionally on the list of possible end-points, being very rare indeed against humanity's war declared against cancer. And often, I savour moments where patients are told news involving the word "cure".

Mrs. EE is a 43-year-old primary school teacher who has been in and out of radiology departments due to breast lumps. 15 years ago a lump caught her hand as she was undressing and the first ultrasound found multiple lumps, all of which were biopsied, coming back as benign (non-life-threatening) tumours. Her doctors insisted she get regularly investigated to ensure nothing changed and I'm glad they did because a suspicious lesion was discovered recently. The biopsy demonstrated a small breast cancer; it was barely palpable on examination.

Our paths were destined to cross when the consultant recommended a lumpectomy and sentinel lymph node biopsy to exclude metastasis. We met in the operating theatre, after she consented to the procedure. Like most procedures, I was distracted with paperwork and didn't notice her anxiety; someone had to fill out the pathology forms (both specimen and frozen), double check the admission form, ultrasound and biopsy results and ensure the consent forms were signed. When I turned around to see how she was, the Anaesthesiology resident had already sedated her and she was in a mixture of unconsciousness and horror.

By the time the endotracheal tube was in situ, I was already scrubbing for surgery. When I was gloved and gowned, the consultant was already drawing the incision lines and planning the procedure. After he left, it was up to me to coat her chest with iodine-based antiseptic and drape her properly. Next thing I knew, the chief resident was gloved and gowned, helping out. Then, the consultant and I were side by side and he was holding the 15-scalpel. May we start? - his routine of asking the Anaesthetic team if he could proceed; an amazing gesture of respect. He would never begin the incision before their blessing... and I literally mean their blessing.

20 minutes later the lesion was out. The blue dye he injected had made its way to the axillary lymph nodes draining the breast and the sinister tumour within it. He made a small incision in the axilla and after a few minutes of dissection, the sentinel lymph node was glowing blue in his hands. Let's take this to the Pathologist now and see what's under the microscope.

We waited as the technician made his way to the Pathologist in the operating theatre. There was a short while of pause and the only sound was the patient's heart translated into digital beeps from the anaesthetic bay.

"What happens if the lymph node is positive for metastasis?" I asked, wondering what the end point was.

If it is positive, I will perform an axillary dissection.

Spoken like a true surgeon, I thought.

Results were in - negative. There were no cheers of joy or relief. The chief resident and I were left to suture the incisions while the Anaesthetic team slowly restored the patient's consciousness. She woke up, disoriented and gagging on the endotracheal tube. Once the simple reflexes are restored, the Anaesthetics resident pulled out the tube, and maintains the airway until the patient regained full control.

Mrs. EE is different. I feel she was suffering in her state of sedation because she begins to ask whether there was spread to the lymphatic system. The theatre team dismisses it because they assume she clearly won't remember; but I'm sure she's awake, aware. Her facial expression, affect and tone of voice are telling me a story - one of desperation and fear.

I accompany Mrs. EE to the recovery ward as I do every patient and hand over to the post-operative nurses. She continued to ask about her illness. I hesitated by her side; I knew the biopsy results and for that moment, I was in a dilemma. It was customary for the chief resident or consultant to let the patient know the result of any operation. She peered in my eyes, searching for an answer.

The lymph nodes are negative for metastasis.

She cried, exhaled deeply and fell back into her temporary bed. She prayed to God for us, the surgical team, her children and her own health (in that order).

I felt a sense of relief for her, but also a sense of fear provoking me to double and triple check that the frozen pathology results were in fact negative. This was the first time I gave good news to a patient. It was an amazing feeling to provide relief to someone, though out of my moral judgment rather than my contribution to her cure. For I knew her operation would've been done with or without me.

One of the residents pulled me aside the next day. I want you to accompany the lumpectomy to the radiology department. She has deranged liver function tests and I'm concerned she has liver metastasis. Would you mind letting me know as soon as you find out?

So what? She would be known as the metastatic liver if the scan was positive? I thought... Surgeons love to define patients by their disease and refer to them the same way. It's an awful habit.

After he clarified the point Radiologists perform ultrasound scans in the hospital, it made more sense for me to attend her imaging procedure because ultrasound technicians (i.e. Sonographers) perform ultrasound scans back home.

Her husband and I walked with her as the porter wheeled her down to the imaging department. The receptionist said there was a wait, which was no surprise. Ms. EE looked up at me. 


"Your face looks familiar. Have we met before?"

Yes. We met in the recovery ward and spoke about the pathology results.


"You gave me the good news?"

Yes, I did. 


"Thank you, son."

My pleasure. We were all very happy for you. 


"You all work so hard."

I smiled. Do you know why you're having this scan?


"No, they didn't tell me much. They don't tell anybody very much do they?"

No they don't. We're here to scan your liver to make sure your disease hasn't spread there. 


"Oh..."

She was under the impression she was cured. But a new fear struck her heart and her face showed the same hopelessness as before the procedure. The pain from the wound no longer mattered and her body slumped in the wheelchair.

"Pray for me son. Please pray for me."

I am. I promise.


What felt like several hours of tension was actually ten minutes and the Radiologist finally called her name.

She was young, probably a senior resident, but she had the personality of a Radiologist from a mile away - blunt and apathetic.

After Mr. EE helped his wife to the examination table, the Radiologist looked at me as if to say "what the hell are you doing here?"

Doctor thank you for seeing Mrs. EE, who had an invasive ductal carcinoma in the right breast, which we resected via lumpectomy yesterday. She had a sentinel lymph node biopsy, which was negative for metastasis. We've asked for an abdominal ultrasound to exclude hepatic and visceral metastasis.

"Very well. Let's have a look."

The scan took about 15 minutes and I was looking at the ultrasound screen, trying to orientate myself to the anatomy.

"I could not visualise the liver in entirety, however the portion I did see was quite large. Within this portion I did not notice any lesions. The spleen, pancreas and kidneys appear within normal limits."

Mrs. EE had no idea what happened. She was too busy holding her breath and wimping from the pressure the Radiologist exerted on her abdominal wall. As her husband pulled her up, she looked at me and asked "so is there anything? Could you see anything?"

It is clear.


She cried again, almost instantaneously and pulled my white coat toward her body and hugged me. She prayed openly as we helped her to the wheelchair.

And just like that, she was discharged... there's a very good chance I'll never see her again. I'll never forget her. I hope she lives to hold her grandchildren and I pray she never has to worry about cancer again.

Sometimes... just sometimes; all the efforts, endless hours of retraction, resuscitation and intervention; demoralisation and negative criticism from the senior staff... someone comes out in remission.


And this one person, Mrs. EE, restores my faith in what I do. That not all of our efforts were in vain; that it's possible to hear the word cure and experience the joy of sharing it with the person at the centre of it all, even if it wasn't politically correct.