They say you’ll never forget your firsts in Medicine…
I’ll never forget how she walked through the hall, away from the room: Slowly, unsteadily, like her feet were bricks of lead. That hallway was probably the longest one that she has walked through in her life. Moments before, she stood frozen at the threshold of the doorway to the exam room. I clambered over to her, assuming she needed some kind of assistance, but her face was blank and bleak. Her swollen eyes looked at me searchingly: “Thanks, dear. I’m fine – I’ll be fine. No, I don’t need you to call anyone for me.”
Thirty minutes earlier she was tentative but jovial; she sat expectantly in the little room and was excited when I entered with my chart and my pen. I introduced myself: “Hi, I’m G. I’m a medical student working with Dr. X. today and I’m going to ask you a few questions before he comes in.” She answered my questions with confidence and ease. The first question was the hardest for her to answer, but she tried to remain cheerful:
“I’m here because my doctor told me I should see a gynecologist. They found a pelvic mass on some ultrasound I had a few weeks ago.”
I flipped through the paperwork in front of me and found a faxed copy of a recent ultrasound report. Highlighted in fluorescent yellow, it said: “Large pelvic mass of uncertain origin. Consistent with malignancy. Must rule out ovarian neoplasm.” A lump formed in my throat and I tried not to let anything show in my voice. I wanted to be hopeful but I knew this appointment would be different from the rest.
I finished asking my questions and looked at my watch. It was 4:00 – the last appointment of the day. Rather than waiting for my preceptor to return to me and ask a few more questions before asking the patient to undress for her exam, I decided to save a few minutes and I instructed her to take her clothes off below the waist and await my return with the doctor. She obliged, but tentatively. Moments later I returned with the doctor and I followed the steps that I’d been doing all day: Donned the gloves, placed her feet in the stirrups, “slide down here until your bum is at the edge of the table.” I took out the sterile plastic speculum and attached the light. ”You’ll feel me touch now, and the speculum is going in, lots of pressure…”
I had done plenty of speculum exams all day and I was getting good at them. But this time I couldn’t find the cervix. Posterior… posterior… open… no cervix. Try again. No cervix. Lift up, lift up… there! There it is – so high up there… Kind of odd. But it looked normal, and Dr. X agreed. I removed the speculum and stood up to continue the examination. ”Okay, you’ll feel my fingers now… lots of pressu…
I didn’t even finish the words.
My fingers entered her in the expected way. I reached for her cervix but I met with resistance: A hard rubbery wall of resistance. Fixed, matted, immobile. There is only one possibility. I move my fingers searchingly to the right. The wall continues. To the left. It is relentless. Where it is supposed to be soft, supple, and palpable, there is only tumor. It was filling her whole pelvis. It was unmistakable. I withdrew my hand and Dr. X. Proceeded. He asked me was I found but I was speechless. Finally, as he began his exam I said, “I wasn’t able to palpate the uterus.” (what was I supposed to say?)
I watched his face as I said this, as his fingers reached the same wall that I could still feel on my fingertips. His facial expression was wiped away and his eyes met mine. ”You didn’t feel this?”
“Yes, I did. It made it impossible for me to palpate the uterus.” (It was true. I still didn’t know what to say)
The exam was over and he heralded me over the the sink. As we washed our hands he asked, “what do you think it going on?” I knew the patient could hear us and I couldn’t bear to say it right there, with her listening. ”Um. I don’t know,” is all I could bring myself to say. (She has cancer. She has a huge tumor filling her whole retroperitoneum and/or pelvis. It’s unmistakable – even though I’ve never felt cancer before… it’s unmistakable.)
Dr. X took a seat. I remained standing but I stood closer to the bed than I did with the other patients all day. He opened his mouth and without hesitation he gave her the news, blandly and simply. In that same instant I placed my hand atop hers and I felt her start to shake. I steadied her back with my other hand. It was all I could do.
“I’m going to be honest with you: This is not a good sign. This is very likely a malignant type of cancer.”
“I don’t know what that means. Am I going to die?
“It is really too soon to tell, I don’t even know what is the source of the tumor. I will send in referrals to all the right people so that we figure this out as quickly as possible.”
“Should I tell anyone? Is it possible that it’s nothing? I don’t want to worry my kids if it’s going to be nothing.”
“I think you should be prepared that this is something very serious. I think your family will want to know.”
“Am I going to die?”
“I will be honest, this is a large tumor and we don’t know where it is coming from. Many people do die of cancer, but some people survive as well.”
There are tears. Disbelief. Denial. Fear. Uncertainty.
Dr. X stood up to leave. He was back to business: “Is this your correct phone number? You will be getting a few phone calls in the next day or so with some appointment times.”
He leaves the room, but before he does, he says, “if you need to come back and talk some more, please just call my office and we’ll get you in.” He leaves.
For the first time all day, I didn’t follow him. I stayed next to this poor woman who just learned that she has cancer. Serious cancer. ”Are you okay?”
And her eyes look up and lock with mine. Fear. I see it. I feel it. ”I’m going to get dressed now.”
I take my hands off of her and I leave the room. As I walk away I hear her tell me “thank-you.”
Standing the hallway, I see the door open and the woman who was so cheerful only a half-hour earlier stops at the threshold of the tiny room.
I will never forget the first time I felt Cancer.
I will never forget the first time I watched cancer ravage a person’s life… instantly.