Collecting bottles, tossing leftovers, taking out the garbage
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When I went to see the dermatologist, I had no suspicious spots I wanted examined. It was just a preventive measure you take once you are middle-aged. I’d made the appointment for early in the morning, because I’m a doctor — a pediatric lung specialist who treats cystic fibrosis — and I know how the patients pile up as the day goes on. I sat in the waiting room alone on a plastic chair, reading the posters about droopy necks and sagging eyelids, privacy laws and co-payments. Country-pop music emanated from overhead speakers. As I always do, I had brought a typed page with my medical history, medications, allergies, and so on. At every new doctor’s office I debate whether to tell the staff that I am an MD; sometimes, when it’s just a checkup, as this was, I’ll remain incognito and see how they treat the civilians. But I always come clean with the doctor in the examining room.
The nursing assistant took me back and told me to get into a gown and that the doctor would be right with me. I hate hospital gowns, so I undressed down to my boxers and sat on the exam table to wait.
The dermatologist was a thin woman with thin hair and a pair of squarish glasses riding the ridge of her thin nose. I got the impression she was not much of a joker. She began looking me over right away, starting with my face and my bald spot. At first she talked while she worked, but by the time she got to my arms and hands, her patter had run out, and she proceeded in silence: over my elbows, under my arms, down to my thighs and knees and shins, along the tops of both feet, and between my toes. She told me to stand. I stood up straight and sucked in my gut. Then she asked me to turn around so she could inspect the other side of me. When she got to my lower back, she stopped and said, “Huh.” She continued up to my shoulders and ruffled the hair at the back of my neck. Then I felt her cool fingers slide down to my lower back again, and she asked, “How long has this been here?”
I told her I didn’t know what she meant.
“It’s just a precaution,” she said, “but I think we’d better biopsy that. Can you come back tomorrow afternoon?”
The next day I lay facedown on the crinkly white paper of her exam table while she did the biopsy: five stitches, no shower for a few days, keep it covered, she’d call me on Tuesday.
And now here it is Tuesday, and the phone rings, and I answer it. “I have your biopsy results,” the dermatologist says.
Since she is calling to give me the results, instead of asking me to come in to her office, I assume that the biopsy has come back fine. I never give bad news over the phone. I always deliver it in person, so I can see the parents’ reaction and adapt. I am experienced at telling mothers that their baby has a disease with no cure, then quickly adding that what they’ve read or heard from their aunt Martha about cystic fibrosis is out of date and that kids who have it do pretty well these days. It’s important to say this face to face. I can’t know if my mixture of kindness and reassuring authority is working if we aren’t in the same room.
The biopsy shows malignant melanoma, stage II, the dermatologist says. Her words bypass my brain, flowing directly from my left ear to my right hand, which writes them in block letters at the top of a yellow legal pad, then underlines MALIGNANT MELANOMA. While she talks about the depth of the lesion and the presence of “mitotic figures” in the cell, I think, I am going to die of cancer. Will I go out bravely, seizing the day and having the time of my life? That doesn’t sound like me. Can I keep this a secret from friends and co-workers and avoid all those sad, pitying looks? At least I can stop worrying about going to the gym.
The dermatologist is still talking. I should ask questions, but I’m afraid to seem dumb. She assumes because I am a doctor that I know what she is talking about. Finally I interrupt her to say I am a lung specialist; I don’t know anything about malignant melanoma. Could she explain it, please?
By now my yellow page is filled with blue ink, and there are dashes and underlines I don’t remember making. She asks where I want to have the “wide resection” done, and I tell her I prefer the academic hospital in the city. She recommends I call them today: “There’s no use in waiting.”
Yes, I say. I’ll call them today. Yes, goodbye. Yes, yes, thank you for calling.
A Google search brings me to a melanoma life-expectancy calculator. I plug in my numbers and the biopsy-result details from the yellow legal pad. The calculator tells me that I will likely die at the age of seventy-three. If the surgeon gets all the cancer, I could live longer. If it has already metastasized, I could be dead before I’m sixty. But, on average, I’ll have twenty more years. When did I think I would die? How old was Dad when he died? Still terrified but also relieved, I laugh, alone in the room with my diagnosis.
I arrive at the surgery building downtown at 5:45 AM, and the waiting room is already full. Groups of three, four, and five people are sitting together. I’m here alone. On the nearest TV a muscular, out-of-breath man in workout clothes promises us we can transform our bodies in ninety days. At 6:03 a woman comes out of an unmarked side door and, in a Philadelphia accent, asks, “Who’s first?”
A man of about seventy gets up and makes his way across the room, his new-looking sneakers squeaking against the linoleum. He looks pretty healthy. I wonder what kind of cancer he has.
A woman is called to the desk next. The receptionist, whose name is Erta, asks the patient if the man with her is her husband, and the woman laughs and says, “No, he’s my friend.” Her companion, who is wearing the kind of sports shirt that men wear only after retirement, puts his arms around her, and Erta says, “Honey, he is more than a friend today. Today he is your ‘significant other.’ ” Erta marries them right there at the desk using a white plastic wristband in place of a wedding ring. They hold hands as they walk back to their seats.
Erta calls my name, and I approach her desk. She asks for my birthday, and I stumble and give her the wrong year, then correct myself and say it again, twice. Erta attaches the white plastic band around my right wrist. I am just about to tell her that I am a doctor when she says I can sit down now.
Twenty-five minutes later a woman in sky-blue scrubs leads me through a pale-green hallway to Bay E3, where she pulls the curtain behind us. This time I obediently change into the hospital gown. At least it is made of cloth and not that crepe-paper material that rips the moment you put it on. The gown is a marvel of snaps and folds and ties. I wrap it around me but don’t bother fastening it. My usual modesty is gone. This morning I am not a doctor; I’m just a man in a gown. For a moment the anonymity frees me to be nervous or uncertain or silly; I can crack jokes or cry, because today I do not have to be in control of my face or my emotions or my fears. The professional manner I have practiced for so long — the low voice, the serious eyes — is unnecessary. I can be just the overweight, bearded man in Bay E3, the 9:30 AM case, here for resection of malignancy with local anesthesia. A patient.
I sit in the chair meant for the family member I have not brought. My relations all live five states away, and I wasn’t sure how to tell them about my diagnosis over the phone, so I didn’t.
My surgeon parts the curtain and grips my hand in his bony fingers. I can tell he is in a hurry. (I hope it’s not so obvious to my patients when the same is true of me.) He is tall and thin with an irregular birthmark above his left eye, and his hair is turning gray. When he calls me Mr. Robinson, I do not correct him.
It is time for him to mark the spot that he will cut out. I turn around in the chair, and the starched edge of his white coat brushes my naked shoulder as he moves behind me. I can smell the magic marker and feel the cold circle he draws on my back. He asks if anybody is here with me, and I say no. I know what he’s thinking: that he won’t have to come out and talk to the relatives in the waiting room after the surgery is over. I wonder what he would have said to the family members I did not bring and how he would have said it. Would he use a soft, low voice, as I do? Would he sit down and speak slowly and take his hands out of his coat pockets? Would he try to project confidence?
I sense that he wants to get away before I can ask any questions. We don’t need to talk about cell types and incision depth and prognosis and margins — we did that in his office last week — but I want something more from him than nonchalance.
“See you in a bit,” he says, and he leaves.
A nurse named Brian walks in and, with great speed, snaps up my hospital gown and ties the cords in back. Then he puts me in a stretcher chair and pushes me out of the cubicle and down the green hallway to Operating Room 7. I was not expecting a full OR. Nor was I expecting a nurse to be scrubbed in for a procedure that requires only local anesthetic. The room is set up as though this were a serious operation. There is the glass-front cabinet with all the scalpel blades, organized by number and name; the sutures stacked neatly in their boxes by size and color; the screw-top bottles of sterile water; the syringes, each in its individual wrapper. There is the anesthesia machine, with its synthesizer-like dashboard. There is the Bovie cautery machine, with its dial for turning up the electric current to cauterize the incision. I try to figure out who is in charge, but no one looks at me or talks to me. What is happening? Why do they need the code cart? Am I really that sick?
I am grateful to lie facedown on the table, because maybe I can close my eyes and imagine that I am somewhere else. Brian puts a sheet over me and straps me down. I go over in my mind what will happen: the surgeon will remove from my lower back an area of skin, blood vessels, nerves, and fat about the size of a deck of cards. Last week I took a picture of the spot with my cellphone — nothing special that I could see, just a biopsy scar.
Someone attaches leads to my back and puts an oximeter on my finger to monitor my pulse and the oxygen saturation of my blood. Within a few minutes the oximeter’s beeping slows, but no one says a word. I imagine they are as practiced as I usually am at ignoring it, but now that the beeping monitor is on me, I think someone should react. Should I say something? If I don’t, I worry, my heart will stop and my blood pressure will rise and I will stroke out and never leave this room alive. Did I forget to take my blood-pressure medicines this morning? Or was I not supposed to take them? Shouldn’t I know? What were you thinking? they will say as I die on the table because I am a bad doctor who missed his own cancer and didn’t bring anyone to the hospital with him for his surgery.
I wouldn’t be having these thoughts if I were the one in scrubs. I would be checking my equipment or getting the forceps and sample containers ready. I would be comfortable in the OR, because it’s a place where I am in control, my skills sharp, my mind focused on the job. I have always liked the OR — until now.
Someone is washing my back with Betadine and cold water. My body is covered by stiff, sterile drapes. I hear the rustle of a gown, and I know that the surgeon is here, though he says nothing. I feel the table being raised and his belly pressing against my side as he leans in close. He asks for lidocaine with epinephrine — the anesthetic — and then announces, “This will sting and burn,” as if speaking to no one in particular. He is right; it stings and burns. The surgeon checks my sensation with the prick of a needle, and I flinch, so he injects me again. I feel the sting, and then I don’t feel anything, not even any pressure. In my mind I envision the scalpel cutting a smooth line, brilliant drops of ruby blood rising up, then the incision being deepened by the electric blade of the cautery, white fat shrinking back from the heat and forming a faint gray edge, the blood turning from red to black. I wonder if I will smell my own blood and skin being burned away. And then I do smell it. I lie still and hold my breath.
A sudden pain makes me say, “Oh!” in a choked voice. Embarrassed, I clench my teeth. “Sorry,” the surgeon says. “We’re deep.” Then, “That was the muscle.” And, “Another lido with epi, please.” I wince, and the drapes rustle again. I blame myself for flinching and worry he will think I am a weak, silly pediatrician who cannot control himself. The surgeon asks for more Vicryl, an absorbable type of suture. Then the drapes come off, and a new voice says, “I am putting Steri-Strips on.”
Brian tells me to stand up. The surgeon is gone. The scrub nurse is doing the count and cleaning her table. The circulating nurse is typing away on a computer keyboard. Brian snaps my gown back up and wheels me out of the room, past people walking the corridors. I do not look anyone in the eye because I am afraid that my face will show how I feel: shaken and scared and nauseous and numb and angry and sad and relieved all at once. I want to cry and cower under a soft quilt and sleep and dream and wake up in my own bed and not on this stretcher chair in these fluorescent-lit halls that smell of air freshener.
Finally Brian deposits me in a different cubicle with a new nurse, who takes my temperature and blood pressure. When she has finished, she says I can get dressed, and I yank off the gown and put on my clothes.
In the hall bathroom I lift up my shirt to look at my back in the mirror. The bandages are higher up than I expected but clean and dry: lumped gauze under three strips of white tape, with the light-brown Betadine stain around them. I can feel the tape pull when I raise my arm. I want to put my fingers on the bandage. Like doubting Thomas, I have to touch the wound to believe what has happened to the body. But I can’t reach. My face in the mirror looks pale, my skin like a wrinkled handkerchief, but I’m alive. I gather myself up for my return to the world.
I sign all the nurse’s forms and accept the painkiller prescription that I will not fill because I know Tylenol will do the trick. Then she points me to the exit just down the hall and wishes me luck. I am back in my own clothes and on my feet, with only my white bracelet to mark me as a patient.
I open the exit door, expecting to see the waiting room again, but instead I am on the far side of the elevators from Erta’s desk. She is still there, reading the paper. The waiting room is brighter now because of the sun shining through the windows. The televisions blare ads and weather reports. I walk down the flight of stairs to the lobby, but I don’t want to get in the car and drive home until I am calm. So I take a seat on a bench.
The cancer that was removed from my back will travel quite a bit in the next month. It’s already passed from the hands of the surgeon into the clear plastic jar held by the nurse, and then on to the specimen basket at the main OR desk. Later it will move to pathology, where pieces of it will be thinly sliced and pressed between two rectangles of glass. After the pathologist has determined that the margins have no visible cancer (he’ll also comment on the hair on my back, as I’ll read later in the report), he will place the slides in a cardboard tray for storage. The part of me not thinly sliced and preserved under glass will be unceremoniously incinerated, along with all the other hazardous hospital waste, and the slides will be sent to a file room in Philadelphia. I imagine fluorescent lights and gray metal shelves with numeric codes at the end of every row: a library of human flesh, preserved in case doctors need to revisit a diagnosis.
I have often squinted through multiheaded microscopes at such slides — peering at swirls of red and blue tissue I have snipped from the newly transplanted lungs of a child in an operating room like the one where I lay facedown a few minutes ago. I do not want to see a certain pattern in these slides. The absence of this pattern tells me that the child’s immune system is not attacking the new lungs; we have fooled the body into accepting foreign tissue. I’ve learned through the years to trust that if I do not see the pattern, it isn’t there. This is also my task now as a patient: to trust that more cancer is not hiding somewhere we did not look — in my lymph nodes, in my bloodstream, in my chest. I decide to be reassured of my safety until I am proven wrong.
I sit for a few minutes more, watching people move through the lobby, a three-story atrium of chrome and glass. This one is a resident. That one is a fellow. There is a nurse practitioner, an X-ray tech, three medical students, a woman in a wheelchair being pushed by a nursing assistant, a cafeteria worker, a surgeon. There’s a man with Marfan syndrome and a baby with a tracheotomy.
A little girl with a white bandage across one eye (ocular-muscle repair?) waits with her mother by the elevator to the parking garage. I go and stand next to them, then look down at the girl and smile the smile I know works with sick children, and her lips turn up a bit at the edges. When the elevator comes, I hold the door for her and say, “After you, sweetie. You’ve got to move quickly with these hospital elevators. And make sure you hold Mom’s hand.”
I am a doctor again.
Walter M. Robinson
Dr. Walter M. Robinson’s account of being on the operating table [“This Will Sting and Burn,” January 2016] should be required reading for everyone involved in the medical profession. No matter how well educated and trained we may be, when it’s our own skin in the game, we’re all human.