Saturday, May 13, 2006

Cancer

Right. Sara much recovered, and transporting cats hither and yon in preparation for tomorrow's catshow.

The other night, out to dinner for Sara's birthday, I sat next to Natalia. She's someone we both used to work with - the "movie-star good looks" ex-emergency registrar, someone who gave up the lure of low pay, frequent abuse and crap hours for... pretty much anything, really. To be honest, not really the public medicine type. A much smarter doctor than me, a vastly better renal physician or neurologist, but maybe not such a stayer in drugs and alcohol, or psych, or emerge.

Anyway, after fleeing Emerge at Florey she did a bit of medical registraring, thought about GP, and is currently doing some emergency shifts - but at Lakeview, one of the biggest private hospitals in the city.

"You should come to Lakeview, it's very, very different", she tells me.

And it is.

Firstly there is the pay, which is approximately twice per hour what she (and I) used to get working at Florey.

Obviously there's the backup - twenty four hour CT, MRI, angioplasty.

Another "plus" from her point of view is there is no psych cover. Lakeview simply does not provide a psychiatric service, and all psychiatric patients are halted at triage and referred down the road to teh Royal.

The proximity of the Royal means there are neurosurgeons around the corner, that kind of thing.

Plus it means that anything really bad - multi-traumas, burns, industrial accidents - go directly there. Do not pass into Lakeview, do not pay eight hundred dollars (or whatever).

Anyway, while attempting to lure me there (seriously, anyone who has a need to be needed should consider being an emergency registrar. I remember a few years back taking Sara into Cabot Public Hospital, the big teaching hospital near where we used to live, with what looked to be a weapons-grade migraine. As the smiling consultant plunged what looked to be a cavalry lance into my wife's wrist, he tried to get me to quit Florey and work there. He raved about the great working hours - nimbly evading mentioning why he was there at three in the morning - and asked for my email address so he could send me out some paperwork) - and all this while my pale and sweating wife sobbed on the bed.

Now where was I ... oh yes, while attempting to lure me to work at Lakeview, Natalia told me about the wonderful medicine I'd be doing there.

"It's cancer," she said. "Cancer, cancer, cancer."

"Great," I said.

"It is hard," she admitted. "I don't know why. It's really exciting medicine, and nice people, and most people are healthy, much better off than at Florey. But I don't know. It's hard."

She paused. "You wouldn't believe the things I've seen. I saw..." and she told me.

Three months back. Twenty nine year old man with lung cancer. School-teacher. Never smoked a cigarette in his life, healthy. Came in with some aching joints, a wrist that ached. A series of investigations, a cascade of not-quite right results, each blood test leading to another, each time another doctor brought in, worried conferences in the corridor.

Diagnosed, eventually, given maybe to Christmas. When Natalia saw the family this time (they were coming in for the chemo, after the cancers had spread to his brain, given him delirium) they were clustered around him, bright eyes shining, happy.

"Professor Jamieson said we'd have till Christmas," said one young woman, "but now he's said we may get to next Easter."

And a few weeks after that, a thirty two year old woman, some kind of lawyer. Advanced ovarian. Very poor prognosis. A lot of ovarian cancer is fairly extensive by the time it's discovered - the symptoms are subtle, the signs easily missed, often brushed aside by a woman who has a lot on her mind, who doesn't have time to get sick. Thirty two, no family history, never pregnant (which increases your risk, apparently), but never really suspected a thing. Natalia was the one who told her.

And last week, an Asian woman, wealthy, slim, pretty, with metastatic melanoma of the lower intestine - they didn't know if it was the primary or the secondary, but by that time there was little point looking, spread to the liver and lung, dead by Christmas. Not Easter, Christmas.

Another trajectory interrupted, a bright object in its upward arc, struck down before apogee.

And the next day, another.

There is something about cancer, something in it that means it retains its ability to horrify when other things no longer do. Even in the molecular biology lectures we had, there seemed something wrong about it, something unclean. It was a disease of health, of growth and vigour and fecundity, something almost too healthy.

It has something of the flushed red face of the fevered child, the sparkling conversation of the tertiary syphilitic, the long awaited weight gain in the old man who has not eaten for so long - but it's not appetite, it's heart failure. Things that should bode well that are the signs of something terminal. Growth, abuindance, vigour - these things should mean well, but they do not.

Having cancer seemed different to having, say, pneumonia, or kidney failure. Sometimes the cancer seemed the living thing and us the weak, as if, in the end, it was us who failed the cancer. It grows and consumes and waxes, it is us who cannot keep up. Us who sleep and starve while it busily gorges itself. It outgrows us.

I remember hearing - and I don't know that it's true - that cancer is a necessary consequence of life. If cells are to continue to live, they must divide, and if they divide long enough, they will make mistakes. There will be a miscalculation, and a certain number of those mistakes will lead to cancer.

Some fine thread of DNA will be drawn into the wrong cell at mitosis, the genetic material will be unequally distributed. One daughter nucleus will end up with the wrong instructions. Will know how to live but will quite literally not know how to die.

If this is true (and I don't know now, five years later, if it was a memory or an imagining or a dream), by the time you are sixty, or seventy, or eighty, you may have enough microcancers within you (bone, skin, fat, nerve) to make another body.

Tiny islands of malignancy that never managed to expand beyond a pinhead size, cells that learnt the trick of doubling and doubling and doubling their numbers, swelled rapidly... but never managed to work out how to divert blood their way to feed themselves.

They remain as buds of malignancy in bone and marrow and gut. They are buds that do not blossom. Unfulfilled promises, impotent, whispered threats.

I think that was what was knocking Natalia around. FIrst, it was cancer: cancer, cancer, cancer.

But also it was the kind of person she saw die. These people, she was saying, the people who were getting sick and getting chemo and dying... they were like us.

"Good people," she said. "Hard working people." She didn't say the next bit, but I could see her holding the words behind her dark red lips. People who were doing something, working, studying, making successes of themselves. Doing the right thing, doing all the right things. Well-spoken lawyers, slim schoolteachers with devoted fiances, bank managers and their families.

People like us.

That wasn't the case at Florey or psych or drugs and alcohol - or not so obviously.

It's easy to imagine the people at Florey are not like us. They are grotesquely fat, or poor, or tattooed, or smoke cigarettes that they roll with one hand. They come in, drunk and beaten after a fight at three in the morning, when all decent folk are abed, and they go back to teh men who beat them. They curse, and spit, and say "f" instead of "th".

In drugs and alcohol they have done things that we would not imagine ourselves doing - injecting into the veins beneath the tongue, twenty five dollar head jobs (half a cap of heroin), in and out of prison.

And in psych - well, psych is predicated on the existence of a fundamental difference between the healthy and the well. There is a reason early psychiatrists used to call themselves alienists.

But not at Lakeview, not with all the cancer. At Lakeview the careless observer, presented with a mingled crowd of doctors and patients (naked, say, but allowed to speak) might not even be able to tell them apart. There was an unsettling intimacy about what Natalia saw that you don't see as easily at Florey.

At Lakeview Natalia was seeing people like us getting sick. People doing all the right stuff and yet not being protected. Ending up the subject of whispered conferences in corridors, the treatments that don't work, the chemo and the radiation and the spread to the brain. Dying.

We are all standing huddled together, Natalia was saying, and someone is shooting bullets into the crowd.

Anyway. The conversation moved on. She wasn't going to do this for long, not really. There was other stuff. GP, renal - maybe something involving research. Something that gave her time and money, space to be with her family. Do the stuff important to her. Because, and she did actually say this, you never know. You have to do this stuff while you can. Because you never know.

Anyway, off for a father-son bonding thing, down the pub, drinking and watching the football. Shall write again soon.

Thanks for listening,
John

2 Comments:

Blogger organiclemon said...

As a borderline I welcome your comments. You may find Professor Anthony Bateman's work interesting.

3:51 PM  
Blogger Bronze John said...

Thanks,
I have found the book and will try to hassle my manager to pay for it. People tend to speak highly of his stuff, along with CBT and that Dialectical Behavioral Therapy - especially since the first two seem to be relatively easy to learn and teach.

Thanks for the pointer.

John

7:13 PM  

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