“Here’s your disconnected limb,” my surgeon, Dr. Vogel, said distantly. Thinking aloud while rolling through the fresh CT images, he continued, “How’d they get contrast down there?”
“I did it.”
Turning to me with raised eyebrows and eyes kind beyond his years, he then chuckled slightly and responded, “I should’ve known.”
It helps to know what your surgeon would like, and needs, to see. For better or worse, I possess such knowledge. It is terrifying. Am I really here? In this clinic? Is it already that time?
I didn’t sleep at all last night. But wait, what about the dreams? There were dreams. The sort of dreams that a mind’s eye can describe about as vivid as the translucent gossamer of perfect nothingness. Their colors remained brilliant and smells pungent and sounds precise. They had a boundless taste. I can still feel the texture of their every object. But, as hard as I might try, I cannot commit to the discrete description of a single experience. I dreamt in illusion. I dreamt in metaphor.
Then was I more afraid of death than ever,
For nothing more was needful than the fear,
If I had not beheld the manacles.
– DA, Canto XXXI, 14th Century.
My dreams last night perfectly recounted the betrayal of Ephialtes as if he were the seed that opened my body to onslaught. I dreamt of poison. I dreamt of pain. I dreamt of war. I dreamt the stress of the coming day. I am my own betrayer. My body wears its own chains and guards its own pit, all self-forged and self-shoveled. My manacles – my fucking manacles – have done nothing to suppress fear. They perfect it. Doré couldn’t have laid it out any clearer. Indeed, I dreamt of cancer. Yeh, man, what about those dreams?
“Lungs and liver look great,” Vogel said smiling while quickly rolling through my chest and upper abdomen.
“Ok, now the plan,” he quickly scrolled back down my virtual body. “There’s your stoma.”
I leaned in a bit closer to the screen.
We continued to look through the images as we talked about the plan. Surgeons always have a plan. Whether it be stop-the-bleeding trauma chaos, hours-long transplant plumbing or – as is my plight – meticulous oncologic resection, there is always a plan, a backup plan and a backup backup plan. Years of training teach you that lesson.
“We’ll start laparoscopically to take down the splenic flexure.”
We both knew that this conversation was for the most part superfluous. However, there was an unspoken agreement between us that we needed to complete the entirety of the ritual.
“Then, I’ll open.” He held up his hand, thumb and first finger generously apart to indicate the length of the forthcoming wound. “You’re a big guy with a narrow pelvis. This is the safest way.”
Big guy? Why do I feel so small?
Turning away from the screen to face me, he asked, “What I’m not sure about is the stoma. Can you please raise up your shirt and sit straight up?”
I was adjusting my clothes before he completed his request. I already knew the next topic of discussion.
“I hope we won’t have to take down the colostomy, Tony.”
“But, depending on length,” he continued, placing a small measuring tape against my abdomen to the right of my umbilicus. “We may have to put in an ileostomy.”
Throughout our friendly but somber visit, the fateful “Consent to Medical Procedure” form lay prominent and unmistakable on the desk between us. The consent was there – heavy – like some saccharinely mute siren ready to shipwreck the whole voyage with a song whose sensual lyrics were filled with weapons speaking of surgical risk and uncertain outcome.
“You’ve responded so well to the neoadjuvant.”
“Yes,” I agreed with a pleased, albeit reserved, sigh. “It wasn’t fun.”
“I know.” Cheerleading, he placed his hand on my shoulder and continued, “but you took it like a champ.”
“So,” cautiously pointing at the screen with the tip of his pen. “Here’s the tumor.”
I still can’t believe that it was my name in upper-left of that screen.
“We’ll take the left colic and superior hemorrhoidal.”
“There’s no oncologic reason to take the IMA,” he continued, drawing the roadmap of the pelvic arterial blood supply for our mutual benefit on a dog-eared steno pad that he found in the second drawer of the exam room desk. “Especially since we don’t want to bang-up the sympathetics next to your aorta if we don’t have too.”
I nodded again. Tony, we’re talking about cutting arteries that are millimeters from your aorta. I secretly shuddered, trying desperately to maintain my composure. Get it together, man.
Michael and Johnny showed-up at the house about an hour after I got home from my appointment. Brian was already there waiting.
We were going to lunch.
My three best friends didn’t get to participate in my fear today…
“Tony, can I examine you,” he asked politely, understanding that the exam is difficult. Holding a thin, crisp hospital sheet at arm’s length, “I want to get a feel for that tumor now.”
Behind his considerate makeshift curtain, I reached for my belt buckle and moved to the exam table.
“It’s at least a centimeter higher,” he concentrated. “Keep breathing Tony. Almost done. Breathe.”
I have performed this same exam many times before. Like Vogel, I have felt tumors on the tip of my lubricated finger. As he continued his exam, I grimaced and wondered if I have been empathetic enough with my patients. Now I am the patient.
“Ok, all done. Thank you. I’ll step out for a minute and let you clean-up and gather yourself.”
Then, imaging viewed and examination performed, the time came. Together, we scribbled those risks – anastomotic leak, abscess, obstruction, hemorrhage, DVT, etc etc – onto the form. We worked with matter-of-fact, data driven percentages like mentor and student rather than doctor and patient. Whether unconscious or deliberate, it was far easier for me to play the role of student than subject. My delusion, however, was abruptly coerced into reality as he uttered those two most menacing and feared words: local recurrence.
“We’re looking at five percent or less Tony,” he waited until I looked up from the form to make eye contact.
I stared into his eyes. I’m sure my gaze was horrifying.
“In your case, I’d lean toward the ‘less than’,” he continued. I heard nothing. The only things going through my head were dangerous words and phrases, each dripping with the poison of finality.
Local recurrence. Stage IIIb. The scan was unfortunate, Tony. We’ll get an MRI to confirm. More chemo. Fucking irinotecan. Radiation wounds. You’ll never operate again. Lymph nodes. Re-Op. Permanent colostomy. Ileostomy. Fistula. G-tube. J-tube. Liver. Lungs. Mets. Palliative bypass. Inoperable. We’ve got a clinical trial. Let’s try. Hospice.
“We’re gonna get it all out Tony.”
“Concentrate on the ninety-five.”
I convinced myself that I might have convinced him. The siren’s didn’t get me, Dr. Vogel. No shipwreck here.
There was at least one person in that room that wasn’t convinced.
The form concludes with two stark black lines upon which to place a signature. One atop the other. The top line is reserved for the patient; the bottom for the surgeon. It’s almost laughable the silly trivialities that one fixates upon when faced with powerlessness. For me, in this little exam room in the Multispecialty Surgery Clinic on the sixth floor of the Anschutz Outptient Pavilion, my fixation was transferred from mortality to something seemingly less dangerous…the lengths of those two terrifying lines. They are exactly the same. Patient line is the same length as doctor line. Doctor same as patient.
How frozen I became and powerless then,
Ask it not, Reader, for I write it not,
Because all language would be insufficient.
– Canto XXXIV
We’d arrived at Dante’s thirty-four. For me, today’s canto had my two lines rather that his three faces. Two identical lines, one familiar and one foreign. Two lines, one atop the other.
Today, manacled, I signed the top.