Grand Rounds

Monday. 9:06 am.

If you were to ask me to list the two most important academic rituals in medicine and surgery, without a doubt, I would tell you the first is morbidity and mortality conference – the second is grand rounds. I think most physicians and surgeons would agree.

This morning, after an eight month absence, I returned to the latter. As you well know, my truancy has been due to, in loose chronological order and with no uncertain terms, the physical and psychological morass that is the globally grotesque repugnance of life-plundering, high-dose FOLFIRINOX whose well-plumbed drip drip drip of poison reminds me of, but far outperforms, the decay culture petri that is the rotten maw of the most downtrodden of any number of Colfax Avenue sewer drains, each seasoned with the false hope of corticosteroid and 5HT3-receptor antagonist comfort, all the used-condom and dope-syringe cesspool of systemic cancer therapy; then there is the slow provocation welcoming the seemingly tempered corporeal throbbing that is the three-dimensional, pelvis-molded, cyclotron sunburn of high-resolution and high-dose IMRT where, for a mere five minutes per day, five days per week, five weeks in a row, one can buy a ticket to the sonorous break-beat trance that is the hum of x-ray radicalization, a solo rave where the energy-siphoning hangover is subtle but lasts unrelenting for five months – rads and the tyranny of the fives; and then, lest we short-shrift, there are the slow-healing, radiation bolstered incisions that then stir-up the drunken uncle that is the shit-stalling squeeze of delayed, post-operative ileus, an uncle pickled with the dry whiskey of dehydration and stamped with the Marlborough Red breath that is oxycodone haze; and, of course, I still can’t feel my toes. Though I fear that I have done little justice to a cracked description of cancer treatment, it was within the slimy folds of this setting that I sat in the sixth row of the Bruce Schroffel Auditorium in the Anschutz Medical Campus’ new, state-of-the-art conference center at a little after six this morning.

I took my seat as the attendees – fierce emeriti, stoic professors, overworked residents, frightened medical students, mid-levels and nurses and admins, and on – filed into the auditorium, filled cups with bad catered coffee, and briefly mingled. Monday morning grand rounds for the University of Colorado Department of Surgery are a liturgical affair. As an extended metaphoric abstraction of collegial fraternity, grand rounds have a long-rehearsed history wherein scholarly inquiry is entertained joyfully and aggressively, with the requisite bagel roster and pastry litany for fuel. It is an erudite and reciprocal experience. It is hallowed. This morning, I was received warmly. I enjoyed pats on the back, more than a few “how are you” and “you look great” greetings and many more again knowing nods of empathetic welcome. It was good to be back. I felt that I belonged again.

Looking up to the projection on the prominent, ten- by thirty-foot screen dominating the front of the room, I read  –

Management of Hilar Cholangiocarcinoma
R S——–, M.D., M.B.A
Professor, GI Tumor & Endocrine Surgery
Aragón/Gonzalez-Gíustí Endowed Chair, Department of Surgery
University of Colorado

Today’s discussion: cholangiocarcinoma. Great, I thought, a cancer talk. Why couldn’t it be trauma? Nope, cancer. Cholangiocarcinoma, dreaded cancer of the biliary system. Bad cancer. Intrahepatic, Klatskin, periampulary. Hepatectomy, extended hepatectomy, Roux-en-Y hepaticojejunostomy. Gtube. Jtube. SBO. TPN. Cholangiocarcinoma, of the worst kind of carcinoma possible. A killer.

Welcome back.

Silently, as the vapid, staccato internal voice’s bark of carcinogenic clauses trailed off, I paused – enjoyed a moment’s pleasure really – in the thought that cholangiocarcinoma is bad and I don’t have it. In fact, it’s not simply a bad cancer that I don’t have, it’s far worse. In even the best-case scenario, the rare situation where surgery – resection being the only realistic therapeutic mode – leaves the patient with clean margins and a well-functioning reconstruction, there remains an approximately seventy percent chance that the patient will be dead within five years. Seventy. As a surgeon as well as cancer patient, I know well that the Kaplan-Meiers don’t lie. I know these data and I have learned to hate both Kaplan and Meier and their goddamn curves. But, this says nothing of the morbid toll of these large, encompassing operations, ultimately unsuccessful in the long-term, with their foot-long subcostal incisions rife with the promise of uncontrollable pain, guarantees of drain-staining bile leaks as disheartening as any image of a far-off white-sand dreamscape slicked with the stain of spilled crude, and the inevitable seep of a scarred-in feeding tube perpetually crusted with the dried carbohydrate precipitate scab of sickly-sweet Isosource. It goes without saying that these patients will, like me, become familiar with the late-night odor of the Colfax sewer as they lay themselves face-down in the scum-layered gutter, painfully inebriated, after dancing at the radiation rave. How is it that I can sit – as a dedicated surgeon located in a large room filled with dedicated surgeons, each gilded with a lifetime of academic pursuit, each with a zealous, at times militant, commitment to bettering the lives of their patients, regardless of individual nature and temperament – and take personal pleasure in the realization that another human being, ultimately dying of deep-to-the-core bile duct cancer, is worse off than me? This is a new emotional experience for me, a state of survivor’s guilt, I suppose. It is one that I was not expecting this morning. And, it makes me ashamed. Sure, I imagine that these types of feelings are entirely in-line with human nature and any rational concept of self-preservation but it doesn’t change the fact that I am happy that I don’t have the worst. Again, the questions infest.

Answerless, I simply sat in my auditorium chair, legs crossed, and listened. For an hour, I listened. Perhaps I can gain absolution through invigorated rededication, I thought. I have been welcomed back, after all. In the end, today’s gathering became more than a lecture on cholangiocarcinoma. It became, like everything in medicine has become, personal.

Grand rounds today. M&M tomorrow.

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