Tuesday, October 13, 2015

Office

                           

I have, on occasion, described the perfect surgical practice as one where one operates every day, performing a wide variety of cases, while never having any patients in the hospital. Perhaps this fantasy is a bit facetious. Boiled down it means that the surgeon gets to perform the most interesting part of surgery, that is the actual operation (unless it’s a vein stripping) while never having to deal with the more mundane and frustrating aspects of the surgical practice, such as dealing with a draining wound or impatiently waiting for the post op ileus to resolve.
There is one aspect of the surgical practice, even a perfect one, which is absolutely necessary: the office.
In the office new patients are seen for the first time, evaluated, examined, treatment options explained and discussed and decisions made. Patients recovering from surgery come to have their wounds checked and concerns addressed:
“When can I go back to work?”
“When can I drive?”
“What can I or can I not eat?”
“When can I start having sex?”
“Will this lump go away?”
“Is it supposed to be numb?”
“Do I have cancer?”
Each question is patiently answered, worries and fears are laid to rest, as the patients make their way down the path towards recovery.
Most clinic days are a predictable mix of patients who suffer from hernias, gallbladder disease, lumps, bumps and pockets of pus, with an intermittent spattering of thyroid conditions, gastrointestinal masses, hyperparathyroidism and other less common ailments.
There was a day however when my office patient was filled with a stream of colorful patients. I should have known something was up when I saw the name of the first patient:
Hazy Racy Autumn.
Unusual name…swollen groin…here I come, Hazy.
I knocked on the exam room door and went in.
“Ms. Autumn? I’m Dr. Gelber. What brings you in here today?” I began.
I’m not sure how to describe Hazy Racy Autumn. She was tall, taller than me and her height was accentuated by a tall furry hat perched upon long blonde hair. She looked to be the forty years she had reported on her history form. She had a long silken blue and pink housecoat on and fuzzy Winnie the Pooh house slippers on her feet.
“Racy, please,” she replied as I shook her hand.
“Ok, but what brings you in here?”
“Dr. N. said it was my nose; my limp nose.”
Her nose looks OK to me. Besides, I’m not much of an ENT doctor. Limp nose, swollen groin…lymph nodes.
“You mean your lymph nodes, I think,” I explained.
“That’s right. Lymph nodes. Under my arm and in my groin. There swollen according to Dr. N.”
“Is that why you went to see him?”
“Three months ago. He gave me antibiotics and then more antibiotics, but the swelling is still there.”
We went through the rest of her unremarkable medical history and then it came time for me to examine her. I’d already noticed that her submaxillary glands looked enlarged, giving he a little bit of a chipmunk look.
“Put this on so I can examine you,” I requested, handing her one of our cheap paper gowns.
“Oh, I don’t need that,” she decided as she jumped up on the exam table and opened her housecoat, which revealed Hazy Racy Autumn and nothing else.
She had neatly trimmed her pubic hair into a blonde replication of Adolph Hitler’s mustache, the remainder was clean and smooth.
I saw Miss Autumn in the early 1990’s, a time when the current custom of clean shaven pubic areas was not in vogue. The only women who regularly shaved “down there” were strippers and hookers. Perhaps I was presumptuous to assume that Ms. Autumn was in one of these lines of work. My inquiries as to what she did for a living were answered by a vague, “I work from home” response.
I proceeded with my exam, noting multiple enlarged nodes in each groin as well as each axilla, all 2-3 centimeters in size.
“I think we should take out one of these lymph nodes. That’s what Dr. N. wants me to do and I agree with him,” I explained.
“Is it something bad, Doctor?”
“Well, I worry that it could be lymphoma, a cancer of the lymph nodes, but there are other less serious possibilities. The simplest thing would be to biopsy one of the groin nodes. Do you want to have that done?” I asked.
“Yes, yes, of course,” she replied with a shrug.
I finished my exam and explained the procedure and Hazy Racy Autumn was scheduled for a lymph node excision two days hence.
A fine start to the afternoon. What’s next? J.F. Romanov, lump on foot and buttock.
I picked up the chart, knocked and went into the next exam room.
“Ms Romanov?” I asked, “I’m Dr. Gelber, what can I do for you today?”
“Hello, Doctor,” she answered with a bit of an accent, holding out her hand. “I am glad to meet you.”
She was stocky, didn’t wear any makeup, and had dark brown hair with wisps of gray which was tied back in a ponytail.
“I have a lump on my, what do you call it, butt and one on my foot. They do not pain.”
                   “How long have they been there?”
“About two months.”
“Painful?”
“No.”
The rest of her history was unremarkable.
“Ok, put this gown on and I’ll be back in a minute to examine you.”
I left her alone and sat at my desk and wrote out her history while she changed. When I’d finished I knocked on the exam room door and went in, with my Medical assistant, as always, in tow.
Ms. Romanov sat on the exam table, completely naked. My assistant handed her one of our paper gowns, which my patient loosely placed across her waist.
“Where are the lumps which you feel?”
“You Americans are always so ‘funny’ about nakedness,” she observed. “Let me show you what I can do.”  
She shifted her legs up and down  before deftly bringing each leg up and placed it behind her head as the paper gown floated to the floor; a remarkable demonstration of her flexibility.
“You must have been in the ballet to be so flexible,” I commented, doing my best to act nonchalantly.
“Ukrainian circus,” she answered. “But, you see the lump good, no?”
As she said those words I looked at her right buttock and, sure enough, her exhibition did demonstrate the outline of a mass in the right buttock, about 6 cm in diameter, mobile, discreet, almost certainly a lipoma.
“And, you see my foot, the left one?” she added.
I palpated the left foot and felt another mass on the lateral aspect, about 3 cm in diameter, likely a fibroma.
“Anything else?” I wondered out loud, referring to the physical findings. Ms. Romanov, however, interpreted these words differently.
She pulled her legs from behind her head and jumped on the floor and executed a handstand and began moving her legs back and forth in a scissors-like manner.
“I’m sorry, Ms. Romanov, I meant, do you have any other lumps that you are concerned about?”
She went back to sitting on the exam table and answered in the negative.
She related that she wanted to have the lumps removed and we set a date for her surgery. I left her to get dressed and went on to the next room.
Next was Karen Smythe, 58, breast cancer. She came with a mammogram showing a suspicious mass in her right breast and biopsy which revealed infiltrating duct cell carcinoma, the most common type of breast cancer. The mass appeared to be about 2.5 centimeters on the mammogram and there was an enlarged lymph node, also apparent on the mammogram.
Not good..
“Good morning, Ms. Smythe, I’m Dr. Gelber. What brings you in here today?”
“Mrs. Smythe, my husband is Malcolm Smythe. He’s on City Council. Dr. Z sent me. She said there’s a lump in my breast,” she answered, her voice quiet, but steady.
“She’s right, there is a lump and I see they did a biopsy. Did Dr. Z tell you the results?”
“No, she just told me to come here.”
Great, I get to tell this poor lady, whom I’ve just met for the first time, that she has breast cancer. Here goes.
“Well, Mrs. Smythe, I’ve looked through all the reports and the biopsy show that the lump in your breast is cancer.”
“It is?”
“I’m afraid yes, it is.”
Her calm quiet demeanor started to change as tears welled up in her eyes. She did her best to compose herself as I handed her a Kleenex.
“Am I going to die, can it be treated?”
“It certainly can be treated,” I replied, “there are far more women living and walking around with breast cancer than die from it. Let me ask you a few questions.”
I took some more history and then left the room while she changed into an exam gown.
My heart sank a little when I looked at her breast. There was some retraction of the skin and dimpling over the area of the tumor. The mass was about three centimeters and there was a hard, but mobile mass in the right axilla.
Stage III at least. She’ll need chemo before any surgery.
“Mrs. Smythe, I think it might be best to have you see one of the cancer doctors, an Oncologist, before we think about doing surgery. Let me call one that’s on your insurance. I’ll be back in a few minutes.”
I called Dr. S and arranged for her to be seen that afternoon. We sent Mrs. Smythe away with some literature on breast cancer, instructions to call with any questions or concerns, and a box of tissues.
Something isn’t right when a patient has to first hear that he or she has cancer, particularly breast cancer, from a complete stranger, even if that stranger is a doctor.
I zipped through the next five patients who were all post op from hernia or gallbladder surgery.
“Eating Ok?”
“Yes”
“Any fever?”
“No”
“Bowels working?”
“Yes”
I reached my last patient, Billie Jean Muller, 59, abdominal pain.
“Good morning, Ms. Muller, I’m Dr. Gelber. What brings you in here today?”
I’m not very creative with my introductions.
“Dr. M sent me. I’ve been having pain in my abdomen for a while.”
“How long is a ‘while’?”
“Ever since my hysterectomy.”
“And, when was that?”
“I wrote it down on the paper.”
‘I know, but I like to hear what you have to say. I find it helpful when trying to figure out what’s wrong; helps me do the right thing or order the right tests.”
This could take a while.
“Tests? I’ve already had every test. I’ve had CAT Scans, Ultrasounds, EGD, colonoscopy, HIDA Scan, and MRI’s. My gallbladder is gone, along with my uterus.”
I glanced at her history form.
“Your hysterectomy was eight years ago. Did the pain start immediately afterwards? Or a few weeks or months later.”

“I think it was immediately, or, maybe a month or two later. Then again, maybe I had the pain before that surgery.”
I need a different approach.
“Has the pain become worse recently? Why did you decide to come today?”
“Dr. M. told me you could help me. I guess he’s tired of seeing me.”
“Where is the pain the worst? Upper abdomen, around your belly button or lower down?”
“Lower down, I guess. It’s really bad when have to go to the bathroom. I have to push on the left side of my old hysterectomy scar or else it doubles me over.”
Really? Could it be something so simple?
Let me have you put this gown on so I can examine you, Ms. Muller.”
I gave her a few minutes to change.
“Let me check you standing up first. Can you cough?”
She gave a weak cough.
“A bit harder, if you can?”
Sure enough, there was a definite bulge along with the typical findings of a hernia. I finished my exam, not finding any other abnormality.
“I think you have a hernia, that is, I’m sure you have a hernia at the end of you hysterectomy wound. You will definitely benefit from having it fixed.”
I explained the procedure and surgery was scheduled.
Hazy Racy Autumn had an inguinal node excised which was benign, a reactive node. The enlarged nodes eventually were determined to be caused by Epstein Barr Virus, a benign condition.
J. F. Romanov had two lipomas removed. I did not get any more demonstrations of acrobatic ability.
Karen Smythe was treated with neoadjuvant chemotherapy which shrank her tumor to almost nothing. She underwent a lumpectomy and axillary node dissection months later and is still with us today.
Billie Jean Muller had an uneventful repair of her Spigelian Hernia. She did feel better, but still complained of some pain. She saw a Pain Management specialist who helped her get the pain under control.
All in an afternoon’s work.