The Art of the Surgeon | lifebookscancer

Diagnosis 3: The Art of the Surgeon

and the State of Grace

Glenn Ward

Posted on February 11, 2018

Labour as a State of Grace

In the mid-70s, I worked for a year in a fab shop — short for fabrication shop — at a pulp and paper mill in Thunder Bay. I was doing part of my plumbing apprenticeship there, learning how to fit and weld pre-fabricated pipelines, brackets etc., for installation elsewhere in the mill. I ended up working for much of my time there with a retired/rehired welder/fitter named Walter. He’d spent most of his working years at the Port Arthur Shipyards, beginning in the 1930s as a blacksmith and later on as a welder/fitter, and he seemed to know everything that there was to know about creating something from a piece of iron or re-working something that had already been created. Watching him work the iron was always an incredible experience for me and, for the rest of my life, at artistic exhibits and flea markets, I’ve gravitated to the blacksmiths and watched them, comparing their formidable craftsmanship with that of Walter’s.

Years later, I read Cormac McCarthy’s “Child of God” and was struck by his sensitive portrayal of the blacksmith. If, like me, you’ve read the book about a necrophiliac named Lester Ballard, you likely found it to be so disturbing that you can’t recommend it to anyone. Still, one saving grace of the book lies in its portrayal of the blacksmith to whom Ballard brings an axe head to be sharpened (what he needed to use a sharpened axe for was left mainly to the imagination of the reader). McCarthy describes the work of the blacksmith as art being created by an artist, from reading the colour of the flames of the forge combined with knowledge of the time one should leave the piece in the forge, combined with the way one would hammer the surfaces of the piece. He describes the way others would make mistakes not as poor work practices, but as a commission of mortal sin, and to him there was no difference between the two. When I read the chapter, I thought of Walter and wondered if he could make a distinction between the two acts. At the end of the chapter, the blacksmith gives Ballard a few words of advice about grace (the following excerpt contains no quotation marks as they are not included in McCarthy’s writing):

Shape ye fire to the job always.

Is that it? said Ballard

That’s it. We’ll just fit thee a handle now and sharpen her and you’ll be on your way.

Ballard nodded.

It’s like a lot of things, said the smith. Do the least part of it wrong and ye’d just as well to do it all wrong. He was sorting through handles standing in a barrel. Reckon you could do it now from watchin’? he said.

Do what, said Ballard.”

For years after I’d worked with Walter, I would drive by his house, as he lived on a street that was part of the drive around Boulevard Lake in the Current River section of Thunder Bay. As I drove by, I’d wonder if Walter would still remember me if I were to stop and visit. If he did remember me, I wondered if he’d considered me one of the saved or, at least, one who tried to achieve a state of grace through his labours.

One night, after I’d left the trade and become a university student, I saw Walter standing on his front porch as I passed. He was looking away down the street and so I was able to drive by without him seeing me, and I was surprised at how rattled the close encounter left me, for I knew that Walter wouldn’t care about my being a university student but would only want to know if, unlike the necrophiliac Lester Ballard, I’d found grace through my labour. Years later, I saw his obituary in the paper and felt relief that I wouldn’t have to worry about running into him and disappointing him anymore. After all, I lived in a universe schemed in absurdity and, in such a universe, there seemed little chance to achieve grace through mastery of my labours.

Attempting a state of grace through one’s labour is common in Cormac McCarthy’s portrayal of the human state. His books bring to mind Norman Mailer’s defense of his use of the words “shit” and “fuck” as necessary if he is going to also say “noble”. McCarthy shows the evil — the bloody conduct of the evil in human affairs — so that he can also show the tempered grace made possible — and necessary — by such affairs. From the dancing of the judge in “Blood Meridian” to the taming of the horses in “All the Pretty Horses”, to the developing relationship between the boy and the wolf in “The Crossing”, his characters find grace in their physical actions: grace that mitigates the effects of the evil done either by them or by others.

“The Crossing” contains a section in which Boyd Parham, younger brother of the book’s protagonist, Billy, is shot through the upper torso in an encounter with horse thieves in northern Mexico and has his wounds treated by a Mexican country doctor. For twelve pages, the doctor’s treatment, from his initial evaluation of the patient to his cleaning of the wounds by the light of a flashlight held between his teeth, to the instructions he gives for post-treatment care, is described in detail; in loving detail. The doctor isn’t just treating the wound, he’s achieving that state of grace that only a character in McCarthy’s books can achieve, a state that I never achieved as a blacksmith or a student or even a scientist.

“The Crossing” is the second book of McCarthy’s “Border Trilogy”, which I read between my hospitalization for the abscess and my initial treatment — both surgical and non-surgical — over the next two years as support for my claim for disability insurance, an embarrassingly mundane task. I read the initial reports of the infectious disease specialist, the surgeon and the attending physician during the surgery and the pathologist who analyzed the tissue removed from me during surgery and, as I did so, I looked for those signs of grace in their written reports. It seemed to me that professionals who approached a state of mastery in their work could reach more closely a victory over disease, and I saw many signs of mastery in those reports, but it wasn’t enough. What was my role in what after all was my cancer. Wouldn’t I need to achieve that state in my life if their efforts were to be rewarded? Try as they might, and as good as they were, the doctors and surgeons and pathologists could simply visit my diseased state accompanied by their art, and leave behind a mark of their visit, but only of a visit. In this case, the larger battle was mine to fight.

Surgery and the Diagnosis of Cancer

I used to tell my students that the treatment of cancer, even in this age of advanced cellular biochemistry and immunology, was still predominantly a matter of slash, burn and poison. Slashing was the art practiced by my surgeon and poisoning through the use of chemotherapy was later carried out by my oncologist or, more accurately, by the tumour board headed by my oncologist. Burning, through radiation, was not deemed appropriate in my case (and I am thankful for that). When one has colon cancer, or most forms of cancer, there is often no clear distinction between the initial treatment and the resulting diagnosis. This is because the first act of treatment — the surgical removal of the newly discovered tumour and the tissue surrounding that tumour — also allows for the completion of the diagnosis. Furthermore, surgical removal of the local lymph nodes allows for the assessment of the degree of infiltration of secondary tissue by the “cancer cells” and for the extent of the original tumour or tumours. In other words, the surgery is often planned before anyone knows just how much of the patient will be removed and discarded or studied. Therefore, over the next few days, I awaited surgery and the likely removal of various sundry parts of my digestive and lymphatic systems.

The slash, burn and poison approach also has larger implications for the treatment of cancer, and these larger implications often determine the characteristic features of a cancer patient. Theoretically, the success rates of current cancer treatment could be increased to 100% if only more tissue could be removed, through chemotherapy or surgery, until there is no tissue left that has any likelihood of housing invasive cells. In the real world however, such an intervention is impossible, as at least some of the tissue in question must be saved. However, if brand new tissue could be implanted or, more likely, stem cells implanted that are programmed to form new organs and tissues, then most cases of cancer could, theoretically at least, be eliminated at the tissue level by removing any tissue with even the possibility of housing harmful cells. However, the amount of tissue that can be removed is finite, and so surgeons struggle to remove most of the invasive tissue while leaving behind an amount that maintains the function of that organ. In my case, the amount of tissue that could be removed included all of my ascending colon and cecum, much of the adjacent muscle cells, and the regional lymph nodes.

My Surgery

The day before surgery, the surgeon came to see me and described what they were going to do, and he mentioned that he'd decided that I was not a good candidate for an epidural anaesthetic, as I was still recovering from the infection that had lead me to the hospital in the first place. Part of the epidural procedure involved the insertion of a needle into the epidural membrane, and then using that needle to insert a line through which spine-numbing drugs can be injected, during both the surgery itself and after surgery, to control pain. Such a procedure always carries a risk of allowing an infection to enter the epidural space, and my white cell count — in the low 20’s at that point, likely as a result of the recurring and aggravated abscess — indicated that I was at higher than normal risk. Furthermore, I’d been on blood-thinners for over a week prior to the surgery, rendering me more susceptible to bleeding from any sort of needles. No, epidural anaesthetic seemed out of the question for me.

Later that day, the anaesthesiologist (actually, a resident doing her rotation in anaesthesiology who would be assisting the regular one) came by to visit me. She announced that they were going to stop my heparin since they were going to give me an epidural the next morning. Heparin is a blood-thinner and would work to increase bleeding if needles were to be used as part of epidural anaesthetic. A while later, a nurse came by to give me my heparin injection. “There might be a mistake,” I meekly suggested. “The anaesthesiologist mentioned that I wasn't going to get any more heparin.”

“I’d better double check,” she said and left. She returned shortly. “I spoke with the surgeon,” she informed me. “You are supposed to get another shot of heparin”.

“Sounds good to me,” I answered. Everything they suggested sounded good to me.

The next morning my wife found me on a gurney in the corridor outside the operating room. I was relieved to see that she’d found me, as the regular anaesthesiologist had approached me with a copy of the consent form and said that he needed my consent to do an epidural anaesthetic.

“Epidural anaesthesia is perfectly safe and effective in cases like this,” he said, or something to that effect (I wrote notes on it about a week after the events took place). He was a very sincere and confident young man and, when he finished, I took the clipboard and the pen he was holding out to me.

“Sounds fine,” I said.

“Wait a minute,” my wife said. She proceeded to give him all the reasons why I shouldn't get an epidural. I felt a little embarrassed by the fact that my wife was disagreeing with him. The anaesthesiologist, on the other hand, seemed to take it all in stride. "Fine”, he responded graciously, “Whatever you say, it's your decision,” and so I didn't get an epidural but, rather, I was to be kept unconscious through inhalant anaesthetic. I’ve spoken to a few physicians since then and learned that there is no clear consensus regarding the relative benefits and risks of epidural versus inhalant anaesthetic in terms of risk of infection, labour-intensiveness, etc. although there is no denying that epidurals do increase the risk somewhat of infections, but only by a small amount. Still, they felt that, given my concurrent infections, an epidural would have been slightly more risky for my particular surgery. Not having a spinal epidural in place post-op would make post-surgical pain control management slightly more difficult. In other words, the situation was messy as is most decision-making in real life.

My surgery certainly did take a long time — 5 hours — although I learned later that the operating room had been booked originally for 3 hours. In other words, the original booking was estimated from the guess of the stage of the cancer and the time actually needed to remove a relatively discrete tumour in my cecum, the large section of the colon where the ileum deposits the remainder of the food as it is processed. As the cecum is in the lateral-most section of the ascending colon, it should have been easily accessible but, in my case, it was not, and the actual time required to remove it thoroughly reflected the true stage of progression of the disease.

Furthermore, a major complication that contributed to the length of my surgery was caused by the mess made by the abscess that had been drained just three months earlier. The dead tissue from the abscess had not been thoroughly removed and digested by the cells assigned the role, and so the remaining cells comprised a mass of dead tissue that infiltrated the existing tissues and organs. My surgeon later compared it to removing the mushy inner part of an overripe cantaloupe.

The messiness had to be dealt with through recruiting two other surgeons. My surgeon had to identify my ureter (the tube carrying waste liquid from the kidney to the bladder), a task made difficult by the surrounding mass of dead and dying tissue from the original abscess. The surgeon consulted a urologist to place a stent in my ureter to help identify and not injure it during the ensuing surgery. A complication did arise from the difficulty in identifying the site of the primary tumour and determining the safest place to cut into the surrounding tissue so as to separate the “invaded” tissue from the healthy tissue. In this case, the task was made more difficult by the infiltration of tumour cells into the various planes of muscle lining my abdominal wall. Dead and dying cells from the abscess had infiltrated the muscle and this made the task much more difficult. More messiness from an overripe cantaloupe. Another surgeon had to be brought into the operating room to help my surgeon locate and identify the muscles lateral to the ascending colon. Afterward, I wondered if, and hoped that, the professionals involved did indeed approach mastery with their labours, and that this mastery brought them close to grace. Although my wife claims that I met both of them, I don’t recall ever doing so and having the chance to thank them. I hope I did so, as I hope I told my surgeon that I appreciated his willingness to seek help when appropriate.

I recall waking up a couple of times during the surgery, asking for my wife, and a female voice told me each time that the operation wasn't over yet. Afterward, the surgeon mentioned to my wife that the anesthetist was kept pretty busy with the anesthetic to keep me from waking up, so I assumed that these times I awoke were due to the light anesthetic. I also recall hearing two men arguing rather heatedly about something, so now I wonder if that also really happened during the operation or during post-op, and what they were arguing about (after all, they could simply have been debating some new change in the Blue Jay’s line up or something similarly unimportant). I’d heard of cases in which patients awoke during their surgery and found themselves traumatized and in terrible pain, but neither feature was true in my case, although I did feel distressed by the fact that my wife was not close by.

My wife isn't convinced that I really did wake up during the surgery (although she does accept that there were problems with keeping me deeply under the whole time). She points out that, even though I may have thought that I was asking for her, no one would have been able to make out anything I said because I would have had a tube in my esophagus and a mask over my face, etc. On the other hand, I recall that I found it hard to get the words out and was trying to articulate as clearly and loudly as I could and, anyway, it doesn't really matter if they actually understood what I was saying or whether it just sounded like mumbled gibberish.

Since my surgery, I looked up the data on patients waking during their surgery. A large survey of the phenomenon called the 5th National Audit Project on Accidental Awareness During General Anaesthesia (“accidental awareness” is a great concept for those of us who live in a universe schemed in absurdity) was published in the journal Anaesthesia on September 9th, 2014 (almost exactly the time during which I underwent my surgery: the absurdity continues). Although the report looks at various factors and sub-groups of surgical patients, the overall percentage of cases — about 1 in every 20,000 patients undergoing anaesthesia — suggests that I was in the distinct minority if, indeed, I did wake up during those times.

I had the surgical procedure called a hemi-colectomy (they removed the ascending colon and cecum), so I felt relieved at the thought that I could possibly get out of this without a lot of physical changes. My most immediate problem after the surgery was pain from my abdominal muscles around the incision. I've learned that you can't avoid using your abdominals, even if you're resting. Thankfully I didn't catch a cold: the few times I had to cough were excruciating. There's almost nothing that I can do that doesn't pull them and cause pain. Still, the doctors seemed to think that everything was a success, mainly because they didn’t have give me a colostomy even if it was at the cost of having to remove my right internal oblique muscles. I certainly lost a lot of weight, though, due to both the necessity of staying on TPN (“total parenteral nutrition”, in which nutrients are delivered directly into my bloodstream) for so long and, after I was returned to oral nutrition, due to the yeast infection in my mouth caused by all the antibiotics I'd been taking. For the first time in at least 20 years, I was below 180 pounds.

A drawing on my notice board done be my surgeon to show me the parts of my colon that were to be removed during my surgery. The frilly section indicates the part of my cecum that are "messy" due to the dead cells from the abscess drained a few months earlier. In truth, the messy section turned out to be much more extensive than originally thought.

Waiting for the Diagnosis

I was discharged from the hospital almost three weeks after being admitted. According to my surgeon, the biopsy results were originally going to take, at most, a month, but they ended up taking much longer due to a sudden and unexpected shortage of technicians in our local pathology lab. I quickly adjusted to a comfortable if fitful daily schedule after my discharge: sleep lightly through the night (although my sleep improved as the incision site healed), wake up around 7, make coffee for myself and my wife, have breakfast and read news online for an hour or two, sleep for a couple of hours, get up and have something for lunch, walk around a bit and then sit quietly and try to read for a couple of hours, go back to sleep until supper, etc. etc. It wouldn't have been a bad life if it wasn't for the spectre of cancer hanging over everything like a gargoyle perched up on the corner cupboard in our newly renovated kitchen.

I'd even gotten tired of reading, since it was all I did most days. Finally, the day came when I could drive again, so I celebrated by driving to the outlet mall to get my haircut (the greatest excitement of my week). Actually, I also browsed through some furniture stores and had a strange experience. After our kitchen renovation, we found ourselves in need of two counter-height stools for our new "breakfast" counter. However, I really didn't want to have to deal with any salespeople at the furniture stores, as I didn't have enough energy yet. Therefore, I was relieved to see that, although I was one of the few customers in each store, the sales staff would nod to me and say hello but, other than that, they kept their distance and left me alone. As I continued to shop, I became more and more uncomfortable at how they seemed to avoid me until I began to feel somewhat alarmed. Perhaps my weakness was becoming obvious to the others in the stores. Then, when I got home, I saw the blood stain on the front of my shirt. It was about three inches in diameter and almost exactly in the middle of the front. The blood had dried by then, so it must have been on my shirt for much of the time I was out in public. Imagine this: a late-middle-aged guy (with a new haircut) walking around with a rather large blood stain on his t-shirt. I had a hematoma at the incision site on my abdomen and, probably because of the activity of driving and getting into and out of the van several times, it had begun to bleed, and I was completely unaware of it.

Otherwise, I felt very well during those days and sometimes would get more obvious reminders, although less public ones, that I was actually on the mend from surgery (for example, when I would absent-mindedly try to lift a hockey bag into the van). I'd gotten very good at pretending I hadn't hurt myself when lifting too much so that my wife wouldn't get angry at me (she gets frustrated by how terrible a patient I am, and I admit it, I'm not a very compliant patient).

My Diagnosis

Eventually, we received the biopsy results. For colon cancer (as in many solid tumour cancers), the results are often referred to as “staging” of the cancer. The short form for cancer staging is the TNM system. The T stands for the extent of the tumour spread (in my case, pT4a), the N stands for the number of lymph nodes to which the cancer has spread (in my case, pN2b), and the M stands for the spread of the cancer cells to the liver and/or lungs (in my case, M0).

The first aspect of the staging is to describe the primary tumour itself. In my case, the tumour stage was on the cusp between stage 3 and stage 4. This reflected the fact that the tumour cells had not been found in the liver or lungs (thus making it a stage 3 tumour). However, cells had been found in other more local tissues such as the muscle and fat cells, which made the staging consistent with tumour stage 4.

Next, they reported lymph node involvement, which confirmed that I was probably going to require chemotherapy and would determine the type of chemotherapy I would receive. The stage of lymph node involvement was NIIb, which was a technical way of stating that, of the 39 lymph nodes “sampled”, more than 7 of them were deemed positive for cancer cells. So a bit of good news mixed in with a bit of bad.

Combined, these numbers provide an indication of such features as what type of treatment should be given, the likely outcome of the treatment, and so forth. For patients such as myself, however, what interested me the most was to be able to predict how many years/months I was likely to survive with the stage of cancer I had. Therefore, I looked over the literature and found that the 5-year survival rate (in the U.S.) for this specific staging combination is about 10-20% (10 to 20% of individuals with my stage of colon cancer could be expected to be alive after 5 years. However, this estimate may be an underestimate of the true odds. For instance, I suspect that most of the research was based upon a sample with an average age in the mid 60's at least, given that the average age of diagnosis is around that age, and that I'm probably getting better care than the average colon cancer patient, given that I'm married to a doctor with the tenacity of a pit bull when it comes to getting the best medical care available. Furthermore, the numbers provided by this research were collected over at least a couple of decades, and so the treatment many of the earlier patients received is probably out-dated by now. Therefore, I'm making the assumption that the "average" isn't relevant in my case (I assume everyone else thinks this way too, but I feel that I have more justification for my assumptions which, again, is probably what everyone else thinks too).

In other words, what this 58 year-old man — conceived in a universe schemed in absurdity — lacks in mastery and grace, he makes up for in hope.

Will that be enough?

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