I had heard and worse yet, felt “the wall” some medical residents fortify around their feelings like a moat that somehow will keep out the pain inexorably experienced in an internal medicine training program.
God, they had so much to wade through. “Dr. Plumber”, as she refused to use her first name lest it might crack her wall, had much work yet to be done on the fortress around her heart. The windows to her soul were shuttered too tightly. Superb in her clinical care, she was deficient in her caring.
Her call to me was crisp in presentation, thorough and clipped at a staccato but calm and self-assured pace. Her voice was more like the Dow ticker than the beat of a heart telling me one of my heroes had fallen, both literally and figuratively.
Felipe was a brave and devoted Philipino husband, father and patriarch who had served dutifully in the Air Force and his community post retirement before he was felled by one of nature’s cruel immunologic tricks, the usually innocuous Epstein Barr virus. It is best known because of its association with “mononucleosis” but it could also insinuate its DNA deep in the belly of some cells and work out a darker fate; from nasopharyngeal carcinoma to lymphomas. He had the former.
There was no braver or truer “Yes, Doctor” uttered by a patient in my twenty plus years than when we told him how we would combine the powerful Cisplatinum with 5 FU with radiation. In savage synergy they would attack the cancer and exact a toll of leathery skin, diminish the ability to taste or even produce saliva, and in his case might depress his hearing to the point that even devices would only moderately help. The prize was a real shot at survival, but in a world requiring enormous adjustment and sacrifice. He focused on those odds every day of therapy and in the three years’ since with zeal
It was three years later that the news of his prostate cancer landed. Once again he stood up to the beast and beat it. It was local stage and the potentially emasculating surgery was painfully accepted by this proud patriarch.
So now this clipped voice, referring to herself always as “Dr. Plumber”, never by her first name, was telling me the tale of rapidly deteriorating strength in the lower extremities and other widespread neurologic findings in a manner not quite following the blueprint of our neurological wiring. There was, of course, more. The lesion on the MRI of his brain had revealed a probable area of foreign tumor in the brain and its location was quite likely to have seeded cells throughout the whole wiring diagram and central computer; the brain and its covering. His tumor was bathing the lining of the brain and spinal column; meningeal carcinomatosis. Only a spinal tap could confirm what I knew had to be. This often treatable, sometimes curable and frequently fatal condition could be a third cancer, it was; a Non Hodgkin’s lymphoma.
The positive spinal tap is not the point of the story. First was “the telling”. All of the family was there including two who were nurses, a difficult position to be sure. Often times in such situations personal grief must do battle with a sense of duty to engage as a health care provider, spokesperson and some form of second authority.
Happily, the spanking new one stripe Airman who had been with my wounded warrior since admission, boldly asked to be with me through “the telling talk”; all the way. The family agreed. In we paraded, M.D.’s in training in tow. I stopped in front of every family member, particularly noting the somewhat starched but not really distant demeanor of one of the older daughters as she called me Colonel, not doctor.
I took special care with this family. After a warm, strong embrace of my patient’s hand I motioned for his acceptance to sidle up to and hunker down my six foot three, 220 lb frame next to this ex marine weighing in at barely 145 pounds. There is a personal, intimate, space for every patient and it changes with every doctor as well as throughout the relationship. The time was now to sit hip to boney frame, eye to eye, grasp a wasted handed firmly and search deep into the heart behind those steely eyes veiled with a mist of tears. I leaned into his ears as his hearing was as ravaged as predicted and grunted “Hoorah! Sempre Fi”. “ He grasped my hand tight and responded in kind. My heart has never heard the call so ready for the fight..
We began. “O.K., Felipe, this is a big one. You sloshed through the fetid swamp of Vietnam and stood tall in blazing, burning oil fields. You faced a cancer that threatened to take your face and your life and you accepted surgery that left you unable to be the man you saw yourself as; you were forced to adjust. This one is bigger”. I paused to take his measure. He was unwavering, his grasp unlocked. The true essence of the physician is much more than a ounce of teacher, be it by metaphors, parables and the like, you must meet patients at their ground, on their turf or you are never in the game and could do great harm. It is may be hard to think about what you are about to say, but to say only what you are thinking and what you know they will hear, that is the rub. That is the art of the teacher-physician.
“Felipe, your car has oil and you know why?” He nodded affirmatively.“ And it goes all through the critical engine parts. It must be pure, clean, no dirt, right?” Again a nod. I grabbed the nearest piece of paper and drew a brain and a stalk, sort of like a lopsided sideways broccoli or cauliflower. I then had a long cord from the stalk ending in what looked like a horses tail with hairs splayed out in a fan. I explained the anatomy of the central nervous system to him in the most basic of terms.
I gave dramatic pause to let the picture and metaphor begin to grow in the mind’s eye of Felipe and family, all eleven that were there at his request. Gesturing to all with my free hand I said “lets open the broccoli and learn that there are chambers that hold fluid and a canal that connects it all and it is all in one long sac. The meninges cover the brain and reflect downward to the stalk and cord and horses tail, the cauda equina. There is fluid that bathes the brain and the cord and is pumped around in a circular manner up and down and back and absorbed by cells lining the rooms or ventricles in the brain. Just like oil has a certain set of necessary characteristics so does this fluid, in this case, sugar, protein, pressure – do you see?”
As I waved my hand through the imaginary circulating cerebral spinal fluid in their minds eye I turned to Felipe, “ We cannot have any foreign debris, or dirt or foreign bad cells here, can we?” He was unmoved. “We cannot have those cells grow and multiply.” He was still unmoved. I continued knowing he was processing the inevitable conclusion and racing ahead of me. “Now stay with me”, I cautioned, “ We cannot have those cells grow in a closed tight space like the one I explained for if they do they will damage whatever function wherever they land.” His eyes cleared and he stared at his emaciated legs. “So that is why I can barely walk now Doctor and maybe one or two places it is worse than others, maybe it can go anywhere in that canal system or my skull cannot take the pressure eventually, is that it? I simply said a quiet “yes.” Unshaken he uttered, “this is very bad, Doctor, can we treat it, can we cure it, do we know its name, is it from my Nasopharyngeal cancer or prostate”
Slowly I explained to him the vagaries and mysteries of the amazing immune system, the role of normal white blood cells and the types, using the Military as my metaphor, and the rise of Nazism as my parable of the malignant, un-arrested clonal growth of a lymphoma, a third cancer that was seizing his senses and threatening a painful death. We waded carefully through the many types and what difference it made to him. I explained he had a third cancer, possibly related in ways we have yet fully discerned to that same Epstein Barr virus. It was primary to his central nervous system, which he now understood, and it had seeded his meninges like stucco sprayed erratically by a whip lashing hose in a closed space.
He got it, and they got it. I explained that there was a realistic chance of recovery of some, and uncommonly, all of his leg function because it was a lymphoma and that the very potent high dose steroids we were using were in part killers of these cells.
He would need a catheter connected at one end to a small port about the size of a quarter that led into the rooms, the ventricles in his brain so that chemotherapy could bathe his brain. I explained the risk of the procedure and that we could do that all here but that he also needed radiation to his entire central nervous system and high dose chemotherapy with very close monitoring. I asked him if he got the science of it all after reviewing endlessly the metaphor, the parable and the treatments, they all did. I then turned to the young Dr. and said, “that was the longer and easier part” Turning back to my patient I said “Now let’s talk, Felipe”.
“Let us talk about the fear, as the anxiety, fear of the unknown is gone, we killed it with knowledge, didn’t we? Let us talk as men and children of God, of fear. Talk to me Felipe. “He lessened his grip and gestured to his wife who was bereft, but very present. In angelic strains only heard between true lovers, she said, “It is your decision, my love, and I know what it will be. I will be here and there and with you always”. She gained strength and momentum, ”you are my man, no prostate surgery changed that, you must talk to God, and he will hear you. You are a Marine and you know how to fight and when to surrender. My love, we will be the ones left behind” and at this Felipe broke down for just a moment, Admonishingly, she almost barked out, “We will be fine, there was no promise for forever but until forever ended and it has not. You know what to do, talk to Jesus”.
The room had become a sacristy and the Spirit was holding the very floor under all dozen of us as we heaved each breath with heavy hearts. Felipe, the Marine, fixed his jaw and set his eyes on mine. “Colonel, can we have a few days?” “No!” was my response. Without missing a pulse, his grip firmed again. “It is that fast” he questioned in disbelief. “Yes”, I answered sternly. You always may have until forever comes but to fight it you must start now.” With strength and uncommon valor, he declared he would talk to his family alone and give me his answer in 10 minutes. The stage was set for our final dance and the entourage of shaken medics left the room, gently closing the door. I intentionally separated myself from the others as they needed to stew in the juices of the sweat of life’s struggle privately for a moment and we were not done.
Sufficient time had elapsed and this time I stood astride him facing the family. I need not speak. It was his show now. He spoke as I thought he would, “Let’s do it”. I quickly spun on my heels and intentionally almost pinned Dr Plumber in the direct line of sight of all, including the patient. Knowing how deep this man’s faith ran I knew we were not done “Now Felipe, the most important part. You are a Christian, is that right? Are you praying?” I gently asked and a chorus of yes echoed through the room. I continued “Felipe, do you think God is going to heal you or help you handle this?” He said, “ life is not easy, he will not cure me, he can do anything but he does not work that way. We know the love of Jesus and understand”. I asked. “Was he with you in Vietnam and Kuwait?” Instantly he retorted, “Oh yes, and a smile that filled the Philippine seas warmed the room. I asked, “Do you remember in the Garden of Gethsemane, do you remember what Jesus first said while praying to his Father when he was alone without the disciples”. His beam of faith grew brighter and he excitedly replied, “Oh yes, he asked to get out of it and he sweat blood.” At once my heart was less heavy as I softly uttered “Yes Felipe, yes, and we too may cry” and he did as our eyes met.
Through the corner of my eye, I unmistakably saw a right arm ceremoniously lifting into a salute. It was his sister, the starched one I had noticed before, standing more proud and erect. “Chief Petty Officer Angoco requests the honor of a return salute, Colonel, sir!” I felt I was on the U.S.S. Missouri in WW II and there was only one right response to this wet eyed soldier obviously soon to assume command of the family. I abruptly turned and returned the greatest salutation I dare say I have had in many a year.
Turning back, I continued,” Felipe you are a hero. I doubt I could ever do this even with the most beautiful family you have”. He waved me away, I sternly stared him down. “No! Damn it, you are a hero and you will listen to me. Dr Plumber, what is he, hero or not? Could you do it, can you even conceive of it?” She was motionless and, head down; she whispered “No.” I continued and pressed her “And tell me have you ever had an Attending physician do this?” The same response. “And tell me, and I parsed my words for maximum dramatic affect while in tempo staring at each family member in turn, “ and will you ever forget Felipe Angoco, ever?” The same response, “No”. I stood taller and took in a commanding breath. “ There is more, Felipe and Dr Plumber, there is much more here. “
Again, I began but this time with the fluttering of my eagle-wing epaulets almost audible, I challenged her “ Will you see cancer again?” A meek “ Yes” was uttered. In instant retort, again I challenged “Will you see meningeal carcinomatosis as a possible differential diagnosis again.” This time it was “Yes, Yes Colonel”.
Taking dramatic pause I reached out for her hand, put it in his and said as gently as I could, “ Then thank the man on behalf of the thousand Felipe’s who will cross both your path and those you will teach in the next thirty years. Look in his eyes and tell him you will never forget”
Time stood still although; thank God, their hands did not.
Post Script: While writing my note for the record in the on call room littered with charts and Dr. Plumber burying her face in melting tears, the young black single stripe Airman who had asked to be there during “the Big Talk” approached. He had undoubtedly raced in dangerous screaming streets in earlier years as was so apparent in his vernacular and visage. He walked in without a sound and cleared his throat from the tears he had obviously shed. Standing proudly at attention, staring through me at the wall behind me less he break down he passed me a note and searched my eyes for more than just a moment. He spun on his heels and solemnly faded away. It was written on a prescription pad and read:
“To Dr. Plumber
“I am just writing this to thank you for everything you have helped me with today. Even though it may seem little to you, it was a great world to me. I appreciate it so much, more than you can ever know. It pushes me to strive and reach my dream to be a Doctor also. May God bless you richly.”
Airman Jeff Smith
PPS: I waded over the moat of Dr Plumbers Jericho walls and handed her the note softly, almost cooing, “Here is your second of thousands of Felipe Angoco’s yet to come”.
PPS: Felipe responded to all the therapy and while modestly neurologically disabled from it, he survived. Dr Plumber follows him in her clinic. Sometimes, we win big