Twelve Patients: Life and Death at Bellevue Hospital (13 page)

Over many months that became years, I could see the attachments and the expectations returning. Invisible strands, gossamer-like, but strong as silk floating in the ether to be reattached. What I had now was the crystal-clear understanding and ability to make decisions about what was allowed back in and what wasn’t. Only the deep, caring, loving relationships came back in. It had been very hard-earned.

It is a myth that cancer empowers you to witness the beauty and majesty of life. The gloss we try to put on suffering is that it offers us some insight—existential or otherwise—into life and its mysteries. That the sun is brighter and the air is clearer after a rousing contest with our corporeal being. That the relationships with our families matter more. That we learn to savor the small things in life, the colors, flavors, tactile sensations, a breeze blowing, the smells of flowers. That beautiful music resonates at a deeper, more profound level after we have been blasted from our mundane daily existences. That somehow out of the monumental task of being a cancer patient one deepens oneself and reaches into a repository of feelings, a depth of existence, a mode of being that was not previously expressed, that was hiding in plain sight, that but for the cancer might not have seen the light of day. It does occur. It can happen. But it is not the usual experience or the common one. People who were mundane are still mundane; things we found banal are still banal. As for the ties that bind, they can be loving and supportive or simply bind tighter still. There may be a window, a brief opening, a glimpse of an opportunity, a possibility, a path that could have been taken. There are the powerful social expectations of what cancer is supposed to feel like, what the “victim” is supposed to feel and express socially. I didn’t have the strength or the good manners at the time to play the victim.

On October 13, 2011, we’re at home, cooking and wrapping presents. Alexei, Gladys, Mateo, and new baby Zoe are coming over. Marina and her boyfriend are here. She is baking her special cookies. Lura sings in the background. We’re happy and excited. We’ve bought flowers. The door opens and Mateo runs in. “Nana! Poppa! Nini!” It’s his birthday.

I could smell him before I could see him.

The heavy sweet smell hit me as I reached the end of the corridor. Dr. Kantor was waiting for me. He had called my cell phone a few minutes earlier as I was driving into the parking lot. I headed up to the tenth floor immediately. Maria, the secretary of the surgical intensive care unit, handed me the chart of Octavio Salcedo, the young undocumented Mexican who was behind the closed sliding glass door. His room was obscure, half backlit from a light behind the bed. A TV was on; the sun was coming up and streaking the sky the deep color of papaya. The orange light was reflected off the glass towers near the rectangular United Nations building. I could see Octavio’s wife sleeping on two chairs next to him. He was hidden in the shadows in his bed. I could see his left foot sticking out from the sheets. There was no right foot.

Dr. Umut Sarpel, the attending physician, was from Turkey. The energetic young cancer surgeon with jet-black hair came down the hall with her chief resident, very dyed blond and very young, dressed in crisp white MD lab coats. Erika the social worker and Zita the head nurse quietly joined us, nodding good morning. We settled in to discuss Octavio, lying in the room in front of us. Red signs taped to the glass partitions warned that he was in “contact isolation,” a no-touch containment zone. To enter, people had to don gowns and gloves to prevent germs hopping a free ride from room to room and patient to patient. Nurses and aides coming in and out during our discussion squirted white foam on their hands and wore disposable yellow paper gowns, face masks, and latex gloves in obeisance to the overlords from
the bacterial world. With every swoosh open of the doors, a heavy humid smell washed over us.

My brain’s limbic system registered the molecules from thirty-plus years of clinical medicine. I knew more from two inhalations than I would learn in the next thirty minutes. Putrefaction of dead and dying organs, tissue, flesh is singular and unmistakable. Scientific medicine peered into bodies with computerized millimeter-thin X-ray slices, giant whirring magnets that lined up protons in MRI scanners, and radioactive-tagged molecules that illuminated the footprints of altered enzymes and metabolism even before the landscape was altered. Paradoxically, physicians were losing the ability to connect directly with patients by doing an old-fashioned detailed history and a complete physical examination. The stethoscope connecting the ears of the doctor to the heart of the patient twelve inches away was more than symbolism. Any shaman worth his pesos knew that.

One whiff was enough.

“Mr. Salcedo…,” Umut began in the classic medical case presentation. She was totally on target, parsimonious with her words yet hitting every key point. I would not have many questions to ask when she was done. “Mr. Salcedo is a thirty-two-year-old undocumented Mexican who has been living in Queens for the last five years. He developed swelling in his right groin a year ago. A biopsy revealed squamous cell carcinoma, and an extensive workup was done to look for the primary cancer. It was never found. An unknown primary. We have all of the documentation, X-ray results and summaries from the physicians at the local hospital. They did a colonoscopy, a CT scan, an MRI, an endoscopic look into the bladder, HIV tests, everything. Surgery was not promising, as the tumor had spread. Octavio was referred to oncology and radiation therapy, where he underwent a standard chemotherapeutic regimen of platinum for seven weeks, three doses two weeks apart and seventy thousand rads to his pelvis, daily treatments of two thousand rads for seven weeks. The tumor melted away, and he spent the next few months recovering from nausea, vomiting, radiation colitis, exhaustion, and weight loss, all treatment-related.”

Futility.
It was the single word that entered my mind. Metastatic
squamous cell carcinoma was an unmovable object. Why overtreat? The fleeting response would be a Band-Aid on a five-alarm fire. The side effects from the treatment itself lasted months. Palliation, for God’s sake, and a discussion about the end of days, how to spend it and where to spend it and who to spend it with. You could practically hear the mitotic spindles of the cancer cells splitting and dividing through the glass doors. I had heard this particular mitotic hum before.

“By the sixth month, he started to lose weight and started to ooze serosanguineous or bloody drainage from both groins. After several months of self-management, he reappeared at the clinic debilitated with bleeding from the right groin site—and while in the emergency room, the femoral artery exploded. A vascular surgeon attempted to stent the vessel unsuccessfully, and it was bypassed. This clotted off and his lower leg became gangrenous, requiring fasciotomies or long incisions down to his thigh muscle to relieve the pressure on his leg muscles and tissues from the swelling. At that point, their surgical team called us for a consultation-transfer. They had run out of ideas.” Umut wasn’t finished. I decided to let her go through the entire presentation without interruption and leave my questions for the end.

I got the picture and the sense of urgency from Umut’s body language and her intensity. She was obviously desperate to do something for Mr. Salcedo and had run out of things to offer. Her skill set ran to complex tumors of the liver, pancreas, and biliary system. This often involved creating ingenious treatment options in complex sequences coordinated with other specialists. In Octavio’s case, her sleeve was empty and she knew it. His disease was running wild. It had come out of nowhere, like a wildfire with a Santa Ana wind at its back. The cancer cells were doubling and growing, invading all the tissues around them at a prodigious rate. SCC usually advanced locally, like a ground army taking over adjacent territory block by block—in this case Octavio’s pelvic organs, blood vessels, nerves, and bones. It was a bad actor. If you didn’t get it early you never got it. I knew it well.

“Mr. Salcedo arrived here in an ambulance in septic shock—low blood pressure, acidosis, high white blood count, and tachycardia to 160. When he was stabilized we took him to the operating room and
explored both groins. The tumor invaded everything from nerves to muscles, tendons, and blood vessels. The leg was gangrenous. To prevent another arterial blowout and a hopeless dead leg, the orthopedic surgeons disarticulated his right leg at the hip joint. There was nothing surgical to be done at this point.” Cancer surgeons did not give up easily. They were creative in attacking tumors from their blood supply, radiation, local chemo infusions, and resections. A morphine pump was the only tactic left. Saturate pain receptors while the tumor killed its host.

“Okay. Now what?” I asked, looking at the semicircle of people standing in front of the room. Umut looked at Octavio through the glass. “He wants to go back to Mexico to die,” she said. “He hasn’t seen his family in six years. He has parents and three kids. He doesn’t even know his two youngest sons.”

I followed her gaze and saw the patient dozing in his bed. It was clear now why they had brought me in; what was not clear was what I was supposed to do about it. I looked around at all of them. The whole team was deeply invested in Señor Salcedo. Umut, Ken, Maria, Marilia the psychologist, Erika the social worker, Zita the head nurse. They looked at me and said everything without saying a word:
Your turn.
I pulled on a yellow paper gown, face mask, and gloves, and pulled open the sliding door. We went inside together.

The light was brighter outside by this time, and everything in the room was visible. “
Buenos días, Señor Salcedo y Señora Salcedo
, I am the head doctor. Your team has asked me to talk to you…”

I switched off the sound on the TV, telenovelas playing early in the morning on Spanish-language TV in NYC courtesy of Televisa. There were photographs of young children in small frames on a shelf, a pretty round-faced girl and two impish little boys. The room was large, comfortable, with magnificent views to the north that included the UN, the Empire State Building, and a broad swath of Midtown Manhattan. Liliana had been sleeping between two hard-backed molded plastic and metal chairs she pulled together next to the window, softened with folded sheets and blankets. She had on a few extra sweaters and gray baggy sweatpants with black sneakers. She was rumpled, and her face
had creases and red streaks from the impression of the sheets she used as a pillow. She was totally alert now, shrugging off the night, and focused on my eyes. We looked at each other. I smiled under my mask and started talking in Mexican-inflected Spanish.

I shook Liliana’s hand as she got up. She stood by the bed rails on Octavio’s left and squeezed his hand as soon as she released mine. The first few minutes we talked about Mexico. I explained my Mexican connection to defuse any tension. Liliana smiled as I spoke, and I could see Octavio gradually coming around from his drug-induced semi-coma.

Octavio took all the cues from his wife. She was his lifeline to the world—that and the white button connected to the gray cord of the morphine pump. His luminous black eyes were sunk back deep in his head. He swiveled his eyes from his wife to me and back again as we talked. With what life force remained, he was willing himself out of the molecular tumor hailstorm that tracked every move he made. He made no movements, but it was clear there was an enormous effort under way to gain control.

Liliana did most of the talking at first. Between the infection Octavio had in his abdomen, the multiple surgeries, the open abdominal wound, the bleeding, the leakage, renal failure, and malnutrition, it would be unimaginable that he could do anything except focus his faltering attention on his wife and her comments about his children, his parents, and herself. “
Somos de Morelos, de Cuautla
, we are from the state of Morelos from the city of Cuautla,” she said in a quiet voice.

I knew Cuautla personally, since Morelos was my home in Mexico as well. Our small house in Tepoztlán is a half-hour drive from Cuautla. I had adopted Mexico as my own many decades earlier, and my wife and I went there to escape from the world of work. Liliana’s voice relaxed into a familiar chatter when she realized she didn’t have to explain everything to me, that I understood where she was coming from. Any anxiety about formalities and making sense of what lay ahead fell away. Octavio interrupted, “
Doctor, conozco Tepoztlán muy bien. Cuando Kat, mi hijita, tenía cuatro años
… When
my daughter Kat was four years old we would go there by bus, to Tepoznieves. Do you know Tepoznieves?”

“
Por supuesto
. It’s my favorite place to buy ice cream in Mexico.”

“Doctor, I would bring my daughter and my wife and we would walk the town and buy some
Beso de Angel
, angel’s kiss, my favorite flavor. What flavor do you like from Tepoznieves?”

I thought a moment and then said, “
Zarzamora
, raspberry.” He smiled broadly. The unexpected warmth and child-like vulnerability coming from this hulking body covered with a white sheet touched me instantly.

I asked Octavio why he had left Mexico six years earlier. He took a long time to answer. “My daughter asked me for a toy. She was four years old.
No había chamba
. There was no work. No jobs.” Tears streamed down his eyes, and he took a long time to finish. The room was totally quiet except the insistent beep from the monitor, like a car alarm at two a.m. “I borrowed money and made arrangements for a coyote to meet me. I crossed the border and went to California on a bus.” The deep humiliations and desperation of poverty had driven him at age twenty-six to leave his home and family, summed up in the streaks of tears on his face and the muffled sobs.

Maria, the Puerto Rican majordomo of our unit, translated quietly in the background for the medical team as we chatted. After a while it was clear Octavio was too exhausted to continue, and I asked Liliana if she would join me outside. The head nurse invited her into her office, then got her some coffee and a snack; I watched as the surgical team unpacked Señor Salcedo’s abdomen and hip. The bandages were soaked in the nonstop bloody ooze leaking from his abdomen and pelvis. Umut dosed him from the narcotic pump and took out the last packing, which left exposed tissue, muscles, arteries, nerves, and cancer tissue, gray blobs of ill-defined tumor that bubbled up in all directions. She carefully cleaned out the wound with saline, patted everything dry, repacked the abdomen with white absorbent bandages, and bound it with Kerlix. I have had to develop a stomach for just about everything over the years and have seen almost every variety of
assault on the human body, from knives sticking out of right ventricles to silverware protruding from various orifices. It wasn’t the visuals of an abdomen ravished by tumor and surgery open to the world, but the smell of decomposition and decay that held me in its grip.