Closing up the Cabin
I met Burt the Monday before Labor Day. As I walked into the room, he stood up--a sturdy, fifty-three-year-old guy with a direct, sky-blue gaze. Although he was a little etched around the eyes, he mostly looked the picture of health.
Two years before, he'd had a cancer. It was treated and thought to be gone. But for several weeks now, he'd been having excruciating low-back pain; he rated it a ten out of ten. The day before, a new CT scan had revealed that his original tumor had spread to his liver and bones. A spiderweb of tumor damage in his spine was the cause of his pain.
If I were a layperson or if this were my brother, I'd be hysterical. But I'm a radiation oncologist (a doctor who gives radiation to cancer patients), and this was my patient. I'd seen this kind of thing before, and I felt hopeful that radiation could help.
During our visit, I spoke frankly but moved slowly, trying to both honor the situation and help the family cope with the nightmare Burt now faced: the near certainty that his lifespan had abruptly been cut to a matter of months; the stark reality that most likely we had no treatments that would change the date of his death. I could only dimly envision the agonized kitchen-table conversations he and his family must be having.
But having spent two decades witnessing radiation's magical palliative powers, I felt pretty confident that our treatments could help Burt spend his remaining days pain-free. So I told him, "From here on out, it's all about comfort, it's about getting rid of the pain, it's about getting back to spending quality time with your family, doing the things you love." And I outlined a plan for two weeks of radiation to his spine.
We started the radiation treatments that same Monday, and sure enough, Burt improved rapidly. On Tuesday, he said his pain was down to an eight. When I walked into his exam room on Wednesday, he jumped to his feet and said, "The pain is less than a five!" On Thursday, his pain was a zero.
He and his wife and son and I stood in the exam room that Thursday, giving each other high fives all around. It was one of those magic moments in medicine where everything--your training, your treatment, your connection--all comes together for the patient.
"There's only one thing," Burt said. "My right leg feels a little funny."
"Well, that's odd," I said.
"Yes," he said. "I think I pulled a muscle getting out of bed."
I examined him; I couldn't find any change.
"Let's keep an eye on things," I said.
On Friday afternoon, Burt's family pushed him into my office in a wheelchair. The night before, he'd suddenly become completely paraplegic.
Burt's face was flushed; he kept his eyes on the floor; he could only move his toes about an inch.
I stood still for a moment, riveted with horror. There's a long list of things that can cause sudden paralysis, but here the only likely explanation was that, despite the radiation, Burt's spine tumor was still growing.
Part of me wanted to fall to my knees and cry, "Oh my god, this is the most awful thing I can imagine--this big, strapping man now has to lift his legs up with his hands!" Another part of me wanted to stamp my feet and weep with frustration and rage at cancer's unimaginable cruelty.
But I'm a doctor. I don't get to fall to my knees or stamp my feet. I have to do what doctors do: stay clear-eyed, get a history, do an exam, make an assessment, create a plan.
So I did. I asked Burt some questions. I lifted his legs and tested his reflexes.
I went to my office and sat down and closed my eyes. And then I opened them again, picked up my phone and called my colleagues. That's what I do when I'm standing in a room full of horror: I go and call my friends.
With my friend the neurologist and my friend the medical oncologist, I worked up a plan: I would call our friend the neurosurgeon and arrange an emergency consultation.
I went back to the exam room and sat in front of Burt, who gazed at the wall behind me.
"Listen," I said. "What's happening here isn't normal. The radiation should have worked. But I think the tumor is still growing, and my only hope is that a surgeon can go in and take some tumor out. I don't know if he can; I don't know if he should. I just know that we can't sit here and hope this will go away by itself. We have to get you to a neurosurgeon who has a wide-open operating room on Labor Day weekend and is ready to roll."
Burt still couldn't look at me. He sat for a while, then said, "This is my last Labor Day, we know that. We were going to our cabin. We were going to go fishing; we were going to close it up."
One thing the cancer clinic teaches you is that there are times when words are worthless. So I didn't say anything. Partly I didn't have any words, and partly I could barely speak.
I just looked at Burt. I looked at his wife. I looked at his son, who had been starting to text the recent developments, but whose phone now lay still in his lap. I looked at Burt's legs.
He looked down at the floor and closed his eyes. After a long moment, he looked up at me with his sky-blue gaze, gave me a half-smile and said, "Whatever you say, doc. Whatever you say."
His wife whispered prayers under her breath. His son began texting. I reached over and squeezed Burt's hands, then got up and went out to make the rest of the arrangements.
At 4:00 pm he went to the ER. At 5:00 the ER doctors called me, asking for background. At 7:00 a neurosurgery resident called me out of dinner with my two teenage boys, asking technical details.
At 9:00 I called the neurosurgeon.
"We have OR time at nine-thirty," he told me. "We'll have him on the table by ten. We'll probably be operating most of the night."
I hung up the phone and pumped my fist in the air. Later, at bedtime, I told my boys, "When you grow up, you should really consider becoming neurosurgeons."
I thought about Burt all evening. When I got up the next morning, an email blinked from my inbox.
"Hello," the neurosurgeon had written at 6 am. "He is better after decompression of the L3-4 spinal segments last night. Now better than antigravity."
Translation: The surgery worked. Burt could move his legs again. One day later, he took his first, halting steps.
He lived four more months.
Six weeks after the operation, the weather held, and with the help of a cane and a walker and his family, he made it back to his cabin; they fished, and they sat on the porch and talked, and then they closed up the cabin.
About the author:
Robin Schoenthaler has been a radiation oncologist with the Massachusetts General Hospital for the past twenty years. She lives outside of Boston where she is raising her two sons. She has been writing essays about being a doctor and being a parent for most of the last decade and has been published in the Boston Globe, Brain, Child, Hospital Drive, the Boston Globe Magazine and numerous other publications. "I want to give special thanks to my writing groups who over the years have brought out my best."