They All Know | to pdf >>
by Thomas Paluch, MD

We call it somewhat crassly "peek and shriek." Each of us who have had the privilege of opening the body's cavities have, at some time or other, sooner or later, been victim of the foul surprise: cancer everywhere and nothing to do about it. The shriek is a silent one, more of an "oh shit" sans exclamation mark than a cry of terror; it is for the other, the patient, that those too-numerous-to-count, hard white blobs of flesh hold significance: the significance of one's mortality, all bold and ready, all cold and patient and waiting; but not for long. We spend time treading water, pushing aside loop after loop of intestine swollen by the cruel, malignant trick, delaying the inevitable decision to close the incision and quietly retreat. The room falls silent. Some comment is made regarding the patient's age: "how terrible" if young, "well, at least he's eighty" if old, as if the accumulation of years justifies the insult of death.

One or another of the operating team promises to get that colonoscopy at an early age, or the long-delayed mammogram in the hope of forestalling their own "peek and shriek" some years hence. Each turns inwardly to the thought of those loving and loved; gratitude mixes with the gravity of the moment, and we each celebrate our aliveness, our seeming wholeness. As the minutes slip by and the case draws to its close, I rehearse my speech in silence. I curse the job that at times brings me such joy, at other times such agonizing moments as these, moments for which no Jordan-esque salary would be enough. I usually stay until the bitter end, often applying the dressing, half to delay the coming conversation, half to reconcile my impotence with the reality of the magnitude of my foe.

Finally it's over, and I rip my gown and gloves away, thanking my team who scurry about, cleaning the gore I've left behind; cleansing the room to cleanse their souls, moving quickly to the next, almost certainly happier case. I huddle with the chart and telephone, writing and dictating the mundanities that make up the medical record, a document which, for all its sterile language remains the most consistently dramatic of all written testimonies: the story of the beginning of a death.

I can delay it no more. A fifty-foot walk becomes a morose marathon as my brain buzzes to create the patina of professionalism: the firm confidence and quiet reassuring that I alone know are platitudes, but to his family are the threads of hope in a life's fabric come unwoven. I'll never get over how stupidly I always begin these reports. The half smile I wear can fool no one, but I can't make it go away. "Everything went well; he's fine," I always begin. The com
plete and bald lie that "he's fine" is unbetrayed by my tone in those first words. Their eyes flash for a moment, hands clutching arms, and the first tears, those of relief begin to swell in their eyes.

"But I'm afraid . . ." Afraid? Afraid of what? What a silly figure of speech! My fear is the reality of mortality. What is that fear compared to theirs when I finish my sentence, "... the news isn't good." In that instant I can only wish that I had chosen a profession where failure is met in some other way; where inability didn't cost a life. I usually just wish I were high on Haleakala's shoulders, breathing the thin, cold air that blows so hard across the home of my God. The arm clutched in reassurance seconds ago is released to its own devices as almost every hand reaches to cover a mouth opened in a gasp, a gasp of angry disbelief, and bitter anguish. The description of the findings follows, euphemized, painted in pastel instead of blood, purposely sanitized by my jargon to leave that glimmer of hope where I know only hopelessness is real. They always say, "But you took it out, didn't you?" as if the cancer were a weed to be pulled. Its words I stumble over yet again as I try to explain the futility of "getting it out." I wish they could see the cancer: the countless tumors that everywhere bulge and glisten, almost smiling as they cover the surface of his guts. I want them to know in their hearts as I do that it simply can't be done, that I can't "get it all."

I rely on my time-tested deception: "It would kill him to take it all out," I say with a set jaw and a straight face, knowing full well that it's a lie, but also knowing that these words seem to convey the truththat we have met our match. I offer them reassurances, retreating to the safety of statistics to leave that glimmer of hope that I know doesn't exist but believe must never be extinguished. We briefly discuss further treatment, me knowing it won't work, them certain it will. And then, with little more, it's over.

We both don't want it to end. I feel better having broken the news, having finished the first dreaded task. They are comforted by my presence, by the gaudy green of my scrubs, by the bleached white of my coat, and by the ever-increasing streaks of gray in my hair. I don't pretend to understand why this is so, but I've felt it time and again: their silently asking me to stay, as if I'll change my mind, change my story, change the truth. I'll often bend to hug his wife, or place my left hand on her husband's shoulder as I shake his right. "I'll take good care of him," I vow, as if that will somehow make everything all right, as if I can make up for the failing. I turn to take on the morose marathon in reverse; it's only slightly easier in this direction. I always see them in the corner of my eye as I return to the sanctuary of my operating room. Always they're sobbing, hugging, and sobbing. I always sigh, as if this deep breath will clear my heart as well as my lungs, and with a shake of my head close the door behind me.

Recovery from anesthesia works in two directions in these cases. The patient uses the time to struggle for consciousness, reawakening in a world of blinding pain, cold and harsh light. I use the time to collect myself, remembering that the task of informing the patient will be mine as well. With luck, the case is late in the day. The patient retires to the bliss that is morphine. I retire to the laughter of my children, the arms of my wife, and a deep, forgetful sleep.

The next morning again brings pain. Post-op day one is a blizzard of nausea and morphine to the man who hours ago stood smiling and confident, joking with me that he felt lucky to have a young surgeon, as I must still remember what they taught me.

His wife is at the bedside as I make my rounds. She's holding his hand as if this were his deathbed, scarcely concealing her terror at being left alone after thirty years of marriage. He is, thankfully, comfortably numb. The narcotics are working their subtle magic. I walk in, erect and seemingly proud, extending my hand in greeting, not noticing that it is shaking. "Good morning. You did good yesterday," is the attempt at a pleasant greeting. His eyes appear sunken, the pupils tiny black dots in a sea of green.

"So how d'ya do, doc?" he asks, wincing with the effort. It becomes clear that she has told him nothing of our conversation yesterday. She's embarrassed by this, of course, but I've come to expect little else. "I did fine and so did you," I reply, clearly dodging the point.

"Did ya get it all?" he asks with a wink.

"Well I'm afraid . . ." there's that 'afraid' again, as if I had something to fear. " . . . it's pretty bad." I curse the God that gave me this language, this job, this inability to forestall mortality. I want so many better words. But the patient will have none of it.

"Hey, you did the best you could." He dismisses me with a wave of his hand. And I, me, the surgeon, the healer, the doctor, quickly accept this endorsement; accept it because it comforts me, because it forgives me.

"Yes, I did," I mutter somewhat obsequiously. I beat a hasty retreat. Sometime later that day, I pass by his room again. He's brushing his teeth despite the fact that he's attached to two towers of equipment and tubes; brushing his teeth because it gives him the dignity of being human in this place where dignity and modesty are the earliest casualties.

I come upon him as he's seated in front of the mirror, comfortable in his morphine-induced euphoria. "You knew, didn't you?" I asked, safe in the knowledge that years in this business will give.

"Yeah, I guess I did," he replies without a trace of regret.

"How long have you been sick?" I ask, hoping that his self-induced delay will somehow clear me of all guilt in the matter.

"A while," he says, still brushing.

"Why didn't you come in sooner?" I said.

"I just knew it was my time, and I didn't want to worry Phyllis," he offers unapologetically. I touch him on the shoulder, feeling the strength that wells up inside of him.

"Thanks doc," he says.

"For what," I reply in surprise, "I didn't do anything."

"You told her," he says, "I couldn't."

"So you knew."

"Yeah, I knew."

He knew. They all know. By God, they all just know.