May 31, 2007 - Seeing the Surgeon

Today I visit the surgeon, Dr. Gornish, in his office, to consult about my upcoming biopsy. I've brought a huge pile of scan results with me, in their oversize envelopes (checked out from the radiology file room at Ocean Medical Center). I asked them to give me everything. It's sort of a data dump, but I didn't want to risk leaving anything behind that the doctor may need.

It turns out Dr. Gornish looks at none of them – the only thing he's interested in is the radiologist's narrative report that Dr. Lerner's office faxed over, describing the results of my recent CT scans of the neck:

"New enlarged right level IB lymph node anterior to the right submandibular gland measuring 21 x 13 mm.

New enlarged right supraclavicular lymph node measuring 19 x 17 mm.

New enlarged aorticopulmonary window lymph node measuring 16 x 15 mm."

That's radiologist- speak. In ordinary parlance, those are lymph nodes near the jaw, near the collarbone and somewhere deep in the chest.

Which one to remove? Dr. Gornish has a clear preference: "I don't do jaws, if I can avoid it." (Maybe because I'd be left with a highly visible scar?) Since the one in the chest is pretty inaccessible, that leaves the one behind my right collarbone as the most likely target. He says he'll plan to remove most or all of it.

He palpates the area by the collarbone, and locates the swollen lymph node. He moves my finger over to it, and I think I can feel it – though, if he hadn't pointed it out, I don't think I'd ever have known the difference between it and the surrounding tissue. Its size – 19 x 17 mm – is about the diameter of a nickel. It's down pretty deep. Because I'm overweight, the surgeon explains, he'll have to cut down through a large area of fat just below the skin, just to reach it. That will make the surgery more difficult – something I remember him saying about my port-implantation surgery a year and a half ago, which was in roughly the same area.

Then, I raise my biggest concern with him: anesthesia. I have sleep apnea, and use a BiPap breathing machine every night to keep my airway open. During my last two surgical experiences – the core-needle biopsy and the port-implantation surgery – I woke up on the table, feeling pain. I understand why this happens: under the relatively light sedation used in these quick operations, if I go into an apneic episode, the anesthesiologist scales back the anesthetic, until I start breathing again. Unfortunately, that also means I start waking up. It's not fun, believe me.

I explain to him that I've discussed the situation with my pulmonologist, Dr. De La Luz, who's offered to consult with the anesthesiologist about getting a BiPap machine, calibrated to my prescription, into the operating room.

Dr. Gornish explains that this is the anesthesiologist's department, not his. He suggests I get the phone number of the anesthesiology group, and talk with that doctor several days ahead of time – not just on the morning of the surgery, which is the usual practice.

I make a mental note to do so – but, to me, it's a tragic illustration of the fragmentation of modern medicine. There are many advantages to the hyper-specialization of medicine, but sometimes there are things that fall through the cracks. My experience has been that the specialists I don't see, or choose for myself – the anesthesiologists, the pathologists, the radiologists – are the ones most likely to cause problems. Most of them perform their narrow specialty duties extraordinarily well, but they don't know us, the patients. They only know a small piece of us. They have no opportunity to consider us holistically. Last time, I mentioned my sleep apnea to Dr. Gornish, and I also mentioned it to the surgical-masked anesthesiologist, as he came in to introduce himself to me, just before they wheeled me into the operating room. By then, it was surely too late to get a BiPap into the operating room, and have it calibrated according to my prescription. Even if I'd been aware of that possibility – and I wasn't, back then – I couldn't have done much about it, other than ask that my port-implantation surgery be postponed (and, with my first chemo treatment planned for the next day, I wasn't about to do that). The result was some really nasty – but entirely preventable – pain.

After speaking with the surgeon, I go into the surgical group's scheduling office. The date they offer me is Monday, June 25th, nearly a month away. (Mental note: call Dr. Lerner's office, and make sure this biopsy truly isn't so urgent.)

June 25th is just two days before Claire and I are due to fly to Utah, for a national retreat for Presbyterian ministers. I ask if I can travel so soon after the surgery. The booking clerk says she doesn't know, but calls Dr. Gornish in, and asks him. He says there's no reason why I can't fly – though I'll be wearing a bulky bandage, and I'll want to bring a lot of extra gauze with me.

No thanks, I think to myself. The retreat would hardly be the relaxing, restorative experience it's meant to be, if I were worrying about caring for a surgical incision. And, if I were to have a post-operative infection, thousands of miles from home – I don't even want to think about that. Better to sacrifice my enrollment deposit than be a nervous wreck for days. (It's a good thing I haven't bought plane tickets yet.)

That timing also means I'll find it difficult to get any quality time in our Adirondacks place this summer. During the month of July, when I'd planned to be up there, I'll need to be running back and forth between Dr. Lerner's and Dr. Portlock's offices, getting their opinions on what the biopsy results mean, for good or for ill.

Bottom line: whether or not this is actually a relapse, cancer is still causing havoc in my life. I'll do what I have to do. But I won't be very happy about it.