Medicine, Extending Life – Part II

Pain has an element of blank;

It cannot recollect

when it began, or if there were

A day when it was not.

It has no future but itself,

Its infinite realms contain

Its past, enlightened to perceive

New periods of pain.

Add fear to pain and this is the depth of vulnerability in which medical professionals engage patients. My dad died at 67 from lung cancer. He was too sick from chemo to come to my wedding. I was with him in his last hours, wondering where his strong legs had disappeared to, and where his distended belly had come from, listening to his wheezing words, watching him choose a starvation-induced morphine-clouded death. I vowed not to die like that. But my mom’s dad and my dad’s dad both had terminal cancer. My great uncle on my mom’s side. My mom’s sister. Both of my dad’s brothers and at least two of his sisters. Those are just the ones I know of off the top of my head. I’m a data analyst, and in spite of my vow, it doesn’t look really promising for me. Even as I write this, my blood pressure has jumped up a few notches. I’m afraid. Imagine a child in a state of fear. The eyes jump rapidly side-to-side, hoping beyond hope for somebody to save her from a horrible impending fate. She screams or cries or sucks in her breath aiming for complete silence, wishing she could hide from her invisible attacker. She’ll panic and start running erratically or completely freeze. Irrationality has set in. She would do anything to be extracted from this scenario. I would gladly pay almost anything to have a cancer-prevention drug. If I really thought it would make the difference, I would sleep more, work less, drink less alcohol and coffee or become a vegetarian. But just like the child, what I need most is to reach out my hand to someone strong and safe who, even if they can’t save me from what might be out there in the dark, will at least join me in the pain and fear, and at best lead me to see that there is more to life than just me. 

Richard Selzer is an American surgeon, writer, and educator. Born and raised in Troy, New York, Dr. Selzer was on the faculty of the Yale School of Medicine until 1990.  He tells a story about Hugh Franciscus, Chief of Plastic Surgery when Selzer was a medical student. Franciscus “was the archetype of the professor of surgery – tall, vigorous, muscular, as precise in his technique as he was impeccable in his dress.” As a third-year student, Selzer observes Franciscus interacting with patients with “dispassion,” “a man of immense strength and ability, yet without affection for his patients. He did not want to be touched by them. It was less kindness that he showed them than a reassurance that he would never give up, that he would bend every effort…to solve the problems of their flesh.”

Franciscus invited Selzer with him and some colleagues on an annual humanitarian trip to Honduras “to operate on the natives down there.” “We were more than two weeks into our tour of duty – a few days to go – when it happened. Earlier in the day I had caught sight of her through the window of the dispensary. A thin, dark Indian girl about fourteen years old. A figurine, orange-brown, terra-cotta, and still attached to the unshaped clay from which she had been carved. An older, sun-weathered woman stood behind and somewhat to the left of the girl. The mother was short and dumpy. She wore a broad-brimmed hat with a high crown, and a shapeless dress like a cassock. The girl had long, loose black hair. There were tiny gold hoops in her ears. The dress she wore could have been her mother’s. Far too big, it hung from her thin shoulders at some risk of slipping down her arms. Even with her in it, the dress was empty, something hanging on the back of a door. Her breasts made only the smallest imprint in the cloth, her hips none at all. All the while, she pressed to her mouth a filthy, pink, balled-up rag as though to stanch a flow or buttress against pain. I knew that what she had come to show, what we were there to see, was hidden beneath that pink cloth.”

Imelda Valdez had a hideous looking, severe cleft lip and cleft palate “with the lip split all the way to the nose. One white tooth perched upon the protruding upper jaw projected through the hole. Some of the bone seemed to have been gnawed away as well.” Imelda sat in shame and fear for what to her seemed like an eternity while the doctor assessed her and developed in his mind a plan for surgery. Before she left, Franciscus’ words to her were simple and matter of fact: “Tomorrow, I will fix your lip. Manana.”

Imelda returned the next day with her mother to the operating table. She was prepped for surgery, anesthesia administered, face scrubbed with soapy iodine mixture, ready for the surgeon to begin. He took measurements and marked out the geometry with marking pen on her face, then called for his scalpel to begin the surgery. As he was lowering the knife, the Anesthetist yelled “Hold it!” Her temperature was climbing. One hundred seven, one hundred eight. The Anesthetist yelled for ice, but there was no ice to be had in the rural Honduras village. The surgeon reached for the girl’s groin but there was no femoral pulse. “EKG flat. My God! She’s dead!”

The mother had been sitting outside carefully folding and refolding her daughter’s cloth that she had held to hide her face. Dr. Franciscus approached her and in his broken Spanish and clinical matter-of-fact way walked her through the steps of what had happened. Her face contorted in grief almost to match her daughter. After a long silence, she said she would go home now and her sons would return the next day to collect the body. She told the doctor that he must not be sad, that God had decided, and that she was happy now that her daughter would go to Heaven without her deformity.

Selzer, in his surgical support role went to meet the family when they came for the body. The body had already been loaded into the donkey cart and was covered with a straw mat. Selzer gave them some money for flowers and a priest. The mother thanked him, then added thanks for the doctor, saying, “The doctor is one of the angels. He has finished the work of God. My daughter is beautiful.” Selzer thought she must be delusional because Imelda had died before they even had a chance to begin the surgery. He lifted the mat and saw that her face had been repaired, even perfected. All that remained where the cleft lip had been was “a fresh line of tiny sutures.”

Dr. Franciscus had spent hours alone in the dimly lit surgical room with Imelda that previous night. He precisely cut and meticulously sutured. He formed the perfect triangles with the feel of completely natural skin tension. That night he was the father who agonizes that he couldn’t have done more to protect his daughter but resolves to stop at nothing to try to make it right. Yet in all her pain and his helplessness, he knows the best he can do is reach out and gently wipe away her tears.

His actions may have been inspired by a search for redemption or to assuage guilt. But somewhere in the mix of motives there was a glimpse of purity. There was an eternity where Imelda was all that existed for the doctor, where he went beyond trying to prolong her life and lost his own life in hers. 

Since 1975, life expectancy has been the primary indicator of a nation’s level of development. There are others from infant mortality to literacy levels to more recently, measures of happiness. But hands down, life expectancy has been and remains a primary measure of the level of a society’s development. Life or living longer isn’t a bad thing, and society should invest in helping our parents and grandparents stick around. But there is more to life than maximizing its quality and duration. 

The health services professional is obligated to work for the better health of the patient. At the same time, he knows that goal is doomed to failure. Against his tireless efforts, he is guaranteed quality of life will deteriorate and life will eventually end. In that dichotomy, the doctor can encourage the patient’s natural fear and resulting inclination to worship heartbeats and breaths above all else. Or he can leverage his unprecedented power and lead his patient toward something more. Encouraging the patient to value life above all else will leave her in pain, likely alone, and most certainly afraid. Doctors help slow life’s deterioration. That’s not what we patients need, nor is it what Hippocrates intended with his oath. What we need is a foundation such that in the face of our pain, we will not be overcome by fear. We need reassurance that there is more to being alive than just the length and quality of our own lives. In our vulnerability, medical professionals are maybe “the patient’s only familiar in a foreign country.” The doctor is the example for the patient – living a life lost in those he serves and leading them to life beyond themselves.