As with most professions, there are typical traits reflected in those who choose to pursue surgery. These traits are subject to stereotyping, meme creation, and endless source of humor or psychiatric investigation (pending how you'd like to roll). Personally, I believe our various traits, preferences and idiosyncrasies that lead us to make decisions and ultimately follow a specific purpose just points to the fact that there is a God. An orchestrator of the universe, who poured his love and intention into each unique DNA creation. We are all created differently, and it's what makes the world go round.
Along these lines of generalizations, a surgeon is going to be a problem-solver. When presented with a patient, will try to zone in on the concern and find a way to arrive at a solution. In a way, a surgeon is in the business of restoration. I have found these generalizations whether good or bad, to be true to myself as a surgeon. If at the end of the day, I haven't fixed the problem, I find myself to be unsatisfied with the work that I did. That inner voice constantly asking what could I, or should I have done differently? How could it have been managed better, sooner, or more efficiently?
These are the traits of a surgeon that makes them tend to bulk at the idea of hospice and or palliation. As if hospice is admitting defeat, or acknowledging failure at restoration. They are also the traits I have struggled with most often while here. There is a subset of patients with advanced disease, who are simply beyond the scope of the resources available here. The question is no longer how can I fix the problem, but can I even help, and would that help be worth the risk? Answering that question, is complicated at best, and frequently met with resistance.
For example, a patient presented for surgical triage with a large neck mass. He was not having trouble breathing, but swallowing and eating was difficult. Taking ultrasound probe to the mass I could discern displacement of his windpipe (or trachea) by a large left thyroid lobe mass with associated enlarged lymph nodes (lymphadenopathy) of the left neck. I ordered a few extra lab tests, X-Ray and gave him a rendezvous for consultation a few days later.
He presented to that rendezvous with the above xray, findings in agreement with what had been suggested by ultrasound. The solid red line in the left picture is tracing the man's trachea, severely displaced to the right from where it should be (the dotted red line). The calcifications circled in the right picture help paint a picture that was already the concern, a stage IV thyroid malignancy.
Proceeding with a working diagnosis of stage IV thyroid malignancy, I then ask can I help? Clinically, the patient could not eat, and knowing the pathophysiology, it would only be a short matter of time before he had trouble breathing. Yes, that we could help. But overall prognosis, no we could not help. And to proceed with any surgery for palliation in hopes of relieving the obstruction on his esophagus and impending obstruction of his trachea would be fraught with its own risk, even to death.
Despite the many objections and concerns voiced by both the other surgeons currently here and the Togolese anesthesia team, we did elect to proceed with surgery. I listened to the concerns and acknowledged each objection as valid. However, prognosis aside, the patient's quality of life could only potentially be improved if we proceeded.
This patient is just one example. There is no satisfaction in these decisions, and either way an unanswered question of did I even help. I remind myself, these patients are not here for me either way. My role is superfluous, as it is the Chaplain that will come by post operatively and introduce him to the true Physician. The only Physician who can truly heal, and the One who can save.
Much Love.
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