Heart: An American Medical Odyssey (9 page)

Over the next eighteen months, I used antihistamines to suppress the hives. Medical students are often world-class hypochondriacs, miraculously manifesting fatal diseases they just studied. Still, I felt uneasy about the fact that my immune system was apparently duking it out with a phantom irritant.

In the late winter of my last year of medical school, I developed an intermittent and difficult-to-localize pain in the back of my mouth, at first vague and easy to ignore, coalescing over the next several weeks into a subtle soreness that I treated with periodic ibuprofen.

Probably a wisdom tooth,
I thought.
The pain will go away.

In the beginning of April, when the pain had not gone away and eating was becoming increasingly uncomfortable, I went to my bathroom
mirror to take a look. After gently pulling my tongue toward the left with one hand and aiming a penlight with the other, I identified the obvious source of my discomfort. Illuminated in the narrow beam of light, midway back, along the right edge of my tongue, was an angry-looking, inch-long, and exquisitely sensitive mass.

Okay. No reason to panic. Maybe I bit myself.

I decided to wait a week or two to see if the lesion would disappear, a plan based more on principles of magical thinking than the principles of medicine.

Two weeks later, after gathering a critical mass of courage, I checked again. The growth was even larger, its center now discolored and starting to look necrotic (dead). I forced myself to suppress a rising wave of panic as I vaguely remembered a lecturer describing how a tumor will sometimes outgrow its blood supply.

Oh, this is definitely not good.

I made an appointment to have an ear, nose, and throat (ENT) surgeon at Georgetown take a look at my mouth. ENT surgeons, also known as otolaryngologists, and now more simply described as head and neck surgeons, are the people to see for chronic ear infections, sinusitis, nosebleeds, hoarseness, and also neoplasms (tumors) of the mouth, throat, and neck.

Lest anyone mistake me for a patient, I arrived for my Monday afternoon evaluation wearing my white coat. With it on, I am a healer, possessor of special powers and privileges, the saver and not the sick.

No one else was in the clinic waiting room in Georgetown’s Gorman Building when I checked in for my appointment. After filling out the usual paperwork, I was brought to an exam room where I scanned the equipment with both curiosity and dread. In a few minutes, a young woman entered the room.

“Hi, I’m Catherine, one of the residents. What can I do for you?”

“I have something on my tongue that hurts like hell,” I said.

“Oh, okay, let’s take a look,” she responded gently as she grabbed some gloves and adjusted a light.

Reclining in the examination chair, I tilted my head back, opened
my mouth as wide I could, and stared at Catherine through the glare of her light. I noticed her squint slightly as she fixed her gaze on the side of my tongue.

“Did you bite yourself, Jon?”

“Not that I remember.”

“It almost looks like there could be a little piece of a chicken bone embedded in the muscle,” she said.

“I don’t think so.”

“I’m going to get my attending and have him take a look,” Catherine said as she took off her gloves and left the room.

She returned quickly with an attending ENT surgeon, an all-business, middle-aged man who repeated some of Catherine’s questions before also peering into my mouth and probing the sides and base of my tongue.

“Could be an inflammatory disease,” he said. “Just to be safe, let’s do a biopsy.”

I didn’t ask, “If you think it could be an inflammatory process, why do you want to do a biopsy? Why don’t we try some more anti-inflammatory drugs before we snip off a piece of my tongue? What are you really worried about?”

I knew what he was really worried about and instead simply said, “Okay.”

I took a deep breath and opened my mouth. The attending wrapped a dry piece of gauze around the tip of my tongue and got a firm grip before handing it off to a student to hold.

This is going to hurt.

Suddenly, a white-hot flame exploded in my mouth, like someone had taken a torch to the side of my tongue. I groaned as tears dripped down my cheeks and heard Catherine say, “I’m sorry, Jon.”

Ironically the pain was the anesthetic; the biopsy itself I didn’t feel. There wasn’t much else to talk about. I was told to return Friday when the pathology report would be back.

It was an extraordinarily long week, particularly when I wasn’t distracted by work. At dinner with friends or while walking alone in a quiet
hospital corridor or in the drowsy still darkness before sleep, the pending biopsy report was never far away.

As I sat in the clinic before my Friday appointment, I spotted Catherine standing behind the reception desk checking something in a thick textbook.

If she’s reading about me I’m screwed
.

I was brought to the same exam room in which I had the biopsy four days earlier. Catherine opened the door and, after briefly inquiring about my week, cut right to the chase.

“Jon, it is cancer. I am very surprised.”

It was hard for me to hear much else of what she said. Her attending came in and examined my neck, searching now for enlarged lymph nodes that would signify spread of the disease and maybe portend the end of my life. I caught only bits and pieces of the diagnosis and his proposed surgery, like I was listening to him on a phone with a bad connection:
squamous cell carcinoma, hemiglossectomy, tracheostomy, neck dissection.

If I understood the attending correctly, he was going to remove half of my tongue, dissect the right side of my neck, and place a tube through my throat with which I would breathe. I reminded him that I was due to start my residency in two months.

“This is cancer,” he replied starkly.

Catherine, so much her attending’s junior but in some ways so much wiser, instinctively knew that the point to reemphasize was not the diagnosis, which I undoubtedly would remember, but the much more important prognosis. It was a lesson, and a kindness, I have never forgotten: show the patient that the glass is still half full.

“This is curable,” Catherine said.

•  •  •

Physicians don’t typically experience or imagine the whirlwind of terrible tasks that envelops a patient in the aftermath of a serious diagnosis. I had to tell my girlfriend, Betty, also a Georgetown medical student, that I had cancer. I found her working in the ER at Arlington Hospital, and
we cried together in the ambulance bay. From there we went to the Armed Forces Institute of Pathology to get another opinion from a pathologist who specialized in head and neck cancers. He graciously reviewed the slides while we waited and concurred with the diagnosis. Next, it was back to Georgetown to tell the school administration that I needed some time off. I met with the dean who told me that even if I didn’t get back before the end of the school year, I could still graduate with my class in May. I thanked him but told him I would be back in a couple of weeks. He also suggested that I consider deferring my internship a year, but I told him I had no intention of doing that. Most difficult of all, I had to fly up to New York for a painful conversation with my parents.

•  •  •

Although I was already tentatively scheduled for the operating room at Georgetown, when the smoke inside my head cleared, I realized I needed to consult another surgeon. Patients grossly underuse second opinions, but there are many good reasons to get one, among them to confirm the diagnosis (we did that at the Armed Forces Institute of Pathology), to validate the proposed treatment, and to ensure that you have the right doctor.

I had already matched for my internal medicine residency in New York at a Cornell program that included Memorial Sloan Kettering, the legendary cancer center in Manhattan, so seeking a second opinion there was the obvious choice. My mother knew of a head and neck surgeon there who specialized in the type of surgery I needed, and on Saturday morning I called Memorial and asked the operator to page Dr. Ronald Spiro, who promptly returned my call. I told Dr. Spiro I was a soon-to-graduate medical student and tried to describe my problem as dispassionately and professionally as I could manage, as if I were a colleague discussing a mutual patient.

“Oh, my God,” Spiro replied, genuine concern obvious in his voice. “I can see you Monday morning. I’ll alert my secretary you’re coming.”

“One other thing,” he added. “Do you
have medical insurance? Memorial doesn’t take patients without insurance.”

I did, but I’d almost gone without. At the beginning of my fourth year, Georgetown had changed the way medical students acquired insurance, but I had neglected to buy it. When I discovered the error in December, I toyed with the idea of going without it for the last half of the school year. Millions of young adults forgo health insurance either because of the expense or a mistaken sense of immortality. I was twenty-six years old. What could happen? Ultimately I decided that it was worth the few hundred dollars and bought the insurance, a fortuitous decision that probably saved my life.

•  •  •

Occupying an entire city block on the Upper East Side of Manhattan, Memorial Hospital is the oldest cancer hospital in the United States and in the world, an elite institution that attracts the best and the brightest clinicians. After registering and receiving a blue and white patient card embossed with my name, definitely not the type of hospital ID I was hoping for, my parents and I took a seat in the filled waiting room of the head and neck clinic. I tried not to notice the people breathing through tracheostomies or speaking with the harsh robotic sound of an artificial larynx, as if refusing to acknowledge their presence would somehow prevent me from joining their club.

When my name was called, my parents and I were ushered to a small, spare examination room where we waited in silence until the doctor entered. In his mid-fifties, with short salt-and-pepper hair and matching mustache, Dr. Spiro projected confident competence. A warm smile softened his steely seriousness, forged by years of treating people with very bad problems. He asked me about some of the typical risk factors for my type of cancer.

“Do you smoke?”

“Never.”

“How much do you drink?”

“A couple of beers on the weekend.”

After a thorough head and neck exam including a look at my vocal cords, Dr. Spiro described a less extensive approach for removing a tumor like mine. He would take many of the lymph nodes from the right side of my neck but would be able to spare most of my tongue.

I asked why his surgery would not require the removal of as much tissue or the tracheostomy planned by the surgeons in Washington.

“With all due respect to Georgetown, we do more of this surgery in a month than they do in a year,” he said without a hint of bravado. “This is a procedure that I developed.”

He swiveled on his stool and faced my parents.

“I want you to know that many patients do very well after an operation like this,” he said, “but some don’t do well.”

“I know that,” I replied.

“I know you do, Jon,” he said modulating his voice with a paternal benevolence. “I need to tell your parents.”

•  •  •

A procession of fluorescent lights and acoustic ceiling tiles waft past the stretcher as I float through the hallways on benzodiazepines, swaddled like an infant in warm blankets. I enter the operating room headfirst, able to see from where I have come but not where I am going.

After I am moved to the table, Dr. Spiro appears directly above me, his masked face silhouetted in the round OR lights above his head.

“Are you ready, Jon?”

Absolutely.

From somewhere behind. I hear the anesthesiologist say, “Okay, Jon, this stuff works pretty quick.” There is a faint burning in my hand, and then nothing.

•  •  •

A moment later I am lying in a noisy, brightly lit space. An oxygen mask is covering my nose and mouth. I do a quick systems check, reach a hand up to my neck, and find a thin length of clear tubing draining into
something resembling a plastic hand grenade that is pinned to my gown and half-filled with bloody liquid. A nurse, noticing I am now awake, asks how I feel. I don’t have any pain, but I am very nauseous, a side effect of the general anesthesia. I start to tell her, but my words are unintelligible, as if I’m trying to talk with golf balls in my mouth.

“Comp-a-zine,” I say again, pronouncing each syllable of the antinausea medication very slowly.

“Compazine? Sure, I’ll go get it,” she said.

I can talk.

•  •  •

I remained in the hospital for another week fed through a nasogastric tube until it was deemed safe for me to eat. Outside the hospital, the world continued to spin. A nuclear reactor in the Soviet Union exploded, there was a lunar eclipse, my classmates continued their final rotations. On post-op day five, I learned that the final pathology report showed no spread of tumor to the lymph nodes, remarkably good news. I was discharged from Memorial a few days later, a little more than two weeks after I first visited the ENT clinic at Georgetown. My hives disappeared.

•  •  •

On a shelf in my closet sits a beautiful inlaid wooden box in which I keep a variety of mementos: expired passports, an old watch, keys to long-forgotten locks. Inside the box are both IDs from my time at Memorial Hospital. The tag labeled “House Physician” has a photo of a bearded young doctor resplendent in his white coat; the other card contains the account number of an incredibly lucky patient.

On September 10, 1984, I was at work on Capitol Hill when I began to experience discomfort in my chest and throat. It wasn’t painful, but I could tell something was not right. I took the elevator down to the Capitol physician’s office on the ground floor of the Capitol to have it checked out. The physician thought I should head to Bethesda Naval Hospital to be safe and called an ambulance to take me there. Although an EKG performed that night at the hospital showed none of the changes you would expect to see with a heart attack, cardiac enzyme tests the next day did show elevation consistent with a mild heart attack.