Brian T. Maurer
Abstract: After four decades of medical practice, a primary care clinician finds himself cast in the role of a patient in need of dermatological surgery for skin cancer from a former colleague he had never met face to face until the day of the surgical encounter.
The night before the surgery I plowed through the Delia Owens novel “Where the Crawdads Sing.” I hadn’t anticipated the ending and fitfully drifted in and out of sleep for a couple of hours, finally succumbing to exhaustion and the warmth of the bed. Nonetheless, my eyes opened at 5:00 AM. I got up to do my morning exercise routine, showered, dressed, and padded down the stairs to find my wife in the kitchen with a cup of coffee in her hand. The clock on the stove read 6:27 AM.
“Gotta go,” I say, giving her a peck on the cheek. “I doubt that I’ll be back before noon. It all depends on how much skin they have to take.”
The drive to the surgical office takes less than half an hour. I listen to “Living on Earth” on the radio along the way. Climate change will eventually do us in, I muse; but the thought of my grandchildren having to endure the consequences of humankind’s collective folly merely add to my unsettledness.
Only two cars dot the parking lot. I pull into a space directly opposite the front entrance of the complex and follow an elderly couple into the building to the elevator. We enter the same suite on the second floor. I wait behind them; and when it’s my turn, I step up to the window to check in.
Young employees in surgical scrubs appear regularly in the doorway to escort patients into exam rooms in the back of the office. Shortly, a young woman named Nikki calls my name. I rise from my seat and follow her down the corridor to Room #4. “You can have a seat in the big chair in the center,” she says.
A large solitary black padded chair stands in the middle of the room below a circular surgical light. A smaller black stool rests nearby. I lay my book on the only other piece of furniture in the room, a standard grey chair in the corner, and climb into the big black surgical chair. Vertical blinds, half open along the entire length of the side wall, reveal a grassy embankment outside dotted with several young deciduous trees.
“So you’re here for surgery on your ear,” Nikki muses, swiping the screen of the tablet in her hand. “Can you kindly tell me your name and date of birth?” I consider stating my name, rank, and serial number; but in the end I provide the requested data. “Good,” Nikki says. “And now, can you tell me the part of your body that the doctor will be doing the surgery on today?”
“My right ear,” I say. “The helix of the right ear.”
Nikki looks up from her tablet. “The helix of the right ear,” she repeats. “I don’t think I’ve ever had a patient be that precise before. In any case someone will be in shortly to prep you for the surgery, and then the doctor will come.”
I nod my head in acknowledgement. Nikki pulls the door closed behind her, and I wait.
Minutes later the door pops open, and a young man introduces himself as James. “I’ll be assisting the doctor with your surgery today,” he says. “Meantime, we’ll get you ready.”
James swipes his tablet to verify my name, date of birth, and the body part undergoing surgery today. He tucks a pillow behind my head, neck and upper back, then operates the pedal unit on the floor to raise the chair up into the air and tilt it back. “How’s that?” he says.
“Very good,” I say. “I feel like I’m on the bridge of the USS Enterprise.”
James chuckles and readies the Mayo stand behind me. He tucks a drape into the collar of my shirt along the right side of my head and neck.
“I’ll let the doctor know that you’re ready,” he says.
Shortly, the door opens again. A tall lanky man strides into the room, offers me his hand by way of introduction, and recites his surgical script.
“As you know, you’ve got a skin cancer on your ear called basal cell carcinoma. This type of cancer doesn’t metastasize, but because it can spread locally, we like to take care of it before it gets out of hand. Treatment options include surgical excision, electrodessication, radiation, or topical treatment with an anticancer salve. Of all the options surgical excision offers the highest cure rate. This is the option your dermatologist recommends, and that is the procedure I’ll be doing today.
“We’ll do the surgery in stages, taking a little bit of tissue at a time, which we’ll examine under the microscope for cancerous cells. We’ll continue the process until the tissue margins are clear. We’ve got snacks, coffee, juice—whatever you’d prefer—while you wait for the results. Any questions?”
“I think I’m good,” I say. “Thanks for giving me a room with a view.”
He chuckles through his mask. “You’re welcome. And now, can you tell me your name, date of birth, and the part of your body we’ll be working on today?”
Once more I recite the litany, finishing with the phrase “the superior helix of the right ear.”
The words bring the surgeon up short. “Have you worked in medicine?” he asks.
“General pediatrics,” I say. “Forty-one years.”
I give him a brief synopsis of my years in practice. “As a matter of fact, I believe I’ve referred any number of patients to you over the years,” I say, “via the pediatric dermatologists.” I drop the names of one or two colleagues.
“Yes, yes,” he says. “Well, glad to finally meet you in person. I’ll step out while James administers the local anesthetic. Once you’re numb, we’ll start.”
The first pass goes smoothly. It takes surprisingly little time for the surgeon to shave off the initial layer of tissue. “It will take about an hour to get the results,” he says. “James will show you to the waiting area.”
The waiting area is full. James apologizes and escorts me back to Room #4. “I can bring you something to drink or a snack,” he says. “What would you like?”
“I’ll pass for now,” I say. “I don’t mind waiting in here by myself. I brought a book to read in the meantime.”
I look at the clock on the wall and note the time. I glance out the window, then retreat to the grey chair in the corner and open my book.
I have been reading Martha Gellhorn’s “Travels with Myself and Another” for some time. I found a copy in the Little Lending Library at the town green and picked it up on a whim. Despite the accolades displayed on the back cover, it proved to be rough going, tough to hold my interest. It lay on my bedside table for weeks. Periodically, I’d pick it up and start in where I’d left off, following Gellhorn as she explored East Africa behind the wheel of an old Land Rover. I brought it along today, thinking I might be able to catch up in the never-ending saga.
This morning Gellhorn is lost on an unmarked back road, mired in mud. As I wade through the words, I try to understand why she set out on such a journey to explore an uncharted region by herself.
What does one think about while reading a disjointed narrative of another person’s thoughts? I have trouble keeping focused. Some sentences I reread two or three times without comprehending the lines. My thoughts drift in and out of East Africa as I periodically check the wall clock. It’s been almost an hour.
Suddenly the door opens. It’s Nikki again, coming back to give me the results. She waves a sheet before my eyes, which contains pencil drawings of the ear. She points out the areas marked in red: those are the cancerous zones. “The doctor will be back shortly for another go round,” she says and dashes out the door.
While the surgeon works under the brilliant beams of the overhead light, I decide to make some small talk. “I recall one patient from years ago—it must have been a decade or more—a little girl, a toddler, who had a nevus on the lower leg. I was quite concerned and arranged a derm consult, but the mother pushed back. I finally got her to take the child in. After the derm evaluation, she was referred to you for an excisional biopsy. As I recall, the path report showed melanotic spindle cells, and—”
“Yes, yes—I remember the girl and her mother. That was a difficult case. The father was resistant. I remember writing letters, long conversations…. Do you recall her name?”
I search my memory banks and come up with a first name.
“Yes, that’s it; she’s the one!” He’s animated now. “I have to check my files. Do you remember whatever happened to the family?”
Again I sit in the corner chair and open my book. I try to concentrate on the words with little success. Another eternity goes by before the door opens. James has returned to give me the results. “Still some cancerous cells. The doctor will have to shave off another layer.”
“I remember seeing her back after the excisional biopsy,” I say, my voice muffled under the surgical drape. “There was the scar, of course; but the wound had healed well.”
“Did you know that we had to arrange to do the final procedure secretly?” the surgeon says as he leans in under the light. “The father was livid. I’d never dealt with anyone like him. I was worried for the mother’s sake.”
“In the end she finally grasped the seriousness of the diagnosis,” I say. “Thankfully, the little girl went on to do well. I followed her for a couple of years. Eventually, the family moved away. They may have returned to their country of origin; I don’t recall.”
Once more I wait, this time in the waiting area. All seats but mine are vacant. I sip a cup of warm coffee and open the book.
“It’s high time that I learn to be more careful about hope,” Gellhorn writes, “a reckless emotion for travellers. The sensible approach would be to expect the worst, the very worst; that way you avoid grievous disappointment and who knows, with a tiny bit of luck, you might even have a moderately pleasant surprise, like the difference between hell and purgatory.”
James returns to give me the news. “Margins are clear: no more cancer cells!” I can’t help but break into a grin beneath my mask. “The doctor will talk with you about options for closing the wound. He’ll be with you shortly.”
“So the cancer is taken care of: all gone,” the surgeon says. “The surgery left a bit of a divot in the ear. The options are: you can let it heal on its own, or we can close it with a skin graft. The choice is yours.”
“May I see it?”
“Certainly.” He passes me a hand mirror. A nickel sized chunk is missing from the pinna—well, half a nickel anyway, sort of like the subtle difference between hell and purgatory.
“Any difference in healing times?” I ask.
“If you let it granulate in, it will take 8 weeks. With the skin graft, it should be fully healed in 2 weeks.”
“Would the graft be covered by my insurance?”
“Reconstructive surgery after cancer is always covered.”
“Where would you take the skin from?”
“The pre-auricular region—just in front of your ear.”
I pause, unable to speak. Like Gellhorn, I am mired in the African muck.
“I’ll give you a little time to think about it. You can let me know your decision.”
Hope is indeed a reckless emotion for travelers. I hadn’t counted on reconstructive surgery, the need for a skin graft. Would it take? What if it didn’t, what then? Cosmetically, I didn’t much care about the final appearance. But in three weeks I had a 3-day business trip to Georgia coming up; I had already committed myself. Now there was this wound that would require time and attention to heal. What to do?
“I’d say that you’re overthinking this,” the surgeon says. “Most people your age would opt for the graft. If you were, say, 90 years old, that might be a different story. But you’re relatively young. You’ve got a good stretch ahead. In any case, it’s your decision.”
I look in the mirror one more time, then close my eyes. “I guess I’ll go with the graft,” I say.
“Personally, I would have done the same thing. Michael will be in to prep you for the procedure. It shouldn’t take more than twenty minutes or so.”
The door opens; a young man dressed in black surgical scrubs enters with a tablet. “Hello, I’m Michael,” he says. “I’ll be assisting the doctor with your surgery. For the record, would you mind stating your name, date of birth, and the body part that the doctor will be working on today?”
Michael preps me for the procedure; the surgeon returns. He works diligently under the brilliant light. I hear the click of the needle holders as he sutures the graft in place.
“All done,” he says. “Michael will apply the dressing and go over the wound care protocol with you. Perhaps you can give him some pointers on how he can get into a PA program. He’s already applied to several and had an interview last week. Happy chatting! I’ll see you back in the office in two weeks.”
Michael talks me through the steps as he dresses the wound. “First you’re going to apply the antibiotic ointments to the graft site. After that comes the Xeraform dressing, then the Telfa, then the tape to hold everything in place. You’ll want to change the dressing daily, preferably after your morning shower.”
He sits on the stool by my side. Together we review the written instructions. He hands me a paper bag with handfuls of supplies: gauze, Telfa pads, bandages, Q-tips, tape. “Your prescriptions have been sent to your pharmacy. Now let’s see if we can find a time for your follow up appointment.”
“So you want to be a PA?” I say. “What nudged you in that direction?”
“I’ve been working in the hospital CCU for a while to get some clinical experience. The PAs there pretty much run the unit. They’re awesome. It’s what I really want to do.”
“Have you always been interested in medicine?”
“Actually, I got my undergraduate degree in finance. Absolutely hated it; don’t know why I did it. Anyway, I discovered that medicine is my passion. I really want to be a PA.”
Another traveler filled with that reckless emotion of hope.