Tuesday, July 08, 2008

Sara's Smile

She was a vibrant, friendly, outgoing and thoroughly lovely young lady, I have been told. I did not meet her -- let's call her "Sara," to simplify things --- until she was around 50, but all of those qualities were present in abundance when she came to my office the first time. That was not quite 10 years ago, and I recall her warm smile and easygoing manner as something uncommon in a surgeon's office.

Sara had quite a history. Diagnosed at 27 with a deadly disease, ovarian cancer, that took much from her in her youth. She had been a nurse at my hospital, and by all accounts there had been an an outpouring of support during her initial treatment. My partner and a gynecologist had operated on her, followed by intraperitoneal chemotherapy, systemic chemotherapy, and further surgery. Though she never spoke of it, she was quite ill with treatment.

And then, something wonderful happened. Time didn't stop, but somehow not all the grains in her hourglass continued to fall. She continued to be a lively, lovely, warm and vibrant young lady, but one who I am sure awakened at night wondering if the next day would bring evidence of recurrence. But she continued on, amazingly healthy, and as the years passed, so did her fear of what may lie ahead. She raised her children, laughed, loved, and lived her life to the fullest.

The day I first met her is one not easily forgotten. A new patient on my schedule, I knew nothing of her past; there was just a note requesting a cervical lymph node biopsy. I was greeted with a warm hello and a welcoming smile. Sara explained the particulars of her medical history, with now something new --- certainly, it couldn't be related --- a somewhat enlarged lymph node at the base of her neck, in the hollow just above the clavicle.

There is something indescribable about the sick feeling one gets in the operating room making the diagnosis of a malignancy simply by feel. It is as if the room goes completely silent, and whatever little thoughts that are racing around in the subconscious stop, take notice, and respectfully go away. It didn't take long to make the diagnosis clinically, but I wasn't sure what type of malignancy we were dealing with until the pathologist called with the frozen section results. He had been the same patholgist who had read her original slides, 22 years before, and described essentially a déjà vu type of experience. After a long hiatus, her ovarian cancer had decided that it was time to return.

I don't really know how I told she and her husband. There are not words in the dictionary that can relay that information gently; I felt as if I was hitting them with a sledgehammer while trying to give them some sort of supporting hand.

I saw Sara intermittently over the next 9 years --- placing a port here, evaluating her for abdominal recurrence with partial obstruction, etc. Other than that first day, I never saw her downcast. She carried herself with an uncommon dignity and grace, and I never left her without wondering what part of her generated that beautiful smile. It was if her soul was shining through, as if she wanted to make others feel better about her lot in life.

Much can, and did, happen in nearly a decade. I don't know all of the particulars of her life, but clearly Sara did not simply stop being herself once her recurrence was established. I would hear snippets about how she was doing from her oncologist, or from whatever other specialist had been recruited to help with her care. Not once did those conversations fail to include some mention of what a truly nice person she was.

About a month before she died, I spotted her husband on the oncology ward, and he was kind enough to ask if I would stop in and say "hello." "Sara really trusts you, and has always said how much she appreciates the care you have given her." What a far cry from how I really felt --- that all of my interactions with her brought misery, pain, or both. It was clear that she was not going to live much longer, and though her eyes were tired, they still burned brightly when she graced me with one last warm smile. Mine burned with wet salt.

I was not Sara's husband, close friend, sibling, or anything other than someone who occasionally cared for her. But I did feel close to her with a simple bond that does not exist outside of a patient-physician relationship. That's the way it is for physicians --- outside the "normal" circle of folks who grieve the loss of a loved one, we still share enough feelings at times to grieve silently alongside them. And so I will miss Sara, her liveliness, her warmth, and her smile. I will definitely not miss having to cause her further pain in trying to treat her disease.