A Most Valuable Offering

Posted: July 5, 1998  Author: Dr. Moss

 

 

Originally published in Indiana Alumni Magazine

It may have been a fortune cookie that brought me to Thailand. At one of my favorite Chinese restaurants, a place called "Number 1," in New York City's Chinatown, I read, "Do not forsake your dreams for material security."

It couldn't have come at a more opportune time. I had just completed residency training in otolaryngology in New York City and a fellowship in facial plastic surgery in San Francisco, but I didn't know what to do next.

For years I had dreamt about working abroad in developing nations. I wanted to see disease at its worst, among the people who needed help the most. I wanted to live in an environment with a different language, culture, and religion, far away from home. There was only one problem: I had no money. And be-coming the Indiana Jones of otolaryngology wasn't going to earn me much.

But because at some level I may already have made up my mind, I took the fortune cookie to heart. I was 32 years old, single, and broke. What better time to go?

When I first set foot in the Prince of Songkla University Hospital in southern Thailand, I had been in Thailand a year, working in the northern part of the country, at Chiang Mai University. I had chosen Thailand mainly on the basis of a letter from a doctor in Chiang Mai. She had written that they needed me. And Thai-land, the nation, intrigued me.

As I rode the elevator to the fifth floor, accompanied by a young otolaryngologist named Vicharn, I wondered how my experience here would compare with Chiang Mai. When we entered the floor devoted to ear, nose,and throat cases, I noticed that the wards were bright and clean. There were communal rooms with beds lined up Army-style, but each bed could be cordoned off from the next by curtains, and there were individual lights, suction devices, and oxygen. I noticed the absence of cots in the middle of the halls, patients sitting on the floor, or huge entourages of family members surrounding each patient - all of which were typical of Chiang Mai.

I had learned a great deal at Chiang Mai, but the experience, initially, was overwhelming. The clinics were crowded, the doctors overworked, and the disease - in particular, the head and neck cancer - was often untreatable. The villagers simply ignored their symptoms until the cancer was out of control. At first glance, the situation here seemed less daunting.

Vicharn introduced me to the various faculty members, including Chanchai, the chairman of the department.

"Yes, yes, Dr. Moss, very good to see you," Chanchai said. "We are making grand rounds now. Please join us."

The crowd making rounds was large, including six or seven of the faculty and a generous number of residents, medical students, and nurses.

Chanchai escorted me to the bedside of a middle-aged man named Boonserm. I listened as a resident presented the history in English. Mr. Boonserm, a former teacher, had received radiation two years ago for throat cancer. The tumor did not respond to radiation, however, and Boonserm had to undergo salvage surgery for removal of the throat and voice box.

After surgery, he developed an infection, not an uncommon complication when operating in a radiated field. This, in turn, caused the wound, already weakened from the effects of radiation, to fall apart. His throat ruptured, and saliva had been pouring out freely ever since.

Because his voice box had been removed, he couldn't speak, and he had to take all his nourishment from a feeding tube. He had been this way now for more than a year.

"What would you like to do, Dr. Moss?" Chanchai asked.

The patient, a slight bespectacled man in his 50s, quickly sat up in his bed and showed me his wound. I saw the scars from his previous surgery, the breathing hole at the base of his neck, and the brawny, thickened skin that invariably results from radiation.

In the middle of Boonserm's neck was a crack, framed by scar tissue. Gauze pads surrounded the opening, barely keeping the saliva at bay.

Boonserm was different from the patients in Chiang Mai. To begin with, he had been to the university, unlike most of my patients in Chiang Mai, who rarely had finished the sixth grade.

I could also see, from his face and eyes, how concerned he was. Most of my patients in the north had a mai pert rat ("never mind") attitude, even when it came to life-threatening disease. While I admired this approach to life, it often got in the way: Many patients refused treatment, even when their conditions were curable. Here, on the other hand, was a man who was suffering and urgently wanted help.

Despite his condition, Boonserm seemed cheerful. He made sure my exam was complete, supplying me with gauze pads. When I finished checking him, he guided me to a sink so I could wash my hands. I was touched by these acts of polite consideration.

I was pondering the prospects for reconstruction when a member of the team interrupted me.

"Excuse me, Dr. Moss," Witchit, a faculty member, began. "I examined this patient recently. He has a recurrent tumor."

Witchit's delivery was casual, but his news completely changed the picture. The open, draining wound was a difficult problem, but recur-rent disease generally meant a slow, painful death as the tumor pushed deeper into the spine and neck. We were no longer dealing with a purely reconstructive problem. The man had a life-threatening disease.

"Did you get a good look at the tumor?" I asked.

"Yes."

"Was it extensive?"

"It is large, but I think it is operable," Witchit said.

I didn't want to get involved in a major case like this without first taking a look "Would you mind if I scoped him tomorrow in the operating room before the surgery?" I asked. "I want to see how large the tumor is."

"We will arrange it," Witchit answered.

As we were about to move on, the patient abruptly stood and grabbed my hands, mouthing words, it seemed, of gratitude, as if he still had a voice. He held my hands for a few moments, gazing at me. There was fervor in his eyes, but also fear.

He slowly released my hands, wai'd me (pressing the hands together before the face, a common sign of respect in Thailand), and bowed. I returned the wai.

In that instant, I felt bound to this sincere man. He was direct and forceful in his own way, and his message was clear: Please return my life to me. His quiet intensity was compelling. I told him in Thai that I would try to help him. As we continued to the next bed, I hoped that I could.

The operating room the next morning was busy The ear, nose, and throat specialists and general surgeons were on hand, in the event we decided surgery was possible. We planned to remove what was left of the man's throat and reconstruct it by using his stomach, a procedure known as a stomach pull-up. The general surgeon would open the patient's abdomen, isolate the stomach, and pass it through his chest and into the neck, where I would attach it to the remaining part of the throat.

It was a high-risk procedure that required passing the stomach up behind the galloping heart. If successful, the patient would be eating in five clays. But complications could be deadly. if the blood supply to the stomach was kinked, the stomach died. These patients did not survive. If the hookup between the stomach and throat leaked or broke clown, infection spread rapidly from the neck to the chest and abdomen. These patients usually didn't make it either.

I knew from Chiang Mai that Thai doctors were good, but I wished my first case here could have been a little more straightforward.

Boonserm was wheeled into the room and placed on the operating room table. I told him again not to worry lie smiled, almost as if to reassure me that everything would be all right. Even at his most vulnerable, he remained composed and considerate.

As I stepped back, I thought what a terrible burden it is to have

your body invaded - to willingly subject yourself to the controlled violence of surgery. I watched as Boonserm submitted to the unpleasant poking and prodding that accompanied any major operation: the insertion of the various catheters, tubes, IVs, gauges, central and arterial lines, all so essential for monitoring the patient during the procedure. He seemed strangely at ease for someone about to undergo such an ordeal.

In his hands, he clasped an image of the Buddha, the "awakened one." I had studied Buddhism since coming to Thailand. More than 2,500 years ago, the Buddha had taught the world to end suffering through detachment, wisdom, and compassion. His calm, soothing message seemed to be guiding Boonserm, who smiled peacefully as the anesthesiologist placed the mask over his face.

With the patient safely under general anesthesia, I stepped to the head of the operating table. From Witchit's description, I thought we could operate. The residents were scrubbed and in sterile gowns, holding the iodine solution that would be used to wash the patient's face and body after my brief exam. The scrub nurse switched on the light for the scope. I grasped the instrument and placed it into the patient's mouth.

I pushed the scope past his tongue but had difficulty getting it into the throat. This was a bad sign. The tumor was bigger than I had anticipated. I removed the scope and tried to feel the tumor. It was rock hard and fixed. Bad news. It must have already invaded the cervical spine.

I got up to look at the patient's CT scans. They were not helpful. Between the scar tissue, distortion from the previous surgery, and the effects of radiation, I could tell nothing about the extent of the tumor.

I returned to the patient and shifted his head, hoping that by relaxing the neck more, the tumor would budge. It didn't. I wondered if the previous surgery and radiation might have caused this rigidity. No, it didn't explain what I saw.

My eyes and hands were delivering information 1 didn't want to accept. I probed and prodded the tumor once more, hoping I was mistaken. Again, it didn't move. The reality was now apparent: There was no way I could remove Boonserm's tumor, short of cutting off his head.

I thought back to the image of Boonsern calmly clutching his Buddha. I couldn't escape the sense that I had failed this trusting man as I said, "Forget it. It's inoperable."

The other surgeons stopped their conversations and came over to have a look. Witchit and Vicharn examined the patient and agreed that the tumor was too far gone. We explained our findings to the general surgeons. The case was canceled.

The next morning I met Vicharn by the nurses' desk, preparing to make rounds. As I turned to join him, I discovered Boonserm, standing before me, garbed in his baggy white hospital pajamas, the usual array of gauze pads around his neck. I wasn't prepared to face him. This man had been so buoyed up by the hope of a surgically rendered cure. His inner fall from grace was marked most eloquently by the tears that fell from his reddened eyes. He stood before me, arms at his side, with no gestures or movement. And, of course, no words from the man who 'couldn't speak.

From looking at him, I knew that he understood fully. He was not angry He only wanted to see the one who had passed judgment. He peered gently into my eyes, as if to impart the message of his pain while simultaneously absorbing some fragment of empathy.So affected was l that I began to mentally replay yesterday's events, looking for reasons to think the verdict was in error.

l pulled Vicharn over to the side. "Did I do the right thing, Vicharn?" I asked. "Do you think I could have gotten it out?"

Vicharn, fortunately, did not weaken. He remained silent for a moment and then said, "No, you made the right decision."

I knew the answer before I asked the question, but somehow I needed reassurance. I acquiesced once more to the painful truth.

Turning to Boonserm, I put my hand on his shoulder. I looked into his eyes. All I could offer him was my sorrow and my prayers. I told him how sorry I was.

A moment later, he clasped his outstretched hands together to wai me, bringing his hands to his face. In that single, profound gesture, Boonserm lifted a great burden from me. I sadly wai'd him in return.

A short time later, I watched as he walked out the door, a brown tattered suitcase in hand. I knew he had only a few months at best.

For the next week I had an empty feeling whenever I reflected on Boonserm. I had dealt with incur-able disease before. In Chiang Mai, it was a common occurrence. Perhaps it was the sight of him weeping, yet unable to cry.

The encounter with advanced disease teaches you many things. Most important, it teaches you to recognize your limitations. Especially in developing nations, where disease is rampant and resources scarce, you learn this bitter lesson every day.

Saying no to patients, though, doesn't necessarily become easier. When surgical skill, medical knowledge, or sophisticated technology can no longer save a patient, it is necessary to offer something else: sonic gesture of compassion, a moment of communion, a prayer. Its little enough, but sometimes, in the cruel battle with advanced disease, it's all we can give.

And sometimes the patient offers us, in return, his forgiveness. In Thailand, a gentle man with an inoperable tumor silently gave me this most valuable offering.

Richard M. Moss, BA'77, MD'8I, spent three years as a cancer surgeon in Thailand, Nepal, India, and Bangladesh. A board-certified otolaryngologist/ head-and-neck surgeon, he now practices in Jasper