Emma Grandsom was a very pleasant woman with a proper English accent, even though she had been living in the United States for quite some time. One afternoon, about three weeks ago, her son, David took her out for lunch. As she sat there with the menu in her hands, the waitress asked her what it was she would like to order. Just at that very moment her mind became a jumble of confused thoughts and she couldn’t figure out what it was she wanted to say, let alone tell the woman what it was she wanted to eat for lunch.
David immediately realized there was something wrong as his mum had a puzzled look on her face and her lips were writhing as if to mouth some words but nothing came out. He immediately put her in the car and drove her 'straight away' to Mease Hospital. A CT scan, and then an MRI were obtained and they revealed a grape sized tumor very close to the speech area in the left temporal lobe.
She was admitted to the hospital that evening and by the time I saw her the next morning her speech problem had cleared completely. This was no doubt due to the lessening of the extensive cerebral edema or brain swelling (which surrounded the tumor), as she had been receiving intravenous dexamethasone or Decadron through the night.
After I introduced myself to her, I asked her how she was feeling. She told me, ‘I feel fit as a fiddle’. In fact she didn’t understand why she had to be in the hospital at all. I reminded her she had a small tumor in her brain and almost immediately a look of incredulity came across her face. ‘I can’t believe it’ she said, ‘because I feel so well’. I replied, ‘I know’. She then asked what it was and I told her it looked like a cancer and probably one that came from somewhere else in her body.
The look of surprise never left her face, as she muttered, ‘How can that be, I always have been healthy and I’ve never felt better than I do now’. I explained to her that the medication she had been receiving was partly the reason she felt so well. I then told her that more tests would be carried out that day to see if we could find out where the tumor came from. She nodded in agreement but said, ‘Well if it is cancer I’m not going to have any radiation and most definitely no chemotherapy’. At 82, I could hardly disagree with her but I told her, somewhat weakly’, ‘Well, we’ll talk more after the tests’ and I backed out of her room in the Critical Care Unit.
I called David, her son at the request of Emma’s nurse. I explained that I had seen her and spoke to her about the findings on the MRI scan as well as informed him that additional tests would be needed before we could come up with a plan. He agreed. I also told him that she told me she would not want any radiation or chemotherapy, let alone any brain surgery. He acknowledged this and I told him I would speak with him once the additional scans were complete.
Somewhat surprisingly all of the tests were negative. To me this meant the only other possibility was a primary brain tumor or astrocytoma; but ‘darn it that scan still looked like a metastatic cancer’ I thought. ‘Perhaps its site of origin, elsewhere in the body, was so small that the scans did not pick it up. That would not be unheard of, after all’.
And so I returned later that day to speak with Emma and her son, David to discuss the results and possibly a surgical plan. Upon entering the room, Emma was sitting in a chair by the window while it rained incessantly outside. David, who was rather tall at 6 feet, was standing quietly by her side. Both of them had their attention on the door as if I would walk through at any minute.
After I informed them of the results of the scans, I realized they had already been told that they were negative by another physician, who had also told them the mass in her brain could be an infection. While I did not particularly agree with this diagnostic possibility I acknowledged that until the pathologist examined the tissue under the microscope we could not be 100% sure.
And so because David wanted to ‘know’ what it was he convinced his mum to, at least, have the biopsy. Emma looked at me and asked me what I thought it was. I paused as I thought what I would say, but merely told her I believed it was a tumor. ‘Cancer?’ she inquired. ‘Yes’, I replied. Tears came to her eyes as she said ‘He’s all I got’, gesturing toward David. David held back his emotions as he turned to her and said, ‘But we won’t know for sure until the biopsy’. She nodded and said ‘OK’.
There were no complications during surgery but when the pathologist called into the room he told me what I expected. ‘It’s a malignant astrocytoma, and probably a glioblastoma’, his voice echoed through the intercom. Though I had hoped for different news, I was not surprised and yet, my heart sank a bit.
After surgery I went out to the surgical waiting room to speak with David and his wife, and gave them the bad news. I explained to them that without any further treatment his mother might survive a year but probably closer to six months. They shook their heads in disbelief; I said I was sorry and turned to go check on Emma in the recovery room.
The next morning I went to see Emma in the Critical Care Unit and found her sitting up in bed having some coffee. I asked how she was and she told me, ‘I’ve never felt better!’ What was strange to me, however, was that most patients as soon as they see me the morning following surgery want to know how the surgery went and what I found. Not once did she ask any of those questions.
After examining her and reviewing her lab work, I volunteered, ‘Well the surgery went well and it was not an infection’, expecting her to make the conclusion that it was a cancer instead. All she said was, ‘Well that’s great it was not an infection’ and she breathed a visible sigh of relief and said nothing more, as she took another sip of coffee.
Emma recovered quickly and was discharged that weekend, 3 days after her surgery.
The following Monday I received a call from Dr. Diaz, the pathologist who informed me that after studying the permanent microscopic sections of the tumor, he determined that it was not a glioblastoma but a primary CNS (central nervous system) lymphoma. Now that may sound just as bad, but in reality Emma’s prognosis went from a survival of 6 – 12 months to possibly being cured with only some radiation treatments!
I immediately called David and told him of the news and how he should convince his mother to have radiation. I explained that other than losing some hair, the course of treatments was generally tolerated very well. He thanked me and hung up. Later in the week, Francy told me that they had made an appointment with the radiation oncologist.
I have to admit I was doubtful from the start that Emma’s prognosis would be anything but dismal; and initially I was willing to let her leave the hospital without any treatment at all, if that was her desire. Quite frankly the only reason I operated in the first place was that one of her doctors made the incorrect conclusion that it could represent an infection.
Many times I draw my own conclusions as to the nature of a patient’s problem and the prognosis and present it to them as ‘gospel truth’. And most of the time I am correct. Emma reminded me however, my knowledge truly is finite and that God is the only one with ‘all the answers’.
Granted my human traits allow me to do what it is that I do. But in the end they are gifts from God and I must always be open to giving up control and allow God to mold me so that my hands truly become His instruments here on earth.
‘Then the word of the Lord came to me:
“O house of Israel, can I not do with you
as this potter has done? says the Lord.
Behold, like the clay in the potter’s hand, so
are you in my hand, O house of Israel.
Jeremiah 18:5-6
