Cancer: Personal, Professional, and Practice Impact

Abstract

I remember the day vividly, a curse of my photographic memory. I had “tucked” my husband into pre-op and waited until he was whisked away for his 7-year overdue screening colonoscopy before proceeding with patient rounds. After I had seen two patients, I heard an overhead page, “Dr. Ramsakal please report to endoscopy!” I had an immediate “Takotsubo” moment, expecting a subsequent code blue announcement on my quantum leap to the endoscopy suite. The gastroenterologist calmly proceeded to show me the large, friable colorectal mass while my husband was still under anesthesia. I just shook my head in the affirmative. Dazed, my thoughts raced ahead; staging CTs, port placement, “sandwich” chemo/immune therapy, colon resection plus or minus colostomy, concomitant 5FU/leucovorin plus XRT to the surgical bed to prevent reoccurrence, etc. Then, of course, the turmoil of emotions kicked in. I tried to find a quiet corner at the nurse’s station before the tears started gushing. Whom should I call first? The logical answer was our son, the physician; he would offer some calm to this storm despite being a young father of a 6-day-old first child. While my husband was still a bit groggy under the influence of the midazolam, I sat on the bed, held his hand, and proceeded to give him the news. He nodded an understanding and acceptance. We were high school sweethearts, married for 33 years, and had great faith. We felt we were prepared to battle this and accept the outcome. The big picture was fuzzy, and I was no artist. Our oncologist kept repeating, “We’re going for a cure.” But I knew, despite the best current evidence-based care, the 5-year survival was about 25%. Within 2 weeks of diagnosis, my husband had completed his staging CTscans with biopsies of liver mets, fiducial placement, Mediport placement, and oncologic, colorectal, hepatic surgical consultations and got his first dose FOLFIRI/bevacizumab (he had the k-ras mutation). It was a medical whirlwind, but what kept us going was focusing on the next step. I understand how our cancer patients feel; navigating the healthcare industry, even with health insurance, is challenging and frustrating. Patients develop progressive disease that may become incurable, or even fatal, while they attempt to schedule appointments for Mediports, physician visits, preauthorization for therapy, and surgeries. It is a reality that you are only aware of when on the other side of the stethoscope. But truthfully, it was the “smaller” challenges that proved to be more difficult. We developed creative ways to secure colostomy wafers and decrease stool leakage. We discovered that sticky white rice and marshmallows ingested 30 min before colostomy bag switches decreased watery stool production during this process. I used this as an opportunity to upgrade my 15-year-old washer and dryer. The new pair had a steam sanitizer and antibacterial cycle so I could sanitize stool-covered laundry. Instructing patients and families on bleaching all contact surfaces to terminate Clostridium difficile endospores had a new meaning to us when he developed pseudomembranous colitis after his jejunostomy reversal. By the way, he failed both oral metronidazole and vancomycin but responded to fidaxomicin (this was in 2016). I smiled and felt a secret vindication when I saw the IDSA 2017 guidelines recommend fidaxomicin as one of the first-line therapies for C. difficile and removed metronidazole.