Please, enjoy.
Cancer doctors tend to get to their profession in one of three ways. Some are drawn in through their love of cancer science. Cancer has always been something like a cobra to those who study it: dangerous and beautiful and endlessly fascinating. Cancer is a universe. One can spend an entire life exploring it without ever getting bored, for the biology of cancer is the biology of life.
Some doctors are inspired by a great teacher. Medicine is still a profession dominated by old-world apprenticeships, where a mentor’s passion can be transmitted to a new generation. I have known several oncologists whose careers turned on chance encounters with inspiring professors.
Others get there by way of their patients. I’m one of these. When I was a resident, cancer patients were the ones who touched my heart. In fact, I can remember the very moment I started my path to becoming an oncologist.
I was an intern at St. Louis University, a brand-new doctor, with my white coat still fresh and creased, when I first met Carmelita Steele. Carmelita was in her early twenties, married, with (as I recall) two young children. She came to our hospital as a transfer in the middle of the night. She had undergone a routine dental procedure, and after her surgery had first oozed, and then gushed blood. By the time she got to us she was severely anemic, and had a low platelet count. There was a very real concern in those first few hours that she would bleed to death.
I was an intern at St. Louis University, a brand-new doctor, with my white coat still fresh and creased, when I first met Carmelita Steele. Carmelita was in her early twenties, married, with (as I recall) two young children. She came to our hospital as a transfer in the middle of the night. She had undergone a routine dental procedure, and after her surgery had first oozed, and then gushed blood. By the time she got to us she was severely anemic, and had a low platelet count. There was a very real concern in those first few hours that she would bleed to death.
We worked through the night stabilizing her. Her veins were hard to access–they had all been used up during her time at the other hospital. In those days (the late 1970's) we lacked modern venous access devices, and I remember it taking a frighteningly long time establishing an intravenous line. Through it all I spoke to Carmie, who was a cheerful if appropriately anxious African-American woman, somewhat overweight, proud of her children and her loving family. We poured several units of blood into her that night, bringing her back from the brink.
We spent the next couple of days establishing a diagnosis. She had Acute Myelogenous Leukemia, then as now a dangerous disease requiring toxic chemotherapy to clear the blood and bone marrow of treacherous cells. I learned the diagnosis shortly after morning rounds. Her staff doctor, an elderly hematologist (or so he seemed then, though I am now about his age) would, I discovered, be off campus until the following morning. I knew that Carmie and her family were desperate for news, so I phoned the staff physician and asked if it was OK for me to speak to her. He agreed.
I had never told a patient that he or she had cancer before. I sat on the edge of her bed and told her that she had a type of leukemia, that it was very dangerous but that it was potentially curable with chemotherapy. I told her that we would be starting treatment the following morning, as soon as her staff physician had a chance to go over the drug regimen with her.
Carmelita had sat quietly while I spoke, a sad look on her face. When I was through she said, almost in a whisper, "Doctor Sledge, who will take care of my children?"
It was the last thing I was expecting, and it was thoroughly devastating. I did not know how to answer. Today I hope I would do better, but at the time I was in my mid-twenties, just a few years older than Carmie, and I did not know how to answer that question. I stammered something, barely maintaining my composure, and then left her room and hid in a stairwell for a half an hour sobbing.
The next day we started her chemotherapy regimen, full of hope. I spoke to her regularly, and to her family. Her husband, a quiet decent man, stood by looking worried. Her mother, a medical technician who understood leukemia, rarely left her daughter's bedside. They were the sort of family we all should have.
For several days things went well. Then, as her blood counts plummeted in response to the chemotherapy, she developed an infection in the area of her intravenous line, followed by sepsis. Her blood pressure dropped, and her breathing became rapid and labored. She was transferred to the intensive care unit, intubated, and treated with broad-spectrum antibiotics. Sometime in the middle of the night, disoriented and alone, she pulled the breathing tube out of her mouth. Though she was quickly re-intubated, things rapidly went from bad to worse, and she died the following day.
I went home that night in a furiously angry mood. I was supposed to be going out with my girlfriend, but in my grief and guilt I simply could not think straight or act civil, so I begged off. I relived every moment of her care: what had I missed, what could I have done differently, what foul-up had I committed that kept a 22 year-old from taking care of her young children? It is the arrogance of interns that they believe that acute leukemia would turn out differently if only they had gotten a little more sleep.
A few weeks later I got a call from Carmelita's mother. She wanted to meet with me. I agreed, with real trepidation. The wound was still too raw, and there was part of me that feared she might hold me responsible for her daughter's passing.
But she was as gracious as I could ever have imagined. I have three sons, all in their twenties, and if one of them died of leukemia I do not know how I would handle it. Poorly, I suspect. But she was dignified, pleasant and grateful. She told me that Carmie, before she had died, had told her that, come what may, she wanted to give me a gift to thank me for my care, and for the hours I had spent with her. She then handed me $40 and told me I was to spend it on something fun. Carmie had wanted it that way.
My patients, starting with Carmelita Steele, have taught me so much about what it means to be a good doctor and, I hope, a good person. I am an oncologist because of her, and it is a job I have loved for three decades. But Carmelita's question still haunts me: "who will take care of my children?"
There are some debts you can never repay.
