Article - Winter 2018

“We’ll Do Everything We Can”

Sometimes, to save a patient, doctors must move beyond textbooks and embrace the ineffable

By Patrick Tripp | December 4, 2017
Photo-illustration by David Herbick

Late Friday afternoon, I was called to the ICU to see Mr. S., a 65-year-old man recently diagnosed with lung cancer. The tumor, oozing blood, rested on the carina, where the central airway, the trachea, divides into the two main stem bronchi, the large airways to the lungs. With the flow of air obstructed by the tumor, he needed the mechanical ventilator to keep breathing. A few days earlier, he’d arrived at the emergency room with fever and shortness of breath. A chest x-ray showed “consolidation,” an opaque, fluffy patch of white against the black air of the surrounding lungs. Doctors diagnosed pneumonia and sent him home with antibiotics. The next day he returned, coughing up blood. This time, a CT scan of the chest showed a mass almost 10 centimeters in diameter in the middle of his chest. The x-ray had missed it, blocked by the heart and the developing pneumonia. The tumor completely obstructed the left main stem bronchus. With no air moving in or out of that section of the lung, it had collapsed. Mr. S. was taken for bronchoscopy, in which a flexible fiberoptic scope is used to examine the airways, and a biopsy was taken to verify that the mass was in fact a tumor. With Mr. S. sedated for the procedure, the scope went down the trachea until a soft, fleshy mass was identified, extending in uneven blobs. Pierced by the biopsy needle, the tumor started to bleed. This almost always happens.

But this time, the bleeding did not stop, and Mr. S.’s oxygen level started to drop. A thoracic surgeon was called, for rigid bronchoscopy, used to remove an obstruction or control bleeding. Looking through the scope, he saw the bronchi filling with blood. Here his note in the electronic medical record said, “Patient’s oxygen saturation dropped from 70 to 60, and he wasn’t ventilating.” He suctioned blood clots from the airways, used a laser to stop the bleeding, and removed the bulkiest parts of the tumor, allowing Mr. S. to breathe. The oxygen saturation monitor showed his blood oxygenation levels returned to greater than 90 percent. With the bleeding under control, if only for now, the scope was removed. Mr. S. remained on the ventilator.

Later in the afternoon, the pathologist issued a preliminary report: under the microscope, the appearance of the cells taken from the mass was consistent with the impression of the CT scan and the bronchoscopy—lung cancer. That’s when the thoracic surgeon called. He recounted the story of Mr. S.’s two trips to the emergency department in two days, the x-ray, the CT scan, the biopsy, the bleeding, and how he, the thoracic surgeon, had been called precisely at the life-threatening moment, when Mr. S. began to desaturate. “We don’t have staging yet,” he said, meaning the work-up scans to show the extent of the cancer, whether curable or incurable, had not yet been completed. “But the way he looks, I thought you should see him.”

“I’ll go see him right now,” I said. “You think he needs to be treated today?” Typically, radiation treatment is delivered using multiple intersecting beams: computerized treatment planning uses a CT scan to show the tumor in three dimensions inside the patient, with a virtual rendering showing how the radiation dose is distributed. Planning the treatment routinely takes a week or two.

Mr. S. appeared stable, the surgeon pointed out, but there was no way to predict whether the tumor or blood would again obstruct the airway. “I think you should treat sooner rather than later,” he said.

“Right,” I said. “I’ll call the wife, treat him today.”


 

At a 1937 meeting of the American Surgical Association, Henri Coutard, then regarded as the leading radiation oncologist in the world, said that radiation treatment could cure cancer. In 1895, when German physicist Wilhelm Roentgen announced he’d produced an image of the bones of his wife’s hand on a photographic plate, Coutard was a medical student; by the 1920s, he had become chief of beam therapy at the Radium Institute in Paris, under the guidance of Marie Curie. Using an x-ray machine in the basement, he carefully recorded his observations and refined his technique. At the time, the energy available, a hundred kilovolts, was sufficient to treat cancers of superficial organs like the skin, or the larynx and upper airways, just under the surface of the neck. But the strength of the beam attenuated rapidly as it traveled deeper into the patient, losing most of its intensity by a depth of five or six centimeters. For that reason, Coutard would place the radiation source immediately next to the surface of the patient, nearly touching the tumor. He used sheets of lead supported by wooden buttresses to shape the treatment fields. A typical radiation session lasted 15 hours. Contemporaries in Stockholm and Erlangen recommended using the highest possible radiation dose, delivered in the shortest possible time, an approach that produced a dramatic tumor response. But patients suffered debilitating side effects, such as severe swelling and soft tissue destruction. Coutard found that dividing the total dose over several weeks had the same effect on the tumor while limiting damage to neighboring organs.


 

In the ICU, a nurse in blue scrubs stood in the hallway adjacent to Mr. S.’s room, jotting down numbers in a blue three-ring binder. “I’m from radiation oncology,” I said. “How’s he doing?”

“He’s holding up. They’ve still got him heavily sedated.”

Inside the room, the mechanical ventilator gave its rhythmic whoosh, and the monitor for vital signs emitted its steady, high-pitched beep. Two I.V. bags full of clear fluid dripped into plastic tubing connected to needles in Mr. S.’s left forearm. According to his chart, he weighed 342 pounds; his elbows flopped over the guardrails on either side of the mattress. The great mound of his chest and neck heaved in time with the ventilator. A pajama top draped loosely across his upper body, partly covering wires from electrocardiogram leads stuck to round adhesive pads on his chest. His face appeared bloated, distressed, with thick beads of sweat pooling at his upper forehead, dampening the thin hair above his ears. A coiled hose from the ventilator machine snaked across Mr. S.’s belly and connected to a tube at his mouth, secured at the edge by two strips of white tape, a third piece crosshatched perpendicularly across his lips. Velcro straps fastened his wrists to the bed’s guardrails, preventing him from pulling out the breathing tube. His eyes fluttered to a half-open position and flickered intermittently. Listening to his chest with a stethoscope, I heard a dull sound, the air moving in and out, a gurgle, an echo—consistent with the diagnosis from that first chest x-ray: pneumonia. Monitors suspended above the bed showed his heart rate was almost 100 beats per minute, blood pressure a little low, oxygen saturation steady above 90 percent. I pictured his chest CT scan, the tumor blocking the airways, the left lung unexpanded. I needed to talk with his wife to get consent for treatment.

I called her from the ICU and introduced myself. She’d been in the hospital most of the previous two days, she said, in the emergency room, waiting outside the operating room during the bronchoscopy, waiting in the ICU, in her husband’s room. A few days earlier, they’d traveled together, intact, upright, to the emergency department. My five-minute visit with her husband had just happened to fall in her moment’s break from the hospital, a stop at home to shower, change clothes, eat. “The other doctors told you the diagnosis?”

“Lung cancer.”

“Right. I know it’s been a long day. I don’t know if the other doctors told you that radiation oncology would be called?”

“I think they mentioned that.”

“Great. I’m calling to offer treatment for your husband.”

I explained that we weren’t sure of the extent of the lung cancer. We didn’t know if it had already spread outside the chest, for example. More scans were needed, but because of the tumor’s location, wedged between the central airways in his chest, the esophagus, and the great vessels and heart, it was inoperable, regardless of whether the cancer had spread to other organs. Completing the work-up, I continued, might show that the cancer was limited to the chest; if so, he stood a chance, a small chance, to be cured. But the more pressing problem, I said, was that her husband could die if the tumor or bleeding obstructed the main airways to his lungs. I recommended starting radiation right away.

“The treatment does have side effects,” I said. “We’re pointing a high-energy x-ray beam into his chest—radiation can affect his heart, lungs, esophagus, and other organs.” I further explained that risks included problems with breathing or coughing. I ran the list of less common but serious side effects such as spinal cord injury, or complications of treatment leading to death. “Bad as all this sounds,” I said, “he doesn’t look very good right now; on balance, he stands to benefit from radiation. Any questions?”

“Not right now,” she said.

After the call, I stopped to talk with the nurses, telling them we would treat
Mr. S. that afternoon. One nurse looked up from a computer screen, raised an eyebrow. “You mean while he’s on the ventilator?” she said.

“We’re going to need a hand,” I said. “Yes, while he’s on the ventilator.”


 

To treat advanced lung cancer, a typical radiation treatment course with chemotherapy runs six or seven weeks. The total radiation dose is divided into equal subdoses, the approach first developed by Coutard. With advances in biology in the 1950s and ’60s, such as the description of the cell division cycle and DNA, the molecular mechanism for Coutard’s observations became better understood. Radiation causes biological damage in two discrete ways—one by direct effect of the x-ray’s action on tumor DNA, another by indirect effect on DNA by free radicals, highly chemically reactive atoms, created by the first effect. Cells damaged by radiation make an effort to repair themselves. Cancer cells, dividing more rapidly than cells in noncancerous tissues, are more vulnerable to insult from radiation or chemotherapy. (Some normal tissues, such as hair cells or cells lining the gastrointestinal mucosa, divide at rates similar to cancer cells, which explains why radiation can cause hair loss and diarrhea.)

In the 1940s and ’50s, “megavoltage” radiation treatment machines were developed that delivered energy thousands of times more powerful than Coutard’s x-ray units. These machines, with the capacity to deliver radiation farther into the body and to treat deep-seated tumors, allowed for more sophisticated treatment, such as cross-firing multiple beams from opposing or perpendicular angles.

For patients with advanced lung cancer, radiation treatment combined with chemotherapy offers a substantially better chance to live an additional one or two years. But the likelihood of surviving more than three years is low. Still, no matter the odds, some patients are cured—I have met them. The possibility of recovery, no matter how remote, is the reason all patients are treated as if they can be cured, unless scans show the cancer has spread.

Each patient’s treatment planning starts with a CT scan in the radiation oncology department, where the patient receives India ink tattoos that serve as alignment markers. The CT scan images are then transferred to a specialized computer. A technician called a dosimetrist manipulates multiple virtual radiation beams, testing combinations of beam energy, proportional weighting, and angles of entry to find the approach that delivers an even dosage, while avoiding excessive radiation to adjacent organs.

But Mr. S., unconscious, on a ventilator and unable to leave his hospital bed, merely needed an approach that could deliver radiation safely, accurately—and soon. The dosimetrist designed a square field large enough to cover the bleeding tumor, with energy sufficient to reach its depth. The plan looked like what Coutard had developed nearly a century earlier: a single beam positioned directly over the tumor would deliver the dose.

Just then, in the hallway outside the dosimetry room, I saw Mr. S. wheeled around the corner in his large hospital bed, escorted by a nurse from the ICU and a respiratory therapist, the man charged with running the portable ventilator attached to the side of the bed. The nurse from upstairs recognized me. “Thanks a bunch for bringing him down,” I said. “We’re going to need your help on this.”

We were joined by the radiation therapists, who operate the radiation-emitting machine, called a linear accelerator, or linac. Together we maneuvered Mr. S. into the treatment room, where the clack, whoosh, and hiss of the ventilator echoed off the concrete walls of the vault. We brought the bed parallel to the treatment table, and the therapists rotated the linac so that its beam pointed directly at Mr. S.’s chest. With the overhead lights in the room shut off, the middle of the room glowed from the light field shining from the head of the machine. This light, a surrogate for the actual x-ray beam, showed the alignment of the beam as it would exit the linac, pinpointing where it would enter Mr. S. Usually, at this step, India ink tattoos guide the placement of the light field relative to the position of the patient. But in the case of Mr. S., whose expedited treatment had been planned from the diagnostic CT scan obtained in the ER the previous day, alignment was deduced by correlating an exam of Mr. S. with a measurement from his CT scan. Using the collarbone’s junction with the sternum as a landmark, I counted down the surface of his chest seven centimeters—on the CT scan, the distance to the target. My index finger under the light field beam gently touching his chest, I looked to the radiation therapist. “Let’s try here,” I said. She marked a small “x” on his chest.

The next step was to take an x-ray to prove the target was included within the treatment field. Four people rolled Mr. S. onto his side while a radiation therapist slipped under him a two-foot-square metal cassette frame holding an unexposed film. Everybody stepped outside. From the control room, a therapist pressed a button, taking the x-ray. Afterward, when the cassette was retrieved, one of the therapists brought the film to an adjacent darkroom for processing, then returned through its black rotating door a moment later. In the control room, an already tight space that felt even tighter with so many people scrunched into it, all of us watched the video monitors trained on Mr. S.

After a moment, the ICU nurse turned to me. “Do we really have to do this?” she said.

I was taken aback. “We don’t have to do anything,” I said. “And no, we don’t know if this is going to work. But it might.”

“It’s just that, getting him down here, the ventilator, rolling him around—”

I turned to watch Mr. S. and his vital signs on the video monitors. His oxygen saturation monitor was flickering around 90 percent, and his chest continued to heave, but his distress, in that moment, was his sign of life. I turned to the nurse. “You’re right,” I said. “It’s not easy, rolling him around like this, trying to get him to hold still while he’s out of his mind.” I rechecked the monitors, then turned back to her. “But just yesterday, he walked into the emergency room. I think it’s what you would want.”

The beep from the film processing room sounded—the film was ready.

Mr. S.’s x-ray displayed the trachea descending to the carina, where the airway was interrupted by a dense, white cloud: the tumor. The x-ray graticules—one-centimeter crosshairs in the treatment beam’s head, magnified on the film, allowing accurate measurement of dimensions within the film’s field of view—showed the central axis of the treatment beam exactly in the middle of the tumor. “We’re right on target,” I said. “Let’s treat.”

At the control panel, one of the radiation therapists read aloud to her colleague the instructions for treatment, including the patient’s name, the dose, and beam energy—a standard double-check before treating any patient. “Right,” the other therapist said, “here we go.” She turned a key and punched a green button on the control panel. The linac clicked its signature beeping to indicate the beam was turned on. In a few minutes, the beeping stopped; the radiation therapist turned the operator’s key back to its disengaged position and looked to her colleague. “Hit the door,” she said. “We’re done.”


 

Three days later, I checked the computer chart to see how Mr. S. was doing. I hoped he was still alive. “Successfully extubated,” said the medical student’s note from the previous day. I went upstairs to his ICU room. Looking through the glass panel door, I saw the ventilator had been replaced by a tube with a hand-held applicator: Mr. S. was holding the tube, blinking, yawning, looking around the room, as if waking up into an unfamiliar space. An aerosolized gas seeped slowly from the tube as he held it to his mouth—a breathing treatment. “He looks pretty good,” I said to the nurse standing outside his room. “Is he still coughing up blood?”

“Not on my shift. I think he has been doing better.”

Opening the sliding glass door, I saw a woman sitting next to him, talking softly. The early morning sun streamed in from the room’s one window, falling softly over the bed, its blanket smooth, pulled neatly across the middle of Mr. S. He didn’t look as if he’d almost died. “Hi,” I said, closing the door behind me. Mr. S. adjusted the breathing treatment hose, getting a better view of me. Then he offered his free hand, and I gave him a shake. Looking to the woman, I said, “I talked to you on the phone Friday. I’m from radiation oncology.” She said she remembered. Turning to Mr. S., I told him he probably didn’t remember, but we started treatment the previous week, for lung cancer—had he heard that was the diagnosis?

“I told him,” his wife said. “Yesterday his nurses called at five in the morning, said he thought he was dying, asked me to talk with him. So I told him what you and the other doctors said, that this can be treated.”

“Right. We still need the work-up, a PET scan, a brain MRI. But for the moment, we can keep going.” Then I explained how we’d begun treatment in the most rudimentary way, simply so that we could give him something, which, we thought at the time, was better than not giving anything. I did not tell him that the technique we’d used the week before was borrowed from the 1920s. With him feeling better, I explained, we wanted to get a CT scan.

Mr. S. looked to his wife a moment, then turned back to me. “I’m claustrophobic,” he said.

“Many patients are,” I said. “It’s normal. And if you need something to help you get through it, a medication, we’ll give you something.”

“You sure?” he said. He placed the hollow, hissing tube on the table next to him.

“We do this all the time,” I said. “We’ll get you through it.”


 

Half an hour later, Mr. S. returned to the basement, this time in a wheelchair. Despite his fears, he managed to hold still for a CT scan, after which we sent him back to his hospital room. The dosimetrist manipulated the computer model of Mr. S. the rest of the afternoon, trying different beam angles, different beam energies, giving more or less intensity to one beam or another, and compressing the work of several days into an urgent several hours. Before leaving the hospital that night, I reviewed what he’d prepared—a treatment plan with four different beams from oblique angles, the computerized Mr. S. turned one way, then a different way, for each. The dose distribution through his chest avoided, to the extent possible, adjacent organs. “Let’s do this,” I said, and signed the plan, using my electronic signature.

The next day, Mr. S. was awake in the treatment vault. The therapists used alignment lasers attached to the walls to position him precisely as he had been for the treatment planning CT scan the previous day. “Hold still,” the therapist in the control room next door called over the vault’s speaker as the treatment machine head rotated into place at the exact angle specified in the computer plan. “We’re going to snap a picture.”

Again we waited for the film processor, as this treatment plan, too, required quality assurance films to prove that we were on target before going forward with treatment. Standing in the control room next to the treatment vault, squeezed in with the therapists and the medical physicist, I recognized the nurse from the ICU who’d accompanied Mr. S. a few days earlier. She recognized me at the same moment, and smiled. “I know you said he might get a response,” she said. Together we looked to the video monitor, its camera trained on Mr. S. in the room next door. “But I didn’t expect this.”

I smiled, too. “Sometimes this stuff works.” It doesn’t always. In fact, maybe one large shot of radiation wasn’t what got Mr. S. off the ventilator; maybe the thoracic surgeon had been able to debride the tumor enough so that the airway would open and the bleeding would stop.

In the 1940s, Coutard, then in his late 60s, was recruited to develop a cancer treatment clinic in the Rocky Mountains. Back in Paris in the 1930s, he had treated a laryngopharynx cancer in a wealthy patient named Spencer Penrose, who’d made his money in gold smelting at Cripple Creek, Colorado. Years later, after Penrose’s death from esophageal cancer, his wife founded the Penrose Cancer Hospital. Once a week, Coutard hired a chauffeur to take him to the Garden of the Gods, in an area called Calvary, where he meditated amid the rock formations. He did not know about DNA, the biology of tumor growth, the mechanism of cell kill by high-energy x-rays; he did not know about megavoltage radiation treatment machines or computerized treatment planning. Far from the agricultural village in France where he’d grown up, he sat alone, studying layers in the sedimentary rock, figures in the limestone, the remnants of ancient tectonic events. Suspicious of too much scientific understanding, wary of the tendency to name phenomena, he regarded therapeutic radiation with something of the same mystery he saw in the creation of rock formations: ineffable, unknowable.

That Friday afternoon, while the radiation therapists situated Mr. S. in the treatment room, while the ICU nurse and the respiratory therapist monitored his heart and lungs, and as I observed the scene from the corner, for just a moment I felt outside myself, displaced. To become a radiation doctor, an additional four years of training is required after medical school, after an internship year. The education includes cancer biology, radiation physics, cancer treatment, and results of treatment for all cancers at all stages. Training also includes education not written in any modern textbook, such as the trick of counting ribs palpated on a patient’s chest to calculate the number of centimeters down from the collarbone to put the x-ray beam on the tumor, thereby matching the physical findings with measurements from the chest CT scan. That was not something that came to me in the moment—I’d done it before, in a similar situation. Although I was always hopeful, always thinking the treatment was going to work, sometimes it didn’t; sometimes the tumor did not respond, the cells did not die the way the textbooks suggested they should. The biology of a big man on a ventilator, bleeding, tends to be more complicated than a book can describe. So when the treatment worked, when a man suddenly got better, sometimes I felt like Coutard, staring at the rocks. One day Mr. S. is about to die, and a few days later he’s giving himself a breathing treatment, talking with his wife.

“These nice doctors are going to take good care of you,” she said to him, when I met him awake for the first time, the day after he woke up thinking he was dying. Looking across the bed to me, she said, “Isn’t that right?”

I took a step to him. “We’ll do everything we can for you,” I said, taking his hand for the second time that morning. “We’ll do everything we can.”

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