Table for One

We’ve been very busy lately, and so it was 6:30 this evening before the last patient was escorted to the linear accelerator to be treated.  She had had a compression fracture of a lumbar vertebra last week due to metastatic breast cancer, and had been in excruciating pain despite a procedure called a vertebroplasty, where cement had been injected into the crumbling bone to shore it up.  When that gave her no relief, and her doctors were concerned about impending spinal cord compression, she was referred to me.  Despite the already packed schedule, what could we do except get her planned and treated as an add on at the end of the day?  The alternative of paralysis was not an option. I grumbled to myself all the way down to the vault—my feet were aching and I was tired.  As I walked into the shielded “maze”, I heard my radiation therapists cheerfully assisting the woman onto the treatment table as if she were the first patient of the day.

Once a week, on Mondays, I see all of my patients on treatment.  Each patient is escorted from the linac to an exam room by one of the therapists.  There is never a Monday where at least one of the patients, and many times all of them, comment about what a great “crew” I have treating down there at the machine.  I smile, nod, and say “That’s because I hired them!”  I am lying.  I did put that team together, but the truth is that radiation therapists everywhere have much in common. They stand on their feet all day, helping patients who are sometimes tearful, sometimes anxious, sometimes immobilized by pain or fear. Between each patient who is honestly grateful for their services, they deal with those demanding a schedule change daily, those who are chronically late, those who are chronically early, and those who will only be treated by a (woman) (man) (person with blue eyes) (whatever—you name it). They risk injury all the time, lifting and assisting patients who cannot do for themselves.  They smile, and they are pleasant and they care, leaving their own problems at home to be kind all day, every day, for their entire careers.  This is a profession, and believe me they are professionals, that selects for genuinely nice people.  It’s a hard job, both physically and emotionally and if you do not have the temperament for it, you do not last long.

There is one radiation therapist that I worked with longer than any other, for nearly nine years.  I changed jobs in 2004, but George is still there.  An exceptionally tall man at six foot five, his size alone inspired confidence in the patients.  Despite the fact that I always explained the treatment to them ahead of time, little old ladies would get two or three days into treatment, and say, “George, tell me again what the side effects of treatment are going to be.”   He would reply, without missing a beat, “You will have an irresistible urge to BAKE!”  And bake they did, cookies and brownies, and cakes and cinnamon rolls to make very sure that their special guy did not go hungry during a long treatment day. I remember the very first time I followed a patient into the treatment room at that place.  The linear accelerator, imposing in its immensity was ready; the treatment table, which we call the “couch” was covered with a clean white sheet. George stood by the set up smiling, one arm outstretched, gesturing like a maître d’ at a fine restaurant.  When he said, “Table for one?” the patient collapsed into giggles.

Nothing kills cancer like kindness and a good sense of humor.

The Leaky Roof

In this dry Southwestern part of the United States, there are only two seasons:  fire season and rainy season.  Fire season will end in another month, hopefully without further casualties or homes lost. The rainy season will start, such as it is.  Here we average 9 inches of rain a year, and we are perpetually unprepared.  The roads, slick with oil from a summer of busy vacationers’ rental cars, become virtual “Slip ‘N Slide” games for unsuspecting drivers who, not used to navigating in “weather”, hit their brakes hard and the famous freeway pile ups begin.

My small radiation therapy department was designed to give patients a sense of quietude and peace.  From the laminate flooring which absorbs sound, to the Japanese vases on the hall tables, to the landscape photographs which line the walls, each element was chosen to calm the anxious spirit of the newly diagnosed cancer patient.  Most of the department’s day to day functions take place on the second floor of the building, where offices and exam rooms and our consultation area are simple, functional and comfortable.   To get treatment however, the patients must descend down a floor to the “vault”, since the shielding of a linear accelerator cannot be retrofitted easily to an existing space.  Even the elevator down is “Zen”, wood paneled and carpeted, moving slowly and unjarringly to the lower level where the patient receives the radiation.  When the patients exit the elevator, they enter a sun filled anteroom, then walk down a ramp into a large well lit room with a state of the art linear accelerator.  The walls of the anteroom and the ramp are furnished with spectacular photographs of Bryce National Park, taken by a well known landscape photographer, who also happens to be a radiation oncologist, who is still working as such despite his beloved avocation of landscape photography because he is still paying the legal bills of his daughter, who famously refused to dry clean a certain blue dress, lest she be called a liar by those who sought to protect a President.

Our “vault” was an “add-on” to the building in 2008.  As such, there is a junction between the vault structure and the building itself.  Shortly after we opened in October of 2008, we realized that the roof was leaking precisely at that junction.  By November, mornings after a big rainstorm, we would exit the elevator into a large puddle.  By January, the puddle had become a river, flowing down the ramp towards $2.5 million worth of equipment.  This was not good.  We complained, and the builders of the “vault” did their best to seal the leak, to no avail.  The university got involved—after all, it was THEIR building.  A lawsuit ensued.  Meanwhile, we solved the problem by stationing a large gray rubber garbage can directly outside the elevator, lined with sheets of plastic which ascend to the ceiling and disappear behind the ceiling tiles.  Now, when it rains, the garbage can fills up.  It is the duty of the maintenance man to empty the garbage can every morning during our season of rain.

Somehow, our garbage can and plastic sheeting do not fit with the “esthetic” of our very Zen-like department.  But like anything else in a landscape viewed daily, they have become mundane, ordinary and invisible to our therapists, and even our patients once they’ve had those first few treatments, when the whole process is new and very frightening.  Four rainy seasons have come and gone, and at last report, the litigation has been “continued” until next spring.  Meanwhile, I fantasize that my department is an anchored antediluvian world where wickedness will soon be washed away by the great flood of floods.  I imagine myself as Noah, and reluctantly consider an ark (while replaying in my mind the great Bill Cosby routine where God asks a recalcitrant Noah, “NOAH….How long can YOU tread water?”).  If the waters breach the top of that garbage can, millions of dollars of equipment will be ruined, and our department will close until the damage is repaired and a new linac installed and commissioned.

How many University bureaucrats does it take to fix a leaky roof?  You tell me!

Who Wants to be First?

After much preparation, we opened our new radiation therapy department in September 2008.  Many many elements and “players” had to come together to produce a new state of the art community cancer center.  No detail was overlooked– the existing space had to be renovated  to create a more “zen-like” work flow and feel; the front office staff  had to be selected whose faces and voices would materialize as the “first impression” that our new patients would form as they entered a “brave new world”. My nurse had to be hired, who would play a critical role in the education and management of the patients.  Radiation therapists were recruited who would see the patients daily for up to eight weeks of treatment, directing the beams with the utmost precision while acting as “parents”, confidants, psychiatrists, social workers and otherwise infinite sources of knowledge, gossip and entertainment.  The physics staff– the dosimetrist who does the actual treatment planning and the medical physicist, ultimately responsible for the function of the machines and the safety of the patient—were chosen first, because in order to get a new radiation therapy department going, the linear accelerator must first be installed, and then “commissioned”.

A Linac is a very complex piece of equipment, housed in its own “vault”, a lead shielded room in the department.  Long ago, and far away, for precisely 24 hours before my written board exam, I could tell you EXACTLY how one works.  Now when a patient (and it is nearly ALWAYS an engineer!) asks me, “How does that thing produce radiation?”, I take his arm, and escort him to the office of my physicist who will gladly  explain everything (and I do mean EVERYTHING) to the patient.  Usually the patient emerges an hour later, with eyes slightly glazed over, and I am never asked another question.  And when it comes to explaining, and commissioning a linear accelerator, my physicist is simply the best.

The process of commissioning takes up to six weeks.  The company provides the “specs” of how the machine is supposed to perform, however we don’t just take the manufacturer’s word for it and plug it in and run with it.  After all, this is radiation, dangerous stuff if applied incorrectly.  The physicist uses his equipment to measure the output of the beam, at every different energy, at every different depth, for every different radiation field size.  Internal shields and beam adjustors and compensators are put through rigorous use to try to find faults. Computer connections are tested; video systems are monitored, and no stone is left unturned.  It is an arduous process, producing reams of data. At the end, when all is said and done, the machine must produce beams of sufficient strength, and fields of precise shape, or there will be no “acceptance”, and back it goes to the manufacturer.

So it was with great excitement and anticipation that we finally were ready to treat our first patient.  She was a lovely elderly woman with breast cancer, diminutive in size but full of personality!  She wore a royal blue boucle suit to her first treatment, replete with a silver flower brooch that she had made herself in her eldercare silversmithing class. She took tiny steps on her kitten heels down the ramp leading inside the vault.  Her hair and make up were perfect.  She was composed and polite to the staff.  She beamed at me.  As directed by the therapists, she changed into her gown.  They positioned her on the table, five feet off the ground.  They set the machine to its assigned position.  Everything was ready, so I pronounced, in my most important special occasion voice:  “Mrs. B, you are about to be the very first, number one patient EVER to be treated in this department on this machine.”

There was a moment of silence, and then Mrs. B EXPLODED into action, causing all of us, the therapists and me, to take a step backwards in surprise then forwards in alarm since she was at a height which could practically guarantee not only orthopedic but also neurosurgical injuries, should she fall.  She sat bolt upright and began to climb off the table, all the while exclaiming:  “The first?  THE FIRST??!!!  You never told me that I was the FIRST!   YOU GET ME DOWN FROM HERE AND EXPERIMENT ON SOMEONE ELSE FIRST!  I am not your guinea pig!  I’m going home RIGHT NOW!”

Okay…..would anyone else like to be first?