Getting to the finish line with a patient can mean many different things in my world. It could mean we have exhausted all standard of care treatment options and there is nothing left to try. It could mean the patient is nearing death. Every once and a while it means we have completed curative intent treatment and I get to discharge the patient hoping above all that I will never see them again because their cancer is cured. I would like to tell you about Mr. M and a happy finish line.
I met Mr. M and his wife in late 2021. He was diagnosed with invasive gastric adenocarcinoma. Rectal bleeding initially brought Mr. M to medical attention. His hemoglobin was low and over a few months, it continued to trend downward. An upper endoscopy demonstrated a large cratered ulcer in his stomach. A biopsy of this ulcer confirmed cancer. A CT and laparoscopy did not show evidence of cancer spread. His disease remained contained to his stomach and therefore it was potentially curable. The recommended treatment included four cycles of a rather difficult four-drug chemotherapy regimen called FLOT, followed by surgery to remove his stomach, followed by four further cycles of FLOT. It takes about six months to get through this treatment if all goes well. It is a marathon, both physically and mentally.
Mr. M came to me with a generally well-controlled past medical history that included a kidney disease called IgA nephropathy, high blood pressure, diabetes, dyslipidemia, obstructive sleep apnea for which he utilized a CPAP machine at night, and post-traumatic stress disorder. Mr. M is a past smoker. He lives with his wife. They have two adult children. He is a retired navy cook with thirty years of services in the Canadian Armed Forces.
FLOT chemotherapy includes the medications docetaxel, oxaliplatin, leucovorin, and fluorouracil. It is given every two weeks. We discussed the potential side effects of this regimen in my usual fashion so that Mr. M could provide informed consent. He consented. We got started.
Though he was very stoic, it was not long after chemotherapy started that Mr. M began having difficulties. He developed diarrhea, fatigue, and a decreased appetite almost immediately. When he came in for consideration of his second cycle of chemotherapy, his creatinine, a measure of how well the kidneys are functioning, had almost doubled. His white blood cell count was in his boots as well. The change in his kidney function was not surprising with his baseline kidney disease but it was still problematic. His kidney function had decreased by almost half. This was not good. Further, with his low white blood cell count, his chance of developing a life-threatening infection increased. If these two issues persisted, we would have to abort chemo. If we aborted chemo, his chance of cure dramatically decreased.
We delayed his treatment and administered intravenous fluid twice in the following week to try to make his kidneys a little happier. This extra time away from chemo would prove to ameliorate his white blood cell count. A week later, he was ready for cycle two though he still felt like he had been run over by a tank.
On and on his troubles went. Each time he came in, he looked a little more run down. His kidney function continued to suffer. His bone marrow got more tired, not wanting to produce those much-needed white blood cells. The first four cycles of chemotherapy took over three months to get into him instead of the usual eight weeks. His treatment was delayed each time we tried to give it to him. He was making two, three, and sometimes four trips to the cancer centre in each two week block to get topped up with intravenous fluid and have his blood work checked. Each dose of chemo knocking him down further and further. Yet, each time I asked him how he was holding up, he said something like, “I’m fine” or “Let’s just get this done”, and “Thank you Dr. Spratlin”. We had discussions about whether he thought he could make it through every other week and he insisted we continue, that he could take it.
When he came back to me after his surgery to receive the final four cycle of chemotherapy, his condition was worse. His surgery was tough. He had lost his stomach. He could not eat as well. He was getting used to his new anatomy; it required much smaller and more frequent meals. Hitting him with more chemotherapy compounded his already debilitating fatigue and anorexia. It also continued to tease him into kidney failure. His white blood cells had all but disappeared and he now needed medication support to keep them up. His last four treatments also took over three months to deliver. He developed sepsis and require hospitalization at one point. I can’t even count the number of extra times he came to our building for supportive care.
Mr. M didn’t just run one marathon, he ran nine continuous ones: one for each dose of chemotherapy he endured, and one for the large surgery he underwent. There was sweat, blood, and tears during his run. It took a lot to get him through – an entire team of trainers and coaches and medics and cheerleaders. There was a massive team helping him to keep running: nurses in our outpatient and inpatient departments, clinical associates, drug access coordinators for the drug we had to get him to help his white blood cell count stay up, clerks to organize all his appointments and so many other people who helped him get across the finish line. His wife ran right beside him the entire way. He wouldn’t have made it through without each one of these teammates.
On the day prior to his last chemotherapy, he and his wife came to my clinic and presented my clinic nurse and me with challenge coins from his section of the Canadian Armed Forces. These coins are very special. They symbolize membership and are they boost morale. Historically, I believe these coins were awarded based on achievement or perceived merit. In more modern times, they are traded with other members of the same or similar organizations as an act of comradeship.
He presented the coins to us with tears in his eyes. He said the words on the back of the coin were exactly what he received at our cancer centre. He was very gracious and complimentary. I knew it meant a lot to him. It meant a lot to me too. The coin has the words “Service second to none” on it.
I gratefully accepted his coin. Though Mr. M presented it to me, it is truly a gift for the team of colleagues who helped Mr. M get to his finish line. I now carry his coin around in my doctor jacket pocket. Every once and a while, I put my hand in that pocket and my fingers find the coin. It is a powerful reminder of one of the most important goals in medicine – service to our patients.
Author Notes:
A few weeks ago, I was a spectator at cross-country running race. Just before the starting gun went off signaling the start of my son’s race, I saw the most remarkable thing. The race before had all but finished. There was one runner left on the course who had not yet crossed the finish line. He was a kid about the same age as my son, in his mid-teens. He appeared to have Down Syndrome, a common genetic variation.
This teenaged boy was running with a trusted adult. I’m not sure if the adult running mate was a teacher or parent or volunteer but anyone watching could tell the adult was enthusiastically encouraging the kid. With less than 100 metres to go before the finish line, the boy stopped. I was close enough to hear him say he was tired and couldn’t go on, that he was done. He sat on the ground, breathing hard, not wanting to get up. His adult running friend continued to encourage him. Then something beautiful happened.
Three girls from the same school saw their friend on the ground. The girls were runners too. The three girls yelled him encouragement and rushed over to him. One of them went on to the course and tried to help pull him up off the ground while the other two continued to yell “You can do it!” and “You’re almost there!” and “You got this!” from the other side of the tape. They were cheering him on so loudly and proudly. After a few long seconds, the boy got back up. He, his adult, and the three girls jogged to, and across, the finish line together.
I’m not sure who was happier that he got there – the boy, the adult, or the three girls. I wish more people could have seen this impactful display of sportsmanship, friendship, and love. This kid and his team are just like Mr. M – effort and courage and grit rolled into human form. I had tears in my eyes watching them cross the finish line. They were similar tears to that which I had when I left Mr. M’s room the last time I saw him. The wonderful boy who finished that race should be so proud of himself. Those three girls should be too. So should the adult who ran with the boy. What an individual and team effort! I’d go as far as saying it was “Service Second To None”.
I am curious, reader, if you have ever helped anyone over a finish line. How did it feel, on the inside, for you?
