Oh God, forgive us for sins of omission

“Are you sure you have had this lump for six weeks only?” I asked Emily at the end of my examination.

I did so because the size of the lump belied the stated duration.

“Could be a little longer,” Emily replied, making her vacillation obvious.

“How much longer?”

“More likely months rather than weeks.” Emily now sounded contrite at her cageyness.

“As matter of interest, why did you leave it for so long?” I was carrying out a survey at the time on why women ignore breast lumps.

The reasons I had gathered were, the lump was painless, I was scared, it might disappear, I was trying other treatments, I went to my doctor but he told me not to worry.

When I heard Emily’s reasons, I could not place them in any formal category.

Special prayers

“First of all, it was Lent when I noticed the lump and I did not want to interrupt my 40 days fasting and special prayers for Easter,” she explained.

“You mean you waited all that time?” I asked, both surprised and impressed by her religious fervour.

“Yes,” replied Emily. “That’s the duration that Jesus fasted and prayed in the desert.”

“Okay,” I said. “How do you account for the rest of the delay?”

“Then my son announced that he was getting engaged and set a date two months ahead. I thought it would be such a damper if I started getting them all worried about my breast lump.”

As I sat aghast, she concluded dismissively. “Anyway all that is now behind me and I am here.”

As Emily dressed up at the end of my clinical examination, I made my notes, recording some of the conversation verbatim.

As I usually do, I made a diagrammatic representation of my findings. I made a line drawing of both breasts and adjacent to them I drew two triangles to indicate the armpits.

I marked the tumour in the right breast with a red biro and the three glands in the ipsilateral axilla in the right triangle. I then turned to Emily and her husband Moses.

“I am not happy with what I have found in Emily’s breast,” I said. “Nonetheless, we have to do certain tests to confirm the diagnosis and then proceed with the treatment.”

“What will that be?” Moses asked.

“Very likely mastectomy.”

“Fine,” Emily said. “No point in waiting. Is there?” I restrained my impulse to say that she had waited long enough.

The operation went on well except that there were more glands in the armpit than those I had felt clinically – a common enough discovery.

Microscopic examination proved that there were nine glands, all positive for cancer. Emily received post-operative chemotherapy and radiotherapy and was also prescribed hormonal tablets.

Complimented her

The chemo and radiotherapy regime finished in September and on her two subsequent visits in October and November, Emily looked fully recovered from the ill effects of both.

“You have done very well,” I complimented her. “Even your hair has grown again and it is thicker and darker than before.”

“Good,” Emily smiled. “I want to enjoy my Christmas and look smart for my son’s wedding.”

“You certainly seem well poised to enjoy both the festive occasions,” I said.

Looking at my diary, I added, “I want to see you in early December before I go to Maputo for the surgeon’s conference.

“I intend to take my Christmas holiday there on one of their beautiful beaches and enjoy their famous prawns.”

It was obvious that she was not a bit interested in my holiday plans. All she talked about was her son’s wedding followed by Christmas and New Year.

I buzzed my secretary on the intercom and told her to book Emily for the first week of December just before I was due to leave for Maputo.

On that occasion too, the topic of conversation was the wedding. “It’s going to be a church wedding,” Emily enthused.

“We have booked a newly opened restaurant in Kitengela for the lunch reception which will follow. The youngsters have decided to extend it into an evening of dance and music.” I could not get a word in edgeways.

“Then there will be Christmas. It will be a special one because we will have a new bride in the house. Mind you she is not a stranger.

“She is my friend’s daughter and has been in and out of the house since she was a teenager. I am so glad the children chose each other.

“It’s not only a union of hearts but they have knit the two families close together.” She was bubbling.

Suddenly she changed the course of her conversation. “Such a pity you will not be here. Couldn’t your meeting in Maputo be postponed?”

“I wish that it could be, but it is an annual event and the dates are carved in stone,” I explained. “Now if you don’t mind, let’s check you up.”

“Oh yes,” she said as if remembering the main purpose of her visit. I proceeded in my usual systematic manner.

I looked and felt the mastectomy scar on her right chest. I felt the right armpit which was empty.

I then put a hand in the hollow above her collar bone. Nothing abnormal there either.

I repeated the manoeuvre on the left side. “Fine, fine,” I went on muttering until I put a hand on her liver.

What I felt there impelled me to look into her eyes – again and again to make sure.

“Well,” Emily excitedly jumped off the couch. “Clean bill for my son’s wedding and Christmas?”

I was washing my hands in the basin. Deeply engrossed, I almost burnt my fingers as I let the hot water tap run for too long.

“Uhm,” I said looking at the calendar above the basin. “Only a week to the wedding and two weeks to Christmas.”

I suppose it was my subconscious telling me something. After all in two weeks time, her desires will be fulfilled. Do I need to be a spoilsport?

“That’s right,” Emily replied adjusting the collar of her blouse. “Any longer to the wedding and the suspense will kill me.”

As I contemplated on her ominous remark and made copious notes on her file, she was out of my office. “Happy wedding and merry Christmas,” I waved as she quickly disappeared.

I asked my secretary to give me a few minutes before sending the next patient in. I sat in stark solitude, wondering if I should have dealt differently with the situation.

I sat gazing into the empty space, brooding on the correctness or otherwise of my decision. The irony was that scientifically, there was another course of action open to me.

On humanitarian grounds, however my conscience was clear. I was happy with the decision I had taken.

At Polana Hotel

I finished my meetings in Maputo and the family joined me for Christmas and New Year at the Polana Hotel. I returned home on January 4 and rang my associate who looks after my work when I am away. “Any problems?” I asked him.

“It has been relatively quiet over the holiday period,” he said and named a few patients of mine he had seen.

“And one more thing,” he said almost as an afterthought. “I had to admit one mastectomy patient of yours. She was jaundiced and breathless and investigations showed metastasis in the lungs and liver.”

“Is her name Emily?” I asked.

“Yes it is. How did you guess?”

“Tell you when we meet,” I said. I went to my office in the hospital before visiting Emily in the ward. I told my secretary to give me Emily’s file and read my notes of December 3.

“Patient full of life. Talks only of her son’s wedding and Christmas.

On examination:

• Scar satisfactory

• Right axilla and supra-clavicular region clear

• Opposite breast – ditto

• Abdomen – Liver tipped, suggestive of some enlargement

• Conjunctivae – jaundice ++

• Auscultation: Breath sounds wheezing

Diagnosis: Likely metastasis in lungs and liver.

Conclusion: Between a rock and a hard place.

Decision: She is so much looking forward to her son’s wedding and the first Christmas with the new bride.

Ultimate outlook unlikely to be affected by conspiracy of silence. Perhaps in this case ignorance is bliss.

Full of trepidation

I was full of trepidation as I walked over to see Emily in the hospital.

“I am sorry,” I said.

“Don’t be sorry,” she replied. Then looking at me, with her feeble, yellow eyes, she added.

“You did the right thing. The expression on your face changed when you put a hand on my tummy and looked into my eyes.

“I knew then but thank God you kept mum, because if you had advised me to come in for tests and treatment, I would have flatly refused.

“No force on earth could have made me miss my son’s wedding or the first Christmas with the newly married couple. Everything else had to wait.”

“Alright,” I said with mixed feelings, “you have relieved me of a huge burden.”

As I drove home that evening I said a silent prayer: “Oh God forgive me and all my colleagues for sins of omission we commit in the interest of our patients!”