A couple of months back, I interviewed a Melbourne doctor, Cathy, who operates on children who have been diagnosed with cancer. Close to lunchtime, the waiting room became packed with parents bearing bored expressions and children joyfully playing with building blocks. The entire interview process took 4 to 5 hours, during which I spent a considerable amount of time in the surgical theatre watching Cathy perform her surgeries on patients.
In the beginning, it was painful to watch young toddlers being turned on their backs and witnessing long needles being pricked into their spinal cords. All of them are leukemia patients, some as young as two. The bone marrow is the factory of one’s blood cells, and there are three types of cells: the red cells, which carry oxygen around and the white cells, which fight infections and palates, and make your blood clot. For patients diagnosed with leukemia, of which the most common age group are children aged 4 to 11, those white cells have gone malignant and filled up their entire bone marrow.
Apart from psychological side-effects from chemotherapy, patients might suffer a rash outbreak on their face, get a really sore mouth or ulcers, put on or shed a whole lot of weight from steroid treatments. They lose their appetite along with their hair. Unsurprisingly, it is the teenagers who have greater difficulty coping with their illnesses, more so than younger children, due to the former’s desires to fit in with the rest of the crowd and the constant fear of their fragile mortality.
During lunch break and in between operations, I walked around the surgical theatre interviewing staff who were on the doctor’s team. For them, the operating theatre is their workplace. Their clients, sick children. Their tools, surgical equipment.
Below are disjointed excerpts from my article of what I witnessed during my trip to the hospital:
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The cries of a child fill the white-washed operating theatre at the hospital. Long, snaky tubes connected to a beeping anaesthetic machine observe an intimidating posture next to the child. Big, white fluorescent lights resembling giant laser disks fix its hostile, beady glare on the child. Members of the surgical team attempt to put a gas mask on the child, but their persistence only makes him wail louder and kick his legs harder. This is the theatre where bone marrow aspirates and lumbar punctures are carried out on oncology patients.
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Katrina* is not happy. She is dressed in flamboyantly bright colors, her attire consisting of a two-tiered denim skirt and fluorescent pink socks spotted with white and pink hearts, but her mood is reminiscent of an approaching dark storm. “No lumbar, no more lumbar,” she protests to medical staff and helpless parents. Minutes later, the protesting child is wheeled into the operating theatre, another statistic in a theatre list of sick children. The situation can easily turn depressing, but the team keeps the spirits up. In the theatre, surgical equipment, thick files and uplifting smiles are jostled around. Apart from the perfect symphony of teamwork in the theatre, there is an orchestrated effort to maintain a cheery and jovial mood. The scent of optimism lingers in the air almost as strongly as the smell of anaesthetic.
Prior to the lumbar puncture, Cathy sterilizes Katrina’s back with antiseptic and inserts a needle into the spinal fluid, which is found in a balloon-like circuit of fluid that surrounds the spinal cord and the brain. The cerebrospinal fluid sample is later sent to the laboratory, where tests are conducted on a microscope slide to detect any presence of leukemic cells in them. Cathy then inserts a syringe filled with Intravenous Chemotherapy, a yellowish fluid, into the child’s back to protect her from leukemia.
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It is 10.50am. A young Chinese boy, Trevor*, is wheeled into the theatre, accompanied by his anxious-looking mother. The anesthetist puts Trevor to sleep, the mother leans down to whisper reassuring words and gives him a kiss, before leaving the theatre. The anesthetist technician, Steven, lifts the child’s shirt up and curls him into a fetal position. A visible bump like a plastic bubble underneath the skin – the fluid port which is the central line used to extract blood or feed drugs straight into Trevor’s blood vessels – along the top right side of the torso comes into view. Besides the anaesthetic, a green mask containing sleeping gas is fitted over Trevor’s mouth to keep him asleep throughout the procedure. Jessy, the oncology nurse, uses a right-angled needle to access the port. Prior to the port accessing, she plies the line with saline and cleans the port externally. She proceeds to withdraw the needle and the sight of blood confirms that it is in the right position. Following which, she flushes the port with saline to prevent it from getting clotted and plants a dressing over the port to fasten it into place. Jessy then inserts a gastric tube down Trevor’s nose and into his stomach, to feed him extra nutrition as he is not well enough to eat properly.
Prior to the bone marrow aspirate, Cathy double-checks the child’s names, details and medical history with Jessy to ensure that the right chemotherapy is given. Cathy then sterilizes Trevor’s back with antiseptic and inserts a needle to extract a sample of bone marrow from the back of the child’s pelvis. She extracts a couple more samples while Jessy assists her to transfer the bone marrow into tubular glass vials. Speed is key. Bone marrow gets clotted faster than normal blood, and the specimen can’t afford to go to waste.
The process, which is called a Minimal residual disease (MRD) test, shows the percentages of blood cells in the bone marrow which will determine the effectiveness of the chemotherapy. Cathy places part of the samples of the bone marrow onto microscope slides and packs them into filing sheets to be sent to cancer and oncology groups in America for further studies and research purposes.
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In another surgery during the day, Cathy conducts a bone marrow biopsy, which is done after the aspiration. The child has a low blood count for unknown reasons, and doesn’t necessarily have leukemia. She attaches a trephine, a surgical instrument with a cylindrical blade, onto the child’s back to extract a core sample of bone with the marrow inside to examine under a microscope. The procedure is done when a small needle is insufficient to suck out enough bone marrow, and so a biopsy is done for extra information.
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It is 12.15pm. The team is seeing its last patient for the day, an overweight girl who has to stay awake throughout the operation because she has difficulty bending and needs to sit up in order for the team to find her spinal fluid. Mohammed, the anesthetist assistant tells the girl to get into an ‘angry-cat position’ which is essentially a hunchback posture, so that he can find the location of her spine. Before Mohammed inserts a needle into her back, he warns, “This might sting a little like a muzzle bite.” The girl’s mother is present, and the team makes a huge effort to create a stress-free environment by engaging in casual conversation. The girl stiffens her upper jaw and burrows her head into the pillow during the procedure. After the needle is pulled out of her back, Liz, the senior anesthetist jokes, “The pillow’s got a big bite out of it.” And, everyone in the room laughs, including the girl.
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*Names have been changed.
Afternote I: During my visit to the hospital, I witnessed parents of cancer-stricken children with gloomy expressions, and then I turn my focus to the kids. Happy, carefree smiles all over. How do the children deal with such painful, invasive procedures? The truth was that the children were all very strong and their illness hardly bothered them. Rather, it was the adults who had difficulty coping, and not the children themselves who have to pay several visits to the hospital and endure multiple needles poked through their skin twice or thrice a week while children their age frequent beaches and playgrounds and come home with a scrapped knee or elbow. How nice if we could all be like the kids, full of painless joy. I came away from the interview with a brand new perspective: That we are all growing up, but we should never lose our fragile child-likeness. Fragile, because more than often, it withers away with age.
Afternote II: This article and interview, of course, would not have been possible without the kind permission and grace of Cathy, who not only took time off her busy schedule to answer my questions, but also allowed me into the operating theatre where she worked and to interview her team members.
They can get a really sore mouth. What happens is chemotherapy attacks rapidly dividing cells, so that’s the cancer cells that are reproducing really quickly, your hair cells, your skin cells, so the cells inside your mouth are very sensitive, so they can get mouth ulcers and really sore mouth. They can lose their appetites, they lose their hair, they can lose a lot of weight, and one particular drug – steroids – can make them get very bloated, and they can make them put on a lot of weight, because when they are on steroids, they can get very, very hungry, and they don’t really care what they eat, they are just ravenously hungry.
