The Yellow Men

Two yellow men entered the hospital within a day of each other. Both were yellow (jaundiced) from cancer blocking the bile ducts. Both memorable since they were my first two biliary stent cases. But what was most remarkable, the thing that has remained foremost in my memory, was the extreme contrast between their personalities, their families, and how they interacted with the people around them.

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Old as dirt, Mr. A. had already survived three cancers. One of his cancers required the surgical removal of his larynx. He used one of those little hand held vibrating devices to talk, an electro-larynx. With this continuous monotone device, the “voice” has no inflection and there are no sharp breaks between words; it is off or on. If you have ever encountered someone using one of these you can relate to how very hard it is to understand what they are saying. On top of that, Mr. A. had very few remaining teeth, making it even harder for him to convey consonant sounds. Maybe it was because of this he did not talk a lot; and he never complained. His only family was a son who lived in the city but not nearby.

Mr. A.’s fourth cancer was the worst one by far; unresectable ductal adenocarcinoma of the pancreas. Unlike most patients with pancreatic cancer, Mr. A. did not have much pain… so far… or did not admit to it if he did.

I went up to Mr. A.’s room and had my first chat with him. It is doubtful I understood anything he said, but I gave him my standard talk about the procedure we planned, a percutaneous biliary drainage (PBD) to open the bile ducts. He seemed to understand me just fine and gave me a big ‘thumbs up’ when I told him we would sedate him for the procedure.

Finally, I brought up the possibility of a metal stent. “Once we have the catheter in place, you might want to let us place a metal stent across the blockage. It is a new thing we are doing. With the stent you won’t need to have a catheter sticking out of you and you can bathe and swim again.”

A series of buzzes, but I surmised he was asking me if I had ever done this procedure before. “I have performed dozens of drainages. My experience with stents is limited to helping with three other cases. You would be my first solo case and the fourth done at this hospital.”

I took the proceeding buzzes and accompanying hand gestures to say, “Let’s see how it goes with the catheter first.”

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The next morning, I found the team in a very raucous mood, nothing out of the ordinary. Mr. A. was already climbing onto the procedure table. Two of our nurses were attending to him. The music was on; the Andrew Lloyd Webber collection.

I walked over to Mr. A., who was now lying on the table with warm blankets over him. “How are you feeling today?”

He mouthed out the word, “Fine.”

“You remember what we talked about yesterday? You’re okay to go ahead still?”

He nodded and gave me his classic thumbs up.

With the sedation, Mr. A. slept through most of the procedure. In Mr. A’s case, it did not take long to get a needle into his bile ducts, since they were so dilated from the blockage. Injecting contrast and watching under the fluoroscope, the blockage of the main duct from the cancer was quite obvious. Working through a sheath, I very quickly, and almost accidentally, crossed the blockage with a wire and then a catheter. Strangely, at the same time, everyone in the room was quiet so that the start of a new song on the CD player came as a bit of a jolt.

“Jesus Christ Superstar! Do you think you're what they say you are?”

Everyone laughed then all started talking at once. One nurse told me sternly, but with a hint of a smile, to not let such a coincidence go to my head.

“Coincidence? It was a miracle!” I heard only mumbling and snickering in response. “Maybe I AM a god?” Many disgusted looks. “How are we doing with the sedation? This next part is going to hurt a bit.” I then proceeded to place the drainage catheter.

I’ll get back to Mr. A. later.

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Mr. C. was admitted into the hospital the same day I worked on Mr. A. He looked younger than his stated age of 67. He came with a diagnosis of metastatic gastric cancer blocking the main bile duct. At another hospital a PBD had already been accomplished. He was here for a second opinion. So far, he had refused any other treatment. I was asked to review a CT scan and compare it with a prior exam from the outside institution. The cancer had spread to lymph nodes which were blocking his bile duct. Most alarming was the rate of progression over only a month; a very aggressive cancer. A stent would be appropriate. The doctor I reviewed the CT with requested I talk directly to Mr. C. about it.

Mr. C. was the patriarch of a very large, close family. I guessed they were of central European heritage, probably Romani, but I was never sure. His entourage liked to “camp out” in his room and in the halls outside of his room. At my first visit, there were at least a dozen family members of all ages, mostly women, all around. I don’t remember an introduction to any of the family members… ever.

“Hello Mr. C., I’m Dr. Kriegs…”

“How do you spell that? Is it Gerrrman? Do you have a card?”

Not a good first impression from my standpoint.

As I watched, his face turned angry and red, “Sophie! Come take this blanket now, I’m too warm. More ice, too!”

One of the younger women, probably still a teenager, scrambled over and complied with his requests immediately, muttering, “Yes, Papa. Yes, Papa.”

The rest of the women were suddenly alert looking around, trying to find the next thing he wanted before he wanted it.

“Well? What have you got to tell me, doctor?”

With my detailed explanation of the stent procedure, I included the fact I had never placed one on my own before, but also that I was very eager to “give it a go” if he so desired. At that point, based on my small glimpse of what kind of person I was dealing with, I had lost any desire to work with him and, from his history, I doubted he would let me do it anyway. It was actually a relief to be able to dwell on my inexperience. All through the discussion, he would wave a hand or give a “look” and one of the women in the room would respond (handing him a tissue, pouring more water, raising the head of his bed) as if reading his mind. He had them stirred up in such a way, he didn’t need to yell or even speak to them.

“Okay. I like you. You can learn on me.”

Lucky me.

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Mr. A.’s room was just around the corner, on the other side of the nurses’ desk. Reviewing his chart and visiting with him, I was glad to find he had done well through the night. He wanted me to talk to his son about the stent placement. If his son thought it was the right thing to do, he would do it. On a piece of paper, he wrote down a local phone number for his son, which he labeled “work.” I nodded agreement to the plan and backed out of the room as he grabbed the electro-larynx and incessantly thanked me and my team for all we had done. I thought it interesting he had a son living in town, but here he was all alone, while Mr. C., who was from about 100 miles away, had swarms of family around him.

My phone conversation with Mr. A.’s son was friendly, but business-like. He gave me the sense he felt deeply for his father, but more pressing things needed to be dealt with at the moment.

“Doctor, my father needs to be comfortable now. That is all we can do for him. It sounds like this ‘stent’ would make him more comfortable, without the tube sticking out of him and all. They’ve told us he only has a few months, so let’s go ahead. Can you do it today?” So, Mr. A. became my first biliary stent case.

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As I stepped into the procedure suite, the music suddenly blasted.

“Jesus Christ, Superstar!”

It startled me at first, but then I knew what was happening. I stepped backwards out the door, and the music stopped. Stepped back in… it started. Out… it stopped. In… it started. With my arms out, hands up, I lifted my chin a little, in what I hoped was an arrogant stance and said, “Yes, my children, I am here.”

We proceeded with the stent placement in the fluoroscopy suite. The stricture was dilated with a balloon catheter. The first stent deployed very nicely across the narrowing. Then after a few seconds, before our eyes, it slipped… migrating to a position above the stricture. I groaned in complaint. A second stent was placed across the stricture, partially nested within the first stent. It migrated the other way. “Ah no!” (Expletives deleted.) It was what we call the ‘greased watermelon effect.’ I was not happy, of course, and the room went quiet, the music shut off.

But the third stent was the charm, centered at the junction of the first two stents, perfectly placed. My final look showed robust flow through the stents into the duodenum.

So, my first solo stent procedure had had some problems and, frankly, I wasn’t certain at the time if there would be any ramifications.

The next morning, I checked on Mr. A. According to his nurse, he’d had a bad night, with a lot of discomfort, requiring a morphine pump. Entering his room, I was surprised to see him sitting comfortably in a chair. He started to get up, but I held my hand out like a school crossing guard and he relaxed back into the chair. When he held out his hand I shook it, nodding my head as I questioned, “Feeling better this morning? Sounds like you had a rough night.”

Lifting his electro-larynx to his neck, he smiled and began by saying, “Bzzz bzzz.” I took that as, “Good morning!” Continuing, I found I suddenly could understand him better, “Bzzz ‘ank you ‘ery mu’ bzzz. Bzzz er’y un ‘uzz ‘rate! Bzzz.” Setting down his buzzer, he grabbed my right hand and shook it ferociously, mouthing the words, “Thank you” at least three or four times.

He was a happy guy.

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We had Mr. C. on the schedule that morning. When I returned to the department from Mr. A’s room, there was a mysterious phone call for me on the general radiology line; supposedly another doctor.

The tech supervisor on duty was apologetic, “Not sure who this is, but he insists he is a good friend of yours. Wouldn’t give a name. Sorry.”

“Probably a rep or a salesmen, they’re always claiming to be good friends of mine.” I picked up the line, “This is Dr. Kriegs.”

“Doctor, I need to talk to you about this procedure. I have a few more questions.”

I was shocked. It was Mr. C. calling from his room but over an outside line. Somehow he knew I had placed a stent on another patient who had been in pain during the night.

“Doctor, I don’t want pain.”

It was very concerning that he knew ANYTHING about the other patient, but then again, his room was very close to Mr. A.’s room and the desk was right outside his door. Had Mr. C. talked with Mr. A.? Had he gone to see him?

I found out a few minutes later from one of the internists.

“Hey, Kriegs, tried to kill my guy yesterday with those stents, eh?”

“What do you mean, he looks great today?”

“Oh boy, was he hurting last night! The nurses didn’t pick up on it right away. Stoic little guy. They called me when his pressure went sky high from the pain. If they’d just looked at him… you could tell he was hurting! But we took care of him. AND I gave the nurses at the desk a good piece of my mind. They complained they were too busy with Mr. C.! Apparently Mr. C. was demanding something from them every five minutes or so!”

Then it all made sense. Mr. C. must have heard the ‘goings on’ with Mr. A. outside of his room.

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With Mr. C.’s concerns about pain, I went ahead and arranged for anesthesiology to help us out. The procedure would be much nicer for us with him asleep anyway.

“If you want to go ahead, I have arranged for anesthesia tomorrow afternoon. We will shoot for 1 o’clock, but it could be later, since the morning surgeries sometimes run late.” Mr. C. was not looking at me and acted like he hadn’t heard me. I continued, “To do it in the morning, when the start time would be more predictable, we would have to wait until next week.”

“Sophie! This water is not cold! More ice! More ice!” His face was contorted and angry, staring at Sophie and then the door long after she had run out of the room to find ice. It occurred to me there might be a simple association between his anger and needing ice. After at least 20 seconds, Mr. C. turned to face me. His face seemed to melt, into an expression of… defeat? No, it was still too condescending… but as he spoke again, he betrayed his underlying fear. “This stent is for people with not curable cancer, is it not?”

“The only approved use, yes.”

“I am not about to die yet. They will cure me. Don’t you think?”

“That is not my area of expertise, I cannot say. Are they offering you a treatment?”

“Tomorrow I am to be seen by on-ko-loh’-gee and radiation. You are not radiation, also?”

“No, I am radiology, not radiation oncology.”

“Well, can your stent cure me?

“No.”

“Will it make me un-curable?

“No, it will not change the extent of your disease. It will not make you incurable if you are not already. I don’t think it will interfere with any treatments, but it is a new thing. Maybe we should wait ‘til next week, after they have seen you and confirmed the stent will not change your eligibility for a treatment.”

“Yes, this tube is fine for now… we will wait.” He took a sip of cold ice water and looked at Sophie and nodded approval.

I eventually did place a stent in Mr. C., my second stent patient. Using only one stent, all went well with very little discomfort, even the first night. But he would NOT let me take out the tube, even though he didn’t need it anymore. He was afraid of not having it when he needed it and didn’t want to ever have to have another put in. He called me one other time on the phone in the general radiology department to discuss pulling the tube, but I could not give him a good reason to pull it if he didn’t mind having the tube. He said, “Let’s pull it when I get better.” He underwent chemotherapy. He never left the hospital.

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Mr. A lived another nine months without much problem, which is extraordinary for his disease. At that time, he came into the hospital with a massive GI bleed.

“Kriegs, he’s going down the tubes fast. He’s on hospice, but his son isn’t comfortable doing nothing, if we can stop the bleeding short of doing surgery.”

I went to the ER and talked to him and his son. Mr. A. was quite a bit thinner, but very happy to see me, smiling and shaking my hand rather vigorously, considering his condition. Mr. A. did not want to die yet. I saw the fear in his eyes of someone who knows they don’t have much time. To him, I was the chance of living a few more days or weeks and he wanted that more than anything. Akin to waking up feeling very groggy, near the end of a pleasant dream, and looking at your alarm clock, relieved to see you still have 10 minutes to sleep before it goes off. So you quickly go back into your dream, feeling happy for those ten extra minutes.

Not far into the arteriogram, we found the bleeding. We could see the contrast injected into the artery pooling in the bile duct, oozing through the stent from several sites. Mr. A. was likely going to die in just a few hours, possibly minutes, if we didn’t stop it. The room grew tense.

“Can someone PLEASE change that music?” A very dissonant northern Africa piece of music suddenly stopped, but no other music was put on, since all were quite occupied with the case.

After a number of coils were placed to block the offending arteries that had been eroded by the tumor, the bleeding had stopped. The stents had allowed him a very good quality of life, but now, by holding open the duct through the tumor, his body’s natural means of stopping the bleeding was thwarted. The coils would not likely stop the bleeding for very long.

“I’m pulling out the microcatheter. Let’s wait a few minutes and see how he does. Can we have some music, please?”

The mood was improved; the patient was improved. He didn’t bleed anymore that day and was discharged a few days later. No obvious adverse reaction to the procedure, but he was quite a bit more debilitated; very weak and unsteady. He couldn’t go home, so he went to a nursing home. About 10 days later he bled again and died in the nursing home. I hope he was ready, but I doubt it.