Tropic of Cancer
Outside a pandemic rages. But in a hospital room Madhavi Sakhardande watches her mother, Dr Pushpa Sakhardande, make war on the cancer that began as a cough.
The Doctor as Patient
Shot by Madhavi Sakhardande, Edited by Yatharth Golchha
My mother coughs, doubling up and gasping for breath, but continues working away in the kitchen. We have just watched Contagion and I wonder aloud if she has Covid- 19 too. A dry hacking cough that seems like her lungs will fall out from her mouth. “Gappa bas,” she says. “Shubh bol.” (Shut up. Say good things.)
It’s March 2020 and we are at the beginning of the insanity called the Novel Coronavirus - Covid-19 (SARS COV-2) pandemic. As always, we never saw this coming and many assumed it would #gocoronago. In India, the virus was to disappear within minutes of its arrival, thanks to the perfect and fortuitous alignment of the stars and planets, the cacophony of pots, pans and conch shells, and the applause of 1.2 billion+ people to honour all essential workers.
Meanwhile in February 2020, my mother, a 69-year-old doctor, comes down with severe bronchitis. But Covid - 19 testing is hardly available. Countries are scrambling to do what they can. Ours imposes a lockdown with a preparation time of four hours. Once the lockdown ends, our household help Jaya is finally allowed into the housing society, and my mother takes a break from the household chores. She cannot return to work because the government has prohibited doctors above sixty years to work in light of the pandemic.
By this time I’ve returned to Mysore and the media course takes up all of my time. The next few months move into a blur.
Her cough persists and two Covid - 19 tests are negative. In October, she is able to visit Dr Sujeet Rajan, the chest physician, who rules out both cancer and tuberculosis. The gastroenterologist diagnoses GERD (Gastroesophageal reflux disease) and prescribes medication to provide relief from the constant acidity and acid reflux she has been suffering from, the past few months.
In November, she starts getting low grade temperature in the evenings. ‘’Hope it’s not cancer,’’ I say. An unrelated cough and evening temperature are two most common symptoms. Madhavi, the Google Queen. She says no, that there would be other indicators: her CBC (Complete Blood Count) would fall. Her blood reports are still within normal ranges.
In December, as my course becomes more intense, I forget all about my mother. She travels to Dadar one day and comes down with fever the next. She instinctively feels something is terribly wrong and goes for a series of blood tests. Her WBC (White Blood Cell) count has dropped to 2500 (normal range 4000-8000) in less than a month. Dr Rajan refers her to a haemato-oncologist, Dr Samir Shah.
2021 begins on a miserable note. In the first week of January, she undergoes a bone marrow biopsy. Her reports come on January 12. I remember exactly what I’m doing that time in the evening - I wait and wait for her phone call, then try to distract myself with chores. Around 7:30 pm she messages to ask for a video call. And I do not want to talk. If I ignore, it will not be real and will go away. “It's malignant,’’ she says.
The PET-CT Scan shows enlarged pancreas and nodules in the spine, so she undergoes a painful pancreatic biopsy to determine the type of the cancer. It’s Non-Hodgkin's Lymphoma, which the doctors later determine to be Acute Lymphoblastic Leukaemia (ALL). The cancer originated in the lymph nodes, and has now reached the bone marrow, from where it has entered her blood stream and consequently the rest of her body—the reason the nodules have showed up in her spine as well.
Mother’s cough is now so bad she can barely speak. She sleeps more, around eight hours into the night and another two in the afternoon and is exhausted all the time. We have Zoom calls with Dr Rajan and Dr Shah to decide on the treatment plan.
She decides to get admitted to the hospital for chemotherapy but is discharged within a day after reports show a Urinary Tract Infection (UTI). Chemotherapy cannot start for the patient unless the body is absolutely clear of all infections, no matter how minor. Dr Rajan prescribes a ten-day Intravenous antibiotics cycle which gives her terrible nausea and kills all appetite. By this time, my sister and I have finally returned to Bombay.
She suddenly refuses chemotherapy. We try to reason with her, she owes it to herself that one chance. Then as word spreads, the phone calls start—from childhood friends who are now doctors in the US, and also some colleagues from the hospital. They try to convince her. Dr Shah feels she has a fighting chance, despite her low weight, age, and advanced staged of the cancer.
Ultimately, it’s always the patient’s decision.
For her seventieth birthday, February 4, which is also World Cancer Day, she cuts a cake she has no inclination to even taste. And tells us that she will go through one round of chemo. The mood in our home changes from grim to hopeful.
The treatment requires a minimum of three weeks stay in the hospital. The continuous cycle of drugs lasts four days, the effects start to show around day five or six and the patient has to be constantly monitored and observed for all possible side effects.
A hundred different cancers and more than a hundred different side effects.
All cancer patients undergoing chemotherapy are susceptible to infections, minor and major. Their systems are immune-compromised, so something minor for a healthy person can turn fatal for a cancer patient.
She insists on being admitted to Bhatia Hospital, her second home. Or maybe her first home; she has spent more hours at the hospital since she joined as an anaesthesiologist in 1979, than at any other place on this planet.
She is admitted on February 10. En route to the hospital, we play her favourite songs in the car. She hums along cheerfully. Expect the worst and hope for the best.
The daily tests begin upon admission. Liver function tests show obstructive jaundice; the enlarged pancreas are pressing on the liver. She is immediately put on steroids. In the next twenty-four hours, she puts on three kilograms and develops oedema as a result of the steroids and water retention. Her face and body look like she has been stuffed with a squishy sponge.
Chemotherapy is again delayed. We must wait for the jaundice to ebb and the pancreas to return to its normal size. Thankfully her appetite remains and she has been allowed to eat anything and everything homemade, including ghee, cheese, paneer and other proteins, sweets like ice cream, gulab jamun, and shrikhand. My mother-in-law starts sending her lunch and dinner every day. She cooks whatever my Mom wants to eat.
Then comes the Attack of the Dieticians. It begins innocuously enough—a visit from the dietician to ask what mother likes to eat, instructions to give her protein powders. But that’s the thin edge. The instructions begin. Make her drink milk four times a day, make her eat this and that, paneer, cheese, milkshakes, hummus, pizza in the morning, the list is endless. They keep pestering us with calls and visits several times a day. They want me make sure she eats food enough for one family. By day three I am ready to tear my hair out.
I speak to Dr Rajan and he immediately writes in her patient file, “No Dieticians please.” Barrier nursing is practised. Two surgical gowns are kept outside the room and all those who enter have to wear disposable gloves and the gown. The number of health staff looking after her is kept to a minimum. Four nurses, experienced in caring for cancer patients are assigned. Masks are compulsory anyway. The pandemic is still raging and cases are again increasing. No visitors are allowed.
Her chemo cycle finally begins on February 14 2021. The atheist in me appeals to St Valentine to look after my mother. A Central Venous Catheter (Central Line) is inserted into her neck. The first drug given is Methotrexate, in use for chemotherapy since 1946, to ensure the cancer does not spread to the brain.
The next four days, she is on a twenty-four hour continuous cycle of drugs: chemotherapy, antibiotics, one IV line for fluids. Some drugs have a six-hour duration, some three, some one. The central line is divided into three ports - one for the chemo drugs, one for the IV fluids, one for drawing blood samples. She is in good spirits, is eating well and also moving about. The drugs are monitored and their flow controlled through a specific machine. It can be disconnected for only a few minutes, and beeps loudly when that happens. Interrupting the flow can cause a delay and domino effect for the next drug.
Dr Rajan visits every day, and my mom always feels uplifted after talking to him. Dr Shruti Tandon, the ICU Intensivist is also part of the team. The Intensivist is responsible for the ALL patient in case of an emergency ICU situation due to sudden severe infections, internal bleeding, falling blood pressure or respiratory distress.
The drugs cycle finally ends at 3 am on February 18. As the drugs not only destroy the cancer cells but also healthy marrow, the patient's CBC counts go into free fall. Next few days, her WBC plummets to 250. Platelets drop to 40,000 (normal ranges 1.5-4.5 lakhs).
Mother has never been anaemic in her life. She is now. From a very steady 12.5, her haemoglobin drops to 7.5. She looks at her palms every day and predicts how much it has fallen. “9. 2,” she says one day, and the reports confirm it. “7.5,” she says after a few days and again she's spot on. All the falling levels not only exhaust her, but make her feel very low emotionally.
She is given blood and platelets. Dr Pooja, the resident doctor asks me to sign some consent and waiver forms - she senses my anxiety about the transfusion and assures me everything has been verified. The hospital also rechecks the blood after it arrives from the blood bank to verify it's the correct match, and that all protocols are being followed.
My sister and I are going to switch places on February 19. As I prepare to leave for home I do not know if I will see my mother again. Prepare for the worst and hope for the best.
I cannot even hug my mom tightly. With all the internal changes, external bruising and internal bleeding can occur very easily. This is why ALL patients are kept under observation for so many days in the hospital until their WBC count rises to normal levels and stabilises. To prevent any accidental bleeding of gums, she cannot brush her teeth with a toothbrush. Hence the need for the Central Line - she cannot be pricked with a needle.
In the coming days, she is given four pints of blood and platelets thrice. The second pint causes a severe reaction: high fever and rigours. She refuses ICU admission and my sister has to sign the waiver forms. “Whatever minimal intervention is required, should be done in the room itself,’’ says Mother. We disagree, but have to respect her decision.
On March 3, I’m back at the hospital. Her counts are improving and we are all ecstatic when Dr Shah says she’ll be discharged in the next few days.
All this while, I’ve been watching out for the thing she fears most. After the diagnosis, when asked what she's worried the most about, Mother says, "Going bald." Her hair has always been her pride and joy. Dr Shah, in Utpal Dutt style, sotto voce, says, “Who told you? Your hair will not go.” My mom talks about the books she has read, where cancer patients wake up in the mornings to find large chunks of hair on the pillow. We keep up the assurance right until Week 3.
It's terrifying how fast it falls. Like an invisible powerful hand is quickly yanking it all away. When Sisters Shweta, Trupti and Vasudha, comb her hair, they make sure the pile is quickly disposed of before she can see it. Sister Kamini is different. When she's combing one day, she gestures at me to show the amount of hair lost. I'm sitting across the room and gesture at her desperately to keep quiet. Mom has seen the pile. “It's okay,” she says, ‘’It does not affect me anymore.’’
On March 7, she suddenly gets a tummy rumble. In the next twenty-four hours, severe diarrhoea and high temperature follow. She has no strength to get up from the bed and can only take the bed pan. She starts shivering violently with every temperature spike. I cover her with a blanket right up to to her face. Her temperature rises to 103. As I sit on the bed, trying to warm her cold hands, my eyes begin to smart. The effort to control my tears makes my nose water. I grit my teeth and try to focus on something, anything. I think about the time Jerry Pinto was shouting at us and got logged off from Google Meet. We thought he left the call in anger. But then he returned and shouted at us some more, and got logged off again. It was the internet connectivity and providence. I had giggled helplessly, and was glad I was not on camera then.
I remember that feeling and calm down. My mother continues to shiver, but it's less. The IV injection Parfalgan 1 gm (equivalent to two oral paracetamols) has taken effect.
So begins our descent into hell. Her fever keeps returning every few hours as the effect of the paracetamol wears off, and she is given it again and again. Night turns into day into night. It's only my mother, the fever, and the nausea that has also arrived to say hello, and stay on for the next one week. Her diarrhoea has stopped thanks to a tablet called Enoff. All those energy reserves, lost in one day.
They send her blood samples for a series of tests. Her stool sample needs to be sent to the Jaslok Hospital lab for very specific tests. We look at the resident doctor in frustration. “What a load of crap,” I say. My spouse, volunteers. He says he'll take the sample to the ends of the earth if need be.
Mother has lost all appetite and can now barely get out of bed. Every time she sits up, she gags. Her weight, so steady for three weeks since hospitalisation has dropped to 33 kilograms. We lose track of all the drugs that are being pumped into her being. She is on antifungals, antivirals, anti-malarials, drugs to reduce nausea, and a whole bunch of oral medication she struggles to keep down. One IV line stops, another begins. She is barely getting two to three hours of sleep. Other antibiotics that need to be given after the main chemotherapy cycle are also on. All blood and culture reports are normal and the doctors cannot figure out what is wrong with her.
She bears it all as she always has, without a word of complaint.
As the fever comes and goes, she becomes more exhausted. One such day as the fever has spiked, I am giving her a cold compression, she begins to cry . ‘’I am tired. I want to go home.”
“Just a few more days, and you will be home.” My own voice sounds stilted even to me, like a customer care associate saying, 'Thank you for your time.'
The gastroenteritis panel test reveals a parasite called Cryptosporidium, commonly found in swimming pools, rivers, and lakes. These are the exact infections we have been warned about. She is given a new set of medicines and finally begins to feel better. As her strength returns, she tries gradually to stand up one day to check her weight. She's light as a feather and is supported by three of us, yet that effort drains her completely.
Mavshi Jyotsana gives mom her first bath in two weeks. My mother is more determined than ever now to move around the room as much as possible. Baby steps drain her, but she persists.
Her CBC counts - WBC and platelets are now within normal levels. Dr Shah does a bone marrow biopsy. The report shows no evidence of minimal residual disease.
Three hospital room changes, and five weeks later, my mother is finally ready to go home. We thank the amazing sisters for their beyond comparable care, understanding, and kindness. The mavshis specifically assigned to our room have been absolutely wonderful and helpful. Mother cries as she thanks them all and bids goodbye.
Dr Shah drops a bomb on us when he tells us the next chemo cycle two weeks on, will be even more intense. My mother is not keen on any more chemotherapy. “I’ll see. I’ll decide later,” she says in that tone of hers that always automatically refutes any opposing view point or argument.
In the next few weeks, as Covid - 19 cases surge and Bombay again goes into lockdown, we’re just happy we’re home - it’s the first time in fifteen years all four of us are home together. After almost a month of deliberation my mother has agreed to a weekly chemotherapy session with the lowest possible dosage of drugs. This will require a day of hospital admission to keep the patient under observation.
“Nobody is immune to it. A very unpredictable journey. Take each day as it comes, and always hope for the best.”