Surgery questions

Tomorrow I’ll be set free.  Unless I collapse tonight, all wounds open up or my reconstituted gut ruptures, I’ll walk out of the hospital tomorrow by 10.  This matches exactly the prediction made by the doctors right after the operation.  The nurses and carers have done a great job getting me there.  I’m grateful to them and glad that I’ve met their expectations.  What was extremely tough at the beginning has now turned into a cruise, as if I were rolling towards the easy finish of a difficult mountain stage, well behind the leaders but safely ahead of the broom wagon.

My belly, sliced open and stitched back together.

Before they let me go, a surgeon will update me on how things will continue, when I’ll have to come back, what I’ll have to look out for.  It’s good to receive advice.  It’s better yet to have questions ready and not think of them later and regret not having asked.  This is what I’d like to know:

• When can I go back to work?  Will I be held back in any way?  This is really the most important question to me.  Without deluding myself that this is possible, I’d like to have the life back that I had before.  Work is an important aspect.  I don’t want to waste time at home when no one else is there.
  → The doctor was rather suspicious about my going back to work.  Worse, she hinted at an extension of the sick note beyond the two weeks given.
• Can I travel for work?  How would it be perceived if I tried to reschedule consultations and appointments to be able to travel?  Travel is an important part of my work, and one that I like.  It keeps me fresh.  Treatment comes first, but how flexible can I be?
  → We didn't get to talk about treatment flexibility.  When the doctor grounded me for six weeks after the operation, there was no need to say more.
• Should I make changes to my diet?  What should and should I not eat?
  → Before the surgeon came, a nutritionist educated me about a diet rich in protein and energy.  I need to gain weight and am supposed to eat as richly as I can.  This will require dramatic adjustments.
• Can I expect my digestion to go back to normal?  When will this happen?
  → With time.  It all depends…
• How is my gut microbiome?  Has it suffered during the operation or the past week?  How can I get it back to its full beneficial diversity?
  → A good question, but I forgot to ask it.
• Should I make changes to my lifestyle?  When can I go running again?  When ride my bicycle?  Is there a limit to physical exercise, such as climbing the stairs to the ruin above Baden?
  → Physical activity is good, but I need to take it easy.  No bicycle for the moment.
• When can I expect to be as physically fit as I was before the operation?
  → A pointless question that I didn't ask.
• When will I regain my weight?  Since shortly before the diagnosis, I’ve dropped a good ten per cent.  This might be all right were I fully fit, but to fight cancer, I might need a bit more beef.
  → These were exactly the nutritionist's concerns.
• What might happen that should worry me?  Are there warning signals if further recuperation stalls?
  → Pain, fever, the usual.
• Do the stitches holding the cut in my belly need to be removed?  When will this be done?  How do I care for the scar lest it morph into something resembling an ugly zipper?
  → The stitches will dissolve.  I forgot to ask about how to care for the scar.

This post will be adapted as I get answers.  The oncology questions might go into their own post at some later point.  This blog is fluid.

Relaxing time

The weekend shapes up very differently to the days before.  It’s quite a bit calmer.  There are fewer doctors around and less activity.  When the morning rounds are done, the patients that don’t require constant care are on their own.  Freed of Fred and all outward frills of a patient beside the wristband and my shameful sweatpants, I can go wherever I please and do what I like.

It’s important to be back for lunch at half past eleven and the inspection that comes with it.  Blood pressure, temperature, heart rate, oxygen saturation.  All good, no pain, no worries.  After lunch I rest for half an hour to help with digestion and read or listen to podcasts.  Afterwards, I write or read more.  Visitors arrive after 1 pm.  The entire afternoon is to my own disposal, with no obligations and nothing to do.  I could almost get used to it.

I enjoy it the most because this afternoon, the bag covering the hole into my abdomen was removed.  The hole had closed by itself, healed.  Only a small patch of gauze reminds me that I was carrying a bottle with red-orange liquid with me not too long ago.  At the same time, the tape covering the long vertical cut on my belly was replaced on my express demand.

When this was done a day earlier, I had lounged as if on a Caribbean cruise, my upper body slightly raised by the magic of the adjustable hospital bed.  For this decadence I paid dearly because the tape followed the shape of my body in this position, and held it there.  For a day, I walked like the semicolon that I am.

Now I’m a normal person enjoying two relaxing days off.  I’m normal in all respects besides the microscopic cancer cells that still suffuse my belly.  They are still there, they are growing, and they are evil.  I don’t forget about them, but since I can’t do anything about them right now, I don’t think about them either.  They will be dealt with later.

Hard work

Around the operation, I didn’t eat any food for nearly 90 hours.  For a good ten hours before I was rolled into the anesthesia room and 75 hours afterwards, all that entered my body was saline solution through two intravenous drips and sometimes further solutions with painkillers.  Towards the end of this enforced fast, I was allowed still mineral water, first safely spaced individual sips, then larger gulps.  My stomach, an innocent bystander not only in the surgery but also in the entire colon cancer tour, must have been empty like a teaching model.

Two mornings ago, I found two metal pots on my bedside table.  One was filled with coffee, the other with warm milk.  This was better than water but far from my idea of breakfast.  Drinking up took me until the coffee was cold.  My insides couldn’t cope with it faster, and my belly told me to stop, but then came lunch and then dinner, each a bit richer than the meal before.

I drank and ate it all and suffered for it.  I struggled with my gut, fought against pain and enabled digestion.  This was hard work.  I stayed in bed for most of the day, in similar exhaustion to the day after the operation.

Eating has become a deliberate process.  It takes hours.  I start by surveying the food, choosing which item I would like to ingest first.  What might go down the easiest?  What might cause the least trouble?  I eat in slow, disparate bites, every single one a decision I make at the right time.  After the first bite, digestion has to be kept under constant vigilant surveillance.  Output tends to be as fast and furious as input is slow and controlled.

For a moment in the evening I was struck with how little progress I had made today.  I feared I might have slid back.  I had walked much less than the days before.  I had ventured outside the main building but had to return quickly because Fred didn’t like the bumpy ground that messed with the drop sensor on the IV drip.  The pumps beeped in panic with every second step I took.  But maybe things aren’t quite as bleak as they appear.

• I ate proper solid food, little bits of meat chops and biscuits – besides plenty of liquid, purée and goo. 
• I got rid of the drainage out of my belly, and the curious bag taped to the opening stopped collecting any liquid in the afternoon.  The healing is clearly underway.
• I was relieved of the intravenous drip at night.  If I go down to the cafeteria now, I might be mistaken for a visitor, were it not for the white wristband with my name and an identifying barcode on it and the blue-grey sweatpants I bought last Saturday in a moment of weakness because I couldn’t see myself in khakis in a hospital for a week.

My food was ramped up from a milky coffee two mornings ago over lunch comprising four containers of liquids of different thicknesses to the next lunch of pureed meat and cabbage cooked to death.  Dinner tonight was a real meal, with meat, mash, a dessert and all.  I’ve paid for this speedy progression.  I’ve also not gained any weight.  Getting my digestion going and keeping it going against the protestations from hurt parties inside my belly took a lot of energy, but now things are rolling.  The weekend should be a real pleasure, relaxing times in a friendly environment.  On Monday, I will be released.

Convalescence

It’s silly to speak of convalescence when the cancer is raging unimpeded.  All transformed cells that survived the surgery on Monday, microscopic chunks invisible to the naked eye and thus too small to be removed by knife and individual cells floating around aimlessly are still around and are as menacing as ever.  The cancer has not been stopped.  The cells will keep growing and do the damage that all cancers eventually do.  There is only one outcome.

But I’ve had major growth removed and the remaining bits of my gut reconnected successfully.  The healing process has started and is progressing well.  This morning, I was given a pot of coffee and hot milk, the first food in more than three days.  In four to six weeks I should be strong enough for the next stage on this tour.  That’s when the cancer will be attacked at the source, with the goal to eliminate or subdue all malignant cells.

Since Monday, I’ve been feeding on infusions and small amounts of mineral water.  This will not get me back on my feet.  On the other hand, my reconstituted gut is weak, recently stitched together in places that had nothing to do with each other before, and, at least at the beginning, not ready for more.  Every time I increase input - drinking more than one sip at a time, drinking weak herbal tea brewed with tepid water, drinking milky coffee - my gut revolts a little bit.  Like me, it is lazy and likes to rest, left in peace and comfort.

Shortly after waking up from surgery.

I am my gut’s carer.  I tell it to get up and move, to exercise, to get its juices flowing.  In contrast to my own carer, I’m suffering for it.  I feel occasional stinging pain that moves with the motions of the intestines, as if things were ripping apart inside.  Since the surgeon told me that it’s the scraping of the intestines on the extensively wounded peritoneum, I can deal with this much better.  This pain is just pain, not a harbinger of worse to come.

Yesterday I walked 2400 steps.  I counted every single one.  The hospital corridor is 170 steps long.  My last trip at night comprised three laps.  I was exhausted afterwards but happy.  My goal for today is 5000 steps.  If I spend more time outside bed than inside it, by walking the corridor and sitting on the table reading or writing, my body should see the direction of this tour.  It’s a tour of convalescence, of hope, of survival.

Live strong

Despite wearing my LIVESTRONG wristband, I can feel the difference between me and Lance Armstrong all the time.  When the nurse leaves me with a little plastic contraption to exercise my lungs, I do it only when she’s around.  Lance would be glued to this thing, thinking of L’Alpe d’Huez and Arcalis with every inhalation.  When the physiotherapist encourages me to move and I trundle along the hospital corridor, Lance would have already badgered her into providing an exercise bicycle to train on.  He was strong.  I’m exhausted and weak.

A reminder that suffering is a part of success.

On Monday morning, I was laproscopied.  The doctors liked what they saw but didn’t think it was in the right place.  They stopped the microsurgery nonsense and made a big vertical cut in my belly, almost from the chin to my balls, and took out without much hesitation:

• Half of my colon with a bulging tumor and a lot of surrounding tissue, including lymph nodes in various states of contamination.
• My appendix – for being in the wrong place at the wrong time.
• My gallbladder – just so, because it’s of no use and might be a nuisance, should more surgery be necessary later on.
• A lot of growth on my peritoneum.
• A network of subcutaneous fat called the omentum.

This is a rather long shopping list, and yet I got away easily.  Kidneys, lungs and liver remained unscathed, though the liver got flipped around a fair bit to exclude anything malignant hiding behind.  I still have my spleen, bladder and pancreas.  And, in contrast to Lance Armstrong, I kept both testicles.

I was warned about general anesthesia, weird feelings falling asleep, vivid dreams that can be directed by will power ahead of time, and a long period of delirious confusion during wake up.  I experienced none of this.  Anesthesia was like sleeping, going in and out of it at the switch of a button.  The time lost sleeping was nothing but blackness.

Over the last two days, I’ve tried to recover.  Progress cannot be denied.  I sleep well at night, suffer no pain, and can stand up and walk for brief periods of time.  The latter surprises me the most.  What I’m I doing walking around a day after the operation? This is not my idea of coming back from the dead.

This is why I was mighty surprised when a carer came this morning and asked me to get up.  I had just been operated on and was feeling rather weak.  She insisted.  You need to get your circulation going.  Lying around isn’t doing you much good by itself, she said.  The first time up from my comfortable hospital bed was painful, full of movements my body wasn’t ready for, with skin stretching where fresh sutures were holding things rather rigidly.  It would have been easy and was very tempting to fall back onto the bed and doze, but carers can be insistent.  By the end of the afternoon, I had walked down the corridor all the way to the end and then back to the other one all by myself, accompanied only by Fred, the five-wheeled stand holding my infusions and pumps.

The surgeon told me that the operation couldn’t have gone better, and that my prospect might be slightly better than before.  A full histological examination of the removed tissue is required to know what’s really going on, but all macroscopic lesions, all visible cancerous growths are gone.  Chemotherapy can now target what remains, microscopic evil of much greater danger, with full force.  It’s not going to be pretty, and maybe I’ll be thinking back to the operation with fondness.  It was an easy ride, the first warm-up in the mountains maybe but not a stage in the high Alps yet.

Day zero

Eleven days after my diagnosis of advanced colon cancer, I have already turned into a different person.  This is very hard to make sense of.  Two weeks ago, I was as healthy a person as I knew, a bit short of breath when climbing stairs, suffering as if I were at 1400 m when playing football all out, and a bit slower on the bike than in the past, but without any troubles or problems.  The stings from my belly that would pierce me occasionally drove me to the doctor, but for the rest of my symptoms, I blamed age.

Now, two weeks later, I’m a sick man, and I feel it.  The pain from my colon is almost constant and sometimes insufferable.  Sleeping is difficult because I’m only comfortable on my back.  Last night, I spent quite a bit of time finding an alternative position, slowly rolling left and right, harvesting pain in the process.  I didn’t arrive anywhere happy.  Turning itself hurt.  I ended up back on my back, sleeping without moving.

Today we went for a hike up to the castle on the right side of the Limmat.  The stairs are steep and exposed, up a plate of Jurassic limestone that sticks out from the surrounding hills like a knife edge.  After an hour of climbing, we reached the castle and enjoyed ice cream and the view.  The walk continued along the hill above Wettingen and took a good three hours to complete.  The girl walked all the way.  The boy was also quite active.  It was a beautiful day, with sadness just below the surface.  When will we have another day like this as a happy family?

When I picked my mom up from the train station late tonight, my state had further deteriorated.  Maybe it was the exertion of a day of walking.  Pain slowed down my departure from home and delayed my arrival at the station.  I was walking like a sick man, holding on to the right side of my abdomen to contain the agony and sometimes to walls, pillars or posts on the way for support.  My mom couldn’t hide her shock when she saw me stagger down the platform towards her.

On the right side of my abdomen was a large, slightly protruding, ovoid mass, hard to the touch.  If that was the tumor, how had it grown like this in less than two weeks?  If it was the result of the tumor blocking the passage through my colon, the short-term worst-case scenario outlined by the surgeon during our consultation on Friday, would I die of it tonight?  It seemed like a distinct possibility, and my planned hospitalization the next day had something of a rescue to it.

It’s possible that today was the last day of the life that I knew.  Worry-free Sundays out with the family, walks and laughter, exploring and discovery, these might be things of the past if things go bad tomorrow.  And even if they go well, how will I keep my spirits up in a struggle that seems to allow for one outcome only?

Tomorrow morning before everyone else gets up, I will check myself into the hospital where the operating table will be ready for me.  In the afternoon I might wake up and find myself without half a colon, maybe missing other parts as well.  Harsh as it sounds, I think this would be a good thing.  It would mean that the surgeons considered it helpful to remove the primary tumor.  I can’t get rid of this thing soon enough, to feel somewhat normal again.  I won’t delude myself into thinking that things are in fact normal.  The race has only started.  What will it take for me to survive?

Knife therapy

A Spanish colleague at work had earlier this week spoken about his impressions of the Swiss health system.  Whatever the problem, whyever you’re seen by a doctor, a blood sample will be taken.  Common cold?  Blood sample.  Twisted ankle?  Blood sample.  Headache?  Blood sample.  A blood sample is the answer to everything, and impossible to avoid.  It’s probably also a good way for doctors to make money with very little effort.

Yesterday, I had my fourth or fifth blood sample taken during the current miserable tour.  Today, it turned out no one had bothered to check my blood type.  This was remedied shortly before I left the hospital at 5.  How much blood do you need to get the blood type right?  The technician filled four vials.

But back to the beginning.  The surgical consultation early in the afternoon was less than satisfying because not much was clear.  The two main options with my diagnosis are chemotherapy and surgery or surgery and chemotherapy.  The order seemed a matter of taste.  Doing chemotherapy first might weaken the body too much for surgery.  Doing surgery first might weaken the body too much for chemotherapy.

How do you decide between these options?  It was easy for me.  I want the tumor gone.  The primary tumor presents the risk of blocking my colon and leaving my belly full of half-cooked shit with no way out.  I’m not happy with this risk.  The tumor needs to go.

The surgeon accepted this reasoning and was probably not thinking very differently herself.  "Have you got time for more consultations later this afternoon", she asked.  "I have a free slot for knife therapy on Monday."  After a short think, I told her I was in.

Surgery should have a clear goal.  You don’t cut a person open just so.  My case is not that easy.  Surgery will start out with a visual inspection (by remote controlled camera) of my ventral cavity.  The goal is to identify tumors too small to be picked up by the PET-CT and get the best possible impression of what’s growing inside me, but that’s not really surgery.  It’s just a tube inserted through a hole poked into my belly button, with a few more holes for accessory tools.

Based on what the surgeons see, surgery might start afterwards.  And based on what the surgeon said, it sounded as if they’d juggle the scalpels and see which cut comes most natural.  They might take out the tumor, if that’s unlikely to cause complications.  With it, they’d also take out the surrounding lymph nodes.  They might also remove the peritoneal carcinomas, if there are only as few as were visible during the PET-CT.  If the entire peritoneum is covered as if with slime from a horror movie, they won’t touch it.  They might decide not to do surgery at all and pass my case on to the University Hospital in Zurich for HIPEC, if that seems sensible.  The surgeon wasn’t too convinced of this option.  Or they might be totally repelled by what they see and not touch me at all before doing chemotherapy to shrink what’s grown too much.

This is a lot of options.  Some might be better than others but even that’s hard to tell.  It’s just not clear what would be the best situation, apart from not being in this situation in the first place.  Anyway, I won’t have a say in this as I’ll be in general anesthesia.  When I wake up on Monday afternoon, I’ll have to check my body to see what’s still there and how the knives have fallen.

Three deaths

You die the first time when you get the initial diagnosis.  Cancer.  That’s it.  Out of nowhere, unexpected, inexplicable for the most part.  One day you’re healthy, with a few curious issues maybe that you don’t take too seriously, but healthy.  Nothing that requires medical attention, and it’s been like this for a while, but you finally go have these curious issues checked out.  A couple of days later you sit in the hospital and chat with a doctor with a serious face who says, I’m sorry, just a few times too many.  I died my first death last week on Wednesday.  Adenocarcinoma of the colon.

Today, I died a second death.  The results from the PET-CT and the final histology were ready in time for the tumor board to discuss my case.  My new doctor, a junior chap with the dour demeanor, repeated the story about the malignantly thickened colon wall and the suffering lymph nodes.  This I knew.  He said that the lung was most probably and the liver most definitely clear (at least for the moment).  Flucha perked up and could hardly contain her excitement.  It’s all good, it seemed.

The doctor’s summary of my condition continued.  There were a handful of sizable metastases in the peritoneum, a lining of the abdominal cave that holds things together in there.  The term was peritoneal carcinomatosis, and there was no way of putting a positive spin to this.  The doctor spoke of a slim chance of a cure and the focus on quality of life instead of survival.  It was a brutal comedown for Flucha.  I remained in a daze.  What am I doing here?

The doctor continued with a bit of cautious optimism.  It’s highly unusual to have metastases in the peritoneum and nowhere else.  I’m a bit of an odd case, in the company of a few others who had surprising success with a rather harsh surgical treatment followed by aggressive chemotherapy.  The surgery removes the primary tumor and the afflicted lymph nodes and then scrapes out the larger metastases identified during the PET-CT and the smaller ones discovered in situ.  Directed chemotherapy might then be able to curb or kill remaining cancerous cells.  This is called hyperthermic intraperitoneal chemotherapy (HIPEC).  It doesn’t sound like my kind of pleasure cruise, but there’s a slim chance things would work out fine in the end.

There’s also a chance, and this will be the topic of a consultation with surgeons that I have at the hospital tomorrow, that this kind of treatment is not applicable or sensible after all.  Tomorrow I might die a third death.  If the visible manifestations of my cancer cannot be removed completely or if they’re simply inaccessible, HIPEC might not be possible.  In this case, I’d just be sitting around waiting to die in the most painless way the doctors can manage to cook up.

For the moment, I live in honest disbelief.  This cannot possibly have happened to me.  Someone must have exchanged the names on all the samples and files that are circulating in the hospital.  Maybe there’s someone else with my name and birthday, a guy with a cancerous gut and little time to live.  I’m healthy and happy and fit and ready for decades to come.  I want to see my children grow and mature.  I feel all right.

I’m definitely not all right.  My body is fucked up.  A little part of it betrayed me, subverted the peaceful order, and is on an inexorable path towards mayhem.  I will have to accept that - but if I do, what do I do with that acceptance?  Can I use it to draw extra strength to fight the cancer?  Can I use it for energy to avoid despair and self-abandonment?  The downward slope is still gentle.  I will need to figure out how I can keep myself mentally in shape when my body falls apart.  Screaming fuck this off the top of my lungs and shaking my head violently is not going to be enough.

Time passing

Since the devastating diagnosis, five days have passed.  It has been a strange time.  Even the word devastating in the first sentence doesn’t quite seem to fit.  My diagnosis is clear.  Colon cancer.  If untreated I will die soon, and it won’t be pleasant.  If treated – well, I have no idea.  The doctors are not that far yet.  Tomorrow I will undergo a PET-CT scan, the results of which will shape the conclusions the Tumor Board will reach on Thursday.  There’s also the in-depth histological analysis of the biopsy sample taken from the tumor during the initial colonoscopy.  This should be ready by now, but I will learn the results only during the consultation on Thursday afternoon.

As a consequence, my life has continued normally.  I went to the Heart of Europe Crystallography meeting in the Ötztal during the weekend, arriving there one day later because of my hospitalization but still in time to give my talk.  Flucha and the children were with me, and we had a great time.  This is how it should be, probably, but it’s also strange.

Most of the time, the cancer is a remote concept without practical relevance.  I find it hard to take it seriously without a prognosis and a treatment plan.  There are moments when I forget about it altogether.  Then there are moments when I feel despair welling up inside me.  I realize that I might die soon, before seeing my children off into their own independent lives.  I feel defeated and deflated, though there is not the slightest reason for this at the moment.

I wonder how this will continue.  If the prognosis is bad, I might lose all energy and motivation.  I’m not a fighter for survival.  I’ve always fought to win.  If I was dropped from the leading group (or from my own expected pace) in a bike race or a marathon, I quickly gave up and suffered mightily until reaching the finish line.  If the prognosis is bad, the finish line is death.  How much power would I have to keep it at a distance for as long as possible?

I don’t really wonder how this will continue.  This is another aspect that might seem strange to an observer if anyone were informed about my condition.  I don’t wonder because I don’t work with incomplete information.  What’s the point to read up on possible outcomes of colon cancers in various stages of spread?  I don’t care.  I want to know the updated diagnosis and the prognosis on Thursday.  Until them, I’m quite relaxed.

It’s easy to be relaxed because I feel much better in some ways.  With the iron transfusion, the B12 injections and the folic acid I take every morning, my anemia has improved noticeably.  Walking up the hill after dropping the girl off at kindergarten doesn’t cost me nearly as much breath as it used to.

In other ways, I feel worse.  Much more pain emanates from my colon where I suspect the cancer.  Is this real, or is this in my head? Do I feel worse because I expect to feel worse?  Do I just notice it more when before I tried to ignore it? Why would I feel worse otherwise?  It’s not that I took a big step in the disease last week.  And yet, I feel strong discomfort in bed and I have pain making normal moves.  I also sweat during my sleep.  Whether I did this was one of the questions I was asked repeatedly.  Is this why I notice it now?

Until Thursday, none of this matters.  There’s no pain and no improvement because there’s no reference.  The reference against which everything will be measured will be set on Thursday during the consultation after the Tumor Board meeting.  Until Thursday, I could be anything.  There’s no way of knowing.  I’m like Schrödinger’s cat, simultaneously dead and alive, a paradox that can be resolved only by an updated diagnosis and a prognosis.  On Thursday afternoon, I will find out whether live or die.

Tedium

On the third day in the hospital, routine sets in.  I am familiar with the flow of things and have adjusted to the environment.  Nurses come to give me remedies for soft stool and more blood.  My blood pressure is regularly checked.  This morning, it was abnormally low.  I insisted the nurse try it again.  The second reading was in the range of prior experimental values.  A third repeat was not deemed necessary.  This was not science.  I also had more blood drawn.  A lot of what happens concerns my blood, which is only appropriate, as it was abnormally low blood values that got me into this mess in the first place.

As I write this in the morning, it's not really the third day yet.  Having checked in on Tuesday at 1, I haven't spent 48 hours in the hospital yet.  But it feels like the third day, and I'm hoping for symmetry to get me out of here.

The first day was warm-up.  I was prepared for the major exams that were planned for the next day.  With the ultrasound on the first evening, the curve of activity started to perk up.  The second day was filled with exams, diagnosis and the arrival of the worst possible news.  It was a day that had more in it than you would expect from a horrible week or two.  Things calmed down in the evening.  I was worn out and slept early and without a break.

Today I'll go through the MRI machine to get a better idea of the extent of metastasis.  The contrast is higher with this technology than with X-ray tomography.  Bastards should have used detectors that can see colors.  They could possibly save a lot of money on additional tests.  Or maybe they would just get less money from the insurance companies for tests performed.  Whom do you sell efficiencies in the health services?

Before lunch, the doctor took me back into the little private room for an update on my condition.  The cancerous nature of the growth in the colon wall was confirmed by the first histology results.  A precise characterization with immunomarkers was still outstanding.  The extent of the spread of the malignancy was also still unclear.  The MRI might be clearer on some of these points, but the complete histology would take a bit more time.  There was still no talk of treatment strategies, except in the most generic terms.

Until I leave, there will be a lot of tedium.  The afternoon looks like a cool-down period.  There will be a consultation with an oncologist, another iron transfusion, and maybe a chat with surgeons if today fits their schedules better than later.  I hope to get the drip out of my arm soon after the iron is in, and myself out of this hospital before the night.  I'm not enjoying this a lot.

In a hospital, especially after a life-shattering diagnosis, it's easy to fall into a deep pit of self-pity, to feel sorry for oneself and maybe even lose one's good spirits.  Overall, I feel worse than before going to the hospital.  I interpret every sign from my body with the knowledge of the cancer, even though I'm the same person I was three days ago.  Is a little pain from my gut an indicator that something evil is happening that very moment?  My knowledge of the diagnosis conspires with the pathological vibe of the hospital to darken my mood.

My attitude towards hospitals is bound to change.  When the cancer has been fully characterized and a treatment schedule agreed on, I will be back here frequently, for surgery, chemotherapy and consultations.  I hope I can do most things as an outpatient, without spending much time inside, keeping my life undisturbed.  From work, which I hope I will be able to continue, it's only a 15-minute walk to the hospital.  I want to get on with life as it used to be – for my own benefit but especially for the benefit of those around me, especially the kids.  They don't need to see me suffer.  Flucha is probably taking this less easy than I am.  I need to be there for all of them.  Enough with hanging out at the hospital already.

Nine eleven

At six in the morning, the night was over.  The nurse stole into the room and plonked yet another bottle, the third, of Gwyneth's finest onto the bedside tray and ordered me to finish it within an hour.  On the upside, I was allowed to stay in bed and watch the light slowly crowd out the darkness.  The view from my room on the eleventh floor of the hospital, due south, is staggering.  When the air is clear, the Alps are in touching distance.

View from the top.

With the lack of food now stretching back nearly 24 hours, I was weaker than Gwyneth would allow.  I lounged on my bed until they wheeled me down to the endoscopy department, for the charting of my innards with two cameras inserted into orifices usually reserved for the input and output of food.  This sounded unpleasant, to put it mildly, when the procedure was explained to me, even if the probes were to enter successively.  But it was no big deal.  I got drugs in my drip that made the world swirl and then disappear very quickly.  When I woke up, I was back in my room and it was as if nothing had happened.  Half an hour later, I was permitted my first hospital meal, a half-assed little breakfast fit for a jockey with a weight problem.

The pain started an hour later when the doctor shared with me the diagnosis.  It's a bad sign when you're asked into a private office for this, never mind talk about peace and quiet.  Her words were grave.  I have a tumor in my colon, on the right side where the dull pain that has been my companion for a few months now originates.  This makes good sense as an explanation for everything I have been suffering from.  As the tumor grew it took the oxygen that I would have rather used on the football field.  But it also makes no sense at all.  What am I doing with a tumor?  What have I done to end up with one?  I've always lived and behaved healthily.  Out of the blue, this diagnosis feels like my personal nine eleven, and unpredictable catastrophe of unimaginable proportions.

At this point the tumor was just a thickening of the colon wall.  It was thick enough to impede progress of the colon probe and big enough to have been the target of a biopsy.  But it's not a stage-three growth that has already consumed tissue far and wide, large enough to keep organs from functioning normally.  At least in the stomach it didn't seem to have done any damage.

And so I cling to hope that is as poorly justified as the despair I feel welling up inside me.  I'm only 44.  What is going to happen? My children are two and four.  What's going to happen to them, poor things?  It's too early to build scenarios of the future or draw any conclusions, but how can I not?

Flucha took the news like a champion.  She didn't freak out or panic.  All calm, she declared she'd take the afternoon off and come here right away.  This is good.  I need her now, and I will need her a lot in the future.  Unless they take me down for a CT intended to identify possible sites of metastasis – writing this almost freaks me out – we'll have some time to discuss this, even though there isn't really anything to discuss at this point when the final verdict is still pending.

By the end of the day, the situation hasn't improved.  It's still 11 September.  The CT scan revealed an unexpected allergy to iodine and a large number of suspicious lymph nodes next to the cancerous piece of colon.  There were also a few near the liver.  The organs themselves seemed fine, though the liver might have taken a hit and there was some dodgy signal in the lungs that needs to be studied further.  As I write this, I realize that I'm completely fucked and, a second later, that there is no need to panic before the full CT report is in.  I think of my children and almost lose it.  My world has collapsed from one moment to the next.

Bottle empty

Many years ago when I still followed football, back in Germany in another millennium, the most accomplished German club, Bayern Munich, recruited Giovanni Trappatoni, an Italian manager with a dubious reputation but a history of success.  He was passionate, chaotic and a slave to his emotions – in many ways the total opposite of German structure and discipline.  Bayern probably took the gamble because the previous season hadn't gone well.  Fresh blood was needed.

I don't remember how the season went.  I'm guessing almost no one remembers the season.  What everyone remembers, indelibly burned into the brains of all those who watched it, was the media conference given after a particularly dismal game.

It must have been one of the Bundesliga's shortest press conferences, and it was the most hilarious.  Trappatoni fulminated in this particular German of his that was once described as "courage with words".  With a largely correct vocabulary, expressive language and scant regard for the rigidities of grammar, errors or doubt didn't slow him down.  He ranted with exasperation and indignation, as if personally hurt by his players' behavior.  He bitched about the level of play, scolded the team for their lack of effort – playing "weak like bottle empty" has since been enriching the German language – and harangued individual players who had disappointed him.  Three-and-a-half minutes later, he "had done", got up, and left.  There was no time for questions.

For the last few months, I've felt a bit like an empty bottle myself.  The average speed on my commute to work was quite a bit lower than the year before.  Riding was more work than it used to be, and I rarely felt fresh.  I tried to blame it on late bedtimes, but that wasn't really anything new.  Early-morning runs during conferences were no fun at all.  Climbing stairs got me out of breath by the third level, as if I were 80 years old.

Three months ago, in the midst of all this, I played my first game of football since leaving London, and the first game outside and on grass in 15 years.  In the meantime, I've aged by nearly as much.  On the pitch, I scored a few quick goals and things felt good enough, but they fell apart quickly.  I spent most of the rest of the game standing, hands on my knees, panting for air.

I played twice more since then, and each time I felt weak like a bottle empty.  Every time I was suffused with the most vividly painful memories of my early days in Utah when my body hadn't yet adjusted to the altitude.  It felt as if I were running around at 1400 m, and it didn't get any better.

Finally I went to see a doctor.  The breathlessness and lack of performance were one aspect.  Dull pain in my gut that would come and go was another.  Were the two related?  The doctor didn't have an answer to this but, from the results of the blood test done on site, learned that my hemoglobin and hematocrit values were abnormally low.  Professional cyclists have used a number of schemes over the years to keep their hematocrit value as close to the legal limit set by the Union Cycliste Internationale, cycling’s governing body, of 50% as possible.  Hematocrit reflects red blood cells.  The more red cells one has, the more oxygen gets to the muscles and the higher is one's performance.  My hematocrit value was a meager 20%, my bottle almost empty.  My hemoglobin was equally worrisome, just a few decimals from a blood transfusion to prop me back up.

I got an appointment at the hospital the next day.  There seemed to be a sense of urgency that was hard to square with the slow progression of the symptoms.  Had it even got worse at all? The doctors scheduled exams of my stomach and gut, inside and out.  I got what felt like the world's longest ultrasound, lasting 75 minutes and involving three doctors from a fresh trainee to a venerated specialist with 30 years' experience.  Two endoscopies are planned for the next morning.  Details are probably uncalled for, but let's just say I had to drink two liters of a gut cleaner that made me feel like Gwyneth Paltrow, all cleansed and detoxed and like new inside.

My blood got altogether less attention.  There, the focus was firmly on the treatment of symptoms rather than the underlying causes (themselves yet to be identified).  "We'll inject you with B12", the nurse said, "infuse iron and give you folic acid to swallow.  This will probably go on for a week."  I have a hard time seeing myself in the hospital for a week for something of seeming secondary import, but if it helps refill my bottle, I'll stick around.