Randa’s blood pressure had risen again, and I needed to know why.
An African-American police officer in her 40s and a single mother of three, Randa’s lips parted in a jovial smirk. “You really want to know?”
Randa had already had a rough year. After a protracted battle with painful, heavy menstrual periods, she decided to have a hysterectomy last winter, which went fine; but she had far more than the expected amount of nausea while recovering from surgery. Her obstetrician, Dr. B., ordered an abdominal ultrasound because, as he told me later, “One of my attendings during my residency told me to be curious.” He uncovered an unsuspected problem: a cancer (renal cell carcinoma, originating from one kidney cell gone awry) at the bottom of Randa’s left kidney.
Why didn’t he see this during the operation? Because the uterus, ovaries, intestines, liver, and other abdominal organs lie within the peritoneal cavity. The peritoneum surrounding this cavity is a smooth, sterile, glossy, gray sac that separates the abdominal and pelvic organs from the retroperitoneal space behind them, where one finds the kidneys. Dr. B. couldn’t see the kidneys during the hysterectomy.
He can take credit for saving Randa’s life. Diagnosing renal cell carcinoma is often challenging because it does not cause symptoms suggestive of kidney disease. It occurs in men twice as often as in women, and the age of peak incidence is 60. The only known risk factors for the disease are cigarette smoking and exposure to cadmium. Randa was not the right age or sex, nor was she exposed to either risk factor. All of which proves the tenet that patients do not always read our textbooks; in medicine, we sometimes meet our adversaries in the most unexpected places. We would not have found her cancer until much too late without her surgeon’s “curiosity.”
So, a couple of weeks later, Randa found herself on the operating table again and left it without her left kidney. Fortunately, the cancer had not spread into the fatty capsule surrounding the kidney nor into any of the nearby lymph nodes, so she had a decent chance at a cure and wouldn’t need chemotherapy or radiation.
Over the next couple of months, she did well, and her high blood pressure, which had required two medications to control over the previous three years, vanished. I was able to taper her off both medicines. But while I was doing this, it became obvious that the scar from her kidney operation was forming a painful keloid. Keloids are like nonmalignant cancers of scar tissue; they can grow big and ugly. Sometimes they hurt. They occur most often in black people.
“I can’t wear my police belt,” she complained.
“The weight of it causes too much pain.”
Her scar was now a pencil-thick hockey stick, with the blade pointing down and to the right from the lower margin of her mid-abdomen, just below the sternum, the long handle extending gradually downward from that same margin all the way across to the far left side. Its pink radiance was not the gentle pink of a rose petal but the angry pink of a first-degree burn. Its induration penetrated beneath its visible margins toward Randa’s subcutaneous fat, and the pressure of my hand upon it elicited from her a grimace that one might see on the face of a tough cop nursing a fresh knife wound.
As often happens in today’s managed-care environment, her pain became our pain. The plastic surgeons in her insurance plan did not want to see her, because the plan pays them a fixed amount (“capitation”) for each patient who joins the plan; it doesn’t pay extra to take care of an individual patient. Because a keloid often becomes a chronic problem requiring multiple office visits, many plastic surgeons try to avoid seeing patients with keloids who have a capitated insurance plan.
First, I sent her to see the best plastic surgeon in our region, Dr. K. He met with her a couple of times and once injected her scar with corticosteroids (cortisone analogs), which are strong anti-inflammatory agents and are the first-line treatment for keloids. When this did not help, she tried to get another appointment, but the doctor’s office put her off so many times, she gave up. The other plastic surgeon in the plan refused to see her.
Several months passed. In desperation, I called Dr. T., a personable plastic surgeon five miles away, and he gave us a chance. First, he explained to me the injection technique so that I could give her another trial of a corticosteroid injection. Then he asked me the key question: “Does she have any other keloids from her other surgeries or wounds?”
“Well, then, she should have her keloid excised surgically; she’s the ideal candidate.”
That month, Randa switched her provider plan from the local plan to the one in the next town so that I could refer her to Dr. T. The plan in the next town also pays capitation, but Dr. T. did not let that prevent him from performing the surgery she needed, and now her pain is almost gone.
Which is why I couldn’t understand this latest rise in her blood pressure. “Yes” was my reply; I really did want to know.
For months, a man had been bothering Willis, Randa’s youngest (midteen) son. The perpetrator often followed him home and threatened him. It progressed to where the man and his friends were throwing rocks through the windows of Randa’s house. “I had to file several police reports to make sure we had it all documented.”
One day, the conflict escalated. Her older son Eric came out of the house and found that this man was yelling at Willis and had him in a headlock. “Eric is kind of thin and not a strong guy,” she explained. He yelled at the man to let go of his brother, but the abuse continued. Angry and frightened, Eric returned to the front door. When he found that he was locked out of the house, he summoned enough powerful rage to break through the locked door. He went inside and found his mother’s gun.
Eric did not know anything about using a gun, but it did offer him the possibility of scaring away his brother’s attacker. When the man, upon Eric’s return, still did not release Willis, Eric fired a warning shot. Of course, he misfired. So much so that he hit the attacker in the head. He killed him. Eric could never have hoped to accomplish this if he had tried. For this, he is now in county jail, facing murder charges. “He’s in with hard criminals and is really afraid.”
The dead man had gang connections and a rap sheet 162 pages long. Eric’s strengths have always been academic, and he has a clean record. Nevertheless, the prosecuting DA has revised his initial plans to try Eric for manslaughter; he now wants a murder conviction. Why the DA is so eager to charge with murder a teenager who dared to protect his younger brother from a dangerous thug isn’t clear.
What is clear is that Randa and her other son are not safe; the family of the dead man told them as much at the preliminary hearing. Randa has moved her family to a different neighborhood. Meanwhile, Eric has spent several months in jail and won’t get his day in court before March.
So cancer isn’t the only killer stalking Randa these days. While listening to her story, I felt small. My prescription pad and standard spiels on stress management seemed like spit-wads, when we needed cannons; I didn’t offer them. I remember only that I offered whatever weighty words of sympathy I could find and sent her back to Dr. T. for another surgery. Randa had breasts that were too heavy even for her well-toned back and torso, causing frequent annoying upper-back pain, so Dr. T. reduced her breasts.
Apparently, fate or God or whatever else is in charge of these matters still didn’t think Randa’s plate was full. In mid-January, she came in for me to check her neck. Seven days before that, Willis was driving through town with her in the passenger’s seat. Another driver ran a stop sign and plowed into the driver’s side of their car hard enough to push Willis’s seat into Randa’s. Everyone escaped serious injury, and there aren’t any hungry DAs around who want somehow to blame Randa’s son for the accident. But Randa’s neck has hurt since the day after the event. She came in to find out what she could do about it and how long it would be before she could return to work. “I want to go back Monday.” It was Wednesday.
Feeling but hiding my frustration and disbelief at her latest calamity, I examined her. She could rotate her head only 30 degrees in each direction, and she had even less range of motion looking up and down. The excess tension in her well-developed trapezius muscles, running in a gentle curve from her shoulders up along the back of her neck on each side to their attachment on the occiput at the base of the skull, pressed against my examining fingers, causing that painful wince that I was becoming too accustomed to seeing on her face. The straplike sternocleidomastoid muscles on either side of her neck expressed similar tautness. Other than some new bruises on her recently reshaped breasts, she didn’t have any other injuries, once again demonstrating the value of the modern seatbelt.
A cop who can’t look to either side can’t be competent, and I knew from her description of the accident that she wouldn’t be working the next Monday. Such collisions impart acceleration and deceleration forces that distract our muscles’ interdigitating bundles of red fibers, which can take months to heal. She came back anyway the next week, because her son’s muscles were healing faster than hers. Perhaps the sliding motion of his driver’s seat allowed him a more gradual acceleration and deceleration after impact, causing less of the microscopic muscular disruption, or maybe this was just another example of how great it is to have a young body that mends with such swiftness. I told her it would be at least four weeks before she turns her neck without pain. She took the news with a calmness suggesting simultaneous acceptance and defiance.
I marveled then at her demeanor, but it makes more sense to me now. I wrote this to tell a story of profound misfortune, but in finishing it, I can appreciate the irony in my perspective. This past year has brought her four surgeries, a jail sentence and murder charges for her son, cancer, and a terrifying car accident. If reason prevails in March and her son leaves jail with an acquittal and in good health, she will emerge with a few scars, an occasional stiff neck, fewer backaches (thanks to her breast reduction), and an unwanted relocation of her family home. Oh, and two pills she has to take once daily to control her blood pressure. Beats having cancer and a dead son.