Lou Murray's Green World

I have debated whether or not to make this post, because (1) the images are really graphic and (2) I’m reluctant to make my medical information public.

But if this can help educate people to the dangers of squamous cell carcinoma, and the hazards of relying on an HMO for medical treatment, then it will have been worth it. I’m putting the photos at the very end so as not to gross you out too much.

I noticed a “small pimple” on my left cheek in early December. By three weeks later, I was sure that it was no pimple. It was growing like gangbusters with a scaly surface. It looked like a little red crusty volcano. And at the rate it was growing, I wanted it gone yesterday.

I called my primary care physician on December 27 and asked for an immediate referral to a dermatologist. Protocol with my HMO is that I am supposed to see the primary care physician first, but I had no time to waste. Fortunately, my primary care doctor knows that I can recognize a squamous cell carcinoma, and she gave me an immediate referral. That was one week shaved off of the process of getting health care in today’s managed HMO system. I got the first available appointment with the HMO dermatologist, which was a bit over a week later.

In retrospect, I would have been better off bypassing my HMO and calling a dermatologist who did Mohs surgery. I would have had to pay out of pocket, but I would have gotten my cancer taken care of while it was still small instead of being given the run around from one doctor to another and another and another. As it is, I’m left with a scar on my face that is over two inches long. But I’m getting ahead of my story.

The HMO dermatologist did a shave biopsy, which doesn’t necessarily remove the cancer. By the time I saw her around January 6, my cancer was already 6mm by 11mm. I wish that she had cut a bit deeper and a little wider and taken it all, but my HMO won’t pay for removal without a biopsy confirming that it is cancer. Well, I knew it was cancer, and so did the dermatologist. She even subtyped it as keratoacanthoma type of squamous cell carcinoma, which is a very fast-growing and aggressive cancer. She said to return in a month.

The cancer looked gone after the biopsy. But the wound didn’t heal, a characteristic of cancer. I was forced to deal with twice daily wound care that consisted of washing the open wound with hydrogen peroxide, applying antibiotic ointment, and covering it with a bandage.

At the first sign that it was coming back–and that didn’t take long–I called the dermatologist and asked for an immediate referral to the Mohs physician. I wasn’t about to wait a month to see her and then wait even longer to get an appointment with the Mohs surgeon.  The dermatologist had informed me at the time of the biopsy that my HMO doesn’t have any Mohs surgeons on staff and that I had to go outside the system for that type of surgery.The HMO pays for the surgery, of course, but it has to be with one of the Mohs surgeons that they contract with.

With the Mohs technique, the doctor does cryosections of the tumor and examines them under a microscope to make sure that all of the margins of the tumor are gone. She also looks at the base of the tumor, the part opposite the surface, to make sure that she got all of the “roots.” Tumors can send long “fingers” of cancerous tissue down deep into the normal tissue. If any cancer cells are left behind, then the cancer will return.

The HMO dermatologist gave me a referral to a Mohs surgeon dermatologist that my HMO contracts with for the surgery, but my HMO won’t pay that doctor to close the wound. I had to see a plastic surgeon within the HMO system for wound closure, which meant going to a different office in a different building later in the day, and getting yet another round of local anesthetic injections. Unbelievable.

My HMO decided that this wasn’t an emergency, and put me into the 5-day approval process. I straightened them out about that. I got immediate approval and shaved another week off of the time it took to get treatment.

Unfortunately, I had to see both of those doctors for consultations before they would schedule the tumor removal. That took a week. Scheduling the surgery took another week, and I was only able to get it scheduled that fast because of a cancellation. Meanwhile, the cancer cells were doubling every day and my biopsy site was not healing.

It was January 31 before I got the Mohs surgery, a month and a couple of days after my first phone call to my primary care physician. In the world of HMOs, that’s remarkably fast. Most people don’t get treatment until 2-3 MONTHS after the initial visit.

But by Jan. 31, my tumor was huge. The round incision to remove the tumor left a hole the size of a quarter in my face.  Note that this is only six weeks after this thing was large enough that I knew it was cancer, and three weeks after the biopsy had almost removed it all. Cancer can be very aggressive.

The plastic surgeon would later enlarge the opening into the shape of an ellipse so that the wound could be sewn shut without puckers. That’s why I ended up with a 2 inch scar. If I could have received treatment at the end of December, when I already knew that it was cancer, then the wound probably would have been no larger than my little fingernail.

Unfortunately, neither surgery went smoothly. During the first surgery, the Mohs surgeon hit an artery, which spurted all over the place. Hey, these things happen and that was no fault of hers. But it wouldn’t stop bleeding, so she had to suture the artery closed. Unfortunately, the nurse handed her sutures which were not dissolvable. Since these would stay below the skin, they had to be dissolvable. So the doctor took out the first set of stitches and put in a second set.

Meanwhile, the local wore off and she had to inject me again. Each round of injections was about 8 shots into my face around the tumor. Since there were two separate rounds of surgery (the first cut hadn’t gone deep enough and the doc had to cut down into the subcutaneous fat in a second round to get it all), and the anesthetic kept wearing off (I’m sensitive to epinephrine, can’t have it, and that is what helps the anesthetic last long enough to keep you numb the whole time) that meant that I had probably 40 injections into my face during the first surgery.

Finally, the first procedure was done. I went to lunch with a big bandage on my face while waiting for my appointment with the plastic surgeon. That’s when things really went bad.

Remember I said that I can’t have epinephrine? Well, the plastic surgeon didn’t remember and he used a local with epinephrine in it despite the fact that we had discussed the issue extensively on my consultation visit. I hadn’t had any epi in about 40 years. My older body reacted to it even more badly than my young one had. I began to feel bad before he had finished injecting my face. My heart started to race and I had trouble breathing. It was like the worst panic attack you can imagine.

I asked him if he had put epi in the anesthetic and he said that he had. I asked him to call the paramedics, because if I had a heart attack as a result, I knew that a plastic surgeon didn’t have the equipment or the knowledge to handle it. I also asked for my son, who was in the waiting room.

The doctor was in full panic mode. He knew he had screwed up, and seemed incapable of acting. The doctor was not taking my vitals, so I asked my son to take my pulse. It was 131 while I was lying down. My son asked the doctor to take my blood pressure. But the doctor didn’t have a blood pressure cuff! He had just moved to the new office and wasn’t unpacked. He didn’t even have any soap by the sink in the room where I was being treated. And he hadn’t had me put on a gown (I had to ask the office assistant for one), and in contrast to the first surgery, I had no surgical cap and no drape either. It was like Third World surgery.

By the time the paramedics arrived, I was pretty much out of it mentally. I had said goodbye to my son, because I thought I was dying.

Fortunately, I didn’t. The paramedics said that my blood pressure was 208/110, if I remember correctly. They did an EKG and found that I was not having a heart attack. They wanted to take me to the emergency room anyway though because BP that high is stroke city. But my body was metabolizing the epinephrine, and my pulse was dropping. My blood pressure fell to 180/100 (more or less, my mind wasn’t working right at the time and I can’t remember) while they were still there.

I had already had so many injections to my face that I wanted this over with, so I declined to go to the ER. And God only knows how long it would have taken to get another appt for wound closure. I couldn’t go around with that big hole in my face. The paramedics strongly recommended that I go as soon as the procedure was finished.

Well, the plastic surgeon was a basket case. My son and I had to calm him down enough so that he was able to finish the procedure. I went to the ER afterward, had another EKG and was released with no treatment despite still having high BP. My BP didn’t drop back to normal until the next day.

My body was so stressed by this experience that I didn’t recover my strength until early March, really just a few days ago. I missed a month of work from being so wrung out physically.

Oh, and that wasn’t all of it. I had the stitches removed a week after the surgery, but the plastic surgeon left one in. I had to go back a week later and have that one removed. He didn’t wear gloves, and I bled with stitch removal. This is not proper standard of care. Now I have to ask myself could this guy be HIV positive or have hepatitis. And it feels like he might have used a non-dissolvable suture at the very end of the wound. So my nightmare still isn’t over. Honestly, I’m getting stressed all over again just thinking about this.

Here are the photos.

This is my squamous cell carcinoma about three weeks after the biopsy, and on the day of surgical removal. The tumor had looked gone after the biopsy. Note the raised appearance. The cancer went down into the tissue of my cheek as well as outward.

This is the hole that was left in my cheek after the removal of the tumor. Note that I am wearing a surgical cap and a gown. My wound was draped during the surgery, and I was in a surgical suite in the Mohs dermatologist's office. The blackness is due to electrocautery of the open wound. I was a bit swollen and bruised, but no, it didn't hurt. Amazingly I was able to have lunch with no problem.

This is what my cheek looked like after closure of the incision while I'm still on the table. Note how pale I am. I have not manipulated the color. I think I nearly died due to the reaction to the epinephrine. Also note that I am not wearing a surgical cap. The plastic surgeon hadn't even asked that I put on a gown. I had to ask the office assistant for one because I didn't want to bleed onto my clothes. There was no cap, no drape, no surgical light, just a bare office with a table. There wasn't even any soap by the sink! This place was just not set up to do surgery. At least the doctor wore gloves, but he didn't when he removed the stitches two weeks later, and I bled. That is not good.

So that is why I haven’t planted my spring garden yet. I have been utterly exhausted, I suspect from the trauma caused by the epinephrine.  I hope to get back to participating in Harvest Monday next week.

Fortunately, squamous cell carcinoma is cured with surgery. No need for chemo or radiation. But it will kill you if you don’t get it removed. If you have a suspicious spot, get it looked at.

Now I just watch and wait to see if the cancer is really all gone. So far, so good. The incision is healing very nicely.