There was this man who had his nose completely removed after being diagnosed with nasal cancer. He has been walking around with a plastic nose prosthesis tied to his face with rubber straps. When he came in for his follow-up appointments he would take it off for us to examine, revealing an uncomfortable big triangular hole in the middle of his face with the six delicate bony turbinates clearly visible, and their pink glistening mucosa extending into the black, unlit cavities of his nasopharynx.

It all started about a year ago when he was playing with his little daughter. Somehow she hit her dad’s nose, and it became immediately swollen. In retrospect, he must have had a pathological fracture with bone already unknowingly eroded by the then-insidious cancer, but initially he thought it was just a bruise. Not only did the swelling not resolve, it grew larger and yet larger, until anyone would know something was quite wrong.

He was a blithe person who liked to pull off jokes all the time. After being diagnosed with cancer, undergoing surgery and then radiotherapy, he was still in good spirits. He would joke to his daughter now and then — “Look what you’ve done!!” or “It all started with your punch!” he would say, and then laugh heartily. I’m sure he didn’t mean any of them.

But during the times when he brought his lovely daughter along to see us, it was apparent that the little girl had carried some guilt with her.

Despite our reassurances that her dad’s condition had nothing to do with what she did, I’m not sure if she’ll ever let it go, even as she grows up. Not all jokes are funny.

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We asked if she smoked. “No,” she answered flatly. “I stopped. A year ago.” A glint of pride in the accomplishment, it seemed, flashed across her face with that reply.

But it was too ironic.

She was definitely not alone. In fact, too many are just like her – smokers for all their lives, who suddenly (and finally), out of their own intentions, quit smoking, only to be hit by a diagnosis of lung cancer shortly after. We see this again and again. Why do so many smokers stop smoking just before they get lung cancer?

Not all admit when asked, but often it is because they could feel that something was going amiss, and so they stopped in alarm. It might be some blood specks coughed up, or some strange weight loss that had worsened – not enough to make them see a doctor immediately, but enough to scare them to think, “Gosh, all my cigarettes may actually kill me one day!!”

But it is already too late; and what is done is done.

It is easy to point at others, but there are some things too – small and big – that we – all of us – keep doing, despite knowing they are wrong. Of course we pay, in the end.

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She frowned with worry. Her elderly hands were lightly rubbing on her abdomen. “But this pain… can you do something, dear?” she pled.

How I wish the answer could be an easy and confident yes with a sparkling smile. Then and there I wasn’t even sure about the exact cause of her complaints. It could be something relatively simple, or it could be something fatal too, especially in view of her co-morbidities. Co-morbidities – oh she definitely had a number of those, not the least of which was end-stage renal failure on CAPD.

I had thirty minutes left to go before the end of my seemingly everlasting night shift when I was called to see her. I struggled by her bedside to decide whether her symptoms warranted immediate investigation and aggressive intervention.

“What should I do?” she asked me. Her hands grabbed onto mine, as if not wanting to let me leave. But I had to.

“I’m not sure what’s going on, but we’ll do a blood test to help us find out what’s going on. And I’ll get your nurse to give you some pain-relief now, okay?”

“But what should I do in the meantime?” she asked again.

“Well, it shouldn’t be too long, okay?”

She was talking fine – she wasn’t cringing and shouting. Her abdomen was soft – she wasn’t jumping when I touched her. Her vital observations were still within normal ranges. This wasn’t severe pain, I thought – maybe she was a little too anxious. Maybe. Peritonitis in CAPD is the important condition to exclude, but it didn’t seem to be too pressing at this stage.

I sent for some blood investigations to be done. I handed-over for the morning house surgeon to not delay in reviewing her. I expressed my concern that there there might be some sinister pathology going on – although none overt so far.

The morning house surgeon never got to see her alive, though. She died two hours later.

Could anyone have predicted? Did I do something wrong? About this I have thought for a long time. I remember being warned while in medical school about the inevitability of these questions. Of course I could have done better; I wish I had the experience to pick up the subtleties – oh I hate it when this happens. But if the deterioration was that fast – I wonder if the outcome could have been changed much.

Still, the worried, anxious face she gave me when I walked away haunts me greatly. I should have been kinder to her. There is no excuse. Really, I’m sorry.

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