Traditionally stories are told in chronological order. Nevertheless, this story begins today, Wednesday, August 3rd, 2009. I am almost at the end of my long career as a medical oncologist, a fascinating adventure.
I am standing in my office on the top floor of a hospital building, in Sanremo, Italy. There is no air conditioning, but the heat is slightly less oppressive today, as a veil of cloud has dimmed the huge, ferocious sun. The windows are open, and the sea breeze lifts a few papers on my desk.
Sanremo Hospital is on a hill and even if the view is familiar, it never fails to enchant: the strong green of maritime pines, the dusty olive trees, the ochre hue of the houses and of the monastery, Madonna della Costa, contrast with the silver-blue Mediterranean Sea, which here becomes Gulf of Liguria.
The Oncology Outpatient Clinics operate in the east wing of this floor while the west wing had housed the Pediatric ward; an unfortunate proximity, for which I am partially responsible. Years before, when a new oncology service was being established in the province of Imperia, the essential requirement had been a functional working space. I, as the Primario, or Director, had repeatedly solicited the local health authority, to find a suitable solution. Administration, however, did not see or pretended not to see, the need. The inertia of management made me push my case vigorously and meetings were often unpleasant and confrontational. When the Department of Infectious Diseases moved to newly built facilities, the old premises - a small, separate, two-story building - appeared to be an excellent solution for Oncology. The opportunity, however, was used to create more comfortable offices for the clerical staff. With negotiations reaching such a low point, I accepted administration’s promise that, in time, the entire top floor of Padiglione Castillo would be allocated to Oncology. Logistics would improve even if results would be less than optimal.
Today, five years after the initial agreement, the ex-Pediatric west wing is finally being restructured and redecorated for Oncology’s Day Hospital. Work is progressing rapidly, and the hammering has reached the door of my office. I should be pleased, but I still cannot bring myself to accept this compromise gracefully.
The Day Hospital is where most patients with solid tumors receive chemotherapy and supportive care. Typically, patients are admitted daily for one to five days per week, at times consecutively, every three or four weeks. This care is particularly suitable for patients in good clinical condition but is increasingly used for cases with greater disabilities and symptoms and the Day Hospital also functions as a Day Hospice.
Outpatient hospitalization has disadvantages for the patient. Just reaching the facilities can be difficult. The Italian Riviera, located in the Region of Liguria, is compressed into a sliver of land between mountains and sea, with a narrow and unfriendly network of roads. One advantage, however, outweighs all inconvenience: the patient can continue to live at home.
Sanremo Medical Oncology has for years worked out of a tiny space, 650 square meters, and these precious meters are on two different floors - the Outpatient Clinics on the fourth and the Day Hospital on the first. Since the two areas are separated by both Medicine and Neurology, patients experience navigational difficulties. In addition, the Day Hospital can only be reached by a corridor that runs through the Division of Medicine. From Monday to Friday for eight consecutive hours, this common corridor is occupied by the comings and goings of Oncology. More confusion is caused by the Medical ward’s kitchen, which is located inside Oncology’s space. At 11:30 the stainless-steel food trolley emerges, sweeping past the rooms where patients are receiving chemotherapy, almost occupying all the hallway. Even if the quality of the food is good, the smell of lunch is not appreciated by patients undergoing treatment. The logistics (or il-logistics) just described are a challenging work environment.
When the present refurbishment is complete, all of Oncology will be on the top floor. Although this will be a vast improvement, total space will remain comparable to the prior split situation. The rooms are just enough for our present workload which is a considerable drawback since a rise in patient numbers, not twenty years on, but within the next few years is foreseeable.
Even if restructuring is in full swing, clinics must continue, so consultations are being carried out against a backdrop of incessant noise. I try to concentrate on the patient in front of me. As I pick up my stethoscope, covered in dust, I try to keep my temper in check by telling myself that this process is of vital importance, but I am uncomfortable and irritable.
How did I find myself in this frustrating situation? In 1992 the Health Agency of Imperia Province was recruiting a Director of Medical Oncology. I applied for the position and, along with four other candidates, sat the required public examination in late June of that year. In July, I received a letter advising me that the position was not mine. Attached were the exam outcomes for all participants. The results were expressed in points and the successful candidate’s advantage over me was only 0.183. The outcome was so curious that I requested a copy of the minutes of the procedure. I read and re-read the document but could find no errors. However, the validity of so small a margin remained unconvincing.
I asked a friend for help. He is a radiologist with a sharp eye for detail since he is also an art collector specializing in early 20th century Italian painting. In addition, having held managerial positions in various hospital trusts, he is experienced in deciphering the tortuous language of Italian bureaucracy. Two days later he had found the error: administration in Imperia had miscalculated the score assigned to career seniority for the winning candidate. Using the correct criteria, the result was in my favor. Since the error was mathematical, presumably not open to interpretation even in Italy, I decided to appeal the decision in court.
Before proceeding I spoke to Professor Leonardo Santi, then my Scientific Director, who I much admired and respected. He tried to dissuade me from taking legal action. Having presided the exam commission, he was certain they had followed the correct procedure. I replied that the minutes confirmed his version. On the other hand, the commission’s role, limited to testing the candidates’ professional ability, did not include questioning the numbers prepared by the Trust. My argument did not convince Santi, but I was stubborn, so his reply was unhappy and laconic, ‘If you insist, I cannot forbid you to exercise your legal rights.’
I was 42 years old and found the prospect of a top position in National Health, very attractive. At the time the few female directors were present only in pediatric departments, so I would be the first woman in Italy to direct adult oncology. I was eager for a new challenge, also feeling confident I would have the energy. In Italy, executive positions are almost always reached at an older age. This morning’s news had announced that the President of the United States, Barack Obama, would celebrate his 48th birthday at the White House. The current President of the Italian Republic, Giorgio Napolitano, was elected to office three years ago, then 81 years of age.
I initiated legal proceedings, the outcome of which became final only eight years later. In 1999 both the Regional Administrative Court and the Consiglio di Stato, an advisory body to the Italian government on the judicial implications of administrative matters ruled in my favor. Imperia Trust now had no alternative but to face the disagreeable task of demoting the incumbent and assigning the position to me. The process was very unpleasant for all concerned. After eight years, I was no longer so eager and found facing the late and unexpected results of my legal action very awkward. Over the years my objectives and ambitions had considerably changed. My career had progressed, I now coordinated the Unified Day Hospital of the National Institute for Cancer Research, also known as Istituto Scientifico Tumori (IST), in Genova, a prestigious position. Many acquaintances, more than my share of good friends and a Genova - London arrangement with my husband Garry, a Canadian engineer, all made life enjoyable. I was very happy both professionally and privately and did not relish a change.
One day, standing between beds in a room where chemotherapy was being administered to seven male patients, I was called, ‘Doc, things are not well here, could you have a look?’ I turned to face the struggling patient in the bed to my right and a warm, strong jet of blood hit me, covering my glasses and white coat. The stream of blood also hit the wall behind the headboard, dripping towards the floor, a large red stain. As I moved towards the patient, blood continued to seep into his clothes, bedsheets, and pillow. Everything seemed to move in slow motion. I could see that two patients had ripped their drip out and were running for the door, one man cried, and the rest were stunned. The nurse beside me exclaimed, ‘I’ll call for emergency transport to surgery!’ ‘Yes, Yes, I will stay with him.’ I told a second nurse to administer a tranquilizer to the other patients in the room.
The bleeding patient was receiving an experimental treatment for advanced head and neck cancer. Along both sides of the neck, there are two sets of vital arteries that supply the brain with blood and nutrients: the vertebral and carotid arteries. In head and neck patients, cancer infiltrates the tissues of the neck, also eroding the walls of these vessels. Most frequently the damage to the arteries results in an internal hemorrhage. Rarely the carotid artery bursts suddenly and blood, rapidly and forcefully, flows externally. I frantically reached for gauze to staunch the flow but found that the gesture was useless. Pierfranco had not exaggerated!
Since it seemed like help was taking an abnormally long time to arrive, the nurse suggested that we get the patient to surgery using our own emergency trolley. I agreed, but due to my well know back problems - osteoarthritis - I was not sure I could lift the patient safely. If he, a tall, strong twenty-eight-year-old, could lift the patient’s trunk, I would take care of the lighter lower body. Using the bedsheets, on the count of three we shifted the patient from the bed to the trolley. I had not managed to get one foot inside the trolley and apologized for my clumsiness. The patient, almost unconscious, heard my remark and pulled in his foot, helping me. A gesture came spontaneously: I kissed my fingertips and pressed them onto his cheek saying, ‘You are a darling.’ In return, the patient quivered with gratitude and for a long second, I felt very loved.