What is truth?
When he woke that morning he looked at his left foot, sticking out from under the quilt. Was that soreness, or just stiffness? It looked the same. The two feet, side by side, they looked identical.
He found himself walking carefully, keeping the weight off the ball of his foot, walking on the outside of his foot. He had to walk down the uneven path or work concrete, where the hedge, overgrown, pushed over to the right, and then down the sloping hill to town, gingerly stepping up onto pavements, and avoiding the cobblestones outside the antique shops. He visited the bank, the newsagents and the estate agents. Then walked back up the hill.
He spent the afternoon in the garden, trimming the plum trees, clearing weeds around the pond. More than once he cried out as a pebble or uneven ground pressured a soft spot on his foot.
In the evening Jan called to arrange a meet. “Hi – where do you want to go? The Plume? Or the John O’Gaunt?” He said “could you drop by and pick me up? I am finding it difficult to walk.”
For the next few days he continued to visit people round town, walking on the sides of his feet, before taking the train to London. To catch a 9 am flight, he had decided to stay at a hotel by the airport. Thirty Dutch men and women were in the hotel bar, cheering loudly as Holland´s womens team beat the English. Penne arrabiata and a sauvignon blanc dulled the pain.
After 15 hours in transit, four of them dragging his foot round Chicago airport for a succession of security checks at, it seemed, opposite ends of the giant terminal, he finally reached Lima and took a taxi to his rooftop apartment, reached by a narrow spiral staircase on the outside of the building.
The next day, despite the jet lag, he woke at eight, and took a coffee onto the veranda. His right foot was swollen and soft, a pudding. He went back to bed and slept till four. Waking he realised he owed the landlady the next months rent – because of the trip, it was a week overdue. Groggy, he walked three blocks to the cashpoint, only to find that he had left his cash card behind. He retraced his steps and picked up his card to return to the bank. This time, he realised he had taken his UK card rather than Peru bank card. An hour and eighteeen blocks later, he returned, limping, with three hundred dollars rent.
At school he was impatient with people’s concerns as he dragged his foot around the classrooms. But some of the administration staff told him they had arranged for the school doctor to visit. He did not know there was a school doctor. In the computer room, he took off his shoe and the doctor pressed a thumb in the soft swollen flesh. The depression remained, like a fingerprint in raw pizza dough. The doctor gave him an Allellulia look.
“You see. Do you have diabetes?”
“No.”
“Gout? Do you like red meat? Do you drink alcohol?”
“Yes, and yes.”
“You should go to the clinic, to Urgencia. Like Emergencia but less so. Go today.”
I took a taxi after school to the Clinica Anglo-Americana. The taxi driver charged me 15 soles and drove for ten minutes.
There were several people waiting, and more arriving, some on crutches, others with feet in bandages. Through a door he could see the examination area, several booths closed by curtains. Someone was screaming. At first it seemed like a baby crying, but it grew louder and became abusive and obscene. Someone was wheeled out on a trolley, under a drip. After an hour, as people came and went, he realised that he had been put to the back of the queue, less urgencia than other urgencias. Finally he was taken to a booth and waited again, before a woman who seemed to be in charge of Urgencias came to take a brief look at the foot.
“We will take a blood sample and an ultrasonido”.
A half hour later he was put in a wheelchair and taken to another room where his foot was smeared in gel and the operator moved a probe up and down.
He paused and frowned. “It looks like something on the bone.”
Wheeled back for another wait, until a nurse came to say “we will take you for an x-ray”.
This was quicker. Click click. Turn your foot to the side. Click click. Now like this. Click click.
And back to the booth.
After twenty minutes a smiling young girl came to see him. “ You have a tumour. Do you smoke?”
“I stopped four years ago.”
“Well then.” She smiled.
“I have sent an email to Dr Gordito. You must see him very urgently. You must call him tomorrow. I have asked him to make a space for you even though he is fully booked. Call Vera, his secretary, at 9 tomorrow. Also we will give you some crutches to walk with.”
“Let me write this down.”
“Vera, call tomorrow, to see him a soon as possible.”
She lent down smiling and shook my hand.
“Good Luck!”
My last visitor came to say “the blood sample is fine. But you heard what the other girl said. Go to the counter to get your medicines.”
They gave me a course of antibiotics and anti-inflammatories, which I paid for at the cashier before handing over my payment receipt to get the pills, and hobbling out, without crutches.
Taking a taxi back home, I paid 5 soles, and realised my first cab driver had taken a roundabout route and overcharged me. I could have walked it in ten minutes, on two good feet.
When I called the clinic next day I was told that the doctor was away at a Conference for the next two days, and was fully booked until Thursday the following week. I explained that in Urgencia they had requested an immediate appointment. It took several conversations on the phone, but all they could suggest was I call on Monday. When I spoke to the secretary the best she could offer was to join the queue at his normal surgery.
So the following Thursday with a friend to translate I sat in the waiting room to see Dr Gordito. I was surrounded by people with legs in casts or bandages, on crutches or with a leg swollen like melons round the knee with a line of stitch scars down the front.
He had the ultrasound and the X-ray on his screen.
“You need to take an MRI” he said.
“If you book it today, the insurance company has to give permission and we could do it in three days. Then come and see me next week with the scans.”
The MRI took place the following Wednesday.
They gave me a long paper in explaining the procedure and risks, of metal objects pacemakers, and implants, all in Spanish. “Sign here”.
I lay instructed not to move a muscle inside a roaring clattering machine, legs strapped to a board, for forty minutes of anxiety and twitching nerves.
The school doctor looked at the MRI images, holding the negative plates up against the window of the science laboratory, as my head of department walked in to discuss term grades.
“Can you give me five minutes to finish up here, and then I’ll come to see you?” I said.
The doctor proposed recommending someone he knew for a second opinion, and I agreed. He chose an oncologist, so that was one more vote cast against my long term survival.
Cancers in the foot are very uncommon – unless they are bone cancers spreading from a major cancer such as a lung cancer. In that case, as a major central cancer has already begun to spread, life expectancy might be six months. There were a few things I wanted to do first, including crossing the Rio Mala and seeing the stones again, in the short period whilst the river was low.
I made the appointment for the Monday afternoon. That same evening I would see Dr Gordito to discuss the MRI. I had barely glanced at the scans, after a glass of wine, enough to see a bright white object poised above and between my third and fourth toes. I spent the weekend reading and trying not to think.
I went with Kusi to the oncologist. I had written, in English, a step by step description of what had happened in the previous two weeks. He asked me to take my shoe off and looked briefly at my foot before examining the scans.
“You have a soft tissue sarcoma, we need to do a biopsy. If it is malign we will need to remove it and an area of 1cm on every side around it.”
“Is that a needle biopsy or an excision?”
“We have to get a big enough sample to be sure. We can not do that with a needle biopsy. We will take a good sized piece and will have the results in five or six days.“
A few hours later we were with Dr Delgado.
“I shared your MRI scans with some colleagues at a conference in Sao Paolo. I am very confident it is villonodular synovitis. We will need to operate and remove it.”
“Thanks for taking so much time with it!” said Kusi.
“No problem, it is a very interesting case. “
“I am delighted to have brought some excitement to your dull life” I told him.
I and Kusi asked a lot of questions. What would the surgery involve? What were the benefits of taking a biopsy? Was it benign or malignant?”
“We don’t know unless we take a biopsy. But if we take a biopsy, we may disturb it. If it is a cancer, it is better to remove it at one time. If we make an incision for a biopsy, we want to use the same incision the second time. That can be difficult.”
“I can refer you to a colleague who specialises in growths or tumours. Myself, I am a foot specialist. Maybe he can advise.“
He wrote down the name of a doctor at the prestigious Clinica Golf, at the edge of the golf course, naturally, in the centre of one of the most upmarket residential district of this rainless, desert city of Lima.
The golf course, like the race course and the major parks, only exists because of irrigation systems built throughout the coastal plain by the Ichma people, a thousand years before the Spanish, so they could farm the area. The canal network, in parts now covered over, continues to take water from the Rimac river throughout the city.
Most Lima residents do not know about it, and when I tell them, they refuse to believe it, changing the subject.
I went with Kusi to have a beer and fish and chips in an Irish bar in downtown Lima, and ponder the future. However short it might be.
The following week we went to get the second opinion from Dr Gordito´s friend.
I explained the diverse opinions I had received so far.
“Who was this oncologist? Dr Rodriguez…ah yes, I know him.” He paused meaningfully.
“I don’t think it is a sarcoma. A sarcoma is always malign, that’s what the word means. But we should do a biopsy.”
“Is there a problem with doing a biopsy, if it is a malignant cancer?”
Not at all. We have statistics on survival rates, and they are the same for patients with and without biopsy. If the there was a chance that a biopsy in some way encouraged the cancer to spread, we would see this in the statistics. But there is no change. “
“This is a simple procedure isn’t it?” asked Kusi.
“ Simple? No! There are only two or three people in Peru who could do this. And the same in Brazil, in Argentina, just two or three people.“
I was concerned about the damage to the muscles and tendons that might result, but Kusi was outraged that I could not eat for six hours before the operation.
“Six hours. You can not be serious!”
“Of course he is serious. He’s a doctor.”
But, no water, nothing?”
I would have to arrive at the clinic at 7 am and spend four hours being prepared, providing a urine sample, answering questions about allergies, having a blood test. Then in the afternoon, I would be put under general anaesthetic and they would operate.
“So, are you ready for the biopsy?”
“Yes, OK, lets do it.” I said.
It was Friday afternoon and the biopsy was scheduled for Tuesday. On Monday, I would more to Kusi’s house where they could look after me for the six days or more that I would be on crutches or in a wheelchair. I went home and packed a bag, facing another weekend trying not to think.
I had emailed a friend at home asking if his wife, would be willing to advise on “a medical issue”. She had been a GP for forty years, but GPs have enough commitment in the surgery without having friends consult them at home. I had been reluctant to ask for help. But I had received no response.
I had also sent details to my home town surgery in the UK, which to their credit did reply, but were understandably reluctant to commit.
“Thank you for the note and scans. I am unclear as to what the specialists have given you in the way of a diagnosis or what procedure is planned so am limited in my comments regards to this. I see no condition that would make you unfit to fly should you decide to return to the UK. I have limited experience with regards to the health service in Peru though I would imagine they are quite competent in dealing with problems such as yours.”
It may be that my south american friends would be uncomfortable with the formal tone of the response, and that it said virtually nothing. But I was reassured by the professional response that he would offer no opinion unless he was sure. The truth here is in the spaces, the vacancies.
I replied “I have a specialist saying villonodular synovitis and recommending surgery to remove, and another saying soft tissue sarcoma and recommending biopsy then removal of body and 1 cm surrounding tissue.”
And I received a further reply. “Thank you. I understand your concern as there is quite a difference in the implications of the two diagnoses. I would see operating being required to make the diagnosis and think that this should take place sooner rather than later. Subsequent management could be transferred to a location of your choosing should it be required at that stage.”
It may be that some would see that as the apotheosis of indecision. For me it was a triumph of clarity and restraint.
Then on the Sunday I received communication from Peter, saying my email had been stuck in his trashcan: yes, Jo would be happy to advise and we could do a skype that afternoon.
We talked for an hour. Amongst other things, Jo told me the traditional treatment for growths on the foot had been to hit them hard with a bible. But she was not recommending that.
The next day at school, I cancelled the biopsy, and ordered a pair or crutches on one month’s hire.
I texted Kusi to explain on Sunday evening. At 7.30 on Monday morning she texted me “a biopsy would not be so bad.” She herself had had a biopsy on a suspected skin cancer on her arm, a few years earlier.
“I don’t want to argue with you” I replied. In truth I was finding it difficult to remain calm and deal with the decisions I was taking, without having to deal with people wanting to persuade me otherwise.
I did not hear from Kusi for several weeks, which was fine. I did not want to have a continued conversation about her being right and me being wrong, and figured we would talk again once we could move on.
She explained later that when I had texted her “So how are you?” she had been outraged. And who would not be? She had discussed it with her psychologist who told her I was attempting to “transfer my death anxiety” to her. And advised her to turn off her What’s App so I could not harass her further.
The security men at the school gate – wise old men who watched everybody come and go and enjoyed life a good deal more than the teachers and admin staff of the school – had plenty of advice. “ No eggs, no chicharron, fried pork, and you want some special shoes to support your heel. Its heel spurs that you’ve got!”
I visited the sports department to arrange to use the school gym to do some leg rehabilitation exercises.
“Come in man, come on in, have a seat. So what’s going on?”
“I want to use the gym to exercise my legs, because I am not using them enough walking round on crutches.”
“ Well, look man, I know a doctor, a good guy who fixed my hip last year. Give him a call!”
“I’ve spoken to enough doctors. I’ve had four or five opinions, I’ve spent two weeks seeing doctors, and it’s not been a great two weeks. I going to let it rest and recover. But I want some exercise to strengthen it.”
“Well Giancarlo can help. He’s a nutritionist and a sports trainer. Hey Giancarlo!” He called the student sports teacher. “You gotta help this man” he said in Spanish, “ he wants some workouts.”
“ What is the problem?”
“ Gout. He’s got gout.” he told him in Spanish.
“Well then,” Giancarlo looked at me, “you must stop eating red meat, alcohol and chilli peppers.”
“With this private medicine system, I’ve seen so many doctors, and they all want to make money off me, they all want to operate. I just want to use the gym to exercise my legs a little.”
“So what we could do,” says Giancarlo, “we can do some special work on your balance, an hour three times a week, for a month. Same rates as I give the students, 200 soles a month.”
Another teacher found me sitting on a bench in the school grounds, seeking fresh air to reprieve the dry retching which was, I assumed, more to do with anxiety than stomach problems.
“Maybe you’re just stressed, you need to take some time out”
A teacher passed me on the stairs. He had asked me several times how was my leg, and I had told him what I knew. This time he shouted at me “But you don’t know what it is!”
Some weeks later when I told him “its metatarsalgia” he was greatly relieved.
What came next was the sports therapist with the ozone treatment, but that’s another story.
Go forward to 35 – watering the desert