The man who had been seated in room 2 by the medical assistant had been seen 6 months previously for a small, pigmented lesion behind his left ear, which a punch biopsy subsequently proved to be malignant melanoma in situ. He was sent to the Mohs surgeon in the interim who carefully excised just as much skin as was absolutely necessary and left him with a clean scar. He was following up with us in the dermatology offices to make sure that the wound was healing well without any traces of pigment on the borders that would make us suspect recurrence.
My attending, who I had been shadowing every Friday morning for the past 3 weeks, let me go in to evaluate him on my own first, and to report back to him with my clinical impression. This would give him a few minutes to gulp down a bite or two of sushi while I did my thing.
The patient was already undressed and in a hospital johnny by the time I knocked on the door. He was a stocky short man, with pepper-gray hair, a plethoric face that brought the word “rosacea” to mind, and wide swathes of tan with blotches of white pink and gray spattered in like a Jackson Pollack painting over the skin of his face, torso and shoulders.
“Have you been getting a lot of sun this summer, Mr. Butte?” I asked.
He chuckled and nodded guiltily. “I’ve been using sunscreen though!” he said.
“Do you remember to reapply it every 2 hours?”
I threw my hands up in the air. “You’re killing me, Mr Butte. Now where was that melanoma excised from?”
He pointed to his left ear and that’s where I went.
“Your name is interesting,” I said as I palpated the small pale patch of skin graft. “Butte. Is it inspired by the little mining town in Montana?”
“No, but close. I’m from Seattle,” he said.
I knew about Butte because I’d recently read an essay about westward-bound pioneers in the early 1900s who tore up the prairie looking for oil and minerals, and who discovered them in farflung places like Montana, North Dakota, Texas and Oklahoma. Melanoma is kind of like oil too. It parks itself in unspectacular places like the little V shaped zone between the hairline and the pinna – a place that no one but a dermatologist would ever think to look. Then after we excise it, it’s little more than nothing but a little less than fully rewarding. I ran my finger over the patch. It was flat, cold, thin and dry. A ghost town.
“This is really nice work,” I said. “I think the wound healed really well. You can barely tell that you even had something done.”
“Tell that to the donor site,” he said, and pulled up the johnny to show me a square erythematous patch on his thigh where his surgeon had taken the split-thickness graft.
“Oh but that’s so high up,” I protested. “No one will ever see it!”
He looked at me, startled, and laughed. “No one?”
“Oh no that’s not what I meant!” I said, now laughing as well. “I mean, most people won’t look there, because it hides under your shorts. Not no one.”
Mr Butte’s skin was littered with the barnacles of old age – seborrheic keratoses, cherry angiomas, acrochordons, and the insignia of sun damage – lentigines, actinic keratoses, solar elastoses. I named them to him as I went along; this way we could both learn. I told him what to look for to catch melanomas early. I counseled him to wear large hats and full sleeves when he takes his boat out in the mid-day. Then I turned to go get my attending for the official once-over.
“How often do I have to keep coming back to you guys?” he asked, as I placed my hand on the door. “I mean, not that I don’t enjoy catching up, but I want to be past this, you know? I don’t want to keep worrying every three months as I drive up to your office that the melanoma’s come back.”
But melanoma is kind of like oil. When someone finds this valuable resource, people flock to the area to extract it from the ground. But the newly populated area is a lawless shantytown and doesn’t run by the same rules governing the rest of the body. Just like a booming mining town quickly becomes inhabited by hovels, gamblers and prostitutes, the skin invaded by melanoma refuses to abide the laws of general civilization. It’s a rogue element, a charmless intruder.
“Unfortunately your dermatologists can’t take that gamble on your skin,” I said. “We’re gonna have to poke and occasionally drill, every six months for another five years before we can clear you for yearly visits.
With every boom comes a bust. It almost always plays out this way – eventually the resource dries up or the price drops, and the frontier town dithers away, its empty General Mill stores and corroded Main streets all that remain to remind tourists of what was once there. We’re gambling that the boom will bust. It’s a sign of prosperity when it does.
Samyukta Mullangi is a medical student who writes at her self-titled site, Samyukta Mullangi.