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CHAPTER 1:
Eighteen days adrift

“Hello, I’m Diego. I’m going to do my utmost to remove your tumor.”

That morning, she was scheduled to visit the hospital —probably the place she loathed most. It was a hospital of dirty walls, hallways overcrowded with ailing patients like lifeless souls, and worn-down, burnt-out staff. She was there to collect the results of the latest PET, a nuclear tomography that evaluates tissue damage. Roughly two years ago, Carmen López had been diagnosed with lung cancer. She had wrested the last two years from life, as the tumor had been discovered in a very advanced state (stage IV) and had metastasized twice. But she never gave up. The love and responsibility she felt towards her two young children bolstered her with positive energy and strength, and she responded excellently to the radiology and chemotherapy. The treatments dissipated the dark spots that had spread to her spinal column and esophagus, and decreased the main tumor, which had been straining her vena cava. The results were so exceptional that the doctors went on to present them at medical symposiums. Carmen’s strength was impressive —for several months she was able to conceal the disease from the world, and even her elderly mother. She detested being pitied. During her private time, her hours of greatest loneliness, she would remember reading The Etruscan Smile. In this poignant novel, author José Luis Sampedro narrates the fight of an old partisan revolutionary farmer against his arch nemesis: la Rusca, a stomach cancer that would end up eating away at him until his final breath. Coincidentally, Sampedro had christened the disease with the same name as Carmen’s mother’s shepherd dogs; a name which had been passed down from one generation of dog to another.

There was no reason for that early December morning to be any different. On the wet streets under the cloud-blanketed sky, she arrived optimistically at the oncologist’s office at the same foul hospital, expecting to hear what had already become routine: the original tumor had again reduced in size and activity, despite the new shadow that had alarmed doctors after the last X-ray.

“Carmen, it’s growing back. That dark spot we saw is the tumor growing. It has spread aggressively, and it seems to have become immune to the chemo treatment. The gauges and markers are soaring. I talked with the surgeons and they still rule out the option of surgery.” The words of her trusted oncologist left a dull, ringing sound in Carmen’s ears. His words fell like an irrevocable and abrupt death sentence that she refused to accept.

Despite being numb from shock, she felt that within the doctor’s words lay a tiny sliver of hope. Maybe her husband was hearing him more clearly. Dr. González was a young surgeon who had developed a minimally invasive technique using only a single incision and a camera. With this method, he had achieved many victories and dared to undertake the most bedeviling of thoracic tumors. Don’t bother consulting anyone else, Diego will do this or nobody else in the world will.

“Go see him and do it now! Get going!” Doctor Fírvida was telling her as Carmen regained her hearing. “I immediately believed in it,” she affirmed later. “He told me, ‘If anyone can solve your disease, it’s Diego. If there is any possibility of it happening, he’s definitely the one.’”

***

Carmen’s bed is being guided into the elevator on the way to the operating room. Barely 18 days have passed since her latest diagnosis. Eighteen nights of dread and panic, spent in her husband’s arms, concealing any signs of the gravity of the situation from her two children and mother. Eighteen days and nights of steely mental control to avoid falling into despair.

As a child, Carmen suffered from polio during the final and fearsome plague of the virus that spread throughout Spain in the 1950’s. Her first operation was at only 3 years old, when she was operated on by a German specialist in Madrid. He connected her tibia to her foot, which had become loose and dislocated. Later, at the age of 13, she underwent an experimental surgical technique by Doctor Esteve de Miguel, in which he used a z-shaped piece of metal to lengthen the tibias of ‘the Polio children,’ by two inches. Her father, a urologist, had not hesitated to entrust her to his Catalan colleague. In total, she had eight operations to stretch out the tibia. She suffered unspeakable pain and lost 25 pounds in 28 days. In the old Quirón Hospital in Barcelona, just the sight of Carmen made her mother exclaim to her husband, “I can’t take any more suffering! Make it stop!” And her father, who would visit them on weekends, would tell the girl, “You have to endure.” It was a devastating memory that would teach Carmen “to be tough and cold with myself for life.”

“No. Of course I didn’t accept the diagnosis (of the oncologist). He was telling me that any further efforts would no longer work, and that the strength I had mustered against the tumor until now was falling like a house of cards. How was I going to accept that?”

And that’s how it went: she waited for 18 days, confident that everything was going to get better. “I have two young children and a wonderful partner who supported me; I had to keep seeing my children grow. Also, I believed deeply in science and medicine.” Those 18 days consisted of racing to compile test results and clinical records and trying to pin down that prodigious surgeon who curiously had an office in a public hospital just 105 miles from her city, despite constantly traveling around the globe teaching his innovative technique.

The young surgeon, who after receiving the images of the tumor —God bless him— had said that yes, he’d operate. This, despite the fact that his own team had refused because they simply didn´t feel capable of handling her case: a mass located on the lung hilum, the central cavity between both lungs, where the heart veins begin, passing through the main thoracic arteries. The tumor measured 14 centimeters in diameter, invaded the upper right lobe, and was literally encrusted on the vena cava. On top of that, for two years, she had undergone intense radiology and chemotherapy, which had had debilitating consequences on her tissues. The diagnosis from the surgeons at her public hospital were definite, and grew even more so, “It’s impossible. It’s absolutely impossible to operate on you.” But Carmen and her husband managed to speak with Diego and sent him the clinical records and the latest tests. Carmen’s husband, the stomatologist, Ignacio Romero, will never be able to forget when the surgeon responded, “Impossible is nothing. I’ll operate on her.”

Diego clearly explained to Carmen’s husband and brother-in-law (both doctors) the risks of the operation, which were plentiful, but that he, as a surgeon, and she, as a patient would be willing to take. “I was absolutely sure that I would take the risk,” Carmen recounted months later. “It was the only hope possible. The treatments, besides already having been proven ineffective, had poisoned me unbearably for so long (first the “horse” radiation, and then 36 chemical sessions that burned like tiny stabbing at the top of my stomach). I was so debilitated that walking ten feet to the bathroom was like walking 100 miles.”

It also didn’t seem to them to be incredible, storybook-like, coincidental or outlandish that the surgeon had his office so close to A Coruña, “When they found the tumor in me,” Carmen continued, “My husband contacted the entire world. We reached the conclusion that we had the best oncological medicine in Galicia, that my team in Ourense was (is) unbeatable, and that we wouldn’t turn back. After undergoing treatment for one year, however, I did need a second opinion.”

She told the lead oncologist on the team, and Doctor Fírvida agreed that yes, it’s a good idea to have a second opinion. So, Carmen took her clinical records to a team led by Doctor Josep Baselga, who went on to become the Medical Director of Memorial Sloan Kettering Cancer Center in New York, the most prestigious oncological center in the world. This new medical team would be led by this distinguished Catalan doctor, who personally treats his patients. She scheduled an appointment with the head of the lung cancer program at his institute in Barcelona. After interminable tests, Doctor Felip (Doctor Baselga’s colleague and also a dear acquaintance of Doctor Fírvida) concluded that her tumor was incompatible with the immunotherapeutic treatments usually given by the Baselga Institute. She advised her to cease all chemotherapy because it would destroy her. That was something that the patient again could not accept, “It was as if they were telling me to give up fighting. No, that’ll never happen.” Continue with the chemo until it proves ineffective.

***

General elections were being held in Spain, and again, if there is such a thing as fate, the surgeon would be voting back in the country in a period of, that’s right, 18 days. Carmen even gave thanks to politics. There wouldn’t be time for a consultation prior to the surgery, Diego barely ever saw his medical team. They didn’t feel capable of performing the operation themselves but hadn’t hesitated to send the tests to their colleague, who was spending his days between Shanghai and the United States. The team was used to him tackling challenges that for anyone else would be impossible: those doctors knew that ‘impossible’ was a word that Diego would not tolerate.

***

As they wheeled her bed into the elevator to go down to the operating room, a striking young man dressed in blue scrubs suddenly made an abrupt entrance. He was accompanied by his colleague (and now Head of Services) Mercedes de la Torre, who was wearing a woolen toque. The young man approached the bed, “Carmen, how are you? I’m Diego” (that’s what he said). “Everything will be fine. You’ll see. We’re going to do everything possible to remove that tumor from you.” He took her hand and squeezed it gently but firmly.

Months later, Carmen would admit that the surgeon’s extreme youth, his casual behavior and his humility concerned her. “My goodness,” she told herself, “Close your eyes, and let´s get on with it. I had been expecting —or my subconscious had been expecting— a figure like that of the German surgeon who operated on me for the first time in Madrid at the age of three. That was my memory.” It was a memory that continued to haunt her even as a student of economics in Madrid. “I accompanied a friend to an appointment with his orthopedic surgeon. He had also suffered from polio as a child, and that brought us together. When the doctor passed in front of me, I fainted. At the time, I didn’t know why I had that reaction until I woke up and realized that it was the same German surgeon.” She also had the image of the Catalan Doctor Esteve de Miguel etched in stone in her mind: his smile was ‘slightly Machiavellian’ when he exchanged information with her father, from surgeon to surgeon. Also unforgettable was her father’s best friend: the feared pediatrician, with that low gravelly voice, always dragging deeply from his tobacco pipe, and clinking the little glass vials in his zinc box. “The image of Diego broke the standard of savior that I had had (or that had been stored in my subconscious). And yes, perhaps it made me harbor a few doubts; as I was waiting to be let into the operating room, all these thoughts crossed my mind.” She closed her eyes and got on with it.

CHAPTER 2:
A Crusade Against Fear and Pain

“One who has not gone through it cannot begin to imagine what a person feels when they hear these words:‘You have cancer.’”

“Why even dare to try, doctor?”

“It’s a matter of experience: I feel capable because I believe that with the practice I’ve had, I can handle the complex cases.”

‘Super complex’ are the words he uses to describe the terminal cases he sees so frequently. Only yesterday he had operated on one of these ‘super complex cases’ in the Rambam Medical Center, Haifa; the previous week it was an illustrious citizen of the United Arab Emirates, who had traveled to be operated on during a course he was giving in Amman, Jordan. Diego González Rivas (A Coruña, August 12, 1974) does not like to say he’s courageous, instead he prefers to point to his experience. At 42, his surgical statistical record undoubtedly shatters all others. Still, he’s not one to gather statistics like trophies, even though in 2015 alone, he performed more than 800 major surgeries at Shanghai Pulmonary Hospital. It is the largest center for pulmonary medicine in the world, and in addition to regularly working there, he also directs an international training seminar there every two months. Eight hundred major surgeries when the great thoracic surgeons (in a country like Spain) average less than 10% of that, meaning they perform no more than two or three surgeries per week, often only one.

“Doesn’t it scare you to be responsible for such astounding figures, and the many lives stretched out on operating tables hoping that your hands will restore their ability to live?”

“You are so overtaken by the technical side that you stop thinking about the person and the feelings they expressed days earlier in the consultation, because that would debilitate you. There is a tumor in front of you and nothing else. The patient doesn’t exist, it is sterile, with neither history nor life. I think I would even be perfectly capable of operating on my father with the same detachment and resolve. Logically, it’s something you acquire with experience. I enter the surgery room and I transform: I concentrate on the tumor, the patient is now anonymous, a barcode, a number. You only go back to seeing their human dimension when the surgery ends. The worst thing that can happen in a surgery room is panic; if you start to panic, you’re lost, and if feelings are caught in the middle, panic spreads much more easily.”

***

Part of the blame is due to pain —his aversion to others’ pain— and another part is due to laughter —his desire to spread happiness. As a child, he grew up believing in making possible the most difficult task: the joy of others. Armed with a cassette player, holed up in his room, he’d record tapes of jokes so that he could crack a smile on the faces of whoever listened to them. He dreamed of being an entertainer, a comedian in the literal sense of the word. When he saw gloomy elderly people, he swore that he’d cure their pain someday. That’s how those who knew him best remember him. The second part (the curing) ended up being more urgent than bringing laughter, and that’s why he’s a surgeon. As a result, his life is a total commitment, traveling around the world, practicing and teaching his revolutionary technique: Uniportal VATS. Using this method, a surgeon can remove the most lethal lung cancer through a small intercostal port, only occasionally requiring sedation and local anesthesia. After a painless post-operation period, the patient is sent home 48 hours after the surgery.

Diego’s mother, his guiding light and emotional support, works as a postpartum nurse in the city’s Public Maternity Hospital. Nobody was surprised when her teenager chose his path. He who had been the leader of a group of gypsy boys in the neighborhood next to his grandparents’ house; who had distracted the class at every opportunity; who had bungee jumped using climbing ropes, even though he had never seen it done before; who had surfed waves of the most turbulent coasts, ultimately, opted to study medicine.

Although he trained in thoracic surgery, he would not be immune to the pain and suffering of his patients: the torture of slitting the chest and forcing the thoracic cavity open with the rib retractor. It was an assault that oncological patients rarely survived. He dedicated his life to a crusade of saving lung patients from an agony that he also could not bear. He invented and perfected a minimally invasive and painless technique to remove tumors and operate on severe conditions of the thoracic cavity. Now he travels around the entire world disseminating and teaching it; in this way, he has been able to give relief and joy to thousands of patients and their loved ones, waiting for the five prescribed years to pass before proclaiming the cancer has been cured.

***

He communicates with his patients and surgeons from all over the world through Facebook (his page has already reached its 5,000-follower limit). He is also the world pioneer of broadcasting medical advances on social media. He opened the first surgery channel on YouTube, diegogonzalezrivas surgery channel; more than 2,000 surgeon subscribers follow him. Every time he uploads or posts something, the news is shared instantly 500, 1,000, 2,000 times.

He has come to A Coruña on just a three-day break between Strasbourg, where he gave a course on Uniportal VATS, and Havana, where he will do a live surgery for Fidel Castro’s medical team. There, he will also receive a tribute from the top brass of the government and their favored artists. That’s how they thank Diego around the world: he teaches, and governments and medical administrations of the large hospitals honor him for his efforts. He dedicates almost all of his time to operations and courses for which he does not charge (except for those organized by companies that manufacture surgical equipment). To do this, he takes unpaid leave from his work as a doctor at Sergas (Servizo Galego de Saúde).

He awakens early in his home. It is a house in one of the modern and impersonal sub-divisions of the city. The first order of the day is to head to the coast to scan the waves. Today, the wind is blowing from the northwest, which churns the sea: impossible to surf. Instead, he goes with a friend to swim in one of the municipality’s Olympic swimming pools, the San Diego Pool near the port. In front of the sea, his sea, he speaks enthusiastically about his childhood and career. We are in Riazor Beach, where he grew up, under a rainy, gray sky that from time to time allowed the timid winter sun to shine through. Later, he will eat with his whole family who are waiting for him with great excitement: two months without seeing him.

Also waiting for him tomorrow (Monday) are two emergency patients who have come to the small Galician town: one from Riyadh, Saudi Arabia, and the other from San José, Costa Rica. The first patient was sent to Diego by his oncologist in Saudi Arabia, who believes the patient is a case for surgery, but only trusts Diego. The second patient is an elderly woman (above 80), who only her North American oncologist and Diego deemed suitable for operation. Both will be successfully operated on in the Saint Raphael Surgery Institute of A Coruña (one of the centers in which his Minimally Invasive Thoracic Surgery Unit operates), next to the Juan Canalejo University Hospital Complex (CHUAC), where Diego is an attending physician in the Public Health Department.

Sitting next to the turbulent ocean that day in Riazor, Diego talks about his patients. Everything starts with a verdict: ‘You have cancer.’ “Nobody can imagine what a person feels when they hear that sentence. Fear takes over, and suddenly, your insides burn. You feel like you’re constantly swimming against the tide, and that white-hot fear resurfaces again and again, you trust desperately that the science of medicine will be your salvation.” Until you’re cured, or until a second verdict confirms the worst-case scenario, that of the abyss, there’s nothing else that can be done.

That’s what happened to Carmen, Hadid, Joaquín, and the majority of his patients. Remember that in 2015 alone, he performed 800 major surgeries, many of them very complex cases, which occasionally had metastasized, and were treated with intensive radiography and chemotherapy while still effective. Stubborn and shocking cases, stage IV, misery. Many of Doctor Diego González’s patients have heard the sentence, “There’s nothing left that can be done,” and they sleep with that inside, and wake up, and go back to sleep, until he places himself like a firewall between the verdict and the clinical case.

“We’re surgeons. Surgical patients reach us, and that’s just 20% of all patients. When the disease has spread to other areas, our capacity to act is very limited and operating is not recommended. But each patient must be treated as an individual, and in the remaining 80%, cases are selected based on their responses to treatment and their tumor’s behavior. Even in advanced stages, they can receive what we call a ‘rescue surgery.’ There is hope for those patients despite the complexity, as long as we have the support or authorization of the oncologist.” In the aforementioned cases of the Saudi Arabian and Costa Rican patients, the oncologist had not said “it’s a case for surgery,” rather “let’s talk to Diego.”

“They are very technically complex cases that only expert hands can operate on, assuming the very real risks of an accident in the surgery, or of an adjacent tissue being torn or scratched, likely the vena cava and the heart.” The surgeon’s deepest fear is of a hemorrhage (bleeding in organs or tissues like the brain or vena cava) that may be fatal within instants if it is not addressed in time. In addition, gushing blood taints one’s vision, even more so when seeing an image through a camera, which must be constantly washed during the operation. “There is always a major risk for the patient when the location and history of the tumor are so complex. But in our unit (in his hands), these risks are minimized because of our experience. I’ve been through some really difficult situations in all types of countries and conditions, by myself, without my instruments or my team, in tremendously complex cases. When you overcome one challenge like that, your skills multiply.”

So, he does dare. “I don’t like to say that I dare to try; rather that I feel qualified because of my experience, and I believe in what I can do.” He is only 42 years of age, with just 13 years in the surgery room as an assisting physician and world traveler. But, Dr. González Rivas doesn’t care about figures or calculations. Decked out in an (immaculate) surfer shirt and skinny jeans, underneath his parka with a fur hood, without a hint of arrogance on his baby face, he says, “It’s impossible for me to calculate a total number of operations I’ve done, although most probably, I’m one of the surgeons who’s done the most lung tumor operations in the world.”