Playing Doctor




Initial Visit?

Wednesday, November 16

It’s the Hard-Knock Life

This man is an ex-Army man and he’d been our patient for several days. He’d come to the hospital because of vomiting and severe belly pain. Abdominal X-rays showed a partial small bowel obstruction. Surgery was consulted, but it was agreed that he did not require emergent surgery. So he’d been admitted to us, had an NG tube placed on intermittent suction, was given IV fluids, antiemetics, and pain meds.

A CT scan gave us the likely diagnosis, a large mass in the tail of the pancreas with multiple nodules within the liver and lung—very suspicious for metastatic pancreatic cancer. My intern and I told the man of his probable diagnosis, but also emphasized that cancer is diagnosed with tissue under the microscope, not with an X-ray.

The surgery team and I were both in complete agreement about the next move, but we were agreeing that the next move was ambiguous. If this man did have pancreatic cancer, he would not have long to live. We didn’t want to make him spend his last weeks on earth recovering from abdominal surgery. If we were wrong, if the masses were a different form of cancer or possibly a bizarre presentation of an infection, not making a tissue diagnosis would be allowing him to needlessly die. We decided to meet with an interventional radiologist in the morning for a possible alternative to surgery.


The next morning, the man continued to have pain and to dry heave, despite the NG tube keeping his stomach empty. I changed antiemetics and reformulated his pain regimen. The surgeon and I met with the interventional radiologist and found a liver mass that looked amenable to percutaneous biopsy.


I stopped by later to check on him, his pain was now ‘tolerable’ and he was no longer heaving. I patted myself on the back for my acumen in knowing how to rewrite palliative regimens and told him the plan for the biopsy in the morning.


I went in to see him the next day after the procedure. He was vomiting and wracked with pain. He had felt well enough that morning that his NG tube had been removed and he was allowed to have a little Jell-O. I looked at the cherry Jell-O and bile in his vomit. I was grateful I didn’t see blood, but still, my overwhelming thought was simply: Fuck. Fuck, fuck, fuck.

It’s far easier to keep pain under control than it is to relieve it. This is doubly true for vomiting. What’s worse is that we were now well into his second day of hospitalization. If a small bowel obstruction is going to resolve, it almost invariably does so in the first 72 hours. It was starting to look like he was going to require surgery simply for palliation.

I rewrote a pain and nausea regimen, this time with less confidence that it would relieve his suffering, realizing that things were not going well for the patient and that they were probably going to get far, far worse.



Two hours later, I’m having dinner with friends and pretending to care about the conversation as we complain about the waiter, their jobs, and the traffic.

When I am accused of being too quiet, I grin and tell the joke about the woman who has been in a coma for two months. Her nurse notices some signs of wakefulness when she’s bathed between her legs. I tell the joke as if I’m the doctor taking care of the patient: ‘So I call the woman’s husband and tell him to come to the hospital and tell him if he has oral sex with his wife, it might help wake her from the coma. So he goes into the room and after ten minutes, he comes out and tells us that she’s dead. I ask what happened as I rush in to see my patient. The husband says, I think she choked to death.’

Much laughter.


But in my mind, I have gotten up out of my chair, walked away from the table, and told everyone there—including—no—especially myself—to just shut the fuck up.

6 Comments:

11/17/2005
Anonymous monica writes:

My Oncologist, a husband and father himself, heartbreakingly told my Dad, a casual acquaintance of his, that his daughter's prognosis was most likely three to four months.

Non-Hodgkins Lymphoma, Stage IV
Mediastinal mass approximately 7.8 inches long, 7.6 inches wide, 3.3 inches deep (translated from centimeters for my non-medical, American schooling) with 'tails' whipping around the liver, heart and spleen. Right lung collapsed.

He regained his composure then walked into my room, scribbling something on his prescription pad. "This is what I need you to do kiddo, and I'll take care of the rest" he said as he handed me my 'prescription'.

It said something like this:
Movies: Comedies only!
Draw, paint, dance, write...all the things you didn't have enough time to do before. Take it easy.

Then he tells me to shave my head because it'll be coming out anyway and with a smile hands me a pack of sticker stars to get me started with all the fun things one can do with a bald head.
...And to quit asking him for pot because it was too weak to help with what I'd be going through. Buckle up.

That was over eight years ago and even though it's no longer necessary for me to go for an annual with him, I fly back home, bring some chocolates, and we catch up on our lives. We barely glance at that gorgeous black void on the X-ray.

My Mom saw him quietly crying at a funeral once; it was one of his patients.

Be that doctor. You may still want to walk up from the table from time to time, but it will be easier to settle into the laughter going on around you. And with some practice, it may even make all that pettiness and laughter all the more enjoyable.

 


11/17/2005
Blogger Spider writes:

I think monica said it all... you are obviously concerned and caring or none of this would bother you...

 


11/17/2005
Blogger Erik writes:

The both of you need to just shut the fuck up.

 


11/17/2005
Anonymous Anna writes:

Erik is obviously unconcerned and uncaring.

He is pompous and pusillanimous, a deadly combination.

Trust me when I say he never loses sleep over any of this.

He also eats a lot and listens to bad pop music, in case you were wondering.

Seriously. Who are you people, and why do you insist in molding Erik into your image of the "good doctor"?

He is not, nor ever was, nor ever will be that which you seek. Look elsewhere.

 


11/17/2005
Anonymous monica writes:

Anna...
I appreciate the directions, but I'm not lost.

The seekers are those posting blogs; accept me, berate me; confirm or disprove my insecurities. Please please thing I'm cool, funny, the height of fucking intellect...blah blah blah...

Deny that, and I'll go buy you a beautiful hardcover journal with "liar" engraved on the front.

And in your adjective soup, you forgot transparent.

Good luck, listless Erik.

 


11/17/2005
Anonymous Anna writes:

'Tis true: Erik hasn't done a list in a long time.

 


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