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.

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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.