Saturday, March 1, 2008

A Lost Opportunity

The student had met her earlier last week. During that time she had been quite charming, quick minded, snarky, but with a compassion beyond belief. She had insisted that the doctor come to her home, once she was discharged, and sample some of her homemade jam recipes. She proudly recalled that she grew her own ingredients and her jars of jams and other treats were the talk of the neighborhood. Her daughter smiled lovingly at her. She was decisively independent in action and thought, but euphoric about her improvement. Traits that endeared her to the student and he hoped that he'd see her again when he returned the next week.

Upon the student’s return he found her in an opposing condition. That Friday she had been planning to go home, doing well and feeling optimistic about her time left, but now she was besieged like a cornered animal, clinging to an oxygen mask as life sustaining gas was pumped through at more than 7 liters a minute. Her eyes were screaming at him: “Help. I can’t breathe. Help!” and he recalled seeing that her oxygen saturations had dropped over the weekend to precariously low levels. The room, once full of euphoria, was now transformed into a dark, humorless, shadow full of dispair and exhaustion. The student felt a unique sense of vertigo, as if his entire world was being lost along with her's.

With this remarkable uneasiness that assailed him from every corner of the room, he examined her. He instantly recongnized the revulsion that had grown up in him and stood as a palpable lump in his throat. He found it hard to talk, even when just telling her what he was doing.

As the student arrived at the abdomen he discovered that the once soft, obese stomach was now a massively enlarged, rock hard, mound with discernible peaks and valleys. He could not appreciate any bowel sounds – an ominous sign. She had stopped producing urine and her eyes were no longer white, but were markedly yellow. His horror magnified as he examined these eyes, noting the distinct despair and cries that were manifested there within.

He knew from last week that she had undergone a major surgery to remove cancerous tissues. They had hoped that there hadn’t been any spread, but clearly the truth was here for the student to behold: The tumor had survived and was assaulting the woman from within; taking control of her body, plaguing her kidneys and liver, and making breathing an incredibly laborious effort. She was drenched with sweat from the effort of living. The student felt the sudden need to leave. He did not know what to do.

The morning rounds consisted of lengthy discussions between the doctor and her residents as well as with the family and the patient. The main topic focused on her sudden and clearly unexpected change. He found somewhere during this time that a party had been for her return and the banners still hung in her living room. "I doubt she'll see them" he had thought.

Radiographic films were viewed with the family in the physician’s lounge and the doctor explained the findings. The student already knew – large amounts of a homogenous, grey material obscured large amounts of the normal anatomy, interspersed with tumor. Her abdominal wall was caked in oppressive and magnificent abnormal cellular reproduction that constricted her diaphragm and reduced the patient's ability to move air.

“Metastasis. Outcome looks bad. Kidneys have begun to stop working”.

The family received these messages with stunned silence; then the daughter, the loving woman whom had been at the patient’s side when he initially met her, began to cry. The student looked away. He was surprised to find that he was fighting back tears as well – tears for a patient he’d only met once. Yet he knew what all of this meant.

In the span of 3 days she had fallen down the potential abyss that many patients navigate unscathed. She had “decompensated” and he knew there was nothing more to be done. She was going to die and he felt the acutely ironic scenarios play out before him.


She died later that week - a full code despite the attempts to obtain a DNR. He had avoided talking with the family or seeing the patient since that day unless he absolutely must. The situation was uncomfortable and the interrogations he received or perceived frustrated and confused the student. He didn’t know what to do, nor what to say. The doctor should be doing that. He was angry at the situation and the distinct perception that he was absolutely and completely ignorant of how to proceed. "How is it that after all this time I have no idea what to do"? he would often find himself asking aloud. His mind swam with guilt.

Now, as the student surveyed her lifeless body, tracheal tube still in place, eyes fixed and staring, chest exposed with the disproportions of her abdomen starkly evident, he was disgusted. A sudden and uncontrollable compulsion welled up within him. “I must get out of here!” he thought and he looked longingly at the door and the sanctuary of the nurses station. There he would be safe from the woman’s gaze, from his guilt.

Fighting off this instinct, the student stayed. He stayed when the doctor and residents lefts, he stayed when they cleaned up the woman. He even stayed when the family came in and burst forth in tremendous sobs. He persisted, in spite of himself. He had not been there for them before, but he wanted to be there now. Not so much for them, but for himself. If the student ran from this, then he had utterly failed in his duty.

The day culminated in a total of 20 hours. He had not needed to stay and had been released earlier. Yet he persisted. Wanting to stay and learn from his mistakes he remained and accompanied her to the morgue. He had avoided Death, but clearly it could not be brushed aside. It must be faced, and he had not performed admirably during the patient’s transition.

Though he desired to view her autopsy, he knew that this was an intrusion he could not perform. He had not been there with her during life, surely he should not be there when she was dissected and the tense abdomen exposed - it felt too intimate. He heard the next day that when the pathologist intially began she gushed liters of fluid. Metastatic ovarian cancer with mets all over her body.

At least she’s at peace, he thought. If there is a heaven, then surely she’s making her famous jams. The student smiled, and went about the rest of his day.


Bostonian in NY said...

Sad post MSG. Poignant, but so, so sad. One of the best I've read in a long time

Liana said...

Hugs, MSG. It's never easy to see someone dying... especially if it's a "bad" death.

A bit of training in palliative care goes a long way.

medstud 2 said...

It seems like you should have been more involved, but how much more? Isn't it the residents and attendings who are more responsible for talking to the family?