One of the very first patients I had admitted was a 50-some year old father of three with a newly diagnosed colon cancer. His case read just like my father’s. Sudden changes in stool caliber. More bloating and fatigue. His wife started noticing that he looked thinner.
By the time I had approached him in the hustle and bustle of the emergency department, the news had already been broken by the emergency physician. “You have colon cancer,” he remarked on the bluntness of that interaction. It had left him in such shock that he had little to say for most of the day. I took my time to be thorough, answering questions, gathering the history, doing the physical - his moderately ascitic belly and an enlarged liver already hinted at something more sinister. Having already been subjected to one rectal exam, he asked if I needed to double check again. I politely declined to which he breathed a great relief.
I excused myself to review his CT scan, to get a better understanding of what was driving everything. There, on the black and white screen I saw a liver so large it seemed there would be no space for anything else in that belly. Pocked full of cysts and irregular tissue, it screamed only one conclusion: gross metastasis.
"A few more tests," I reassured him and then he would go home, to follow up with the oncologist for further management options. I explained that the cancer had spread and that the options will be limited. He digested the news silently, his eyes flickered across the floor as he concentrated. When his wife arrived, I made sure to break the news gently. She wept regardless.
By the time I had sent him home, his belly was flatter once again, having been drained of all of the malignant fluid. The oncologist was to follow up with him within a week’s time. The prognosis was guarded but we agreed that he will be fine for at least the week.
Or so we thought.
It was a surprise to me then that not one week later, I saw him again on call in the emergency department, this time looking worse. He was confused, agitated, and grim - his skin had turned yellow. I quickly texted my attending: “Encephalopathy. Icterus.” The response was immediate: “Shit.”
Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden. The liver had started to fail and with that, his kidneys were beginning to shut down. He was quickly transferred to the ward.
We rediscussed code status with the family with the end drawing near and it was decided to change his care to palliative. We kept him comfortable until he died a few days later.
Precipitous multi-organ failure is uncommon to see in someone who is still very high functioning. We never would have expected him to decline so rapidly. It was a surprise to everyone that he could be here one week and gone the next. Given his disease, there would not have been much more we could do medically.
But there are always things we could have improved on. From delivering the diagnosis with care, to advocating for a private room in his final days, to addressing the psychosocial needs of the family. These are areas that we can strive to do better. At the end of the day, this patient was not his colon cancer, he was a person. With a wife and three children. A friend to many.
These were the pieces, in the torrent of changes that ensued on his second admission, that were lost.
"The patient died surrounded by his loved ones. We are grateful to have been involved in his care and offer our deepest condolences to his family and friends…End dictation."
The echoes of my steps resonated within the expanse of the hospital garage. As I made my way to the end of the aisle to my stall, a couple caught my eye.
A tall man, his hair only beginning to turn grey, faced a woman of similar age, dressed in a beautiful white summer dress. Next to them a car, its trunk agape, half packed with a box of personal belongings and a white plastic bag full of clothes sat waiting. Still, they stood, pausing, ruminating.
They stared longingly into each other’s eyes, a deep seeded pain overwhelming them as tears trickled down their delicate features. A warm embrace as they held each other tightly and wept.
I wondered what terrible tragedy had befell them. Did a loved one’s health take a turn for the worst? Did a loved one just pass away? Did their mother, father, daughter, or son, just perish from this earth? I could not help but wonder.
But it was not my place to ask.
I watched helplessly as they buried their heads in each other’s shoulders and comforted one other.
I continued walking.
For weeks, a patient had been ambivalent, struggling with the decision between full medical care or comfort care only. It was only a matter of time between the disease would make that choice for her.
Everything we could do to prolong her life had been done. There was no process left to reverse. The disease was reaching its ultimate conclusion. With great reluctance, the patient agreed to comfort care.
It pained me to see her struggle because I knew how much it chewed her up inside, to leave behind her family and friends, to be confronted with the threshold of death. It was obvious she loved dearly and was dearly beloved.
I saw her briefly again today after finishing my rounds, passing through our hospice. After seeing her struggle for so many weeks with this decision, I was relieved to find her smiling, having finally found peace in these last hours, surrounded by friends and family. As they gathered to look at old photo albums and share stories under the warm winter glow, her eyes flickered with joy as she laughed with her grandchildren.
For a moment, our eyes met as she caught a glimpse of me by the nursing station. Quietly, we acknowledged each other.
When I was waiting for test results I tried to make up a description in my mind of the consequences of a bad outcome; for myself and then for my wife and my children. For myself it maybe is not too bad - straight to the grave - which is where we all go; even if we think it is too early whenever it comes to that. It is awful, it is difficult to get used to that thought - if you ever are able to…it would be worst for my wife…she is the one who has to take the blow.
When I heard of going to the cancer clinic, I began shivering all over my body. As soon as I opened the door here I felt the smell of the house of death. I can still feel this smell. The word cancer is loaded with fear, I think, and I know some persons who have died of cancer. A tumor is a tumor; uncontrolled cell division, something growing and attacking inner organs.
I react severely to the cytotoxic drugs. I feel so sick, and although I get other drugs to subdue the vomiting, the sick feeling is there, rocking my body all the way. I feel as if I am being run over by a steamroller - my whole body is reacting.
I remember when I woke up from the operation the surgeon told me they had found “islands of outgrowths” in the peritoneum, which was negative news. Something strange happened to me; all anaesthetics and all drugs disappeared from my body, my brain become crystal- clear and I thought: “How can I tell this to my wife?
"Unhook me from these machines. I am going home now and not a moment later."
More than an hour before, I stood by the bedside and watched as the team worked furiously to resuscitate him. Esophageal varices, a cluster of severely dilated and pressurized veins, had been slowly brewing within him over his many years of alcoholism. With the tension of its walls reaching the breaking point, the time bomb had exploded in a torrential gush of blood.
In the quiet conference room overlooking the hospital atrium, we sat down with our clerkship site director for the last time to wrap up some loose ends. It was here, less than a year ago, that we gathered for the very first time as a group to discuss what the rest of the year would entail. Now, we had come full circle, gathered to reflect on our experiences, our growths, and our recommendations for improving the experience for the incoming crew.
For a moment, it seemed casually regular, like our typical weekly sit downs. That feeling was broken when the director closed with some heart felt words that hit home the thought that by the turn of this week, this group will be disbanded and a new class will assemble in our stead.
"I congratulate all of you. You all worked very hard this year and you have come so far. Congratulations on surviving third year. Good luck to all of you on your future endeavours and on your final year."
We looked at each other in nostalgia, at the memories we had collectively collected within these walls. There would be no more small talks with the staff, no more late night walks through empty halls, no more patients to follow up. Though I looked forward to my two weeks off, the thought still made me feel hollow like I had lost a part of myself.
After a brief conversation about handing in our paperwork, logs, and badges, the meeting was over and we were set free. The director came around to shake all of our hands before departing with a final farewell and invitation.
"I will see you when I see you."
It has taken almost an entire year to get to this point: I am feeling skilled enough to tackle some of the more complicated patients on my own; I am feeling confident in my work; I have developed strong working relationships with the nurses and staff.
And yet, despite all of the blood and sweat I had poured into this year to make it to this point, I suddenly found myself having trouble leaving it.
It took me by surprise, on a quiet morning in the psychiatry ward. I had arrived a little earlier from my internal rounds to return some books lent to our group by a preceptor. Expecting him to be arriving later, I had originally intended to leave his books in his mailbox. Instead to my surprise, he had unexpectedly arrived early to check on a few issues.
"Tom? What are you doing here so early? Are you back on Psychiatry?"
"Actually, I came by to return your books." His brow perked up. We usually passed along his books to the next person rotating through psychiatry. This was unexpected.
"Were you the last one through Psychiatry?"
"I believe so." He sank back into his chair as a look of sadness filled his face.
"I see…What will you do? Do you know?"
"I don’t know yet. Things are still up in the air. A lot can change."
"Well…Pass this along to your friends as well. No matter what happens from here, I wish you guys all the best in your training and hope you guys find something you enjoy doing. It was a pleasure to…" As he continued, sitting there cleaning his glasses, shyly looking away, I realized that he was actually bidding me farewell.
I suddenly found myself welling up with emotion. I realized then it was possibly the last time I ever worked with him or saw him. I realized then just how close we were to the end of third year. I realized how many people have contributed to my experience this year in hospital and how much I would miss them.
"…It was a pleasure. Good luck on everything. We will see you tomorrow?" He stood up to shake my hand with a smile. For a moment, we exchanged an understanding look to each other, imagining that we were on a typical day at work, expecting to see one another tomorrow morning for rounds.
"Yes…See you tomorrow."
The room was dark and heavy with a burden of a deteriorating situation. On a bed, the patient lay. His breathing sounded difficult as he tried to suck in air hungrily from his slack mouth. The eyes stayed closed even as we walked in and greeted him. The body remained perfectly still.
For a moment, it would have been easy to imagine that perhaps this patient was sleeping; from afar, the stillness would have caused alarm. However, it was not death we were dealing with, at least not yet. As he made that slow and painful transition to that final destination, less and less of his body responded to his commands. Soon, he would lose even more functions vital to life.
Not two weeks ago, the man had been walking, speaking, eating. On our visit, all of that had changed. The nurses painted a grim picture: His terminal illness had accelerated and the man was on a downward spiral. We expected no more than two weeks.
"Are you having trouble breathing?" the doctor asked, giving him a simple binary choice.
"…H…H…Hard," he managed to whisper with tremendous difficulty.
And so went our assessment as we tried to improve his comfort. I observed as the doctor asked questions and explained the situation to the patient. He was once a very strong and independent man, husband, and father. Now he was reduced to a shadow of his former self, trapped in an ever weakening body beyond his control and beyond our capacity to cure.
His life was dictated by his disease progression now.
In being in that room, I felt a helplessness in the same way that I imagined he felt as he lay there at the mercy of his affliction. I wanted to help him so badly. I wanted to reverse the progression and turn back the clock. I wanted to give him answers and solutions. But the truth is that is never always the case and certainly not this time.
The doctor got up and said a few parting words as he left the room. For a moment, it was just me and him, alone. I tried to reassure him, but could not find the right words. Again, I stood there listening to his laboured breathing. I finally reached for his hand and gave him a gentle squeeze.
"Take care. And thank you," I said instinctively as I too left.
That was the last time I ever saw him.