She is a 53 year old female. I am a 55 year old gastroenterologist. I was consulted because she had suspicious tumors in her liver on a CAT scan. She has been feeling increasing distress in her upper belly and has not been able to keep anything down in her stomach for last two weeks. The pain was not the severe pain that curls you up, but it is gnawing, that eats you from inside, it is the pesty visitor who visits you at the most uninviting of the moments, it is the conversation that one has to carry on in the most importunate of the situations.
I reviewed her labs and scans carefully before I enter her room. I take a pause and a deep breath and tell myself: “Hey you, cheer up, have a smile on face, and make sure your patient does not see you gloomy or anxious”. Having obeyed my own advice, I apply several soft knocks on the door. “Come in” I hear from outside and I enter the room.
Laying flat on the bed was a thin lady, ashen looking, covered in white freshly cleaned hospital blanket and the protuberant abdomen sticking out like a sore thumb from under the sheet betrayed her frail physique. Next to her sitting on the rocking chair was her male companion wearing a red bandanna on his head; his white long unkempt beard and cigarette stained handle bar mustache giving out an impression that he would be better fit to the next Duck Dynasty episode casted outdoors in the midst of nature than belonging to this claustrophobic beige colored hospital room with its fours walls closing in on the small space all the times.
I have always found hospital rooms to be very interesting. Some rooms seems to be bright, others dim and dark although when I counted they exactly have the same number of flood light fitted on the ceiling and on the sidewalls. The healthcare architects are great in consistency and meticulous in attention. Master of their trade, from faucet to air conditioning vent to a small emergency switches, all of them in exactly placed in the right position, they have an uncanny skill and attention to details, nothing seems to distract them, nothing seems to make them forget even the smallest of the things in pursuit of their job of designing and planning a hospital. I never had much luck in picking their fault as far as hospital patient rooms are concerned. When I cannot explain by science, I always resort to my inner superstition: I concocted the same about the hospital rooms, since architecturally and physically they are all the same and immaculate. I came to believe, the rooms that are bright, or at least appears to be so in my eyes, patients tend to do well and the rooms that are dim and melancholic, they take their occupants into the abyss of dooms. Sometimes I wonder how the admission clerk assigns the room to the patients, is it first come first serve? Or is it at her whims? Or may be she has no choice, the computer assigns it randomly like many things now a days. In my own obsessed physician’s moments, when I get carried away with my own physical symptoms and there are times when I felt calling the EMS to take me to the hospital, not as a doctor, but as a patient. Then in my mind, like an well orchestrated Broadway drama, I go through the rehearsal: As soon as the EMS takes me to the hospital I ask the admission clerk, “I want room number……..” She will be surprised and I will look at her with authority and make sure I have the stethoscope on my shoulder, or my physician ID still displayed somewhere visible and insist, “You have heard what room number I wanted Ma’am!”. Then she might say, “But Dr. Meah, that room is taken, there is already a patient in there!” . Well, my imaginary Admission Clerk certainly got me, after all I cannot ask her to expel the existing patient, I am only a doctor, not a savvy apparatchik national figure who can order around. That’s when I feel like I should develop a secret list of good and bad rooms in the hospital, my own top secret, I will share with no one, although unethical, its use is my nuclear option, only to be used when my own life is at stake, and I come to this hospital and I will tell them give me this room number…..! “Taken”, she will answer, “No problem, give me number……” I will say keeping my smile hidden. “Taken”, she might say again. “No problem, then give me number…..” as I pull out another room number from my secret private list, I know something has to work out, US hospitals have always rooms empty since most of them are made to an excess capacity. Thus I have thought about making a secret inventory of hospital rooms, that is good and bad rooms, although, my laziness had not yet come around doing this in actuality.
I introduced myself, interviewed her and after obtaining her consent, examined her confirming all the ominous signs that in medical literature we summarize as, “Stigmata of chronic liver disease” with “signs of hepatic decompensation”. She had a large liver, double the size of normal; it was filled with many marble sized tumors and beneath her wasted skin, these felt as firm as the glass marbles that I used to hide away from my younger brother underneath a cotton blanket in my distant childhood. Normal liver feels slippery, soft, gentle and soothing to palpating finger tips of the examiner, unlike these bold and hard knots, there was something aggressive about them. I noticed her feet were swelling too and one area on the right shin had started oozing clear fluid, a sign that her liver was not able to make enough protein to keep her own fluid inside the body. Her chest was full of dreaded “spider angiomata”, although initially imagined by pioneers of medicine as spreading legs of an spider from which the name comes, to me these look like more of the tentacles of an octopus spreading in a radiating manner, a collection of blood vessels branching out of a central feeding blood vessel, a testament to her bad liver.
Although, looking at the scan I could easily tell that her abdominal cavity is holding over 15 liters of extra fluid, physicians have a compulsion of going through the ritual of strange acts that had been passed down from the era of Hippocrates and Imhotep. Diligently following such strange percussive rituals and applying rhythmic pressure rituals while moving patient from side to side I conclude that she has “Positive Fluid Thrill” and “Positive Shifting Dullness”. In this era of advanced imaging these are but total redundancy but it probably goes to mystify our job as healers. Science has changed and came a long way, but the job of a healer had never changed, we are still shrouded in mystery, science, arts and superstition; in this way I see no difference between a Native American shaman to an African traditional healer to myself, a modern day gastroenterologist in the United States. Both the fluid thrill and shifting dullness signs are considered ominous findings which means that her liver had been failing in vital and essential functions of making the protein that human body needs and that her normal liver tissue has been replaced by scars and tumor cells. When this happens pressure inside the liver has gone up so high that the fluid is escaping in her belly as opposed to remaining in the inside of blood vessels. What this means is that massive amount of protein and fluid is being lost inside the cavity of her own body, and thus starving rest of her own organs.
Following the age old medical tradition, I then went on to discuss with her the findings, diagnosis and the management plan. I have always believed in simple honesty, in respecting patient’s right to know and in patient’s intelligence: “Ma’am, I suspect that you have cancer of the liver from cirrhosis, which was due to excessive and prolonged use of alcohol”. Contrary to popular belief, I observe that if not all, at least majority of my patients know their diagnosis in their own language, if not in medical jargon; and they take the honest truth much easier than we used to fear in the past paternalistic belief of medicine. This patient was no exception.
A thin sliver of agony was evident in her face from my diagnosis. We looked at each other’s face for a brief moment and then she took her glance away from me, instead shifting her gaze towards the window that was covered with a floral curtain making the outside irrelevant. We spent a moment of pause and still looking at the window, she asked, “How do you cure it?” “We need to run some additional testing, may be even biopsy to confirm what I am thinking, I will bring a Cancer specialist on board and then we will decide.” Again moments of silence, as she shifted her position to the left towards me from supine. Then suddenly she shifted to her back again with a sigh, and blurted out, “How much time do I have doc?” “Depends on the confirmation of stage of your cancer Ma’am; we can give you a ball park figure, not an accurate one once all of these information are available, that will take couple of days”, I answered. “Do you have any other questions?” “No Sir, thank you”, in her Southern drawl.
I knew what I should do the next moment. I have her permission to leave now, I will open the door and get back at the hospital hallway and then knock on another door of another patient who is next to be seen in my rounding list. But I took a detour from the well-worn path of medicine: “May I sit down on your bed Ma’am?” I asked. “Yes Sir, you may”. “Tell me about yourself Ma’am, tell me your story”, my voice had a sense of urgency. She got up slowly and pushed her white covering sheet towards her feet exposing her freckled leathery skin beneath which the fat and muscles had wasted away slowly. “I retired from working at the Nuclear Plant; I worked in three of them, one in Louisiana and two in Texas. I was a Piping and Safety Inspector and I coordinated and inter-phased with Nuclear Regulatory Commission. Once I signed off, they would sign off behind me and that’s that how nuclear plants would start up. My daddy was in construction and he used to work in building nuclear plants, we moved around a lot and that’s how I ended up doing job at the nuclear plant. I worked up to 110 hours a week, I had unlimited overtime, sometimes I just found a little corner to take a catnap and back to job again when I was refreshed… ah m-a-n! I have three boys all 10 years apart, one son is a Massage Therapist, real good, another son works in a plant and then I have another son, God knows where he’s. My mommy and daddy are still alive, one brother and a sister”. Then she took a pause taking a sip of water, “Oh, I am so dry”. She restarted, “I had a very adventurous life, I have gone to places, I have enjoyed wherever I went, I don’t hurt for me, I hurt for my family I could leave behind” then she stopped and for the first time started weeping, tears rolling down from her eyes, I hold her hand, “I am really sorry” I say, by now she is squeezing my hand, I make it free and get some Kleenex and hand it over to her. I try to console her. But she is braver than I thought. She kept on saying, “That’s okay, that’s okay doc”.
“Who would you miss most, Ma’am if the worst had to happen?” I ask her. “My children and my mom; my mom will really hurt if I die before her; I promised her I will not die before her!”. “Is your mother okay, is her health okay?” “No, Sir, she has emphysema, she used to smoke six cartons a week!”.
“What was the most adventurous event for you?” She retorted, “I tell you what; it is Louisiana, it had to be Louisiana! You know what I mean, lots of good things to eat out there, lots of good cooking, people are really nice, lots of beach, I am a Cajun, my maiden name was Boudreaux! May be then California, I snow skied there, went to Lake Tahoe, I enjoyed the Wine Country and then in Mexico; I climbed all the way up to El Capitan and took a picture with my feet on the sign that says how high it is; boy, was it difficult to breathe up there!” A heavenly smile blossomed on her face and her ashen face lighted up with the glory of morning sun and both of us broke into laughter. The attentive nurse soon knocked the door and came into the room without waiting for an answer and found the terminal patient with the doctor sitting next to each other in the hospital bed and both laughing. To relieve her perplexed mind I offered that the nurse could join us too to listen to the patient telling me her story. My invite only made the nurse more perplexed and she left the room what seemed like in a hurry.
“What’s the best memory you have Ma’am?” I asked. “The greatest thing to see in my life is to see the 50th Wedding anniversary of my parents and my grandparents Sir, I have seen two of them in my own life time, yes Sir, two of them in my own family!” her voice had a measure of pride and peace that only emanates from a wellspring of self-satisfaction. And as I just looked at her, she looked at me; our gazes met perfectly. For a moment I forgot that I was a doctor, I had a white coat on, forgotten was that she was a patient, a terminal patient with cancer in a hospital garb, forgotten was time, our identities, the barriers we put up around ourselves: our education, our finance, our race, our origin, our color, our creed, our religion, our belief, our choices, our fantasies; all were melted away in the simple story of a life, a story of humanity, we were all one, all we could hear was the roar of air-condition duct blowing cool air in a hot Texas summer day; we closed our eyes, we hugged and then we parted. She still had tears, but she had a big smile on her face, I felt a drop or two rolled out from my own and if I could see myself in mirror I suspect I would have caught myself wearing a big smile too. The Duck Dynasty man got up from the rocking chair, sniffed once or twice, rubbed his eyes and stood up facing the other way without saying a word.
Her diagnosis was confirmed to be “hepatocellular carcinoma (a form of liver cancer) with diffuse metastasis”. Yes she was terminal, the Oncologist recommended hospice. “I have a blessed life doctor”, that was her last words to me. Her prognosis in medical literature is just one simple word: “grave”. I do not really know with certainty how long she would survive, but I know that the human experience we had in shared storytelling and knowing each other will live forever. I know this is triumph for our inner selves and for our profession. Prognosis of such human encounter in pursuit of practicing medicine can also be described very simply: “excellent”.