Diary from a Week in Practice
Am Fam Physician. 2004 Jan 15;69(2):295-296.
It's been said that we see the world not as it is but as we are. I think of that today as I pay a call on Muriel Hollander. “I'm great!” she tells me, gray and white hair cascading over a hospital pillow, blue eyes bright and eager. A 92-year-old widow, Mrs. Hollander lives alone. She has no children; a married niece is her only nearby relative. Last week she was diagnosed with a large, poorly differentiated bladder cancer, a depressing circumstance which, for reasons I cannot fathom, does not depress Mrs. Hollander. “I have no pain!” she exclaims. I sit on her bed to discuss options. Palliative radiation therapy, or not? Discharge to home or to inpatient hospice? And, what if her ureters obstruct completely—percutaneous nephrostomy tubes, dialysis, or nothing? I could not have predicted her preferences. Gratifyingly, they match what I would want for her: yes to radiation; no to nephrostomy tubes or dialysis; discharge to an inpatient hospice. When I relay our conversation to Mrs. Hollander's niece, she is surprised. “I thought Aunt Muriel would want to go home!” But, our patient sticks to her decision: “You can sell my furniture at a yard sale!” I'm in awe. Will I nearly match her spunk when I grow old?
We are all in shock. A horrible diagnosis—too close to home. This morning, our program director gathers residents to inform them that one of us—our associate program director, who's been out for months with a mysterious, debilitating back pain—has just been diagnosed with metastatic pancreatic cancer. In her mid-40s, this colleague joined our faculty 12 years ago, shortly before I did. Admired for her intelligence, clarity, and decisiveness, she's contributed to our program with a tireless efficiency that the rest of us hold in awe. To say that she gets things done only begins to describe her gifts. Her patients have loved her compassion; our residents have honored her with teaching awards; and our faculty has treasured her energy, leadership, and friendship. Today, we are all trying to comprehend this awful, awful news. To make matters worse—if they could be any worse—she is already too desperately weak to receive well-wishers. We go through the day hollow-eyed, wondering how to salve this terrible wound. I imagine visiting her bedside, and hope I can arrange to see her. In the meantime, I revise tomorrow's morning conference to include bagels and a pile of note cards. Perhaps writing to her—and pouring out our affection and grief—will help.
I'm accustomed to chronically depressed patients, but today an upbeat woman has taken an unexpected plunge. Maribel, a 21-year-old with an associate's degree in design, looks wrung out. “I sleep for 15 hours, get up for two, and have to lie down again.” She's lost several jobs lately by simply not showing up. Concentration and memory are poor. “I have no energy. I'm not eating.” Her eyes well up; I hand her a tissue. She confides that a recent car accident was no accident: “I drove off the road on purpose.” But, today she has no plans for killing herself. She also denies drug or alcohol use—or abuse by her boyfriend. While Maribel sits crumpled in her chair, my mind whirs. She's already on valproic acid for seizures. And, as I reflect on how she gleefully juggled college and a job on three hours' sleep, I wonder if she might have bipolar disorder. She needs a psychiatrist—quickly—but local mental health clinics have long waiting lists. Luckily, a staff psychiatrist responds promptly to my page. She offers to evaluate Maribel in the emergency room and expedite her entry into our clinic system. I'm grateful when Maribel calls later to confirm that she's been scheduled for an intake appointment early next week.
I'm always learning things I wish I'd already known. Mrs. Gerson, an 82-year-old woman with hypertension and diabetes, presents with a “terrible cough” that has momentarily blotted out her chronic knee pain. She hacks convincingly, clutching her ribs. Afebrile and uncharacteristically cheerful, she has clear sputum and normal breath sounds, but a respiratory rate of 30. Has she been wheezing? (I demonstrate.) She nods. Her peak flow rate—inexpertly done—is 220. Feeling clever, I order an albuterol treatment. If it helps, I'll prescribe an inhaler; if it doesn't, maybe we'll get a chest x-ray. I'm totally unprepared for a third possibility, the one where Yvette, my nursing assistant, yanks me into Mrs. Gerson's room, and I find my patient pale and trembling, clutching the nebulizer mouthpiece. “I'm suffocating,” she pants. Her lungs are tight and musical. What on earth is happening? Disbelieving, I begin another treatment, but stop as she again worsens. Huh? Fifteen minutes later, she's feeling better. Muttering to myself, I send her home on prednisone and the antibiotic I'd hoped to avoid. Later on, I happen across a journal reference to “paradoxical bronchospasm,” a potentially life-threatening side effect of inhaled albuterol. The light bulb goes on over my head, and I administer a mental kick to the seat of my pants.
When I was a medical student, I stood in awe of my confident, decisive physician-teachers. How did they arrive at such self-assuredness? I think of them today when Mrs. Marti, a 74-year-old woman with hypertension who's always running out of medications, says: “I've been short of breath for two weeks.” Her symptoms come on when walking, which also gives her calf pain. The diagnoses seem obvious: angina and claudication. But, when she denies chest pain, acknowledges orthopnea, and tips the scale five pounds above baseline, I begin to wonder—congestive heart failure? On examination, she's breathing easily and her lungs are clear, but I detect 2 cm of jugular venous distension. Hmm . . . . Hedging my bets, I start her on furosemide, continue her atenolol, and add a calcium channel blocker for increased antianginal effect. I prescribe, in addition, aspirin, sublingual nitroglycerin and, for good measure, a statin drug. I send her off for a chest x-ray and an echocardiogram, to which I will add a stress test later. This afternoon, the radiologist informs me by telephone that her lungs are clear but that her left ventricle looks hypertrophied. So, it's angina, then! (Or, maybe bouts of diastolic dysfunction?) Oh, for some clinical certainty! Quoth the raven: “Nevermore.” Or, in this case: “A few tests more.”
I feel impelled to call on my colleague who is dying of pancreatic cancer. She's in the hospital where I trained as a medical student, and the hallways trigger visceral memories—of first-time encounters with blood, suffering, and death. There, in a tranquil room, I find her under the loving, watchful care of her partner and a friend. “She's having a rough day,” they tell me. It's been months of nearly constant pain. I'd been warned that she would look different—and she does, lying quietly, face drawn and jaundiced. I'm reminded of bedsides we visited together as physicians; now, she herself is the patient. “Bad luck, Paul,” she says, reflexively rubbing her sore, distended abdomen. Will this be our last conversation? There in the room, hovering about us, are our dozen years of working together—some exuberantly happy, others more turbulent. Groping for words, I tell her of my ongoing affection and respect, which has outlasted a cycle of hurts and mutual wariness. She responds to the overture, and we commiserate over our battered friendship—a glorious opportunity gone awry. After a long hug, I leave—aching, yet profoundly grateful for this chance to exchange forgiveness and lay our ghosts to rest. Did my visit, I wonder, provide her with some shred of similar comfort?
Copyright © 2004 by the American Academy of Family Physicians.
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