a typical morning

6:00am
i'm already tearing through the underground hallway connecting the parking lot to the main hospital, weaving between slow walkers left and right. i'm walking so fast that the PDA in my white coat pocket is making a smacking noise against my car keys. by the end of the trek, i'm out of breath and reminded of my lack of endurance. i'm heading towards the lymphoma/leukemia service--my home for the month.

6:30am
with the computer on wheels, the intern and i are in front of the first patient's room (of 14 we need to see this morning). a woman with newly disgnosed leukemia. she's doing fine. labs look great. x-ray...mmm, no change. fevers overnight? nope.
in.
good morning, sorry to wake you. any problems? big deep breaths. good. lie back. breath normally now. does this hurt? any pain? k. thanks. be back to see you later.
out.
that was an easy one. and on to the next.

6:40am
nurse stops us between rooms: "ms. l is very short of breath and has been all night. can you come see her?"
i look at my watch. in the next 40 minutes i have to see all these patients, help the intern with labs, then head over to conference.
"ok, check a sat, put in for a stat portable [chest x-ray], and get her a breathing treatment. i'll get there." the nurse looks sceptical but turns and walks away.

6:42am
my pager goes off, and i head to the nearest phone. after the first ring i hear: "yeah, this is the nurse taking care of ms. l. she's really short of breath and has been all night. i don't know what's wrong with her. i just talked to the fellow and he just wants a breathing treatment sight unseen, and i think something's wrong..."
i pause for a couple seconds before slowly saying, "i am the fellow." nothing on the other end.
the nurse starts talking rapidly, "oh i'm so sorry i thought i paged respiratory therapy...i..uh..i..." i tell him i'll be right there and hang up. why can't one morning--just one--go without complication? i see the patient--she's doing ok, but a bit fluid overloaded. as i'm entering a lasix order in the computer, the nurse approaches me and begins to apologize before i cut him off: "you have been up all night taking care of sick patients. i can't imagine how frustrating it is for you to ask for help and not get it immediately. i'm sorry i didn't get here sooner." [that nurse and i are good friends now]

7:15am
mr. r has lymphoma. his room looms on the horizon. the intern and i look at each other and steel ourselves for the predictable onslaught.

in.

"good morning! you're looking very well today! any prob--" my worst fears are realized as mrs. r interrupts with her daily diatribe of her husband's endless pains, aches and sniffles:
"well he had a stomach ache last night around 11:23 but that went away with some mylanta but i was wondering if you knew what that was and also he has this spot on his leg can you look at that i was wondering if it's an infection or maybe something else and, honey, didn't you say that you were having blurry vision in your left eye around 3am this morning or was it your right eye or was it 4am and he had some diarrhea last night about four times at 7:14, 8:23, 9:00 and when was the last time, honey, cuz it's smudged in my book here but i think it was about the consistency of pudding wouldn't you say, honey, or maybe like pudding that had been in the fridge for a while but that last one sure did a number on..."

by this point, i've stopped listening. i'm standing behind the intern who's really bearing the full onlaught, nothing to protect her from query after complaint after suggestion. i'm in a better place. i'm looking past mr. r, past mrs. r, out the window behind them. the sun is rising, casting a warm pink glow on the changing leaves on the trees. i start to smile as i feel myself floating, drifting on the soft clouds...

i snap back to reality as the intern asks me, "so should we send a sample?"

of what??? i've been off in la-la land for the past few minutes and have no idea what the hell has been going on in front of me. now, all three people in the room are expecting some enlightenment from me. i take the path of least resistence, "so, let's see how things go, and we'll re-evaluate." everyone nods in agreement, in unison. i beeline for the door.

out.

as we walk away from the room, the intern smlies and says, "of stool." she knows where i've been. i knew i liked her for a reason.

7:20am
next patient, one of my favorites. this woman has been suffering for weeks with an inflammation of her bowels caused by her weakened immune state. a tube in her nose, IV's in her arms, and a bandana on her head, she has had nothing to eat for days on end. each morning she looks at me with sad eyes and asks, "when can i have my orange?" she loves oranges. one night, while i sit at the foot of her bed, she describes what it's like to eat an orange, pushing her face into a cut half, squeezing it, sticky juice running down her face. it sounds like heaven.

today, i have nothing new to tell her. her belly is quiet since her bowels stopped their natural rhythmic pulsing. no bowel movements. i don't have to tell her the bad news as my eyes say everything. no food for yet another day. she turns her head to the side, away from me in a sign of exasperation. as she turns her head, the NG tube tugs at her, and she grimaces. i stroke her hand before i leave the room. another no-orange day.

the letter

TM died yesterday. this is the letter i wrote to his wife:

dear mrs. m,

i want to tell you how sorry i am to hear of mr. m's passing. for the short time i knew him, i can honestly say that i am a better person for having known him. he had a way about him that exuded faith, confidence, and a love of life. one of my hardest moments with him involved telling him that he could no longer ride his motorcycle--i can't imagine how difficult that was for him to hear. but, he took it in his stride, as he did with his cancer.

i also want to tell you how much you meant to mr. m. from coming to his appointments, to going to motorcycle rallies, to spooning water into his mouth with his medications--i could see his love for you in his eyes when i spoke of you. i understand that you were upset about not being at his side the moment he passed. remember the time you did spend caring for him, all the time you did spend by his side. over the past year, you did everything in your power and more.

i know the coming days will be difficult for you, but have faith that you will get through it. you are a strong person. if you need to talk, please let me know.

____

a comment from the cheerful oncologist, himself! thanks, doc. i will keep writing. of note, i was inspired by the following words from the cheerful oncologist:

"life is only fulfilled when the mind and body are in motion. As long as I can stand and think, I will keep moving - see patients, laugh at jokes, wrestle with my sons, walk the dog, meet my wife for lunch, call old friends - get out and be a part of this great world, not wail in my chair how unfair it all is."

go here for more.

give hope, but prepare for death. part II

i'm trying to be a cheerful oncologist. really. but i just can't seem to get past the suffering. so i use this as an outlet. overall, i'm not a despondent person, but things like this make me wonder aloud about how we continue to live our lives as though nothing is wrong:

TM was one of my first cancer patients three months ago as i began my training. tough guy, leather jacket, tattoos, drives his motorcycle cross-coutry. he has the bad kind of lung cancer--not that there is a good kind. the first day i meet him, i have to tell him that his cancer has spread to his brain despite showing an initially good response.

"i don't want to hear about time, doc," he interrupts me. "i don't need to hear about how much time i have left. let's just do what needs to be done." later on that night, his wife calls me and asks for the gory details. so i tell her.

over the past three months, TM has taken a turn for the worst. he was at a motorcycle rally when he fell and didn't have the energy to get back up again. when i visit him in the hospital he looks tired, different somehow. i sit down next to him in silence.

"you're here to tell me that i'm too sick for more chemo," he sighs.
"yeah," i barely whisper. i find it very difficult to look at this man's man, with the tattoos and the motorbike and the tough build--i find it very difficult to look him in the eyes and tell him he is dying. but this time he wants to hear it.
"so tell me, doc. tell me how long i have." he wants to know the gory details. so i tell him.

he's at home now, under the care of home hospice. i called him expecting his wife to pick up. but he answered, his voice weak over the phone, tv in the background. he has not the strength to get off the couch. he knows his time is near, and i fear his spirit is broken. to die comfortably at home is one thing; to die with a broken spirit is another.

earlier on, when he still walked into my clinic with his chest out and his bald pate shining, he chortled at the comment of the resident who discharged him from the hospital stay: "can you believe this guy, doc? he told me i shouldn't be riding my motorbike? was he kidding me? that's all i got, doc. that's all there is left of me."

i took a deep breath before i said, "mr. M...you can't ride your motorbike anymore."


___

thank you, Chixulub, for your comments. any and all comments are always appreciated.

give hope, but prepare for death.

i've been holding back tears in clinic lately.

maybe it's because i'm tired, or maybe it's because these people are dying in front of me and there is little i can do.

to set the scene: my weekly clinic is at the veteran's hospital associated with Famous Cancer Center (henceforth referred to as FCC), where i am for most of my oncology training. this is a common setup at training programs. it goes without saying that all my clinic patients are vets.

i have been seeing CW for about two months now--this seems like an eternity in cancer time. CW has renal cancer, a fairly aggressive and difficult to treat disease. he has been to other cancer centers but is now seeing me for what he believes to be the best care available. his cancer has spread to his lungs and his brain. two weeks ago he had the tumor in his brain surgically removed. now he's in my clinic asking for more treatment, but i'm in the difficult position of telling him that the best care is really at FCC where all the clinical trials are based. i call one of my attendings who treats renal cancer at FCC. he is more than happy to accept the patient, but the VA hospital will not pay for the study at FCC.

"we have $800 in the bank," says his wife as her eyes tear up. "we are $25,00o in debt from his medical bills, already." CW tells me that they are going to cut down the trees on their property to sell for timber. they have nothing left. and CW is dying in front of me.

thus far, so early in my oncology training, my most difficult interactions have been with patients who are at the end of the line. i struggle with how to tell them they are dying while providing them hope at the same time. isn't this somewhat contradictory?

give hope, but prepare for death.

getting the gist of it

three months ago i began my training as a cancer doctor. i spend my days taking care of patients in varying stages of their disease. some waltz into my clinic with a smile and a new haircut. some are pushed in sagging, rusted wheelchairs. some appear only as death notices on my electronic patient record. all have needs.

taking care of the cancer patient is taking care of her entire family. taking care of the cancer patient is taking care of all her needs, whether or not they relate to her cancer because, at some point, all their needs relate to their cancer.

i worked hard to get to this point in my career. these are the patients i have always gravitated toward, but the more time i spend with them, the more drained i feel. to care of them, i must open myself to them and their pain. hopefully, in the coming days, months, years, i can chronical my interactions with patients, families, and health care workers as i begin to understand oncology.

i'm beginning to get the gist of it.