My second-to-last medicine call I got a telephone call from the ER. "This is Dr. S. I've got a real interesting patient for you." Interesting, in the mouth of an ER doctor, is never good. He goes on to tell me that he has a man in the ER who's been treated for pneumonia by his family doctor for the last three months - is now on oxygen, not getting better, but absolutely had to come to our city for The Big Game. So he came - he almost passed out walking across the street to the stadium, he was wheelchaired into the game, but he came, and he brought his twelve-year-old son. And then the morning after the game, he had a syncopal episode going down to the continental breakfast and presented to our emergency room.
"He'll be a great admission," Dr. S says to me - the ER doctors, they like me, they like to give me interesting things to see and do. "He's got an interesting problem, he's a really nice guy, and he wants to get back home soon." Now, he had a pneumonia on chest X-ray, but not enough to make him hypoxic like he was, and wasn't this new onset atrial fibrillation weird? The ER sent him down for a CT scan of the chest, just to make sure he hadn't thrown a clot to his lung.
I got there as he was getting back from CT scan. He was back in atrial fibrillation - he kept going in and out of it - on oxygen, pale, looking ill but not too bad. And he was a nice guy, married, three kids, a productive member of society, just here for his alma mater's Big Game. And his son, nice kid, polite, well-spoken. We chatted about the game, about his home town, about his condition and what had been done thus far. And I explained atrial fibrillation to him, and I walked out of the room to write my H&P and staff, and Dr. S waves a hand at me. "CT results are back." He sounded quite serious. Post-obstructive pneumonia, central mass, probable carcinoma. Oh, and a pericardial effusion, looks like a big one.
I knew it. I knew knew knew it. Three months of pneumonia in a not-that-old man, requiring oxygen, now with this sort of arrhythmia? Nothing good. And I turned back around and went back in. His son was out of the room. Sat down by the side of the bed, took a deep breath. "I got the CT results back. They just called." Beat. "You have something called post-obstructive pneumonia, which means that there's something blocking off the little breathing tubes, causing the pneumonia." Beat. "Based on the CT scan, it's most likely cancer." Full stop.
He looks at me. "Cancer." Full stop. I nod, watching his eyes, waiting for acceptance. It comes. He says nothing. I continue.
"A full workup can wait until you're back home. For right now, our priority is to get you stable and able to go back home." And he smiles at me, nods. "Sounds good."
I staffed, called cardiology and pulmonology, got him to a room, got a stat echo - on a Sunday afternoon, the only way to get an echocardiogram is to order it stat and call the techs in from home. Results came back about the time I actually met the cardiologist - young, pleasant, unpronounceable name. Results came back with early cardiac tamponade - an effusion so big around the heart that it was impeding its function. Plan to tap it in the morning - keep him under control for the day.
His wife got there around 2100; she'd flown in from home and taken a taxi from the airport. "What's going on?" What do you know? She looked at me. "Nothing, except he's in the hospital." I took a deep breath. "Do I need to sit down?" Yes. Sit down. I did too.
I explained it all to his wife, what had happened here, how he came into the emergency room, the chest X-ray, the CT scan, the post-obstructive pneumonia. "And based on the CT scan, it's most likely cancer." Full stop.
She took it well, all things considered, asked a lot of questions. I answered what I could; we agreed to defer the rest until we had more information. We discussed the plan - what could we do here, what could wait. They wanted the bronchoscopy, they wanted a diagnosis from us. I got the subtle sense of an impending lawsuit. It was the elephant in the room: three months he's been treated for pneumonia without getting better. And he has cancer. I kept wondering if I would have done the same. We finally finished talking, no more questions. We said goodnight, and I went back down to do another admission.
Tap went beautifully, or so I was told. Almost 900 mL's of fluid - close to a liter of blood and water - surrounding the heart. Sent for routine studies, cytology, cultures. And pulmonology caught up with me around 11:45, after I'd spoken with the home doctor to let him know his patient was in our tender care. I did not ask him why he'd spent three months treating a pneumonia without any further workup, although everyone was asking me. I touched base with the pulmonologist; he was expediting the cytology studies on the effusion. We talked about all of the rare and unusual fungal and infectious processes that might mimic carcinoma and how it was all just tossing straws; this man had cancer and we both knew it. And then I was post-call, and it was noon, and I went home.
Still on pager, post-call, I groggily call back when my pager went off. "We just got the cytology back. It's adenocarcinoma." And so he's metastatic, stage IIIB, non-operative and with a less than 8% 5-year survival. "Did you want to come and tell him?" I can't come into the hospital, it's illegal, we'll tell him and his wife in the morning.
Around 1900 I got a page from the covering resident. "Does this guy know his diagnosis?" I explained that he knew he probably had cancer, but that I knew he definitely did, that the cells were positive for malignancy and that we were going to tell him in the morning. "His son," I said, desperate for this vital piece to be included. "His son, they're keeping him out of the talks, he doesn't know anything." And he said okay. I hung up, and then it hit me. What was going on? "It's nothing, right?" Angel listened. "If something were going on he would've told me. Just a routine call, he wants to be prepared." I convinced myself of it.
I found out in the morning. Lab review before seeing patients showed serial ABG's, the sign of respiratory failure and intubation. The last one looked good, really good. Comforting, that. I went up to the floor to see him first. The room was empty and clean. Did he go to the ICU? I grabbed the first nurse I saw. "Mr. C, the man in that room, he..." I got one of those looks.
He died. Last night.
I think my jaw literally dropped open. I closed my mouth. "Died?" Died. They coded him for a couple hours, I think.
I thanked him, went to the phone, paged my cover. He told me the story - more a-fib, more respiratory distress, calling to find out if the diagnosis was made so that they could talk no-code with the wife (and the twelve-year-old son), ventilating but not perfusing, epi and bicarb and all the drugs you use in a code. Three hours of code, chest compressions, chemicals, another echo with the fluid back - maybe a clot - maybe a PE - we don't know, but we coded him for three hours and his wife finally said no more.
And he died. Just after my watch. "I didn't call you to tell you because I didn't want you coming in." I was tired, post-call, inside the ten-hour window. It wouldn't have been legal for me to come into the hospital - but I would have. I might have had Angel drive me, but I would have come just to be with the wife, with this man I had just met and given bad news. I think I would have wanted to be there anyway.
Sometimes, I think, you have to do what's right instead of what's in the book.
I bought a card, for his widow. I signed it and my chief and the covering resident and the ER doctor and the cardiologist and the pulmonologist, all a neat line of signatures underneath a paragraph I struggled so hard to write without sounding as empty and meaningless as sympathy always seems. I'm going to mail it today, I think. Before it's too late to mail it. I want to do more, but I hardly know them and I don't want to press my clumsy gestures into their fragile grief.
So strange. So sad.