the healing muse

Volume 8, 2008

Faulty Armor

Adam Philip Stern

            By the time you reach this point, you’re pretty much a pro. Unlike in medical school, where every patient brings new knowledge and empathy to your arsenal, nothing is very surprising when you are a fourth year resident—least of all the patients. Still, every so often the medical gods send you someone who reminds you to read between the HIPAA lines and see the humanity of the patient before you. This empathic link is plastered so firmly in the foreground that we as diagnosticians usually force ourselves to focus beyond it in order to treat our patients. This time, however, the connection is right in front of my eyes throughout the entire interaction.
            The patient sitting uncomfortably on the platform is appropriately jitterbugged; he is about to undergo a percutaneous CT-guided lung biopsy to determine if the masses seen on his last film are metastatic advances from the obstinate carcinogenic force invading his body. Originating as a set of melanomas on his scalp, the cancer has been found in nearly half a dozen organs since, the lingular portion of his left upper lobe only the most recent manifestation. Today’s procedure will determine if the masses represent a reason to fight on or to give up—to make the patient as comfortable as possible, I mean. Physicians want to believe that they and their patients are in this fight together until the end. That is certainly what we say, and we try to ensure it is how we feel as well—but I’m told by my attending how after decades of experience and thousands of patients, sometimes it becomes difficult to reconcile the two. I am beginning to fathom how this might be the case.
            My attending begins the proceedings.
            “How are you doing today? You seem nervous. Don’t be. Not about this procedure. Won’t be more than a half hour before you’re hanging out watching television in your room upstairs.”
            The patient feigns a smile.
            My attending introduces me to the patient, who greets me with a head nod, almost like one you might see across the bar at a restaurant. The patient’s mannerisms elicit a feeling in me that seems familiar, though I’m not sure from where. I begin to describe the procedure. I explain the risks of introducing a pneumothorax using lay people’s terms to explain that air in the chest cavity can compress the lungs making it harder to breathe, but I stress that this complication is rare and easily treatable should it occur.
            The patient gazes back at me, and I again unexpectedly feel a connection with him, like he’s not quite looking at me as his doctor but as his peer—someone to translate what the medical types are trying to say. We’re on the same team, against everyone else in the room. This moment of bonding with my patient should feel like a victory, but it does not; it is uncomfortable, and it has shaken my routine. It is not insecurity, I’m feeling, but there is something about this encounter that I can’t define, and as a fourth year I live by definition. Somethingis different—there is an ambiguity I cannot overcome. Have I mishandled my delivery? What is this feeling manifesting in the back my throat? Ignore it. Shake this feeling by finishing off strong.
            “And while most clinicians performing this procedure don’t use any local anesthetic, we feel that if it makes the patient more comfortable in any way, we should administer it. After that, you shouldn’t feel a thing during the procedure.”
            The patient does not seem impressed. And why should he be? Were I in his hospital gown instead of my surgical scrubs, preventing unnecessary pain wouldn’t seem like such an extravagant luxury.
            His eyes are conveying a request: ditch the script, and talk straight with me, friend. But hey, I wrote the script.
            “Do you have any questions or concerns about the procedure?”
            “Is there any chance you’re going to puncture the lung?”
            I turn my gaze to the attending, not because I don’t know the answer but because the procedure is in fact designed to puncture the lung in order to get a sample to test. I realize nearly all of my well-rehearsed speech has been for naught.
            The attending puts a hand on the patient’s shoulder and assures him that he’s in good hands and that he has nothing to worry about today. Today. Has he used this word deliberately?
            As I am setting up the materials I need to sample this man’s lung, I hear the attending making small talk as the patient gets situated on the CT’s bed panel. I learn that the patient just celebrated his two-year wedding anniversary and has a baby on the way. He’s hoping it’s a boy.
            “Do you have kids?” he asks as I finish assembling the materials. It takes an awkward, silent moment for me to realize he’s talking in my direction. A spontaneous smile emerges on my face.
            “My wife is due in April,” I answer.
            “Congratulations.”
            “You too.”
            The patient turns back to the attending and tells him about how he was in line for a promotion at the plant before a routine doctor’s appointment one year ago put his plans on hold for the time being. His still middle-aged mother has to be put on sedatives at night in order to fall asleep because she is so nervous for him. The attending says that we should all continue to hope for good news and do the best we can with what we are given. Easy for him to say, I think, and the patient surely agrees.
            I can’t understand it; I’ve done dozens of these procedures already, but something about this patient makes me feel like I’m not really a doctor, that I’m a child in my father’s clothes. He hasn’t said or done anything out of the ordinary, but this gnawing in my gut won’t subside.
The procedure goes smoothly, and a pathology team (resident and attending) lackadaisically awaits the sample, microscope in hand. I deliver the tissue sample with a sense of urgency, and the pathologists accept it with absolutely none. I feel a burst of rage toward them, but I’m not sure why.
Within minutes everyone on the other side of the glass knows that the patient’s masses are malignant. The patient, however, will be required to wait at least forty-eight hours for full lab confirmation. His primary care physician will break the news to him.
            I return to the exam room to reorganize and inventory the surgical tools used today.
            “Hey,” the patient says to me as he buttons up his shirt. “Thanks.”
            With limited treatment options going forward, the medical system has not earned his thanks today. I know this now; he will have to wait.

           During the next forty-eight hours, Iam restless despite knowing the results. I pull up the electronic record of his stay here and peruse his history, hoping to find some glimmer of hope hidden in the cancerous past and present. There is none. I do stumble across one item that may explain my recent unease regarding this patient; his date of birth is July 29, 1981. Of course, I had come across the patient’s date of birth before, but it is not until now that I make the realization: this patient is younger than I am.

Questions about this poem can be found on our Reader's Guide Volume 8

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