Our Deepest Condolences

One of the very first patients I had admitted was a 50-some year old father of three with a newly diagnosed colon cancer. His case read just like my father’s. Sudden changes in stool caliber. More bloating and fatigue. His wife started noticing that he looked thinner. 

By the time I had approached him in the hustle and bustle of the emergency department, the news had already been broken by the emergency physician. “You have colon cancer,” he remarked on the bluntness of that interaction. It had left him in such shock that he had little to say for most of the day. I took my time to be thorough, answering questions, gathering the history, doing the physical - his moderately ascitic belly and an enlarged liver already hinted at something more sinister. Having already been subjected to one rectal exam, he asked if I needed to double check again. I politely declined to which he breathed a great relief. 

I excused myself to review his CT scan, to get a better understanding of what was driving everything. There, on the black and white screen I saw a liver so large it seemed there would be no space for anything else in that belly. Pocked full of cysts and irregular tissue, it screamed only one conclusion: gross metastasis. 

"A few more tests," I reassured him and then he would go home, to follow up with the oncologist for further management options. I explained that the cancer had spread and that the options will be limited. He digested the news silently, his eyes flickered across the floor as he concentrated. When his wife arrived, I made sure to break the news gently. She wept regardless.

By the time I had sent him home, his belly was flatter once again, having been drained of all of the malignant fluid. The oncologist was to follow up with him within a week’s time. The prognosis was guarded but we agreed that he will be fine for at least the week.

Or so we thought.

It was a surprise to me not one week later that I saw him again on call in the emergency department, this time looking worse. He was confused, agitated, and worse - his skin had turned yellow. I quickly texted my attending: “Encephalopathy. Icterus.” The response was quick: “Shit.”

Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden. The liver had started to fail and with that, his kidneys were beginning to shut down. He was quickly transferred to the ward. 

We rediscussed code status with the family with the end drawing near and it was decided to change his care to palliative. We kept him comfortable until he died a few days later.  

Precipitous multi-organ failure is uncommon to see in someone who is still very high functioning. We never would have expected him to decline so rapidly. It was a surprise to everyone that he could be here one week and gone the next. Given his disease, there would not have been much more we could do medically.

But there are always things we could have improved on. From delivering the diagnosis with care, to advocating for a private room in his final days, to addressing the psychosocial needs of the family. These are areas that we can strive to do better. At the end of the day, this patient was not his colon cancer, he was a person. With a wife and three children. A friend to many. 

These were the pieces, in the torrent of changes that ensued on his second admission, that were lost.

"The patient died surrounded by his loved ones. We are grateful to have been involved in his care and offer our deepest condolences to his family and friends…End dictation."

A LETTER FROM AN ABORTED CHILD..

Dear Mum,
I have decided to talk to you, to let you know my feelinqs. I want to know why you did it. My story is short. I have stayed inside you for only three months. I was very comfortable and warm. I felt really protected. I know you are a special person because I ate the food you ate.
I longed for the day I would see your face. Nine months was a long time to wait, but I was determined to wait. I had to be patient….

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"My name is Hazel. Augustus Waters was the great star-crossed love of my life. Ours was an epic love story, and I won’t be able to get more than a sentence into it without disappearing into a puddle of tears. Gus knew. Gus knows. I will not tell you our love story, because -like all real love stories- it will die with us, as it should. I’d hoped that he’d be eulogizing me, because there’s no one I’d rather have…" I started crying. "Okay, how not to cry. How am I -okay. Okay." I took a few breaths and went back to the page. "I can’t talk about our love story, so I will talk about math. I am not a mathematician, but I know this: The are infinite numbers between 0 and 1. There’s .1 and .12 and .112 and an infinite collection of others. Of course, there is a bigger infinite set of numbers between 0 and 2, or between 0 and a million. Some infinities are bigger than other infinities. A writer we used to like taught us that. There are days, many of them, when I resent the size of my unbounded set. I want more numbers than I’m likely to get, and God, I want more numbers for Augustus Waters than he got. But, Gus, my love, I cannot tell you how thankful I am for our little infinity. I wouldn’t trade it for the world. You gave me a forever within the numbered days, and I’m grateful.”

-Hazel Grace Lancaster to Augustus Waters, at his prefuneral. (The Fault In Our Stars, John Green)

The Love of God..

The story starts out where she, Beth, is sitting at an airport terminal, waiting to board a plane. She was sitting there with several other people who were also waiting, whom she did not know. As she waited, she pulled out her Bible and started reading. All of a sudden she felt as if the people sitting there around her, were looking at her. She looked up, but realized that they were looking just over her head, in the direction right behind her.

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Tales Of The Classroom

'I never get anything right', says she as she holds another cigarette with the pressure of her lips and lifts the lighter from the gas station. 'I never get anything right', says she as she takes his hands and pulls, wanting him to throw her onto her bed.
But there never was anyone to talk to, and no one to lead her into her bedroom; despite all she said, she sticked to her words and never got anything right.

Consolidation

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“Look, just tell me. Why did you have me come here?” Sandeep said, taking a last swig of his ginseng tea.

Ji-Yun considered him carefully, head tilted. “Have you drank it all?” she asked. 

“Yes,” Sandeep said, frowning. “What’s with you tonight?”

They were in the cramped old café in Hongdae, at their old table, where they’d met a year ago. The wide windows ran with condensation from dozens of steaming cups of tea.

Ji-Yun took a deep breath. “I’ve been thinking maybe we could get back together, Sandeep,” she said.

Sandeep froze. His lips worked. Finally he turned to look out the fogged window. “I can’t believe you,” he said. “After what you did.”

“What did I do?”

“You know very well.”

“Tell me.”

“You slept with Hiro, that’s what!” Sandeep hissed. “Don’t you remember? I walked in on you and him coiled on our futon like a pair of … serpents.” He shuddered as he remembered.

Ji-Yun swallowed. “How did that make you feel?”

Sandeep’s eyes were red. “Feel? Terrible, that’s how! Honestly, Ji-Yun, if you’ve just come here to torture me …”

“No! Don’t go, Sandy,” Ji-Yun said, taking Sandeep’s hand. “I don’t want to torture you. I came here to free you.”

“What?”

“The tea – I put PKM Zeta blockers in it. I’m sorry. But that was the last time you’ll remember that bad day.” Ji-Yun smiled brightly. “Now we can be together again!”

Sandeep shuddered.

But she’s so beautiful, he thought.

The crazy thing is that this could actually work one day.

Original image by Patrick Zachmann via wandrlust

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