By Will Smythe
Mr. Brown was a young patient to be hit with a diagnosis of lung cancer. He was only a little more than forty at the time the small tumor in his right lung was identified at another hospital in the area, and the appropriate operation to remove it was performed by the surgeon he saw there.
Of course, he had no underlying medical issues whatsoever, and led a physically active life, but unfortunately had been a heavy smoker since he was a teen. He was a hard-driving, successful junior executive for a national oil company headquartered in town – “one of those guys that’s headed for the top of something”, as the referring oncologist commented during our phone call. He had been told that the tumor was completely removed, and that he was “cured”.
A year later, he developed some fluid in his chest and around the lung on the side where the operation had been performed, and some new pain when he took deep breaths. His surgeon reviewed his X-rays, and suggested that he see a specialist, so he was sent to me.
The day I saw him was somewhat depressing before he even arrived. By chance, three patients that I had seen earlier in the day, each of which I had operated on my first year in practice, the previous year, had developed recurrent cancer. One had developed spread, or metastasis, of the tumor to his brain.
In addition to the literal meaning of the word metastasis, meaning “next place”, it also could be translated back, depending on which source language you choose, to “change in stability” or perhaps, “change in balance”. Finding out that your cancer had spread to your brain was definitely unbalancing, and for me as well, an incredible disappointment. It felt like failure, even though I had done nothing wrong. The realization of my limits as a physician, despite my premature perception of prowess as a surgeon the year prior, was settling in rapidly.
I greeted Mr. Brown and his wife and two small children in the clinic room where the nurse had brought them after checking his vital signs, and taking a preliminary history.
“Hey doc,” he said, and offered a firm handshake.
He was dressed in an expensive pinstripe suit, and had loosened his silk print tie. His wife was attractive and polite and engaged, but looked worried. His children were adorable – a “perfect” pairing of a little boy and a girl, who looked to be about three and five years old, respectively. They sat tightly next to one another on a little bench in the corner of the room, not yet old enough to abhor each other’s company, or to be self conscious of touch and proximity.
Mr. Brown exuded confidence, and success. It was obvious that he was the sun around which his family revolved – when he glanced at one or another of his children, a grin at the corner of his mouth, they would straighten up, tilt their faces up toward him and smile. His wife sat next to him, and watched his mouth, and his eyes as he spoke, alternating between the two, paying rapt attention, her outward emotion unconsciously mirroring his.
During the course of our discussion, he related that he had been divorced at a younger age, and remarried five years ago. He was direct, to the point and slightly impatient, although not inappropriately so. I imagined that this was the way he did business.
I explained that the fluid was worrisome for a possible recurrence of his tumor, and he and his countenance darkened. He glanced quickly at his two children in the corner of the room, no grin this time, and quickly focused back on me. His wife was blanched.
“Okay”, he asked as if he had just been told that one of his company’s divisions was failing, and was ready to start fact-finding, so he could then fix the problem, “what do we need to do now, what’s the next step?”
“Well, we need to find out if there is any tumor present. We could start with something less invasive,” I replied, “like having the radiologist withdraw some of the fluid with a needle, and checking it for tumor cells.”
“What are the chances that test will give us the final answer?” he probed, as if talking to one of his direct reports.
“About 50-70% if there’s tumor there,” I replied, “if that isn’t positive, we would consider a little operation, putting a small lighted telescope in your chest and looking around to see if there was anything suspicious.”
“How accurate it that?” he asked again, “exactly?”. “Probably more than 90%,” I said, “but there is a slightly larger risk of a complication of some sort, you’d have to go to sleep and have a breathing tube for about a half-hour, and you would have to stay in the hospital at least overnight as opposed to the needle procedure, which is done as an outpatient”.
“I accept the risk. I want the operation,” he said immediately, and bluntly, “can you do it today?”
This was a man that had no problem making decisions. I explained to him that I could, but that later in the day and in the evenings we preferred only to do emergent and urgent cases, so that those patients need not wait for elective operative procedures to be dealt with after hours.
He then smiled, shrugged his shoulders, and said, “so tomorrow, right?”
Even though I had meetings planned, and did not usually operate on that day of the week, I could tell that he would probably find a way to drive home his bargain as he was certainly more versed in negotiation techniques than I, so I agreed.
The next day we did the procedure, and there was indeed recurrent cancer in the chest, or pleural space – the lining of his chest cavity. It was a small but obvious area of tumor growth, but the size meant less than the fact that it had spread there.
I took a little biopsy, a small piece of the tissue and had the pathologist check my assumption. I then removed the fluid that had collected in his chest cavity, as a result from the tumor’s presence, and put in some powder to try to make the lung stick to the inside of the chest, preventing the fluid from re-accumulating. The operation only took about twenty minutes.
His wife and mother took the news relatively well, they seemed prepared for it, and I didn’t think that this was the time to discuss what the findings meant in the long run. I painted as hopeful an immediate picture as possible, and told them it was too early to know if this was the only site, that other tests would be necessary, and that we would have a better idea regarding his prognosis and what would be required for treatment after those tests. They didn’t pry beyond that discussion, and I didn’t think that they were ready for odds or statistics – they would not be favorable, despite my attempts to create some hope.
The children were on the floor next to where we were standing. Once again, they were dressed immaculately, the little girl’s hair in pigtails, and ribbons that matched her dress, the little boy in khaki pants, and a little polo shirt. She was pretending she was reading to him from a book, and he was giggling and writhing around on the floor, his shirttail out, and his carefully combed hair mussed and sticking out on one side like a bird’s tail feathers.
I looked up at the mother again before saying goodbye. She had followed my eyes to the children, and was looking at them now, oblivious to my presence, with that expression that only mothers can generate – tender, concerned and loving all at the same time.
The myriad muscles in men’s faces are the same as women’s; however, for some reason that are unable to coordinate to create that countenance. As I stood there looking at her, I realized that she was also likely in her early forties. Perhaps waited for this man, for the “right one” with which to have these children? It wasn’t unusual in this day and age for couples to wait to marry until their late thirties, or early forties, but for some it is by necessity, due to the vagaries and vicissitudes of modern careers, and achieving some set of goals or aspirations.
But this relationship seemed different to me somehow, at least related to her perspective – she had not been distracted, she had waited for this man, for her, it had not been so much a matter of her being busy, as much as patient.
The next day he was up and around in his room, almost as if nothing had happened, and met me on Friday afternoon rounds that afternoon with his take charge executive demeanor once again.
“Didn’t find what you were looking for, doc?”, he laughed, “certainly not what I was looking for, that’s for damn sure. Now, there is only one option. It starts with you getting me the hell out of here in the next twenty four hours, if not before, and then me beating the hell out of this thing and getting back on with my life.”
He was a little edgy, but extremely likeable, I could see how he might be successful in corporate life. The Greek meaning of the word “charisma” literally means “gift”, and by definition, we consider the gifted as rare and unusual. This man was charismatic, no doubt. I found myself energized by his attitude, and agreeing with his plan, as if I had no choice but to take his orders, and act on them.
“Yes sir,” I laughed, “that’s what we’ll plan on doing.”
That night, the resident on call in the hospital called me and woke me up at home about three a.m., and told me that Mr. Brown was short of breath.
“I don’t think its anything serious,” he related, “but I just wanted to let you know that he was complaining, and he insisted that you be informed as well. He drives a hard bargain.”
I smiled as I thought of Mr. Brown now having found a way to have my residents report to him as well. He had inserted himself into our clinical organizational chart, near the top, and if I wasn’t careful, I would be misplaced from the top. I told the resident to give Mr. Brown some oxygen and get a chest X-ray. I asked a few more questions, and told him to check the X-ray and call me if it looked worrisome as things didn’t sound acute or precipitous.
I had operated on hundreds of patients that got a little short of breath after surgery, and it was not uncommon, especially during the first two or three days after surgery. I told him that I would be in for rounds at six thirty, but to let me know if anything changed in the meantime.
During the week, it was my convention to make patient rounds in the afternoon, or early evening after I had finished seeing patients in the clinic, or doing cases in the operating room. However, this was a Saturday, and on the weekends, I would walk around the wards with the resident and see patients first thing in the morning. If I was lucky, and things went smoothly, I could get in and get back home before my own children were completely up and around, perhaps catch the end of breakfast or some cartoons with them – still sleepy-eyed, pajama clad, and asking curiously why Daddy had on his “work clothes” on a Saturday morning.
The thoracic surgeons in my group alternated weekend call, and each of us looked in on all of the group’s patients when we did so. I had about twenty patients on the service to see that day, and walked onto the ward to meet the resident at the agreed upon time, obviously only a few hours after speaking to him on the phone.
A typical visit would include speaking to the patient, examining each with the resident on-call, looking at incisions, listening to breath sounds, then reviewing X-rays and labs and wrapping up by speaking with the resident about the plans for everyone for the next twenty-four hours.
By chance, Mr. Brown was near the end of our list, which was based on room numbers and floors. Ten years of surgical residency teaches you many interesting things that are of almost no use in any other walk of life. One of the lessons I learned was something called “Dr Rhoads Rounding Rules”.
Dr. Rhoads was the former Chairman of the department in which I trained, and his rule was that you started at the highest floor, and worked your way down, constructing your plan and your list of patients such that “you never walk past a patient’s room twice.” The residents in my program were still following this rule, more than thirty years after Dr. Rhoads’ tenure.
As an intern, I thought that this was an effort to teach residents to become more efficient; however, I would later learn that was simply a rule created to prevent us from having to answer the questions that patients came up with once they had either woken up after seeing you the first time early in the morning, or processed the discussion at any time of day – a little less altruistic.
We eventually casually walked into Mr. Brown’s room, chatting about the previous patient. However, upon walking into the room, what I saw made me stop my salutation in mid sentence, “Good morning, Mr….” was all I got out.
The patient looked terrible. I immediately reached over and grabbed the sleeve of the resident. “What’s going on?”, I asked, as I approached the bedside.
The resident was mortified, “I saw, saw, him about five a.m., and he didn’t look this bad, I swear.”
Mr. Brown was sweating profusely, and was agitated, fidgeting in bed – his hands moving the sheets around in front of him, trembling. He was breathing about 40-50 times per minute – too fast, too fast. I was familiar with this look, the look of hypoxia, or oxygen starvation – something was terribly wrong.
His nurse walked in just then and told us that he had changed dramatically about 10 minutes prior, and that she had originally just thought that he had woken up and was anxious, or in pain. He was obviously fatigued, but could talk.
“Mr. Brown, what’s going on?” I asked.
“I dunno doc,” he replied breathlessly, “I’m just having some trouble breathing, that’s all.”
He tried to smile, but grimaced instead. He had trouble getting the last couple of words out, and the oximeter, which the nurse had placed on his finger a few minutes earlier showed the level of oxygen in his blood to be dangerously low.
I turned to the resident – “go out and page anesthesia, right now, and tell them that we have someone that needs to be intubated and sent to the intensive care unit. I turned to the nurse as the resident scurried out of the room, his tennis shoes slipping, causing him to almost fall on the floor just outside the room that was freshly waxed early every Saturday morning.
“Nurse, please call for a stat chest X-ray, and bring me an oxygen facemask”.
It didn’t seem to me as if anything terrible was going to happen in the next few minutes, but better to be safe than sorry. I was worried with his recurrent cancer that he might have developed a blood clot that had traveled to his lungs – a pulmonary embolism, or that the talc I had put in the space to prevent the fluid from returning had led to acute inflammation of his lungs, an uncommon complication, but well described, and possible.
The X-ray was done as I stood in the room and eyed both Mr. Brown and the oximeter, which showed that the level of oxygen had improved slightly by turning up the flow on the mask. The radiology tech rushed in with the printed X-ray a few moments later, and I stepped out of his room to review it. It looked bad, really bad, especially compared to the one I remembered from the day prior. There were several fluffy 2-3 cm. round to triangular well demarcated “spots” on the X-ray that had not been there the day before, more than usual for pulmonary embolism, but the right shapes, sizes and in the right locations for that diagnosis, along with his clinical picture – the way he looked.
The resident called up to the nurses desk where I was standing, from the operating room. He had run down the four floors and across two buildings to look for the anesthesiologist when his attempt to page him was not answered immediately. He told me that the anesthesiologist would be delayed a ten minutes or so as he was finishing up with a patient in the operating room.
I walked back into Mr. Brown’s to take a quick look and make sure nothing had changed – it had. Now he was barely breathing, but still conscious, barely, evidenced by the fact that he turned his head to look at me when I walked in. I had to act now, and could not wait ten minutes.
I hurriedly told Mr. Brown that we would have to put in the breathing tube. I moved to the head of his bed, and pushed it away from the wall so I could stand behind. I screamed for the nurse to bring me the intubation box, which contained all the drugs and other items needed to put in a breathing tube, quickly opened it and had the nurse try give even more oxygen by a hooking up the plastic facemask to a rubber bag, pumping it to force air into his lungs. By the time I did this, he was completely unconscious, and there was obviously no reason to give him any of the drugs that would relax or sedate him. No time either.
I grabbed the plastic tube, and the spoon-like lighted device that was used to open the mouth fully and find the vocal cords, the entry into the trachea, and placed the tube into his airway – thankfully, it went in easily. I took the bag from the nurse, attached it to the tube, and began to pump oxygen directly into the breathing device. His chest rose and fell –the tube was in the right place, and I looked over at the oximeter again to see if it showed improvement, but it didn’t seem to be working – didn’t seem to show a pulse of any sort. I looked quickly to the other side of the bed, where another nurse had hooked up an ECG monitor when we started.
Despite the fact that we had the breathing tube in, and it had had taken only two minutes or so once the equipment was in the room, he had lost his heartbeat – his heart was fibrillating – actually quivering rather than beating, the last thing it does before it stops altogether.
“Here, take the bag”, I yelled at the nurse, and rapidly started CPR. I yelled at him, “C’mon man, C’mon! Don’t do this! C’mon man, you can do this!”
I pushed on his chest again and again and again, rhythmically, 100 times or more each minute. Again, and again, stopping every few minutes for a second or two, no more, to look to see if his heartbeat had returned on the monitor, or if I could feel a pulse in his neck. I persisted for more than thirty minutes, during which time the anesthesiologist arrived to help as well, pushing drugs through Mr. Brown’s IV to try to revive his heart pharmacologically, as I struggled to force it back to life physically, and we all, with more than five or six people in the room by this time, tried to will it so.
However, in the end it was no use. His healthy heart, despite his young age, was robbed by his lungs, unable to supply it oxygen as the blood clots dammed up the vessels that returned this sustaining element to the rest of the body – blocked them without regard for his charismatic personality, or the fact that he was the light that his wife had waited for, and that his children would need to grow and prosper.
He could control, command and harness the efforts of hundreds at work, but we learn that biology is largely incapable of being influenced in certain situations, and knows no reason. It is indifferent and inexorable – he was dead.
I am still, to this day, haunted by his face, right at the point in time when I told him we would have to place the breathing tube. He looked right at me and opened for a moment his half-closed eyes, with a look of incredible frustration, and shook his head from side to side, resigned, but pissed off. I almost felt as if I could read his mind in that moment.
“You have to be kidding me, I’m not finished here. I’m going to die? Are you kidding me? I have a lot I still need to do, understand? I’m too young, I have small children, and a wife, a promising career, I am not ready for this, I am not at all,.. ready for this, damn you, I AM NOT READY!”.
I walked out of the room, sweat showing through my white dress shirt, and as I walked out, his wife, who picked by unfortunate random and ironic chance this very moment to come back in and see him walked right up to me, heading into his room. His wife? I hadn’t even thought about the fact that he was here alone, that she perhaps had gone to a hotel room or home overnight.
She stopped, smiling, and started to ask how her husband was doing, “how is…?” The smile left her face as she looked at me, wearing no lab coat, in my sweat-soaked clothes, my tie half undone, loosely hanging around my neck, “is something wrong, did something happen?”
I looked at her, and quickly, but clumsily, it seemed, gathered myself. “I’m so sorry, I am so sorry, so sorry” I implored. I hesitated to try to think how to continue.
“He had an unexpected problem this morning, and I uh, I found him very sick when I came by to see him… when I came to see him, you know, on rounds earlier. He was very sick,.. acutely sick.” I hesitated again, awkwardly.
Her expression had changed from cheerful, to attentive, to anxious, but she did not speak.
I forced the words out at this point, trying my best to sound empathetic, but feeling as if my effort would obviously be pitiful, no matter what, “we’ve been working for the last hour to try to make him better. Some blood clots went to his lungs, and we, we…, we weren’t able to save him, I am so, so sorry.”
The look on her face at that moment has never left me either, despite the fact that I have had to give bad news many, many times in my career. She squinted, stepped closer to me, and literally searched my face, looking for something that I could not give to her, or could not tell her, then fell suddenly and limply to her knees on the floor, hard, her knees making a sickening sharp sound as they struck the tile.
She exhaled audibly, then sobbed, her head in her hands. As a nurse came over and she and I helped her into a chair in the hallway right in front of her husband’s room. I looked up and saw his mother, and his two small children rounding a corner and heading into the ward. I recognized her from the waiting room after surgery, and I could have picked out their children easily anyway.
The mother stopped when she saw us all there, in a configuration that suggested that there was a problem, and the children stopped behind her, taking a cue from her body language as she stiffened.
I took one step toward where she was standing, perhaps twenty meters away, and she broke into a run, never making eye contact, and bumping into me as she rushed past all of us into her son’s room, where I could hear her muffled screams through the semi-closed door, “No, No…. No!”
I looked up again, and the two children were still standing, frozen, down the hallway, oblivious to the scene that had developed around me, or what it meant.
I asked the nurse to call the chaplain, and I walked over as calmly as I could to the children.
“Hi!, I said, “how are you?”
“Gooood,” the little girl, the older of the two responded, wide eyed. She was holding a teddy bear and a card with “Daddy” written on it, and her little brother was holding a similar card with the three year old scribbling signature every parent recognizes.
They were dressed immaculately, as always. The little girl’s hair held back by a pretty glitter-covered barrette and wearing a dark corduroy dress, and the little boy in matching sweater vest and little pants with striped trim, his hair combed to the side, still wet. I stood there for a couple of moments, looking down at them, paralyzed.
They alternatively looked up at me, and then down the hall around me where their mother was sitting, slumped forward, with her head in her hands. The little girl’s face began to cloud, the skin around the edges of her nose crinkling a little bit, her eyebrows raised almost imperceptibly – the look children get a few milliseconds before they burst into tears. I looked up and saw a wheelchair over by the elevators.
“Say,” I said, “who wants to go for a ride in a wheelchair?”
They both smiled and the little girl shook her head “yes”.
I put their Daddy’s cards in the pockets of my labcoat, loaded them into the wheelchair, where they squirmed into place, giggling. For the next half hour we wheeled and twirled on the other hallways of the floor, and in the open common area in front of the elevators.
I pushed them from behind where they could not see me, leaning over with my hands on the plastic handles, my labcoat flapping behind me as we sped from place to place, laughing and singing, tears running down my face.