She was my patient. When the Oncologist told me over the phone that there were no options left, he was kind enough to offer to come in from home to have the discussion with the family. When I spoke with the Surgeon and the Interventional Radiologist, they had told me the same without making the offer. She was my patient. I told him I would do it.
I was an emergency medicine intern at a county hospital working the last few days of my two months in the intensive care unit. I was working overnight, and in the last hour had pronounced one patient dead, admitted another, and expected another to pass at any moment. I felt stretched thin by too many twenty-eight hours shifts and too many deaths in too short of a time. Now, I needed to tell a family that there was nothing we could do for their loved one, and try to help them decide what that meant.
She was thirty-three years old. Little specks of cancer had spread throughout her body, lodged themselves in the creases of her internal organs, and now they were bleeding into her brain and liver. There was nothing to stop it.
I had met her on my first day working in the surgical intensive care unit two months prior. She had already been there for a week when I started. The intern who gave me my list of patients gave me a quick summary of her case but made it clear that she was only waiting for placement in a hemodialysis facility. Her kidneys had completely failed, and we were really just keeping an eye on her until this could be arranged.
My first day was also my first twenty-eight hour call. I had never gone without sleep for that long before, let alone work that long as a doctor. I had arrived at the hospital long before sunrise, seen all of the patients in the surgical unit with the Attending doctor and the other surgical residents, then been given a list of tasks that filled my time until the afternoon. When I arrived to check on her she was having lunch. She had a quiet, private room, isolated from the chaos of the rest of the unit. In her room, I felt a relief in the absence of the pump of the respirators as they breathed for the intubated patients, and the groans of patients separated from each other by only a thin curtain. She was having lunch, and smiled at me as I walked in. I introduced myself and apologized for not checking on her sooner. She waved the apology away with her right hand and said she understood, that she was just ready to go home. Then, she asked me when she would be able to pee again.
I sat down at her bedside, wanting to do this right. My sign-out had stated that she was going to a hemodialysis center, but for a moment I felt like I had made some sort of mistake. We continued to talk, and she understood the general idea of where she was being sent, but she wanted to know how long I thought she would need dialysis. No one had explained to her that her kidneys were dead. The quiet of her room was suddenly suffocating. So, I asked her to give me a second. I stood up and went to read her medical record in the computer, wanting the comfort of her chart and her history before I told this woman she would never pee again for the rest of her life.
Her notes stated that her only pain had begun as a twinge in her left groin when she picked up her baby niece. After one month of increasing pain she had vomited blood and noticed blood in the toilet, so she had gone to the emergency room. She had been admitted to the hospital for the bleeding and the mass in her left groin. She was then taken to the operating room for removal of the mass, and the biopsy was sent to determine what it was. Unfortunately, her bleeding had then progressed to disseminated intravascular coagulation, and the parts that kept her blood liquid and flowing stopped working. Her blood became hard clots in places where it shouldn’t have been, and kept bleeding in places the doctors wished it hadn’t. She had been taken to the operating room four times over the next week. By the end of the week, the surgeons had taken her left arm just under the shoulder, her right foot up to her knee, and six feet of her intestines. During that time, she had bled so much the lack of blood flow to her kidneys had caused them to die, and now she needed dialysis to replace them. After a five-day period of recovery she had begunn to have difficulty breathing, and was found to have a large blood clot in the artery that ran to her lung. Over the next couple weeks she twice had a tube placed from her mouth to her lungs to control her breathing, completed treatment for a dangerous infection called Pseudomonas, and the dialysis that cleaned her blood in place of her kidneys had been weaned down from daily to three times a week. The cause of all of this was metastatic malignant melanoma, a terrible cancer, which had spread to her liver, lungs, and bowel. After everything, she was alive. And she wanted to know when she would pee again.
I sat back down at the bedside. I was as clear as I could be, and told her that I didn’t think her kidneys were going to get better than they were now. Perhaps the information registered in her mind, but she didn’t address it. She began to talk about living with her sister after the dialysis center, and how much she enjoyed playing with her sister’s children. She never asked about her kidneys again. Maybe she had already known. Maybe she wasn’t ready to know. Maybe after all that she had lost she needed to think that she could get something back. I didn’t push. Instead we talked about her sister’s children. Then I left the quiet of her room and entered back into the steady chaos of the intensive care unit. By the end of that twenty-eight hour shift, the conversation about dialysis seemed like it had happened days before. As I deliriously packed my bag to go home, I went to say goodbye. Her quiet room was filled with visitors, who I presumed were her family. So I passed softly by the room, leaving them to the time that they had. When I came back for my next shift, she had been sent out to the dialysis facility. To be continued…
This concludes part one of a two-part series where Dr. Tetwiler shares his experience caring for a patient with terminal cancer. Part two will be posted next month’s edition of the Physician Grind Narratives.
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Keep Scrolling down for Dr. Tetweiler’s Bio
Michael Tetwiler, MD
Michael Tetwiler grew up in a small town in Kansas. After completing his undergraduate studies in English Literature, he pursued his medical degree at the University of Kansas. During medical school, he was awarded a Fulbright Research grant that analyzed clean water initiatives in the Peruvian Amazon. His work in his medical school's free clinic led him to pursue an MPH in Health Management at the Harvard T. H. Chan School of Public Health. These experiences led him to a residency in Emergency Medicine at Harbor UCLA where his work focuses on helping underserved spanish speaking communities and initiatives for resident wellness.
