Beyond the Limits of Medicine
July 17, 2010 Leave a comment
Sometimes stories are difficult to tell. Today, I was greeted behind the curtain by clear blue eyes – like water, more transparent than I have ever seen. My patient, a sophisticated gentleman in his 50s, presented after an unexpected fall at home. He had been diagnosed with glioblastoma multiforme stage IV just a few months prior. The fall had happened as he was dictating a farewell letter to his son.
When I entered the room, I looked at his face – pale, almost ashen. I looked at the monitor. I heard a one-line story from the triage nurse in the room. Immediately, I sensed that something was very wrong. My instinct was that this gentleman had a large pulmonary embolism. I pushed away my diagnosis and tried to perform my duties as a good emergency physician – take a step back, broaden the differential, do not forget any important life-threatening diagnoses that could be missed. But the feeling in my gut would not dissolve.
The phone call from the radiologist made my heart sink – I was half hoping that my impression had been terribly off. I could not hide my disappointment – I let out a long sigh and asked him if he was certain. But it was not a question of certainty nor was it a subtle finding – the gentleman’s main pulmonary arteries had been clotted off completely. I was prepared to rush to anti-coagulate him until one of the nurses reminded me that he had had a recent intracranial hemorrhage due to his brain tumor. The intravenous heparin which we use to dissolve blood clots in the lungs is contraindicated in patients at risk for hemorrhage.
And so we found ourselves stuck between the proverbial rock and a hard place. As my patient said to me when I relayed the news, “Damned if you do, damned if you don’t.” He paused then, looked at me with the bluest eyes. He asked if there was anything I could do to fix this. Anything at all. I dodged his glance to avoid tears. It is amazing how adept I have become at repressing emotions. I calmly relayed to him and his family all of the information – the risks and benefits, the treatment options. But in the end, the patient had said it best himself the first time around. He had been feeling more depressed and had been thinking about the end of his life more and more over the last week – maybe he was more prepared for this news than I was.
There was a brief, curious moment when I noticed an anger rising in me – anger stemming from a brewing frustration that I, and medicine, in all our power, could do nothing to save this man. I have always said this to my patients – the really bad things, the really dangerous, frightening, life-threatening things – are the very things which we as physicians lack the necessary tools to treat. They are the very things which go beyond the limits of medicine. It is only the little things along the way that we do a very good job of moderating (high blood pressure, high cholesterol, benign prostatic hypertrophy).
A good portion of my shift was spent discussing his choices – and ultimately he, his family, and his physicians all came to the agreement that comfort measures were the best option. When just the two of us were left in the room again, I asked him if he had any more questions for me. He paused again, looked off into the distance, his eyebrows rising towards the bridge of his nose. Wandering, thinking. He took his time, then he turned to look me in the eyes. He said slowly, deliberately, “What does one do for this sort of thing?” I began to wonder if the clot in his lungs was beginning to affect his mentation – began to wonder if he was becoming more confused or if he had forgotten our earlier discussion. Somehow, I don’t think he had. I answered again with the same response – that we could not dissolve the life-threatening blood clot without putting him at risk for a life-threatening intracranial bleed. I told him that oxygen was the best medicine for his lungs, and that we would continue to give him as much oxygen as he needed. But he did not seem to be satisfied with this answer.
I only realize now that he was not asking what I could do for the blood clot in his lungs – he was asking what I could do for him, right now. He was asking what I could do for somebody who was dying. And the honest answer was that I did not know. I did not have the heart to be so blunt with him – instead I evaded the question and focused on what I knew best, focused on the easy, scientific answer. This is what I have learned to do as a physician so that I do not fall apart, over and over again. My job is to be there for families – and I need to perform that job well.
I will not forget this man or his family. I will not forget the long, fixed gaze of his blue eyes as I stood in the room at his bedside, helpless. I will not forget his story, or his very last question of me. Maybe it was more philosophical in nature after all. I hope that he was able to finish at least the most important parts of the letter he was dictating to his son – I wonder what pieces of wisdom he had accumulated over the years which he so desperately wanted to share. I wish he could have shared them with me.