Without Work

Frankie had worked as a barber in a small town for over 40 years.  It's important to note that in a small town the barber shop has its own sub culture. Men of all ages, from all walks of life and socioeconomic status, enter on equal footing.  The barber with blades in hand, is ruler of the roost siphoning in information from gossip, secrets, and confessions of clients. The power is all his, as the morsels he collects he can choose to hold tight to or to pass on to others.

For forty years the castle was his. Others clamored for his favor to win tidbits about others. He was respected. He was independent. His job was his life.

When they found a nodule in his lung he started chemotherapy in secret.  He had listened and passed on tales of countless other peoples cancer woes and didn't want the awe filled pity that accompanied the news.

He pushed through the fatigue and side effects, never missing an day at work.

The news came that the cancer was spreading rapidly, but he continued to ignore this reality. Finally one morning he didn't have the strength to make it to work.   With no work to go to, he called hospice.  Now he was ready to die.

I met Frankie the day he enrolled with hospice.  We talked about his life, his hopes, his disease.  I cautioned him that although his weakness and fatigue were preventing him from going to work it still appeared that he had several weeks left, if not a month or so before the end.

Word got out about Frankie's cancer, the very world of information exchange that he had controlled now passed around his own tale.

Without his job, Frankie floundered. He refused visitors, he lashed out at family. He climbed so inward into himself that he'd often ignore my visits. If anything was muttered, it would be about wanting to die.

It's as if, in Frankie's eyes, 100% of  his value was in being a barber and when that was taken away there was nothing left. No amount of medication, dignity therapy, or listening could fix the suffering from loss of identity.  It was agonizing. He laid in bed, rejecting the world for over a month before he died.

I've tried to funnel the heartbreak of not being able to help Frankie into a check up of my own self value. There's got to be balance of worth that comes from both external and internal things.

If only Frankie could have acknowledged that despite not being able to go to work, he was still a father, a grandfather, a friend, and still a barber with a lifetime of stories to be shared.

Absolution

Faye had been dealt an over abundance of difficult things. When she was born, she was not wanted by her drug abusing mom, so her grandmother adopted her, but the seeds of being unwanted were planted.

Faye got married and had children, then her husband didn't want her and left. She eventually met her current husband and they married and another child was born. Unfortunately, along the rocky road of searching for love and being abandoned, Faye was introduced to the same companion her birth mother had found solace in - drugs.

The problem with substance abuse is that it masks not just emotional pain, but physical pain as well. When Faye started having abdominal pain and loosing weight, she and everyone around her assumed it was the drug use. For months, vague symptoms persisted, but nothing was done.

She finally came to the hospital when days had passed and she hadn't been able to eat. The pain was severe and by now she'd lost nearly 70 lbs.  I'm sure you know where this is heading. CT scans showed a mass in her liver, and further tests showed the cancer to be everywhere. Suddenly this 30 year old mother was told she only had a few weeks to live.

I met Faye at the hospice house, the paradox of sunken cheeks and thin upper body with a distended belly and fluid filled legs from her cancer were what greeted me. She was just days into the knowledge of her disease, and it showed, she wanted medications and more medications to knock her out of her reality.

Despite this, her one clear question to me during my exam reminded me that she was absolutely still processing this. Her question came after her family had stepped out. In this private moment of a patient and their doctor, she grabbed my arm as asked, "I'm embarrassed to ask, but I have to know, did my drug use cause this?"

She was asking what everyone asks when facing death at the wrong time; "Why?"  As humans we think if we can ascribe cause and effect to things, we gain some control. Often, though, the why question is laced with culpability, which is what Faye was asking.  Not only was she struggling with the question of why her life was ending, she was struggling with her role in that fact.

I had a sudden dilemma, on the one hand her drug use did have a major role in how late she presented for medical attention, potentially preventing early detection and beneficial treatment.  On the other hand, the drug use didn't actually cause her cancer.

What Faye needed from me was absolution, and though just her doctor, I gave it.  "Oh Faye...listen, you need to know that no decision you've made or action you've taken has caused this disease. It's horrible, it's ugly, it's not fair that you are in this situation, but it is absolutely not your fault."

She began to weep and just say "thank you" over and over again.

As a palliative care doctor, my role is to relieve suffering, sometimes this is done with medications, but often it is done with words. I couldn't take away the suffering related to being young, a mom, and dying with cancer, but I could certainly take away any guilt associated with her disease.

Puzzle solver

I am back on the hospital side again for work.  This change really only amounts to longer hours and sicker patients. 

It is rare in my job to really come across patients with mystery problems. I'd say 90% of the people who come into the hospital or clinic have names for their problems- they have heart failure, or pneumonia. They know they have gout, or liver failure.  If there is any doubt, usually the ER docs label the patients for us.  It's a shame, because I love solving mysteries.  I think a reason I went into medicine was because I thought I would be putting complex puzzle pieces together to figure stuff out.  This, again, doesn't happen that often.

Yesterday I had such a "puzzle".  This pale 50 year old woman hadn't been to a doctor in years. She was admitted for anemia, with a HGb of 5.5 (VERY LOW).  The work up began, as I thought through reasons and ordered tests.  All day I was absorbed, as tests started coming back very unusual.  I was investigating, and solving riddles, and I was loving it.  One of the abnormalities was gross blood in this patients urine.  Tho she hadn't noticed anything, this was an ominous sign.  Immediately, I ordered a CT scan, to look at her bladder and kidneys. While other tests were indicating she was hemolyzing her blood (chewing up the cells) AS well as having trouble making cells with a bone marrow problem, this blood in the urine couldn't be good.  The CT scan came back late last night.  With no radiologist around to officially read the scan, I took a preliminary read.  I was shocked as I saw what used to be a kidney, now 4 times normal with definite tumor.  Then the liver, studded with cancer, and the lungs full as well. 

My game, of solving puzzles, suddenly wasn't as exciting anymore. I think I had expected discovering the cause of her problems and fixing her; feeling delight in the fact that all the hours spent studying and learning would pay off in helping someone.  It was as if my treasure hunt had turned up, not a treasure, but a trap or a dreadful poison or something harmful.  Yes, I got an answer, but now I had to go sit with this woman, who had assumed she came in to get some transfusions, and tell her that she had a very bad cancer that had already ravaged her whole self. 

I guess, being someone who likes to discover new things, I must be prepared for these situations. If you go turning over stones, you must realize that there are very bad things that live there.  

Following is my patient's actual CT showing the tumor, quite impressive!