A heart wrenching lesson in life: learned early, learned well. Part 1 of 3.
For my 71’st birthday, my friend, colleague and former student Alex Vesely asked me to re-tell one of my favourite stories. Indeed I try to tell this story at every opportunity and I don’t hold back as long as someone will listen to it. I was 26 years old and these events changed my life and still affects the way I live and think.
Setting the scene: I am this 26 year old ‘hot shot’ (in my and in my mother’s mind, at least) first year medical resident. I am on call for Medicine in a U of T affiliated community hospital in Toronto (how I, as a “hot shot” ended up in the academic boonies is yet another lesson in life). On call, I cover the hospital and the ER. The ER is staffed by local family doctors and moonlighting residents. They see the patients first, assess them and either manage them or refer them to the various services if they feel the patients may need to be admitted to the hospital for further investigation or treatment. Some of the attendings can be “sloughers” where they see the patient, and rather than make decisions, they drop the charts into one of the “consult” boxes: surgery, ophthalmology, medicine, etc., fill out the billing card, and go to the next patient.
Its late afternoon, I am still looking after my ward patients when I get a page regarding a consult in the ER. I go down, pick up the chart. There is no history, physical, labs, reason for consult. Just 3 letters, hand-written, upper case, scrawled across the writing space: NFW. My head pounds: I look down at the signature of the doc that referred me the patient as I go into the holding area. I am thinking ‘that lazy slougher ass hole!’ The privacy curtain is drawn completely around the bay holding the patient. I spread the split in the curtains and enter the enclosure. On the bed I come face to face with something I had never seen before, and a half century later, I can say never seen it since.
I will try to describe this scene but I am certain you have never seen this either so you will have to extend your imagination. Lying with the back of the stretcher tilted up about 30 degrees was, well, a skeleton. Head was basically a skull like in the anatomy lab skeletons hanging from a hook screwed into the skull. Arms were similarly skeletal with no discernable flesh. The head was bald, and covered by translucent skin where I could discern every bump and even a bit of the sutures. Eyes deeply sunken and eyelids thin little wisps like nictitating membranes on reptiles. I approached the stretcher and called his name. He opened his eyes and spoke to me. I was shocked. This skeleton had a normal voice and his conversation was accompanied by normal animated movements. He was not listless, and didn’t appear moribund. A huge discrepancy with the way he looked. I asked, “what brought you to hospital today?” This was the standard phrase we were taught in medical school to initiate the history taking. I couldn’t think of anything better to ask. He responded, “I haven’t been feeling well”. No doubt he was in the end stages of some sort of cancer I surmised. I said “how long have you been feeling unwell?” He responded, “about 2-3 weeks”.
“OK, before 3 weeks ago, were you well?”
“Fairly well.”
“How is your appetite?”
“I have sort of been off my food a bit for the last week or so.”
“Before that you were eating normally?”
“yes”
I went through a full inquiry about his other organ symptoms: bowels, bladder, shortness of breath, chest pain, arthritis, neurological symptoms. All were “fine”. I felt along his neck, armpits and groins for enlarged lymph nodes. His pulse at the wrist was strong (why not, his artery was sitting there naked on his bone). I took out my stethoscope and tried listening to his heart and lungs. This was not possible because the skin indented between his ribs and I could not occlude the diaphragm or bell. I felt his abdomen. There was nothing there. I felt only the anterior part of his lumbar and sacral spine. I did a rectal exam. No tumor in the prostate or bowel. Temperature normal. ECG normal. Chest X-ray normal. Abdominal flat plate, normal. Electrolytes, BUN, Createnine, liver enzymes normal. Hemoglobin mildly reduced but differential and smear normal. Urinalysis normal. Now what?
This is ridiculous, I thought. I went to the waiting room and brought his wife to the bedside. “He has not been well” “about 3 weeks” “OK, maybe 4” “no complaints”. In frustration, I said “Ma’m, look at me and look at him. When did he last look like me?” She said “before 3 weeks ago”.
I was sure he had a cancer somewhere or some weird collagen-vascular disease. I filled out the forms to admit him to my ward. I’ll figure it out tomorrow, I thought, and went to see my next consult.
Read more in Part 2.
