Being on call is about not killing anyone. But people don’t live forever.
Dave didn’t ride his bike to work that December day; that’s how bad the storm was. Of the seven doctors training to become emergency specialists, he was the sportiest and cycled everywhere. The blizzard had dropped a foot of snow in just a few hours, and the forecast wasn’t promising. I arrived for my 26 hour internal medicine call shift in boots and a Canada Goose parka that masked my slender build. Dawn hadn’t yet broken, a symptom of northern winters. I walked through the dark parking lot, falling snowflakes glistening in the twilight.
After a decade of working as a flight paramedic caring for the sickest of the sick, internal medicine was a synch. Between the chronic diseases and deteriorating bodies, I rarely responded to emergencies. A bit of insulin, a bit of saline, and I could fix just about anyone. Internal medicine is not emergency medicine; instant gratification is never the rule, and dramatic therapies tend to do more harm than good. Rather, small adjustments followed by periods of observation are the key to being a good internist.
Being an adrenaline junkie, found the work boring. An eighty year old was considered to be young, and a work-up could easily take 2 weeks. I longed for the chaos of the emergency room, where diagnoses were made in seconds and electric shocks restarted dying hearts. But as all junior doctors know, we must bid our time and staff the internal medicine service. I did not expect to learn anything profound on the medicine wards. Until, that is, I met James.
James was 93, but didn’t look a day over 85. Normally steady on his feet and sharp with his wit, James came to the emergency room after a “gravity mishap” – he had fallen at his retirement home. Despite not breaking his hip, he couldn’t walk very well and was admitted to my team. A shadow on the x-ray – a hypodensity, the radiologist called it – prompted a CAT scan of his hip.
It didn’t phase me one bit when I read the results: “metastatic cancer invading the pelvis and hip, secondary to prostate cancer.” When you’re 93, I just assume you have cancer. Lacking excitement for this explanation of his pain, or sorrow for his dismal prognosis, I apathetically noted the diagnosis and listed the options for treatment. Chemotherapy, radiation, and drugs to dull the pain were on the list of offerings. Metastatic cancer is rarely cured, but medical advances can prolong and improve people’s lives by months or years. With a plan in mind, I headed to ward E3 to meet with James and his daughter Connie in a stale, semi-private hospital room.
Breaking bad news is a honed skill. My years as a paramedic prepared me well to communicate tragic circumstances to shocked and stunned families. Experience doesn’t make it easy, but it’s not really that hard either. I could tell by the look in his eyes that he knew the diagnosis before the “C” word left my mouth. Connie, on the other hand, was stunned. Short, sturdy and pushing sixty, her thick-rimmed glasses gave her the appearance of a school principal.
James glanced downwards nonchalantly. He face barely reacted. Connie’s eyes filled with tears and she bit her bottom lip. She was too tough to sob, yet any attempt to speak would open floodgates. I looked back at James. I laid out the options, and he matter-of-factly asked questions. Could the chemo kill me? Possibly yes. Will the radiation stop the progression? Probably not. Will the pain medicine make me drowsy? Sometimes it can. If I had spoken any more generally, I might have been saying nothing at all. Reflecting on this useless council, I question my vocation of choice. So often as doctors we are grasping at straws, straws that can break our patient’s backs.
James didn’t want any therapy. “I just want to be around” he declared. Connie’s facial expression reacted viscerally to her father refusing treatment. Sensing the tipping point, I offered her a hug. She accepted, clinging to me like Velcro, her tears flowing down my shirt. I couldn’t quite grasp James’s choice: it seemed as though he had given up, that tomorrow didn’t matter to him anymore. I didn’t judge him negatively, but rather felt disconnected. When Connie released me, I left to call the palliative care team, who would plan James’s pathway to dying.
It was nearly two o’clock in the morning when my pager went off. I walked briskly through long, dark hallways to the ward on E3 to attend to a patient. Crisis addressed, I checked in on James. I found him pushed to the far right side of his hospital bed. Connie was snuggled up against him, her head resting on his chest as she slept. She had regressed from school principal to passed-out kindergardener. At first, I thought he was sleeping too. He must have heard me; he opened his eyes without moving a muscle (well, except for his levator palpebrae superioris). We looked at each other and smiled. His grin was unmistakable: it conveyed total peace and absolute joy. James was living exactly as he wanted at that moment. His glaze shifted to the window of his hospital room, where snow was still falling.
It was then that it struck me, obvious now but profound then. As we age, our priorities change; we no longer look for tomorrow’s adventures, but cherish what we love most today. With that change in priorities comes a change in what we need most from our doctors. It becomes not about saving a life, or even prolonging one. It becomes about helping people realize the moments they desire most.
I knew then what James needed from me. I stepped forward and gently pulled the blue-striped flannel blanket up over Connie’s shoulders. I am indebted to him for imparting a lesson he may not even realize he taught. I became a better doctor in that moment; standing in the dark, snow swirling outside on that cold December night.