Category: Lessons

The urge was to glance at the roster on the wall and go directly to the patient’s room.

Instead, I said to the clerk, “Hi. I’m one of The Patient’s outpatient doctors. May I trouble you to page her doctor so I can talk with him?”

Five minutes later, a man wearing a bow tie and a stethoscope around his neck walked onto the unit. He pitched himself forward when he walked; his shoulders were ahead of his hips, which were ahead of his knees.

“So you’re her psychiatrist, huh? She’s a nice woman.”

Yes, she is.

“GI scoped her this morning to open the stricture,” he said, waving his hand to direct me to follow him. “No complications. She should’ve gotten a breakfast tray by now. You see her yet?”

Before I could answer, he continued, “Interesting case. Not sure why she developed the stricture. You want copies of her notes? I’ll give you copies of her notes.”

My eyes skimmed the papers as he handed them to me. Though several pages mentioned a significant narrowing of her esophagus, none mentioned cancer.

Huh.

After thanking him, I went to go see my patient.

“Hellooooooo!” she squealed, waving her twiggy arms at me. “So nice to see yooooou!”

“Hello,” I laughed, noticing the sign marked “NPO”[1. NPO stands for “nil per os”, which means “nothing by mouth”, which means that the patient should not eat or drink anything for a certain amount of time. The sign should have been taken down since her procedure was done.] above her bed. “Do you mind if I sit down so we can chat?”

“No, no, sit, sit!”

“What did they bring you for breakfast?”

She gingerly lifted the plastic cover off of the breakfast tray. Pointing at each item, she said, “Eggs… toast… cereal… milk… juice… fruit?”

“There’s tea, too.”

“I don’t like tea.”

I smiled.

“Please, start eating.”

She peeled the wrapping off of the plastic utensils, plucked out the spoon and fork, and set them on the table. Her thin fingers opened the small milk carton and the single-serving of cereal.

“What happened this morning?

After pouring the milk into the cereal, she dunked the spoon into the mixture and fed the flakes into her mouth. She chewed, then swallowed, with ease.

“They put something down my throat.”

With the fork she scooped a blob of cold scrambled egg into her mouth.

“Why did they do that?”

“To open it up so I can swallow.”

She bit into a slice of toast. It looked soggy.

“Did it hurt?”

She shook her head. “I’m fine.”

I smiled again.

She ate it all: The eggs, toast, cereal, milk, juice, and fruit in heavy syrup. The tea continued to give off steam in the corner of the tray.

“That was good,” she said.

We sat in silence for a while. She looked out the window. I looked at the thin muscles hanging off of her bones.

Abruptly turning to look at me, she said, “Thank you. You knew there was something wrong and you got me help. I was really sick. Thank you.”

My cheeks suddenly felt warm. A smile blossomed on my face. No longer able to hold her gaze, I looked away and said, “You’re welcome.”

---

Finis! Epilogue to follow. The story begins here.

---

It was raining. Cars were driving through the water collecting in the gutters. This made it difficult to hear her voice through the phone.

“I’m the consult-liaison psychiatrist seeing your patient,” she said. “Thank you for leaving a note for us about her.”

Huh. So she was admitted to a medical service. Good. Points to the primary medical team for getting the psychiatric consultant involved.

“How is she doing?”

“From a psychiatric standpoint, she’s fine…”

But…?

“… but, they scanned her chest and they found a mass. It doesn’t look good. They think it might be cancer.”

I stopped walking.

“What? Are you serious?”

“Yeah. They’re still doing the workup, but from what they saw on the scan, there’s a good chance that it’s cancer. They’ve told her and she’s okay so far. I’ll continue to see her. She’ll be in the hospital for a while.”

The cars continued to splash water onto the sidewalk. I closed my eyes.

“Thanks for letting me know.”

---

There’s an adage in medicine: The nicest people are the ones who get cancer.

God, how could you let a nice woman with a diagnosis of schizophrenia develop cancer? Have you no mercy?

---

Cancer? Could she really have cancer? Did I think it could be cancer? Of course I thought it could be cancer.

Did I?

Why didn’t the ED staff at the first hospital catch this? Could she have developed a mass in her chest in the span of three weeks? Maybe. Maybe it grew fast. But she had been vomiting for months….

Why didn’t I push the inpatient psychiatry staff ask for a medicine consult?

Because we all trusted the medical workup. There was no reason to doubt it.

Right?

But what if I had insisted on one? What if I had demanded it? She was losing weight and the inpatient psychiatrists couldn’t give me an explanation why. They thought her weight loss was due entirely to psychiatric reasons. Their strategy to help her gain weight—locking her out of a bathroom after meals!—wasn’t working. I knew this. They knew this.

I couldn’t stop them from discharging her from the hospital. What was I going to do? Block the exit and demand that she stay?

Maybe I trusted too much.

We all trusted. If they couldn’t find a medical cause, then the problem had to be psychiatric in nature.

How could we have completely forgotten that maybe they just couldn’t find the medical problem yet?

How could I have forgotten that?

---

The office staff were appalled.

“Should we tell the first hospital about this? They need to know. That could be a lawsuit right there.”

“But we’re not actually going to sue,” I said. “It doesn’t change anything for the patient. At least she’s getting treatment now.”

---

A few days later, the gastroenterologist called.

“Thank you for calling me. I understand that she has a mass? that she might have cancer?”

“We don’t know about the cancer part,” he said, “but there does seem to be a mass in her chest. We think the mass has been pushing on the esophagus, which caused the esophagus to get thick, like a callous. Then the diameter of his esophagus got smaller, so it became more difficult for her to swallow food. That probably explains her vomiting and weight loss.”

“Right.”

“Tomorrow morning, we’re going to drop a scope down her esophagus to look around. We’re planning on stretching the diameter of her esophagus a bit so she can eat.”

“I’ll come by tomorrow after the procedure. Thank you for letting me know.”

Nothing had changed. Everything had changed.

---

(Part seven of an ongoing series.)

She was still standing on the scale. 93 pounds. The rest of the team looked at her.

“What should we do?” someone asked.

We all looked at each other.

“Well,” I offered, “this isn’t an emergency—there’s nothing to do right now. She just left the hospital. They won’t take her back right now. Did That Hospital schedule any follow-up medical appointments for her?”

After flipping through the discharge papers, The Worker said, “Nope.”

Unable to restrain myself, I mumbled, “First they don’t call to discuss her care prior to discharging her, then they don’t schedule any follow-up.”

I probably shouldn’t have said that out loud.

Turning to the patient, I said, “I know you just left the hospital. But if your weight drops any more, we’re going to take you back. I’m still worried that there is something happening to your body that is making you lose weight. Does that make sense?”

“I don’t want to go back to that hospital,” she said as she stepped off the scale. “The food doesn’t taste good there.”

“Where would you rather go?”

“I can go to That Other Hospital.” She suddenly flashed a bright smile. “The food there is delicious!”

“Okay, we’ll keep that in mind. Hopefully, though, you won’t have to go back to any hospital at all.”

---

At our request, she came to the office every day. Two days later, the nurse asked the patient to step on the scale. The nurse then knocked on my door and said, “Come look at this.”

The three of us then peered at the numbers on the scale: 87 pounds.

Alarmed, I looked at the nurse. She nodded.

“I’m sorry,” I said to the patient, “but we need to get you back to a hospital.”

Unlike the last time, she did not protest. She only nodded.

“Which hospital do you want to go to?”

“The Other Hospital. The food tastes better there.”

The Worker joined the nurse, the patient, and me.

“She shouldn’t go back to The Hospital She Just Came From. They weren’t good to her there,” The Worker opined.

“Fair, but there are advantages to sending her back there. They already know her recent history, they are less likely to put her through repeat testing, they may take this problem more seriously—”

“Right, but they didn’t take good care of her.”

The patient looked at me with those eyes that looked too large and sunken for her head.

“Okay. Let’s try to get her to The Other Hospital. I can’t go with her—”

“We’ll call an ambulance this time. That way we’ll know that she’ll get to the emergency room.”

And so we went through the circus again. Poor woman: An ambulance was summoned, the medics helped her tuck her spindly limbs into the back of the car, and I again scribbled out a note with her treatment history. It now included a two-plus week hospital stay and subsequent weight loss. Just six months ago she weighed over 120 pounds! I finished the letter with a plea that she be admitted to the hospital.

The medic took the sheet of paper from my hands. We hoped for the best.

---

Thankfully, she was admitted to The Other Hospital.

Two days later, doctors started calling me.

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(Part six of an ongoing series.)