The First Time I Could Do Nothing for a Patient

Illustration by Yi-Min Chun

The first time I realized I was mortal was right after my critical care fellowship. You would have thought that it would have dawned on me before then but dealing with death and near-death daily seemed to insulate me against its eventual appearance in my life.

I was a new Critical Care attending and was taking sign-out from a friend of mine. He told me about a young female who had been admitted after suffering a seizure. Her head CT showed a lesion in her temporal lobe. She was intubated and ventilated. She was starting to wake up. I wanted to examine her before she needed to be re-sedated so I could quickly extubate her and send her to the medical ward to be seen by oncology and hopefully begin treatment. The lesion was relatively small and maybe they could get it utilizing gamma knife surgery. This would be a lucky break for her — the tumor caused symptoms before it got too big.

I started by looking at her ventilator setting — 30% FiO2 — sats 95%, everything looked pretty good. Her pupils were reactive and she seemed to look right at me. I auscultated her chest and felt my heart drop. She had rhoncherous breath sounds on the left anteriorly. I was hoping she had aspirated but the anatomy didn’t make sense to me. It was the wrong area.

I looked at the chest x-ray which had been done to evaluate for endotracheal tube placement. It wasn’t a great film — I could see that the tube was in good position but really couldn’t see much else — the tech had cut off the bottom of the film. We got another film and there is was — that fist-sized atelectatic area on her left side. Please be pneumonia, I thought.

Sure enough, when she was extubated, I found out that she was a smoker but was trying to quit. She had an adult daughter by her first husband who treated her poorly. She married the love of her life a few years ago and was gloriously happy. They were going to quit together.

As I rotated off of my week in the ICU, I continued to see her as a Pulmonary consult patient. I did a bronchoscopy and we obtained a diagnosis — non-small cell carcinoma. I called the oncologist who started treatment immediately. Our facility worked closely with the Mayo clinic. She quickly failed first line chemo. We started experimental chemo. She underwent radiation. I was a month away from my wedding.

Her second bronchoscopy was due to hemoptysis. We were able to stop the immediate bleeding from her endobronchial lesion but knew it would start up again. I talked to her husband about ablation — we took her to interventional radiology and they successfully ablated the vessel leading to the tumor.

Her hair never really fell out. She stayed in the hospital for one reason or another. I rotated off pulmonary consult service but would stop in to see her after my clinic patients.

She fought. He supported her. She felt smothered by him and overwhelmingly guilty about it. I started asking him to leave when I examined her just to give her a break without hurting his feelings.

I knew there was nothing I could do for her. But I sat with her and held her hand. She vented. She cried. She asked me why nothing was working. Her eyes searched mine for answers I didn’t have. Mine searched hers for understanding of the futility of what we were doing. She started telling me about her life — her daughter, her husband, her dog. She liked make-up and nail polish. She loved to read. Her daughter was the single greatest gift in her life.

She didn’t stop fighting abruptly– she gradually shifted from anger and strong will to acceptance and peace. My wedding was two weeks away.

She told me about her first husband, how he made her feel. He wasn’t abusive. He wasn’t a drunkard. He didn’t cheat. He didn’t do much of anything. He made her feel insignificant.

She finally left with her daughter. It wasn’t a dramatic exit. They had simply stopped being married.

She met her new husband. He was younger. He doted on her. He wasn’t rich. He wasn’t extravagant. He simply made her feel like she was important.

I had long ago stopped being able to help her overcome cancer. My job was simply to listen. And, unbeknownst to me, she was the one with the answers.

One week before my wedding, I told her that my fiancé had been married before and had a daughter. My mom fretted about our age difference. I told her I was nervous and having second thoughts. For all of my training, this was an area in which I had no experience. I felt inadequately prepared to become a wife and mother in the same day. My patient told me that sometimes you have to go to a secondhand store to find the lid to fit your pot.

She died when we were on our honeymoon. I have never forgotten her advice. In the end, she healed a part of me I didn’t know was broken.

Dr. Seema Khosla is board-certified in Internal Medicine, Pulmonary, Critical Care and Sleep. She practices in Fargo, ND as an independent sleep physician. She teaches her children about the importance of gratitude.

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