The change in expression was reassuring: her face was animated and bright and no longer lined with torment. The medication had obviously kicked in, likely the first time she had been pain-free in weeks, maybe months. Now in her middle 70s, she exuded warmth. She smiled, and the skin around her eyes crinkled. And with that smile, despite the hospital gown and the sterile surroundings, the years peeled away. I caught a glimpse of a youthful, vibrant woman. She had, I imagined, turned a few heads in her day.
“Thank you,” she said, cupping my hand in hers and squeezing. The IV was visible on the dorsum of her right forearm. She moved this hand gingerly, respecting the line that had allowed her nurse to deliver such comfort. “To you and the nurses. For all that you've done.”
Then her energy withered, her face darkened and her hands fell back to the stretcher. Before me again lay an ill, elderly soul.
She was thanking us, I understood, for relieving her pain and for admitting her to hospital. She had reached a point where she could no longer walk or limp or even crawl in her own home. But, having arrived at a tentative diagnosis, I couldn't help feeling uneasy, as if I personally had uncaged the beast that she had struggled to contain.
I had felt a certain foreboding from my first glance at her chart: “six months of hip pain.” Problems of such duration irritated the emergency physician in me. I have lost, over the years, any desire or capacity to address chronic conditions. Surprisingly, though, this patient had not had any medical attention in the preceding half year. I felt liberated from the usual overlay of unsuccessful therapeutic interventions, as if hers were an acute condition.
As the history and physical examination unfolded, I felt a tension rising within myself. Cancer, it seemed, was the diagnosis of exclusion. She had lost her appetite and, along with it, many pounds. The pain bore into her at night, making sleep difficult. The muscles of her left hip and knee were contracted, guarding the joints in flexion. Any pressure applied to the leg, any attempt to move the limb, elicited shrieks of pain. Three hard subcutaneous nodules, one nearly the size of a golf ball, were palpable on her trunk.
“Why haven't you seen your doctor before this?” I asked, trying to keep the alarm out of my face. How could she have endured such misery?
“I called my family doctor but he had retired — suddenly, it seemed to me. No one was found to replace him. Every doctor's office I called was full; no one was taking new patients.”
I nodded; hers was not an unfamiliar story. “I'm sorry that happened. You're having so much pain, though — why didn't you come here sooner? Maybe we could have helped.”
“Perhaps. But I trusted my own doctor and, really, I'm not the kind of person who runs to the hospital with every ache or pain.”
So it is with certain hardy souls, I thought, who are self-reliant and independent. Too, people of her generation often possess a deep confidence in their own physicians. But hardiness and loyalty alone could not explain her reluctance to come to hospital. There must have been an element of denial, surely. Though I didn't ask, I also wondered if all the media coverage of ER crowding had discouraged her from seeking help.
As it turned out, a plain x-ray demonstrated patchy irregularities in the left side of the pelvis, indicative of metastatic cancer. And while cancer of the breast was a possibility, the physical examination did not support this diagnosis. The chest x-ray revealed the lung as the likely source of the primary malignancy.
“Mrs. Johnston, the x-rays don't look so good,” I said, looking into her eyes, hoping to find trust reflected back.
“Oh?” she said, turning away from my gaze, pain visible on her brow.
“I'm afraid not. There is something in the bones around your hip that shouldn't be there, which is causing all this discomfort.” I waited, watching her face, and wondered if the thought of cancer had occurred to her, if perhaps the fear of it had prevented her from seeking help sooner. She seemed to understand that I had avoided labeling her condition, yet she did not ask me to elaborate. I realized that she wasn't ready for me to confirm her apprehension; I held my tongue.
“I'm going to admit you to hospital. Looks like we haven't controlled that pain yet, so we'll give you some more medication in the intravenous. You'll receive a regular dose of strong painkillers to keep you comfortable. I'll speak to our doctor-of-the-day. She's very nice and a good family doctor. You'll like her.”
“Oh, I hope so.”
As the day proceeded, Mrs. Johnston rested on her stretcher. I checked on her later to find that she was numb with morphine. Eventually, this elderly woman with death on the tip of her tongue, her life in flashes before her eyes, was pushed to the back of my consciousness. The team, the nurses and I, carried on with the work at hand. She was still in the department long after I left for the day.
A few weeks later, I ran into the physician who had been assigned to her care. “How is Mrs. Johnston?”
“Well, she seemed to go along okay, initially. I excised one of those subcutaneous nodules, which confirmed a primary lung carcinoma, a large-cell.”
She had been switched to oral morphine and anti-inflammatories. Arrangements for a consultation at the cancer clinic were made to see if palliative radiation was an option. She never made it. One morning, practically the day after the diagnosis was confirmed, she woke up and announced she was no longer interested in eating. She died within a few days.
But she was comfortable, apparently, right to the end.