A patient’s smile
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* Joy Albuquerque

I met Evelyn during my surgical rotation when I was sent to admit “the bowel obstruction.” My first impression was that Evelyn belonged to a profoundly different time, from a generation of women who masked their strength, determination and age with a powdered face, darkened brows and a uniform hairstyle of rollered curls. She lay on the hospital bed motionless. Her skin was fair and dry, her body slender with a slight stoop of the shoulders that revealed much and her hair a faded blonde that offered no excuses. The soft curls flattened on the left side of her head were the only betrayal of her discomfort.

I greeted her in my usual semi-apologetic way, disclosing that I was a fourth-year medical student and that I was to admit her to the surgical service. Evelyn smiled and told me that it would be fine “my dear.” Sitting up in bed, she adjusted herself and her blue gown with poise as if I were a guest invited for tea. And when her eyes met mine, I felt an unexpected force and for a moment our roles seemed to reverse, as if I were there to ask something of her. Perhaps it was the rough cotton of the gown, slightly askew about her slender neck, or maybe the nasogastric tube emerging from her nose that refocused me. The tube, threaded through her left nostril, was attached to a pump beside the bed, relieving much of her pain and distension. More tubing wound away from her arm upward to an intravenous bag filled with dissolved salts, elemental subsistence.

Evelyn had cancer, bad cancer. I was acutely aware of how little clinical experience I had. Despite her situation, Evelyn was ready to accommodate my naive fumblings. Her generosity left me exquisitely sensitive to each difficult question posed and to any pain my novice examination might cause. It took most of an hour to work through the memorized questions and physical exam. Evelyn lay quietly as I shut off the compressor to examine her abdomen, marked with reminders of past surgeries. Listening for bowel sounds, I heard only eerie silence. I reached over to switch on the pump, grateful for its chugging distraction, while outlining the next steps.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/183/13/1520/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/183/13/1520/F1)

Image courtesy of Jessica Healey

As a medical student, it was my duty to review my patients’ status each day. It was different with Evelyn. I was drawn to her room, wanting to spend time with her. She was always pleased to see me and talked about her life and her grandchildren, occasionally reaching for a tiny chip of ice to moisten her mouth, the pump panting faithfully by her side. The stories were filled with warmth and love. Evelyn could knit as easily as she could story-tell and a baby sweater and booties grew and filled the room with optimism. Surely fate would stop at the doorway and agree to a reprieve.

The day before her surgery, the whole team crowded into Evelyn’s room to review the plan. Evelyn was obviously nervous which, to me, increased her vulnerability. My own upbringing placed an emphasis on hidden truths and appearances. Emotional fragility needs to be camouflaged. I focused on the sore spot on her left nostril as if this trivial absorption might hide Evelyn’s defencelessness. The surgeon sat down beside her on the narrow bed creating a shared space. It was a moment of human connection, of trust and of understanding. They spoke together for only a short time, but it was clear that something had happened. Evelyn was visibly readied and I was an indebted witness. Somehow this exchange made bearable my uncertainties about the upcoming surgery.

It was my first time assisting in an operation, though being the second assistant roughly translated as an extra pair of hands for use in any way deemed necessary, regardless of a student’s muscle fatigue or cramps from hours moulded at awkward angles. As my surgical gown was securely fastened, my resolve deepened and I approached the table. Evelyn was already asleep, neatly draped with only her abdomen visible as the resident painted her golden with antiseptic solution.

The surgeon took his place at the table, and with precise movements cut through the skin, superficial fasciae and then deeper. Flesh jumped in protest as the cauterizing probe sealed bleeders and abruptly tore away. Acrid smoke swirled upward burning my nose evoking an involuntary grimace. Quite distinct from the smell of burning flesh that clung to my nose, the peritoneal cavity emitted rich and layered scents as warm fluids caressed its intimate contents. Tissues and organs with contrasting hues glistened with purpose. The surgeon’s practised hands searched Evelyn’s internal organs and he grunted in dismay, “There’s nothing we can do here.” Gently, he elevated her bowels and showed us Evelyn’s cancer. Her intestines were not pink, smooth, like a chain of sausages that could flow about in the belly, but a singular mass stuck fast like matted hair, backcombed with hair spray. I touched Evelyn, and my gloves, warmed by her blood, held her intestines, rigid and unyielding. The limits of medicine were exposed. The surgeon stepped back, thanked everyone for their help and left the resident to close Evelyn’s abdomen. Holding the scissors, I cut as the resident completed a suture, keeping in time with an ancient rhythm, though dimly aware of emotions stirring below the surface; they would wait until later.

The surgeon would give Evelyn feedback, but I didn’t know what I was supposed to do, what to say, how to act. I didn’t want Evelyn to die. I didn’t want to fail her. And I was going off to another service next week. I stepped into the room to tend to my patient and clumsily broke the news of my leaving. I told Evelyn that I would try to come back to visit, that I wanted to. That much was true.

My next rotation was hematologyoncology, a service that was viewed with both respect and fear, perhaps because we were often summoned to cast the final pronouncement about treatment. For this specialty, the human body took the form of a puzzle that doesn’t easily yield its solutions and sometimes remains indecipherable. We invested the time, excavating each and every aspect of a case, looking for missed clues to clinch a diagnosis or to provide unexplored avenues for hope. Typically the resident and students combined efforts before briefing the specialist. The entourage then travelled en masse to the ward.

It was weeks later that Evelyn’s case came before us, catching me completely off guard. I had thought of Evelyn, though I hadn’t returned to see her, resting on the excuse of being busy and the presumption that she would have already been discharged. The surgeon’s request was a final appeal. Evelyn had to be able to take some form of oral nutrition. TPN, total parenteral nutrition, was being pumped directly into Evelyn’s blood, her only source of nourishment and it could not be justified indefinitely without a treatment strategy. We were being consulted for a viable option but one way or the other, TPN had to end.

Reviewing the details of her case, it was clear that the cancer had the upper hand and we had little to offer. In discussion with the team, I had argued for a treatment trial, any trial, but to no avail. After listening to the oncologist’s recommendations, the surgeon asked a few pointed questions and with a final nod he briefly paused as if in deference to fate, then walked into Evelyn’s room carrying us in his wake. Evelyn, ever gracious, thanked us for all our time and effort on her behalf. She trusted that we had considered all possibilities.

I did not follow the others out; I sat with Evelyn. There was no emotional upheaval, no righteous anger and no judgment in the face of medicine’s defeat. No loss of control, no reason for fear. Sitting in the hospital bed, tubes articulating with her body, Evelyn had not changed. That she would die did not diminish her presence, her composure, her being. This was not due to anything sinister and not because of any wrongdoing. It was simply time displaying its hand, the ultimate victor. Evelyn understood this deeply; she was okay with this ending. She told me I was going to be a fine doctor as we said our goodbyes. I got up to leave, gathering up my new experiences, but hesitating at the door as if unsure of how to face what was to come. I looked back to Evelyn and our eyes met, she smiled and with a deep sense of gratitude I smiled in return.