Bones like porcelain, soul like a sage

I met Ms. T on a busy day, the last patient on my rounds in the late afternoon. My feet were dragging, my spirits lagging, stomach hungry and patience short. I resigned myself to the infection control alert at the door. Earlier that day, a patient in the four-person room had tested positive for SARS-CoV-2 infection, and now Ms. T and her two remaining roommates were prisoners to infection control. I donned the stifling N95 mask, face shield and gown, immediately hot and irritable.

On meeting Ms. T, I could see that, at 86 years old, she was sharp of mind but frail of body, weighing only 80 pounds, less than 1 pound for every year of her life.

“How is your pain today, Ms. T?” I asked, hoping that it was better so I could finish up and head home, to cook dinner and do homework with my two young children.

“Terrible!” she said. “That gabapentin makes my mouth so dry and my head too fuzzy. I told the nurse to take it away.”

Frustration welled in me, as it sometimes does when patients don’t conform to my expectations and I am feeling depleted by a long day. “Why can’t she just get better?” I thought. She had been admitted almost 2 weeks ago and, although she could walk gingerly to the bathroom, her left-sided sciatica and hip arthritis were bad and she couldn’t go home.

Dr. Jocelyn Chase, a geriatrician, with her patient, Ling, whose hip fracture went undiagnosed for a week.

Image courtesy of Jocelyn Chase

“Fine — let’s try an epidural,” I replied briskly. I explained the procedure, hyping its success in other patients, convincing Ms. T and myself that it would be a great option for her, given her preference to avoid oral medication. Eventually she agreed with me, putting her trust in a doctor she had never met before.

The epidural did not go well. “The patient experienced sudden pain in the left hip and knee, and the procedure was stopped just as the local anesthetic was being injected,” stated the report. What did this mean? I had to find out what had happened. On the ward, the nurse told me that Ms. T could no longer fully bear weight on her left leg, and had taken to transferring to and from bed by sitting on her walker, pedalling herself around the room with her feet. She could still get to the bathroom on her own, but it was a step back.

“They were rough, flipping me over, and I felt a sudden pop in the back of my leg,” she declared.

“Surely not,” I thought. Surely not that rough.

Her range of motion at the left hip was surprisingly full and I was somewhat reassured that the pain was an exacerbation of her known severe left hip arthritis and sciatica. I would have felt better sending her right back down to radiology for imaging “just in case,” but at that point Ms. T was fed up with doctors telling her what to do. We both agreed to call it a “tendon pull” or some other soft-tissue injury. Thus began my journey into suffering with Ms. T, who at some point over that week became “Ling,” my teacher and my friend.

Ling, a retired nurse, had travelled the world, gaining a lifelong appreciation for traditional Chinese medicine (TCM) practitioners and chiropractors, who had been able to successfully treat her chronic back pain. She now believed that this approach would be best but, compounding her hospital-related frustrations, a TCM practitioner was inaccessible as Ling was a prisoner to COVID-19 quarantine surveillance. Her goddaughter delivered TCM patches, which I was now charged with applying.

With no knowledge or experience with TCM, I felt myself inching out onto a shaky limb. But it was clear to everyone that I had not done Ling much good; if anything, I had made her condition worse through my reflexive diagnostic and therapeutic pursuits. I wholeheartedly grasped the opportunity to apply the patches, in the hope of restoring rapport, and because we were both interested to see if they could work.

Meanwhile, her room was getting emptier by the day, as her roommates were taken away one by one to the COVID-19 ward. Finally, it was just Ling in the four-bed room, with drapes half drawn and forlorn stretchers abandoned haphazardly. Ling submitted herself to daily surveillance swabs, letting only a bit of her anger show, just to remind us all that we had put her in this situation in the first place.

“God has sent me here to suffer,” she told me on the third day as I hunched over her bed, trying to negotiate the sticky TCM patch off my gloves and onto her buttock. Although part of me wondered what my colleagues would think of this, I increasingly found the visits to be an emotional balm. For Ling, my engagement with the patches was a respectful gesture toward her point of view. For me, the patches provided a welcome way to connect to my patient through therapeutic touch, which I realized was largely absent from my daily practice. The time we spent getting the patch on “just right” was time that we both felt a bit less alone.

“I was put in this hospital to listen, and to learn,” she said. And I started to listen to her. I mean, really listen. Not just humour her, or reply right away with the kind of encrusted platitude that all doctors learn to deliver after years of practice, to shield ourselves from the pain of others, out of our own aversion to suffering or, worse, our apathy.

Earlier that year, I had begun my own journey into suffering, finally facing the impacts that years of overstudy, overwork, overparenting, and now COVID-19 were wreaking on my psyche. Perfectionism and hyperfocus on outcomes, rather than moments of human connection, had become my daily habit; I was choking on my anxiety and self-loathing. I had begun a daily meditation practice about suffering and was seeking this truth from others, to show me the way to self-acceptance.

Over a few days, Ling’s openness led to some sort of truce between us, then admiration and friendship. She became my teacher, my sage. Donning personal protective equipment to see her every day became a ritual in preparation for our discussions about life and spirituality. I got better at applying the patches. Camphor, eucalyptus, menthol and salicylate. I imagined I could smell the pungent herbal odour behind the confines of my N95. Some days she told me she felt a little less pain, and was diligently doing the bed exercises given to her by the physio. We both agreed the patches would start working soon.

But after a week, Ling was not better. She still could not fully bear weight on her left leg. The niggling feeling in my stomach that had started after her injury grew into an ache. And it was my last day on service with her, a time to tie up loose ends.

“Ling, I’m sorry but we need to do an x-ray,” I said, thinking she would refuse, given her painful experience when she was last in radiology.

“I know,” she replied, surprising me. “Something is not right.”

Later that afternoon, the radiologist called me. They only call you when it’s something really bad. “An intertrochanteric fracture of the left hip, with rapid degradation of the hip joint.” Ling’s imaging on admission had been negative for fracture, and she had had no falls or other trauma during her hospital stay, apart from the altercation during the epidural. My skin prickled with shame and disbelief. I had been applying patches to a broken hip for an entire week, while she stoically continued to put up with all of us.

“I am so sorry, Ling — I am so ashamed,” I cried as I knelt by her chair. Waves of disbelief, anger and sadness hit us both. We took in the fact that she had walked into hospital seeking help for her pain, only to have been exposed to SARS-CoV-2 and have her hip broken during a procedure. Although it was an adverse event with an unexpected presentation, my own part in the delayed diagnosis crushed me. I wish I had ordered that radiograph earlier. Although I believed I had been listening to Ling with an open heart, my actions and inactions had contributed further to her suffering.

“God is still teaching me.” She sighed, with tears making their way down the lines on her cheeks. “I must not have learned enough patience yet. But I will be home by Thanksgiving, and we will go out for dim sum. You will bring your kids.”

When I called Ling’s goddaughter to disclose the injury and apologize for the delayed diagnosis, I feared a well-deserved put-down. But she surprised me with her gentleness. “You were following Ling’s preference toward alternative treatments, and you listened to what was important to her. We are grateful that you kept trying to find an answer. We can only move forward now.”

At the time, I thought Ling’s talk about Thanksgiving dinner was a brave face. But two weeks later, she was released home with a new metal hip, having escaped COVID-19, just in time for Thanksgiving with family. After her discharge from my care, I did bring my family for dim sum with Ling, blurring the lines between patient and friend.

She was unbowed by her ordeal and her smile was contagious. “I am standing tall,” she said with her head lifted high, ordering too much food and indulging my kids with egg tarts.

Ling and I agreed I should share her story with the medical community. I could have submitted “Ms. T’s” hip fracture as a case report about trauma post epidural, admonishing all doctors to be aware of the atypical presentations of common problems. Certainly, outcomes are important, and I have shared her case for quality and safety reviews with colleagues. I now know to watch for hip fractures in settings of low-impact injury, with range of motion and weight-bearing partially intact. But that alone would be incomplete. Ling and I wanted the world to know that the true richness of our experience was in our relationship, where Ling made her COVID-19 isolation room a safe space to embrace vulnerability and welcome suffering.

Ling showed me that I could fully experience my feelings of inadequacy, feel the pain of missing the mark on her diagnosis, yet still emerge as a worthy human being. I was not simply there as a doctor achieving outcomes, but as a companion through the inevitable challenges and uncertainties of life. The kindness I received from Ling and her god-daughter, despite Ling’s difficult hospital stay, was a priceless gift that was its own kind of healing.

I still think about Ling, especially when I see the used-up box of TCM patches that sits on my desk. Her persistence. Her patience and compassion for me, a doctor she had only just met. How we all need to be a little gentler with each other, and listen a little better.