When he came into my ER complaining of chest pressure today I was in the middle of sewing a non-bony amputated piece of a man's finger back on for underlying granulation assistance. I called out orders to the nurses for the chest pain workup and glanced at the tachycardia on his EKG. No STEMI but that BP of 204/120 was concerning. Before I could get to his room a call from the lab alerted me to a sodium of 123. Adding the nurse's story of his coughing and chest pressure, my differential started with lung cancer. That isn't typical for me to do, but I kept it on top upon entering his room. I found a frail, worked-hard-all-his-life-and-it-showed patient laying on the bed in front of me. He had been having a hard time finding a PCP to take his insurance and finally his new one started him on BP meds this past week. Admittedly he hadn't started them because he was worried about the possible side effects of angioedema. "I've worked myself down from smoking 3 packs a day to only 1/2 pack." A nitro patch lowered his pressure but the CXR confirmed my fear. The radiologist wanted another look with a CT and then I had to tell a complete stranger that he has cancer. He didn't want me to call anybody. He didn't want anybody to know. I said, "ask me any question." "You don't have time for my questions," he quipped. "I have all day for you," I replied and waited in silence.
- No, I don't know how long you have to live.
- Yes, I think that it is in other places (thank you CT).
- Yes, it's possible that "thing" they found on your liver about 8 or 9 mo ago is related.
- Yes, you can go home today instead of the hospital.
- No, I can't say this is a death sentence.
He removed his oxygen, pulled at his cords, and followed with, "Just let me go home and die."
I went to the doctor's room and cried. I'm FM and pick up occasional ER shifts. I've diagnosed my own patients with cancer before but, strangers seem to be harder for me. Perhaps it's because I can't follow up with them; maybe I feel helpless that I can't walk them through their prognosis like I can my own patients. Mostly, I feel just as alone as they do in moments like this. The walls close in, the air feels thicker. There are no answers. But, I have all day for you...
Sometimes this job sucks.