Opinion

A PIECE OF MY MIND Alexandra E. Page, MD San Diego Kaiser Permanente, La Jolla, California.

Corresponding Author: Alexandra E. Page, MD (alexe.page @gmail.com). Section Editor: Roxanne K. Young, Associate Senior Editor.

Stopping Time John knew the pain was wrong. Yet with his stoic Midwestern roots, it took a month of constant chest pain to express concern to me, his wife. He had lived with reflux for decades, but this was different. “Could you order a chest x-ray for me? Maybe I broke a rib.” Only a couple of orthopedic surgeons would put that first on the differential. When I reviewed the chest film, a memory from my medicine rotation surfaced: a dark room in the bowels of Massachusetts General Hospital, meeting every week for the entire rotation with an elderly radiologist who reviewed stacks of chest films with our small group of third-year students. But fear blinds. “There’s something there,” I warned my husband. “You’re so run down you’ve probably got walking pneumonia! Let’s see what your internist says.” His internist didn’t share my blind spot. “Get a CT scan first thing tomorrow morning.” Ordering tests for family members nibbles at the edges of the ethical practice of medicine. The fuzzy line for me was somewhere between ordering a chest film and ordering a CT scan, but it didn’t preclude reviewing the results. Viewing John’s CT was a peek into what would become a Pandora’s box: 20 years since medical school wasn’t enough to forget that multiple white splotches in the black lung fields were bad news. Despair stripped professional decorum. The clerks in the x-ray file room where I retreated to check the CT scan knew me from years past when films were a tangible entity existing in heavy jackets rather than virtual images in the ether. They quietly left the room, too embarrassed to witness my sobbing as I waited for the official read from the on-call radiologist 20 miles away. Surely the radiologist would correct my paranoid diagnosis. This was some kind of weird pneumonia, like the valley fever endemic to parts of California. With teleradiology, there was no human touch to soften the blow when the radiologist shared his interpretation over the phone: most likely esophageal cancer, metastatic to the lungs and liver. As surgeons with undergraduate engineering degrees, John and I dedicated our professional lives to solving problems with bones and joints. Neither of us had temperaments suited to the long-haul challenge of managing hypertension or diabetes. We both appreciated that orthopedics facilitated near-instant gratification. While it may take 6 weeks for a bone to heal, we could congratulate ourselves on a job well done when reviewing a postoperative x-ray 15 minutes after the patient was wheeled into the recovery room. We told ourselves we could cure what ailed our patients. The joke as orthopedic surgeons was that we didn’t save lives, we saved lifestyles. And if you ran into a technical problem in the OR? Get a bigger mallet! But when my husband, my practice partner, my

best friend, my soul mate, was diagnosed with terminal cancer, there was no solution. There was no mallet big enough. Everything stopped. On the day of the CT scan, the day before Memorial Day weekend, life changed. We made the sudden shift from physician to patient. In the poem by T. S. Eliot, J. Alfred Prufrock measured out his life in coffee spoons; we had measured ours in operative cases, patients seen, and charts completed. Keep the tourniquet under 2 hours for the operation. Get OR case turnaround time under 15 minutes. How many patients can you see in an hour? Now there was nothing to define the days or the passage of time. In summer, even the metronomic ritual of school that ruled our home life disappeared. When I discuss recovery after an orthopedic surgery with a patient, the plan is specific and concrete: 2 weeks at home elevating, 6 weeks non–weightbearing with crutches. From 6 to 10 weeks, progress weight-bearing on the limb. Transition out of a cast and start physical therapy at 10 weeks. In contrast, the oncologist was vague. “Likely under a year. But I have a patient with a similar presentation who is still alive 18 months after diagnosis!” This was supposed to encourage? What about curing patients, like orthopedic surgeons do? As the weeks of the terrible summer progressed, we learned the names of medications that didn’t even exist when we were in medical school. Days marked by rushing from examination room to operating room gave way to quiet patience in waiting rooms. Without the rigid landmarks of the 7:30 OR start time or 8:30 clinic start, mornings faded into afternoons. As John grew weaker, he lost interest in our summertime tradition of watching the sunset together from our bedroom window. Losing my own bearings, I finally set four daily alarms on my phone to keep track of his medication dosing. Looking back, the only temporal placeholder was the second CT scan in early July that pretty neatly cleaved down the middle of his 3 months from diagnosis to death. Despite 6 miserable weeks of aggressive chemotherapy, the tumor had spread. With this, the vague hope of “about a year” fell away as did any attempt for me to continue my practice. How could patients bother a physician about aching knees? My husband was dying. In August, events came quickly but surreally. One morning John awoke with a blind spot in one eye. We didn’t know cancer metastasized to the retina. John started sleeping more during the day and less at night, further confusing time as I matched his schedule to savor precious waking hours together. New chest pain turned out to be pulmonary emboli, loss of balance heralded multiple brain metastases: these were trips

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Opinion A Piece of My Mind

to the emergency department at odd hours. As a surgeon I know that a call from the ED could range from mildly irritating to markedly distressing: a few minutes to review an x-ray or an emergency operative case that extended the night into your already scheduled next morning. But we were patient and caregiver; the windowless fluorescence of the ED suspended time. There was no longer a clear next morning. John’s stoicism delayed his final ED trip. Shortness of breath made even getting out of bed impossible, and John admitted a suffocating sensation in his right chest. Again, as the radiology professor tried to teach his medical students, the chest film had the answer. A malignant effusion filled the right hemithorax, pushing the mediastinum into a constricted left lung field. It was as a wife, not a physician, that I held John’s head and shoulders curled over a table for his pleurocenteses, 10 liters in 3 sessions. Based on some primitive belief that I could forestall death with my presence and defiance, I rarely left his side. Curled next to him in the narrow hospital bed, I carefully avoided resting my arm on his right chest while we slept. Despite his having a chest tube in place, I was haunted by the image of five 2-liter soda bottles suffocating him. Fear, despair, and anger flooded me all summer. Yet panic only surfaced with John’s impending death in the hospital. Fortuitously, at admission there were no open beds on 2 West, the medicine/oncology floor that I had always privately joked was the “waiting-to-die ward.” The patients on 2 West needing an orthopedic consultation had sustained a pathologic fracture through a metastatic lesion or needed an amputation for complications of diabetes. We couldn’t cure them in the usual orthopedic tradition. Instead, John was admitted to 5 South, a surgical ward where the nurses and staff were friends to both of us, having cared for our patients over the years. Despite this, death in the hospital seemed a failure of love and family. The surgeon who placed John’s chest tube understood. My transition from professional colleague to patient’s family was complete as I sat outside his office door, tears rolling down my face. Accosting him between patients, I shamelessly begged for John’s dis-

charge with the chest tube in place. On a gurney, with oxygen and the chest tube, John returned home that day. Death is rare on my service. For the elderly patient with a hip fracture, I speak of the injury as a medical condition more than an orthopedic one. Informed consent for the patient and family includes grim statistics on in-hospital and 1-year advanced mortality rates, but I was always buoyed by the knowledge that I could produce a mechanical construct that would allow immediate mobilization and weight-bearing. My medicine colleagues address the sensitive issues of code status and advance directives. I was a physician, yet death had remained abstract in my treatment of musculoskeletal maladies. John drew his last breath the day before the Labor Day weekend, in the vague time between closing my book at 3 AM and awakening to his warm but quiet body at 4:30 AM. My head was on his shoulder and I was holding his hand, the death in my arms he had wanted. A “good death” had become a concrete concept for me. In the days and weeks that followed, I struggled to restart meaningful time. Instead of 4 daily alarms for medications, I reset my usual morning wake-up, but there was no reason to awaken at 5:30 AM. I was unable to face an immediate return to the professional life we shared, so no patients or operating room waited for me. The orthopedic bravura of “curing” achy joints rang hollow after medical impotence in the face of John’s cancer. I struggled to reconcile “saving lifestyles” with real medicine. What does it mean to heal? Am I a real physician? Meredith, the baby of the family, received her driver’s license over the summer, so even morning chauffeur services weren’t needed. But my daughter did ask about the ritual of her lunch. John, the family cook and general caretaker, had daily prepared Meredith’s bag lunch. I had scoffed at his ridiculous coddling of a high school student, but for John it was one of his many gestures of love. I was searching for a meaningful measurement to define the hours and days of life; prior professional metrics seemed pointless. But making lunch for my child was a reason to get out of bed.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.

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A PIECE OF MY MIND. Stopping Time.

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