Fixed and Dilated.

Two weeks into internal medicine, my resident asks me to listen to the heart and lungs of a man in room 605. He has metastatic prostate cancer and we are giving him fluids to clear out his kidneys—which is mildly dangerous because the spreading cancer has been compressing his right ureter.

The first thing I notice about the man is that he looks like a fish… or maybe a frog. The second thing I notice after I introduce myself and listen to his well-demarcated and steady heart beat and all of his lung fields, is that he reminds me of my father when he says, “God’s thrown a lot of nonsense my way but I keep fighting it--I'm like Superman.” My dad used to call himself Superman when I was younger, when all of the world seemed terrifying—when my young hydrophobic cousin was afraid of drowning in my pool and my dad told him he could walk on water if he failed to stay afloat.

I affirm that he is not fluid overloaded and go to a computer to look up his history. It's unsettling. There's cancer in his liver and in his lungs. That night, when I present him to our attending, the doctor asks us: “How long do you think this guy is going to live for?” The intern says 2 months, the resident says 6 months, I say a year—more out of hope than knowledge. “I bet you this guy is going to live for 5 more years,” he says with his Eastern African accent, smiling. Apparently, prostate cancer can be slow to spread, even when it's already spread so far. We discuss other patients. I feel better. Five years seems like a good amount of time. If my mom or my dad found out that they were dying, hell if I found out I was dying, but that I still had five years left… I wouldn't be able to do everything I'd ever wanted to do, but I could tie up lose ends with my loved ones, get some closure, prepare a little bit, I guess….

The next morning I pre-round on the patient and their is blood in his foley bag, and he's having excruciating, right sided back pain every 15 minutes. I furiously whisper to myself, "I know what he has!" as I rush to the resident's room to annoy my intern with my first ever in-hospital complication diagnosis: kidney stone. I keep badgering him to write an order for painkillers and to give him more fluids. I feel happy with myself. I'm affecting patient care. I matter. 

In the afternoon I stop by room 605 to ask him how he feels. But there's already a student in their from the oncology team. They are in a bit of a tussle--not out of anger, per se, but because the patient doesn't know when he can go home with his wife, and the oncologist hasn't yet rounded on him to tell him what more tests he'll need. The student is just collecting information for his higher ups, and as commonly happens, we aren't able to hand any information back to the patient. I clarify a few points of confusion between the patient and the other student, then I sit down at the bedside and ask him if he has any more questions. "Yea, I got a few…"

I try to answer all of them the best I can. I am surprised when he doesn't seem to understand how the various imaging tests we have ordered for him will help change our management--shouldn't like, a doctor be telling him this? So I slowly talk through all of the order sets that are sitting in meditech that I've written down in my own notes--the medications and the imaging requests. He seems slightly less upset now that he knows that even though it will probably take all day today and most of the day tomorrow to get everything over with, the tests will be important. I think he's happier that someone just took some time to, at the very least, explain what was going on. 

It's the weekend, and when I return on Monday the patient has been discharged, with instructions to follow up with urology in two weeks.

Then, exactly 29 days later, the patient is back. He had a surgery to place a stent in his ureter, but it failed, and he was now recovering poorly on the surgery floor. He was having some trouble that I guess surgery felt more comfortable with medicine handling, so he was readmitted to our service. When the resident asks me if I remember this patient, I am mildly insulted. "Of course I remember [name redacted, thanks HIPPA]! He's one of my favorite patients!" The resident updates me on the patient's condition and it doesn't sound good.  He's in moderate respiratory distress. We go in to talk to him and he looks like he's drowning--he's not able to talk back to us. His eyes dart around behind his glasses, panicking, when we walk into the room, then he goes back to staring at the muted television screen indefinitely. 

I was going to introduce myself, ask him how he's doing, but I realize that I'm not able to say anything. I'm so scared by what's going on, I'm unable to even hold eye contact. The resident and the nurses are making quick bedside assessments and all I'm able to do is count how many breathes he takes in a full minute: it's thirty-four. I can't leave the room soon enough. At one time I felt almost essential to this patient's well being, but now I feel absolutely useless. The patient's family is going to be asked about in-house hospice. 

A few days pass by. The residents keep mentioning the patient. And he's declining more and more.

Then one day we get paged to room 607 because the patient is unconscious and very close to death. Our team sits outside the room, at a computer terminal. The door is open, but I don't have the courage to walk inside. I've only seen his wife and his family once. Death has always seemed like a very private thing to me. I don't want to interrupt anything. I know he's dead not when I hear a monitor flatline, but when his freshly widowed wife begins crying and I no longer feel the need to pay attention to what the resident is telling the intern one has to do to certify a patient has died. Because this woman has just lost the love of her life, her partner for over fifty years, and the fact that his pupils are fixed and dilated doesn't really seem like a significant detail. Someone asks me a question. I respond by turning around and pointing to room 605. "Less than two months he was in there. He was fine. His doctor said he'd live five more years."

And in my head I'm thinking to myself how my grandfather died before I was ever born, most likely from prostate cancer, although since preventive care is almost nonexistent in Nigeria, nobody actually knows how he died. But that was my dad's hypothesis and I wonder if that's how my grandfather--a man who my dad truly admires to this day--died. And what a terrible way to die.