“In all seriousness,” the attending physician says, “he can wear women’s underwear to minimize the pain.”
“Can he really?”
“Absolutely,” replies the attending. “If we can’t prescribe any pain medication, then tighter fitting clothing can help keep things from jostling about too much.”
As we discuss alternative treatment options just outside his hospital room, I can hear our patient rolling around in his sterile white sheets, floundering to relieve the positional pain in his scrotum.
He was diagnosed with stage IV hepatocellular carcinoma just days ago, his stage and prognosis made it seem like he had been battling the disease for years. I remember thinking someone with cancer this advanced must have noticed that something was wrong and would have sought medical attention months ago. In fact, his tumor was so large that upon initial inspection of his abdomen, what was thought to be impacted stool in his left lower quadrant was actually the cancer extending into his pelvis. The tumor was crushing the right side of his stomach, part of his duodenum, most of his ileum, all of his cecum, half of his transverse colon and completely obstructing his right testicular vein, causing his scrotum to swell to the size of a watermelon and become exquisitely painful. Every shift of his weight was accompanied by an audible high-pitched gasp as if he was struggling to undo a barbed-wire knot.
When you start your internal medicine rotation, your physician mentors express to you how many lives you’ll touch and people you’ll change for the better. No fresh third-year medical student is ever equipped to deal with the amount of personal anguish and pain one witnesses. My father is a physician and teaches medical students and residents. When I asked him what the hardest thing is for his new students to do, he looked at me, bowed his head, looked back up and said, “sitting beside suffering patients.”
My attending starts up again.
“He wants to be discharged,” he tells us, “and he wants to go back to work.”
“What about the pain medications?” asks another med student.
“Unfortunately, because of his insurance and legal status, I can only write for a very limited supply,” he replies. “After that, he’d have to wait till he’s back in his home country.”
“Wait, where is home?” I interject.
“El Salvador,” replies the attending.
He had been working in northern Louisiana at a sugar cane factory for the last seven years. Every few months, he sent money back to his wife and five children in El Salvador. He said that he first noticed that he had been losing weight about eight months ago. He reported that it was about 20 to 30 pounds, which currently put him at around 100 pounds. The first symptom he experienced was a burning sensation that quivered down the lateral right side of his leg. Essentially, his lateral femoral cutaneous nerve was being compressed between his ilium and his inguinal ligament, creating a kind of carpal tunnel syndrome of the thigh. He had not thought much of it at the time and ascribed it to just being overworked. The disease silently progressed and about five months ago one of his coworkers noticed that he had “ixtelolohtli coztic,” meaning “yellow eyes” in his native Nahuatl. Eventually, the abdominal pain started and one of his friends drove him to the hospital when he could not get out of bed. He said that he would lose his job if he did not go back to work. He just kept repeating, “pipiltzitzinti, pipiltzitzinti,” which loosely translated into, “my children, my children.”
It had been two days since we’d been able to reach a Nahuatl interpreter and since then we had been communicating in Spanish, which our patient spoke brokenly. Even so, the language barriers prevented our amorphous doctor patient relationship from solidifying into genuine trust. We had another appointment scheduled for today at 10 p.m., seven hours from now.
“We need to explain to him how serious his situation is,” says the attending. “I’m afraid the communication and cultural boundaries here are keeping him in the dark, which I am very uncomfortable with.”
The attending would be doing the talking but I was afraid that I would feel like I did not belong there. I had heard about medical students who excelled during the first two years of medical school but when they started rotations, they could not stand being around sick people. I was terrified that I would be one of them.
Ten p.m. arrives with harrowing speed. We gather as a team in the patient’s room about 15 minutes before the interpreter call. The attending kneels to the right of our patient, the receiver of the blue interpreter phone in his right hand, his left on the edge of our patient’s bed. Our patient lies supine, his small 5-foot four-inch frame ensconced in the large adjustable hospital mattress. Beads of sweat are forging visible moist trails from under his jet-black hair down his tanned sharply curved forehead and trailing laterally past his eyebrow. He is blinking a lot. As he puts the blue receiver up to his ear, a wave of intense pain hits him. He seizes, taking a deep breath in, his eyes opening wide towards the ceiling. The attending hurriedly captures our patient’s hand in his and just holds it, sitting there silently for 30 seconds while our patient enters a visceral nightmare. When it’s over, his muscles done reflexively contracting, our patient is aware of us again and he nods that he is ready to begin.
During my eight weeks on internal medicine, I witnessed some of the most remarkable instances of human physical findings, but they also came hand in hand with some of the most awful mortal circumstances one can be present for. As medical students, we are not always prepared for the ugly truths, but they are often where we can learn the most about our patients and ourselves. I learned that day how essential it is to be able to share in my patients’ future triumphs as well as their losses. I learned that just being there can mean more than just “being there.”