It was a beautiful spring day and I was on call

By Arne Vainio, M.D.
News From Indian Country
 
It was a beautiful spring day and I was on call. I was able to spend some time on this Saturday morning with Ivy and Jacob and we walked along the sidewalks as the melting snow ran in rivers down the streets. The sun was bright and the sky was a blue that promised nothing but warm days to come.
There was nothing pressing and I was planning on rounding later and spending this time with Ivy and Jacob. We were laughing constantly at each other’s jokes as we walked.

My pager went off and it was one of the hospitals. I called the nurse and she told me “Darlene is hoping she can go home.” I wasn’t expecting that. I didn’t know Darlene, but one of my partners had signed her out to me to see over the weekend.

I’d been told Darlene was 68 and had not been feeling well for a few weeks. Her stomach hurt after she ate and eventually the only thing she could eat was peaches. On exam her skin was yellow and there was a hard lump in the area of her stomach. Her doctor put her in the hospital to get a diagnosis.

A CT scan showed a mass in her right lung. Her liver was enlarged and was full of nodules. She had been smoking since she was a teenager and this was presumed to be lung cancer which spread to her liver, but treating it required a definitive diagnosis. Her liver tests were markedly elevated and these confirmed she was in liver failure.

The Gastroenterologist did a scope of her esophagus and stomach and was able to do biopsies of her liver during that procedure. The Oncologist (cancer specialist) was supposed to see her once the Pathologist looked at the biopsies and determined what kind of cancer this was.

I knew the biopsy reports were supposed to be ready sometime today and that the Oncologist was going to see her after reviewing them to talk with her and her family about treatment options.

That’s the information I had and I wasn’t expecting her to go home.

When I got to the hospital, the note from the Oncologist was dictated, but not transcribed yet so I didn’t have any real information about the biopsies. I had the Oncologist paged and he told me the Pathologist was 90% sure this was a small cell lung cancer, but needed another day or so to finish some confirmatory tests. “I can’t treat her on a 90% certainty, the treatments are too different.” With her liver failure, he wasn’t comfortable sending her home and thought having her in the hospital for a couple more days while the biopsies came in seemed reasonable.

 
Armed with this information, I went in to talk to her. The lights were off and she was alone and lying on her side in the hospital bed. She was awake and sat up when I turned the lights on. She looked fatigued and her skin was bright yellow, but she had a quick smile that only a grandmother can have. I could see laughter and love in every one of her wrinkles. I introduced myself and asked her to tell me what the Oncologist had told her. “He said I have a tumor in my lung and it spread to my liver and they won’t know for sure if they can treat it until the biopsies are finished. I really don’t want to wait here for the next two days while that happens. Can I go home?”

“I think so. Let’s see what we need to do to make that happen.” She was on a pump that gave her a constant infusion of pain medicine. She couldn’t go home on that and I called the hospital pharmacist to figure out what dosage of pain medicines she would need.

She was on two blood pressure medicines and one of them was processed in her liver. I simply stopped that one and left her on the other one. Her diabetes medicine was a pill that had some precautions with liver disease and the only choice was to put her on a low dose of insulin. She would need teaching for that.
 
While I was working with the pharmacist and making sure everything was set up for discharge, her husband showed up. He wasn’t there for the conversation with the Oncologist earlier. His hair was white, he was 75 or so and was sitting in a chair next to the bed when I came in. I introduced myself and I could tell he was uncomfortable just being in the hospital and talking to a doctor. I asked him what he knew. “I guess she has a tumor.”

“It’s more than just a tumor. Darlene has a lung cancer that has spread to her liver and has caused her liver to fail.”

He looked at her. “We’ll just have to make sure she eats well so she’s strong for the surgery.”

I pulled a chair next to his and softly explained to him, “this cancer has already spread and surgery won’t help it. It could be in other places besides her liver and we just can’t pick it up yet.”

“What about radiation?”

“Radiation would likely destroy the little bit of liver function she has left.”

“Chemotherapy?”

“Maybe. When I talked with the Oncologist earlier he told me the chemotherapy used for this type of cancer will be very hard on her liver. It usually isn’t used when the bilirubin level is higher than four and hers is six. If they can use any chemotherapy, it will need to be in very low doses.”

“What options do we have?”

“This might not be treatable. Hospice is a good option. They could make sure Darlene doesn’t have any pain or nausea and they would be working with the Oncologists. We’ll stay involved to make sure we do everything we can for both of you.”

“How long does she have?”

“I don’t know. I’ve never been good about giving that kind of information because everyone is a little different. Some people fight harder than others.”
“How long? Months?”

“I don’t think so.”

“Weeks?”

“Maybe.”

He looked away from me and tears welled up in his eyes as he looked at Darlene. She was quiet as she and I had already had this conversation. He looked at me again.

“Will she be OK at home?”

“It’s a nice day. She needs to be home and she needs to have her family and friends with her.”

He stood up and shook my hand. His voice was a whisper, “Thank you, doctor.”
 
I reached for Darlene’s hand and she held my hand in both of hers. In that gentle handshake I felt love and hope, gratitude and sadness, courage and resignation.

My pager broke the moment and I stood up to finish the orders for her to go home.

When I left the hospital the sun was bright and the sky was a blue that promised nothing but warm days to come.
It was a beautiful spring day and I was on call.
 
Arne Vainio, M.D. is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota. He can be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it.

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