This is my third posting from my second medical memoir, Healing by Intent, to be published soon by HARP (www.harppublishing.ca). I especially like this story for the wonderful interweaving that Anne, our trainee pediatric oncologist, showed between her medical expertise and her deep humanity towards her patient, Shelley (name changed). And two months ago, perhaps 20 years since this event took place, Anne got in touch with me to connect up once more and to thank me for being such a good mentor! Not a few tears were shed.
She asked your pardon, Doctor Anne, her voice centred between
laughter and whimper: “Sorry I kept you up all night.”
If you look after people who come to you in life-and-death situations, you inevitably build some very close relationships. Not friendships exactly, more like bonds of intimacy that spring out of shared endeavour, when there is no room for distance or pretense. These relationships are as rewarding as they are essential, for the caregiver as much as for the receiver of this care. It’s not often encouraged by medical schoolteachers, though, for us physicians to deliberately set aside professional time to talk with our patients, or even among ourselves, about the things that touch us most deeply.
Connections like these can take a long time to build, and they are certainly not the norm. I suppose it’s because of shyness on the part of our patients, along with all those lessons we doctors have learned so well about keeping our professional distance. There is this deep-seated idea that getting in too close will hamper our clinical judgment. But after all, this isn’t friendship or affection we are trying to build. It’s that elusive but critical thing, the doctor-patient relationship—a mix of altruism and critical objectivity. Sir William Osler called it equanimity, which you could translate as a state of “balanced mind.” Once in a while, though, the barriers drop away quickly, and patient and doctor meet soul-to-soul. That was how it was with a doctor called Anne and a patient named Shelley.
After her pediatric residency in Virginia, Anne enrolled in our three-year fellowship to master the specialty of pediatric hematology and oncology. She quickly showed herself to be super-smart, intuitive, gorgeous and, to some of us, intimidating. I was the attending on call with her one four-day Thanksgiving weekend in our bone marrow transplant unit. Two weeks earlier, Shelley, a fifteen-year-old patient of ours, had received a marrow transplant to try to cure her leukemia. As a result of her ultra-high doses of chemotherapy, her defences were at rock bottom. She had developed a deep muscle infection high in her thigh a few days earlier; there had been a catheter placed in the femoral vein leading up into her groin, and the bacteria had found a home to nest in. Although we had a bunch of antibiotics that our laboratory tests told us would be effective, these microbes clearly had not read the lab reports, so they didn’t know they were supposed to crawl off and die.
Despite our pouring in massive doses of intravenous antibiotics, an ulcer had developed in her old catheter site, which then tracked up into her abdomen, and onward into her anal and labial folds. Lacking white blood cells with which to defend herself, Shelley could not make healthy pus—the sure sign of an effective local response to infection. The skin over the whole area turned blotchy purple, and within forty-eight hours her thigh and groin had swelled to twice their normal size. There was not a splash of healthy yellow—clear evidence that this potent cocktail of modern antibiotics were failing to hold the infection in check.
I knew there was already a strong bond developing between my young colleague and this woman on the threshold of her adult life. As we discussed our options on rounds with the nurses, Anne’s emotions were on the edge. After rounds were over, I pulled her aside.
“Do you think you can keep your cool enough to make objective decisions, Anne? Shelley’s like your kid sister, and I have a strong hunch she’s not going to make it. It can get real hard when you’re that close to someone.”
Objective means basing everything on facts, free of any bias or personal feelings. It is an odd and not ideal word to use in these situations, but we doctors put great stock in it, as though any caregiver can or should be able to put their personal feelings completely on hold while they are serving the mortally sick. Anne quickly set me straight.
“I’ll be fine just as long as I can have a good bawl when I need to. Helps me keep my head on straight.” She promptly burst into tears, and after a minute or two of this started laughing. “I’ve always been a cry-baby. Don’t mind me!”
Becky, longtime nurse and friend to both of us, had been listening in. She pushed a box of Kleenex towards Anne. I pulled my two-foot by two-foot square Union Jack handkerchief—a prop I try to remember to carry with me for just such occasions as this— from my pants pocket and handed it in several folds to Anne. This got the three of us laughing some more, though it was impossible to know exactly what we were guffawing about. How dare we laugh with our poor young patient suffering such distress, and with all these feelings of helplessness welling up inside us?
It reminded me of being suddenly overcome with a fit of the giggles at my favourite aunt’s funeral service. Someone very kind had said to me afterwards that I didn’t have to be ashamed; it happened a lot at times like that. Tears and laughter are close neighbours. It’s just that one is sometimes more correct than the other.
“Ah, that’s better,” Anne said, drying her eyes. “Now then, where had we got to?”
Shelley died at ten past seven the following morning; Anne had spent the night at her bedside. At one o’clock I had phoned in and offered to relieve her, but she had refused.
“I’ve got a handle on things.” She was very matter of fact. “I’m titrating up her morphine dose, watching I don’t put her out cold. She wants to stay awake if she can.”
She went on to update me on every tiny medical detail—the inexorable progress of the infection, the state of her patient’s kidneys and liver and lungs and brain—in as objective a way as any hard-nosed medical scientist. Then:
“We’ve been talking about her horses. And Christie’s here now” (referring to Shelley’s twelve-year-old sister); “I’m getting to know her, too.”
I had a brief image of the four of them—Anne, Christie, and the girls’ parents—gathering in homage around the dying young woman’s bed. I came in when I got the call at seven. By the time I arrived on the unit, the family was sharing their private vigil over Shelley’s body. Anne was in the conference room with the two volumes of Shelley’s chart. She was writing a full medical report of the events of the last twelve hours.
“I got a bit behind. Things were pretty crazy in there.”
She proceeded to summarize the medical events preceding her patient’s death, detailing in precise fashion the sequence of happenings since we had last made ward rounds the prior evening. She told me one-by-one how she had handled them. Nothing was missing; she had done exactly what was needed, with both decision and compassion: a shining example of Osler’s equanimity. Whatever the state of her feelings after this emotionally demanding night, she remained every inch the consummate doctor.
“So how are you doing?” I asked her at last.
At once the tears welled up. “Christ, where are those Kleenex when you need them?” Then: “We talked all night. Kind of like a slumber party. She wasn’t making too much sense towards the end—but she wasn’t hurting any. Did you know she bred those horses herself? She and Christie. Told me all about it.”
Anne kept in close touch with sister Christie and her mother, who worked in the bank she used. A month later, she went out to visit the horses on the family’s five acres north of town. She admitted to Christie that she was really scared of horses.
Which made me think: “Not much frightens you, kid. Not dying humans anyway, that’s for sure.”