Learning on the job

How a young physician managed his way through a heart-wrenching palliative care case

She was Dutch. Dutch in what many consider a typical physical presence — her bright blue eyes radiating intelligence and good will. Dutch in her name, one which spilled — its vowels conjuring lowlands and tulips — lovingly from her husband’s mouth. Dutch in the stoic way in which she was facing her death, in a strange bed, in a strange hospital and on this occasion, with a strange doctor. Her own physician was away for the weekend, and I, brand new to general practice, woefully undertrained, was on call for him.

Let’s call her Tina. Proud wife, mother, grandmother, Netherlander. Breast cancer patient.

It was a Friday. Months before her doctor had diagnosed breast cancer, and she had recently completed the oncologist’s long list of chemotherapy and radiation treatments. Unfortunately, to no avail: the invading warriors of cancer proved too strong for the weak soldiers of the seventies; she was succumbing to her disease. Most of her ribs had been invaded by tumour and were fractured; every breath was an agony, too much, even for the stoic. Her suffering had prompted her hospitalization. It clearly alarmed her family. It also prompted anxiety in her young physician: too much morphine would cause her death, wouldn’t it? Not enough would let her languish in some twilight pain-filled hell-on-earth. Walking that tightrope was not something I had been trained for.

Intermittent injections of morphine helped only marginally and then their effect disappeared, drowning Tina in a tsunami of pain. Oral medications were useless; she needed a morphine drip. For a moment, I felt entirely alone with the problem, with her pain, and with the appropriate expectation of Tina and her family. I was alone in a community hospital without any palliative care resources, with a nursing supervisor clearly uncomfortable with what was then an innovative approach. I wasn’t however, alone.

I remembered the name of a Palliative Care physician at McMaster — a nurse turned family doc turned palliative specialist. I called her. She talked me through the morphine drip process, allowing me and the family to gauge the impact of lower dosages and its effect on her pain, then increasing it until she was comfortable. I remember that physician, also gone, as well as I recall Tina: we were a team — the disembodied voice of the specialist (kindly, patient) on the phone, the patient, the family and the young family doc, still learning, outwardly confident, inwardly frightened.

She had 48 hours: the first 24 allowing her to breathe without pain, to talk with her family, to say goodbye; the second 24 filled by the overtaking cancer, aided by pneumonia, death’s friend, stealing her away, all, thankfully painlessly.

Tina died late Sunday, but she wasn’t done.

A small plaque sat at her bedside for the entire weekend. It was called ‘Footprints’; maybe you’ve seen it. The picture on the plaque is a beach with a long line of two sets of foot prints side by side, broken by a few spots with only one set of prints. Monday morning early, I found the family in my waiting room. I was surprised. They had every right to be at home, resting up from their round-the-clock bedside vigil, exhausted, but indefatigable. They were Dutch after all.

They said that Tina wanted me to have the plaque as a token of my care over the weekend. This was her gift. After they left I looked at the plaque and its words. I still have it. I’ll paraphrase it. “Lord,” it says, “As I look back on my life, I see we’ve walked together for years but there were hard times when I felt alone. I notice only one set of footprints then. Where did you go during those times? I felt abandoned.” The Lord replies, “My child, those were time when you were too weak. I carried you then.”

I remembered. I had confided to Tina that I had never set up a morphine drip before, but in my cheery bravado, said something like, “We’ll learn to do this together.” She sensed, beyond my cheeriness, beyond my early-practice bluster, that I too was feeling alone. I wasn’t: at the very least, the Palliative Care specialist was only a call away and, even more importantly, I had my patient to guide me. (Today of course, there’s the team, new programs and high regard for the field). This was Tina’s last message to me — mother, wife, grandmother, breast cancer patient — and now, teacher.

In some ways, Tina’s with me still; her message certainly is.

Dave Davis, MD, lives in Dundas, Ontario and Fort Myers Beach, Florida. He’s a husband, father, and grandfather and a retired physician, writer and speaker. If you have nothing better to do, write him at drdavedavis@gmail.com. He likes it when you write.