Ashley Mortenson.com

Mr. Smith

Mr. Smith is a patient that I took care of during my third year. This is his story.

Mr. Smith was a tall, grandfatherly seventy-two year old with a genteel Southern drawl. He was a former Navy man who worked in the shipyards for twenty-five years, building submarines. He also loved gardening, his fluffy Pomeranian dog named Bobo, and telling tall tales. During his hospitalization, I discovered that he possessed a stoicism and quiet courage that I have rarely seen.

He came in with a five-week history of progressively worsening shortness of breath and dyspnea on exertion. He could no longer bend over to tie his shoes nor walk Bobo to the mailbox. On radiography, he was found to have a massive pleural effusion; so he was admitted and had a chest tube put in.

We drained over two liters of bloody fluid from his chest.

Over the next two weeks, we diagnosed him with mesothelioma, a deadly and fast acting lung cancer associated with asbestos exposure, seen primarily in shipyard workers. I was there when the oncologists told him his diagnosis and he accepted it quietly. “I’ve been expecting this,” he said. “All of my friends have died from this cancer.”

We did not accept the diagnosis as readily as Mr. Smith did. We did further tests on the effusion to see if we could prolong his life with chemotherapy. I ran the fluid down to the lab and called them daily to see if they had the results. They found that the cancer was a rare, especially virulent subtype that would respond poorly to any of our interventions. We could maybe give him an extra six to eight months with extensive therapy. The oncologists spent a great deal of time trying to convince him that therapy would be beneficial, but he refused. “Ain’t gonna change the outcome,” he said. “I’d rather be at home in my garden with Bobo.”

Our only option was to wait until the chest tube was draining a small amount of fluid each day. Each morning, I would round on him, and he would say, “Hello, dahlin’. I’m doin’ just fine. How are you today?” He never complained. Gamely, he would pick up his Pleurivac and move it around so that we could examine him easily. When he was hurting, he’d merely say, “I do believe that I’d like one of them pain pills.”

To me, Mr. Smith became more than a patient composed of lab values and diagnoses, or an interesting problem that we talked about on rounds. I started checking in on him before I went home at night, to let him know that he wasn’t alone or forgotten. I thought that I was cheering him up, although now I realize that he was keeping my spirits up.

He missed his dog, and knowing that I couldn’t do much else for him, I arranged for “pet therapy,” where I had his daughter bring in his beloved Bobo. There was some concern about him leaving the floor and about the dog coming into the hospital, but I said that if anyone asked, I’d tell them this was “medically necessary,” and that I, as his “doctor,” was supervising him.

Accompanied by two other medical students, we wheeled him down to the atrium and met his daughter, who had smuggled the tiny dog under a wool coat. Mr. Smith’s face lit up with an indescribable joy as Bobo jumped into his lap. We sat for a while in the weak January sun, making small talk while his daughter took pictures.

We set up home hospice and Mr. Smith prepared to go home. The whole team, including the attending, cried when he left because we knew that this was the last time that we’d see him alive. Going against general rules, I gave him my phone number. He knew that I was on my surgery rotation, so he would call me early in the morning and tell me that he loved me. I could never think of anything to say other than “be well today, Mr. Smith.”

His daughter called me around ten at night, a week or two after I last heard from him and told me that he’d died. She’d found my phone number on his cell phone; and since she knew that he and I had become close, she thought she’d let me know that he had passed away. I was asleep, exhausted from the long day in surgery and barely registered what she was saying. Groggily, I mumbled some awkward condolences. It was too enormous to process. She wanted my address and an envelope arrived soon after with a picture of me and Mr. Smith. I am smiling bravely into the camera, but Mr. Smith is distracted, looking away. Perhaps it was an accident, and he didn’t have time to face the camera. But it seems that he is looking deep within himself, contemplating the short future and wondering what is to come. It is the only hint of sadness that I ever saw.

Originally, I picked him up as a patient because he was about to have a chest tube put in, and I wanted to be part of the procedure. Little did I know that he would be the patient who taught me the most during my third year. I learned about pleural effusions, chest tubes, mesothelioma, the diagnosis and management of atrial fibrillation, breaking bad news, end of life issues and palliative care. More importantly, he taught me about the limits of medicine, acceptance, and doctor-patient relationships. He taught me that despite all of our medical advances, there are some things that we cannot cure. Part of being a good physician is recognizing these limitations, and accepting a patient’s decision to not go on even when we want to try more. He reminded me that some of our best medical treatments are simple acts of kindness, such as bringing in a treasured pet, or stopping by at night. And he taught me that the doctor-patient relationship is reciprocal; that patients often have as much to give to me, if not more, than I do to them.