The Angel of Death

My intern year, we were all required to spend a month in the SICU.  This was in the day where interns still took 24 hour call.  We were in charge of every patient from 5 pm until the next morning.  Although we had plenty of backup in house, it was still a terrifying experience (in a good way . . . I actually really enjoyed my SICU rotation).  The attending would almost always call at some point during the night, just to make sure that everything was going okay.  My first call was a Sunday . . . 2 people died.  [They were both withdrawals of care, but it still sucked].  When my attending called, and asked me how I was doing, I said ‘I feel like the Angel of Death.’ 

This past Friday, my little bat friend made another personal visit.  I’m not sure if it was mocking me . . . it could have been just saying ‘happy Haitian Friday the thirteenth’ . . . or, it could have been an omen to the upcoming events.  [I do admit that I did freak out just a tad . . . I ended up sleeping in the office, which has closed ceilings, and we stuffed any holes greater than ¼ inch with news paper].

Saturday night, well, I guess Sunday morning, one am, I heard a knock on the door.  Apparently there was a patient downstairs who had a breast abscess, and they wanted the gynecologist to take care of it.  [The other doctor who was working for the weekend is basically an intern, doing her year of service following medical school . . . I’m just going to say that it is a little terrifying how much autonomy these physicians get].  I quickly got dressed and went downstairs to see the patient. 

Now, I don’t have much experience with breast abscesses, but this looked pretty bad.  Apparently, it had been there for about a month.  I explained (through minimal interpretation) that it needed to be drained, and the patient said okay.  She freaked out quite a bit with the needle for the anesthetic; I told her she was not allowed to look when I made the incision . . . she did not flinch; When she looked and saw all of the puss coming out of the abscess, she started screaming bloody murder.  It sounded like a mix between a donkey and a bird being tortured.  I tried everything I could to get her to calm down, and nothing worked.  [On a side note, I’m sure that many of the procedures I have performed as a gynecologist have been a lot more painful than this.  Thank God the birth canal is anatomically out of personal sight.  I don’t believe people could handle have of the things we do if they could actually see it!]. 

Today’s story . . . unfortunately much more sad.  First, I get a patient who comes to see me just for a breast mass; 40 years old.  Now, luckily I yet to examine a breast mass that actually ended up being cancer, so I did not have much of a comparison, but this mass she had looked like a cancer.  After I told her she needs to have a biopsy, she shows me the results of a biopsy in PAP, +carcinoma.  She started asking all of these questions, regarding the treatment that she needed, all questions I do not know the answer to.  I had to tell her to come back on Wednesday.

My last patient of the day . . . thirty year old, who came for a second opinion.  She brought a pathology report with her, which, of course, I could not read in full . . . what I could make out . . . cervix, cancer, uterus.  I was hoping that it was just carcinoma in situ . . . wishful thinking.  I was out of speculums, so I decided to just perform a bimanual exam.  At minimal, IIIB cervical cancer.  Then, the patient told me I was the third doctor she had seen.  She started crying.  She told me that every other doctor told her she just needed to go home and die.

Carine was not here today, so I had a 19-year-old interpreter.  She had tears in her eyes as she was translating.  She said ‘I don’t like this.’  It took all the power I had not to start bawling in the room. 

The patient did not have the resources to go to the DR or Miami for radiation.  Thirty years old . . . she would have had her entire life ahead of her.  If I was capable of doing the surgery, I may have offered an exenteration . . . maybe the better of two evils . . . she will just have fistulas to deal with for the rest of her life, or she will die on the operating table.  I found the name of a doctor in port au prince who might be willing to try, but emphasized that her outcome regardless was not good.  [I had been questioning if screening starting at age 25 was too early . . . this answers that question]. 

No matter how many times you experience situations like this in your career (I hope that for most . . . it is few and far between), it never gets easier.  It’s emotionally draining . . . and however bad it is for you, it can only be a zillion times worse for the patient.  You need to maintain enough of your emotions to remain compassionate to the patient, yet be strong enough to remain ‘professional’ (whatever that means).