In broken English, against the backdrop of the emergency department’s chaos and clatter, Mr. Simon relayed his story: unintentional weight loss, gradually yellowing skin, weeks of constipation. He punctuated his list of devastating symptoms with laughter — exaggerated but genuine guffaws.
Over the next few days, as the medical student responsible for his care, I was also responsible for handing him piece after piece of bad news — an obstructing gallstone in his bile duct. Actually, an obstructing mass. Likely a malignancy. Chemo. Radiation.
With each update, he would grin. And then he would laugh.
Did he not understand me? Despite his heavily accented protests — “I’ve lived here for years! I understand English perfectly!” — when the time came to fill out the consent form for surgery, I insisted on using a Nepali translator.
“Pancreatic cancer,” she explained. To remove the growth, Mr. Simon would need a Whipple procedure. Step by step, the interpreter outlined what that procedure entails.
Mr. Simon chuckled. He waved her away. He smiled beatifically.
I studied for hours in preparation. Before dawn broke, I woke to a huge breakfast. For a medical student, the Whipple is the pinnacle of the surgical experience. It is a massive enterprise, involving the removal of half of the stomach, half of the pancreas, the entire gallbladder, the bile duct and part of the small intestine, all followed by careful reconstruction of both the digestive and biliary tracts. The surgery usually lasts around eight hours — ample time for the attending physician to grill me on minutiae. I peed twice before we started.
But Mr. Simon’s surgery took only half an hour. Before the cutting begins, the Whipple procedure starts with a diagnostic laparoscopy — a quick peek within the abdomen. In Mr. Simon’s case, that’s also where it ended.
His intestines, his liver, his abdominal tissues: All were caked with flaky white lesions. We biopsied several, dropped them into a sterile container and accompanied them out of the operating room as they journeyed to the pathologist.
The truth was just as obvious under the microscope as it had been to the naked eye. There was already too much cancer. It wasn’t worth continuing.
On our way back to the operating room, my attending gazed intently at me and my flooding eyes. She was in her mid-30s, young for a surgical oncologist, and one of the few women in the field.
“What’s the mortality after a successful Whipple?” she asked me.
I had studied. I was ready.
“Um. The five-year survival rate is around twenty-five percent, I think.” I couldn’t look her in the eyes.
She nodded. “Correct! So, honestly, he was doomed anyway.”
For a few days, Mr. Simon was quieter than usual. He still laughed, but now, for the first time, it sounded fake. His smiles, once so broad as to be cartoonish, were forced.
He was the first patient I rounded on each morning. At 5:30 a.m., when even Manhattan lay dark and quiet, I would gently rub his right shoulder. Unlike everyone else, he never grumbled about being woken. Despite being more subdued, he was always pleasant, ready to answer my questions, eager to pull up his johnny so that I could examine his taped-up laparoscopy scar.
Except for this one morning, several days after our failed Whipple.
When I walked in, Mr. Simon was already sitting bolt upright in bed, overhead lights on, grin firmly in place. Giggling so hard that he could barely speak, he handed me a folded newspaper.
I opened the paper. It held a piece of poop. His poop. Medium-sized, firm, the color of clay. It was his very first bowel movement in weeks. He’d gift-wrapped it just for me.
He laughed and laughed and laughed. And, for the first time, I joined him.
We were both wary of our futures: I feared that my days were going to be spent in the company of people who believed that answering questions correctly was more important than experiencing human emotions, and he feared that his days were growing ever more numbered. It had not been a pleasant time for either of us. I felt tired, humiliated and belittled, and he felt exhausted, nauseous and alone. I was only one month into my clinical rotations, and I was already wondering if going into medicine had been a mistake.
But that morning, as the sun rose over the city, we didn’t think about any of those things. That morning, we focused only on the good sh*t.
Allie Gips is an emergency physician. This piece was originally published in Pulse — voices from the heart of medicine.
Image credit: Shutterstock.com
