I had heard about night float: a daunting rotation for interns as they cared for patients they often were not well acquainted with, putting out fires until their usual team could take over in the morning. Given this reputation, I was surprised to find a night float week on my schedule as part of my internal medicine clerkship, a core rotation as a third-year medical student.
My first patient was a very unlucky woman in her thirties who, after being diagnosed with a rare congenital defect of her pancreas nearly a decade ago that required surgery for removal, had faced complications leaving her without much of her stomach, intestines, and even her spleen. She never fully recovered, now weakened and malnourished. Last week she had a bout of pneumonia and was admitted at another nearby hospital for pneumonia, but just yesterday, after leaving the hospital against medical advice, her blood cultures had grown a dangerous and drug-resistant organism: Pseudomonas aeruginosa.
After reviewing her records I went to the emergency department (ED) to take additional history. Accompanied by a supervising resident, I initially could not believe I was at the right bed: The woman in front of me looked no younger than sixty! But after confirming her name and date of birth I began interviewing her, a daunting task as she spoke with great effort in a barely audible whisper. The thought that she was so sick as to require an ICU stay crossed my mind more than once. As we proceeded to our physical exam, I realized I was seeing a finding I had only previously read about: cachexia, wasting of the body due to severe chronic illness. After a brief discussion with my resident on her active medical problems I completed my admission note and went home for the night.
Mr. H walked into the ED the following day: an elderly man presenting with shortness of breath and “lumps” poking through the skin of his chest. My heart sank as I opened his medical records: Three years ago he had been diagnosed with stage IV lung cancer, with metastases riddling not only his lungs but the bones of his spine and hips. His oncologists knew that a cure was impossible, but they offered him chemotherapy infusions with the goal of giving him a better quality of life for whatever time he had left. The infusions were successful: the tumors shrank. But that was two years ago, and he had not seen a doctor since.
Even without reviewing images from our ED CT scanner (fondly dubbed the “donut of truth.”) I had a good guess what Mr. H’s masses would be. The images confirmed my suspicions, showing abnormal lung nodules with dense, necrotic centers. One mass had even eaten away at the bone of his clavicle. Moreover, clots were limiting blood supply to both lungs.
This time I wandered the ED hallway looking for cachexia. The fat around Mr. H’s temples had wasted away leaving a scalloped appearance, and as he extended a hand as greeting I noted the bulging of his fingertips: temporal wasting and clubbing, both common findings in extensive lung cancer. The interview was challenging: Mr. H required frequent redirection (and even claimed at first that he had no prior medical conditions before being prompted to remember). As I started to say my goodbyes a thought suddenly struck me: “Does he know he still has cancer?”
The thought was all-consuming. I immediately tried to remember the mnemonic taught to medical students for gently breaking bad news and was relieved when SPIKES came to mind. It started with choosing an appropriate setting, but one glance around the ED showed me there was no hope of finding a private room for this conversation. I began:
“Mr. H, what is your understanding of why you are short of breath and have these masses?”
He did not really know or have any guesses.
“I reviewed your previous records and imaging you have received here, and feel that we might know what is going on. Would you like me to share that info with you now?”
Yes, he would like to know.
“I am sorry to say, but I have some bad news. It appears that your shortness of breath and these lumps are a recurrence of your lung cancer. The cancer also makes it easier for your blood to clot, which it has, blocking flow to your lungs.”
Mr. H was silent, finally breaking the pause with a long sigh and, surprisingly, a thank you. He appreciated that I was direct in telling him what was going on, and we spoke for a few minutes about his journey with cancer until this point. He then asked what would come next, and I explained the next step was admission to the oncology-focused internal medicine team to discuss the remaining options that also aligned with his goals, be that quality or duration of life. I also mentioned that I would not be a part of his primary care team moving forward, but that I wished him the best. Tightly grasping my arm, he said goodbye with a smile.
The rest of the week proved just as intense: GI bleeds, hyperkalemic emergency, lupus nephritis, and even more cancer. In my preclinical years I had realized the language of medicine was foreign to me, and I threw myself at learning the vocabulary from lectures and texts. During my inpatient rotations, I observed it spoken around me and attempted to soak it up like a sponge, even practiced speaking it with my residents and attendings. But it was only now, on my night float week, that I truly performed it while speaking with Mr. H and others; only now did I feel initiated to the responsibility entrusted to me during my white coat ceremony three years ago.
Amish Jain is a fourth-year medical student at Case Western Reserve University School of Medicine. Originally from Sacramento, California, he graduated summa cum laude from UCLA in 2022 with a bachelor of science in molecular, cell, and developmental biology and a minor in biomedical research. His academic journey has been defined by a strong interest in medical education and cardiovascular medicine. He has contributed to scholarship examining the evolving role of lectures in medical training and to work exploring right ventricular function in heart failure. Beyond his research, Jain is pursuing a career in internal medicine, where he hopes to integrate his passion for teaching with a focus on advancing patient care in cardiology.
