The thin callus of experience

Debra wanted to know why I was at work on a holiday. I told her I had come in for her.


As a senior resident at a major Pittsburgh hospital, I finally felt confident facing most daily challenges. I had already been through several rotations in intensive care, the emergency department and oncology. I had learned to stay focused on the task at hand and not be fazed by random circumstances. I had been in the trenches, working for experience, and the experience was finally starting to work for me.

On Independence Day, I was cross-covering several cancer patients. I went to see the sickest ones first, and that included Debra, a woman with advanced pancreatic cancer and metastases to her bones and many internal organs. She was hooked up to a patient-controlled analgesia machine that was pumping huge doses of hydromorphone to help her cope with excruciating pain. A mere fraction of the basal infusion of the drug would have rendered me apneic.

Photo courtesy of Andrew Kurklinsky
Photo courtesy of Andrew Kurklinsky.

Debra lived in a room with a window that overlooked the city's downtown. The view was spectacular in any weather and at any time of the day or night. Fireworks were scheduled for that evening, but they were the last of Debra's concerns; she was writhing in pain as I walked in. I immediately pressed the injector, and the machine released an extra dose of narcotic. I then reviewed the injections log in the machine's memory and realized that Debra didn't really understand how the machine worked. She wasn't using it to receive the drug “on demand.” I had to explain it twice to her, since her attention was hijacked by pain. By the time she finally figured it out, the pain was receding and she felt better. Sometimes, she said, she was so stupefied by pain that she couldn't get the machine to work correctly.

Debra wanted to know why I was at work on a holiday. I told her I had come in for her. I wasn't lying, though I was exaggerating: I had come for several very sick patients. She knew the truth, but liked what I said and smiled. Feeling connected this way helped both of us forget, at least for a brief moment, that she was dying fast.

I sat on her bed and we talked. I took my time. In the end, I felt that not only was it a meaningful encounter, but that I had handled it well, too. As I was about to leave her room, I glanced at some papers with patient personal data pinned on the wall. In a split second I was stricken by the realization that it was Debra's birthday (which I should have noticed earlier when I read her chart). I turned around and, before I said anything, further realized it was her 50th…and her very last birthday. No family or friends to come and visit. She was too humble to disclose this fact to me. I was overwhelmed and speechless.

No matter how prepared you feel as a physician, there will always be moments when you are caught off guard. Experience can protect you from emotional overload, but it is never impenetrable. There are things you simply cannot prepare for.

That day, I made a most unusual record in a patient's chart, unlike anything I had trained for in medical school. In my daily “problems list” section I wrote: “Problem #9. Last birthday.” It was preceded by eight other problems, documented in dry, medical language. For “the plan,” I wrote “Ordered a cake. Well, we'll have fireworks, too. And a spectacular view over the city. We'll party.”