Iām on nights in the ED, and last night was an intense shift.Ā
My first patient of the evening was a woman who was sent to the ED by her PCP for an indicentally-discovered WBC count of over 200, with 8% blasts (immature cells). That, non-medblrs, is very high, and she came in the door already understanding that she almost certainly had leukemia. I sat down with her and explained the next steps, and gave her The Talk that I have started to routinely give to people with new, serious diagnoses. The Talk goes roughly like this:
āA lot of things are about to happen in a pretty short amount of time. There will be a lot of people helping to take care of you. It might feel invasive and overwhelming, but I want you to know that you are the driver. If you are confused, ask questions. If something is happening that you donāt like, you can tell us to stop. This is your body and you always get to decide what happens to it. As doctors we sometimes get swept up in treating your disease, and I apologize in advance if you ever feel like weāve forgotten about the rest of you, but please feel free to remind us. We are experts in medicine, but you are the expert on you.ā
I then placed her first IV. It felt like I was firing the starting pistol at a race that this woman really didnāt want to have to run.Ā
Unfortunately, she wasnāt the last person to get The Talk last night. The second person came in with abdominal pain, something we see often in the ED. While this patient wasnāt feeling all that sick, his story worried me, and on exam heĀ had a large palpable mass in his abdomen. As soon as my hands touched the mass I could envision his CT scan in my mind. We ordered the test, and the actual scan looked worse than what I had imagined. There was really nothing that could look like this except for a widely metastatic cancer.Ā
It was a very busy night, and my (awesome) attending was running all over the place. I offered to go tell the patient the bad news, imagining that she would probably want to be there for that conversation. But she just thanked me, and off I went.Ā
Iāve had serious conversations with patients and families, sometimes unsupervised.Ā I had not, however, actually delivered this kind of news before.Ā Of course it was somewhat hedged; cancer is diagnosed by biopsy, not by imaging. But it would have been impossibly dishonest not to tell them that all of the testing we were about to recommend was a cancer workup.
They were fairly stoic about it, which probably made it easier on me, though it made me worry at first that I wasnāt being clear. They asked good questions. They wanted to see the CT scan, so I went over it with them. I gave them The Talk, and they seemed to appreciate it. We wanted to admit him, but they decided to go home and plan further diagnostics as an outpatient, and I felt like The Talk had worked. He wanted to go home, so he did.Ā
I spent the rest of the night sewing and splinting, which is the beauty of emergency medicine: the heavy shit is mixed in with easy, fun, satisfying fixes. But I honestly really love the hard stuff. I love the type of healing that starts ā and often ends ā with words.Ā
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