What lies beneath

Another on the list of patients who make me anxious is Jonah. He lives in one of the senior high rises, where rent is on a sliding scale of one's monthly income. Jonah has suffered several strokes, the last of which left him with profound right-sided weakness and an difficulty with speech. In the language of medical jargon, we would say he has a dysarthria. He can comprehend language and his brain can form the words, but his mouth won't properly produce them. He slurs and mumbles and is extremely hard to understand. Despite these difficulties, he manages to live on his own, walking carefully through his apartment and relying on a motorized wheelchair to leave. In an earlier life he was a successful mortician with a big family. Now he is solitary, rarely hearing from anyone. What little money he has, he squanders, and is often without a working phone. The building's tenant services coordinator bemoans the fact that his apartment, despite the semi-reliable assistance of a homemaker, is often a shambles and potentially a source of marauding pests. The homemaker has fretted to the coordinator that he drinks, and the coordinator has recounted to me that he brings home "female companions" who wander the halls looking for other clients after through with him. The building wants him out in a big way.

As you might already have gathered, Jonah is very depressed. Through many of our meetings, he sat silently, the hopelessness radiating off of him. Some days I attempted to address and intervene in his depression. On other days, I stuck to his medical problems, or the recurring mechanical problems with his wheelchair, happy to avoid the morass of his sadness. On one day when he seemed particularly distraught, so much so that there was no avoiding it, he recounted an occurrence from earlier that week. His son had come to visit him. Jonah hadn't seen is son in nearly two years. Some friends tagged along for the visit, no one that Jonah knew. For some reason, Jonah left some money, over $200, out on his bed when he went to the bathroom. When he returned, the money and his son were gone. As he told me this, he was near tears. When it came time for me to leave, Jonah asked for two dollars. Was his story all a set-up to ask for this small sum? The weight of his emotions during the telling say no. If it was all an act, what a performance!

So last week, Jonah complained that he felt sick. A little cough, some malaise, his apartment felt warm. In fact, his apartment was warm, and close, and quite uncomfortable. However, he showed me a set of vitals recorded by his visiting nurse the day before and he had run a low-grade temperature with an elevated pulse. His pulse was up with us as well and his blood pressure slightly down. The bottom of his right lung field had some new crackles, so I decided to start antibiotics empirically for pneumonia and get a chest X ray. When the result came in a few days later, it wasn't what I expected.

Similar to Jonah's X ray

His lungs were littered with small nodules while the bones of his right should had a ragged, chewed-on appearance. Without the messy shoulder, the findings in his lungs might be an unusual infection or some sort of reactive process, but taken together, the two findings pointed strongly to cancer.

Now the challenge really begins. The Company doesn't have a hospital affiliation so getting a thorough diagnostic work-up, especially one that will likely involve sophisticated imaging and biopsy. Depending on where the person lives, I pretty much have to make it up as I go along. And with Jonah, I know it will be a special challenge. He has no phone. He will require transportation to each of his appointments. And given his current state of mind, he may be reluctant to uncover the truth. To my knowledge, has no family to lean on as he goes through the painful process of establishing if he will live or die. My challenge in speaking with him, when I finally get ahold of him, will be to project hopefulness without being dishonest. I want him to participate in the tests that follow but I don't want him to do so under the false assumption that everything will probably be all right.

Most importantly, I need to remember to be present for him. This may seem obvious, but I find that when giving bad news, I am often planning my escape. Being in the moment and bearing real witness to the other person's emotions can be incredibly painful. It can feel very out of control. At these times, what I want is to control the whole interaction so that it remains manageable: I give you the news; you react in such a way that I can tell you have taken it in but have not been overwhelmed by it; I reassure you; then I go on with my day. What would certainly be far more helpful to Jonah is if I can provide him with the space to react in whatever way he feels necessary and then return his reaction with acceptance. Even in professional interactions, people really want to be treated like people. And physician/patient interactions because of the weight of the exchange often blur the line between professional and personal. I am starting to ramble. I'll stop speculating. More once I have more to tell.