A Hallmark Moment

DOI: 10.1200/JCO.2010.33.0266 Despite our methodic natures, or our measured, critical thinking, the choices we make at life’s crossroads often eschew science. That is, notwithstanding the efforts we go through to carefully balance the advantages and downsides to important decisions, in the end we let emotions guide us and work backwards to justify ourselves rationally. My first day of residency in Boston, we sat in a conference room that smelled vaguely of Indian food, the remnant of lunches from past noon conferences. We were handed our rotations for the next year, the schedule that would determine whether we would be able to join our families for Thanksgiving, go out to parties on New Year’s Eve, or even wake when our bodies told us to on a given Sunday morning. I was focused more on where I would have to report the next morning: to the medical intensive care unit—the MICU, or Deathstar, as the older residents liked to call it. I had never rotated through a MICU as a medical student and thus was completely unfamiliar with how to manage these critically ill bodies masquerading as sentient human beings. And I was on call the first night. This would turn into the longest day of my life. I met my junior resident, Dave, the person who would share my call nights, at 7 AM, and he helped me make it through rounds with the MICU staff, fellow, senior resident, two other junior residents, and two other interns. To put it more plainly, he did all the work of writing notes, making decisions about patients, and placing invasive lines, while I ran errands for him and was thrilled when I could successfully locate an x-ray in the catacombs of the radiology department. As night fell, we rounded out, during which the other intern-junior pairs told us about their patients and then took their leave, a scene straight out of a World War II movie, in which the company is forced to abandon the two guys whose legs were shot up, leaving them with a certain amount of ammunition to fend off the advancing Germans. They always say goodbye and promise to come back to retrieve the guys the next morning—if they survive the night, which everyone knows is highly unlikely. Among the usual medical disasters we would care for that night—the old people with consuming pneumonias, the patients with dissecting aortas or hearts that beat at one tenth their usual capacity— was a woman, a pediatrician from a nearby hospital, who had widely metastatic ovarian cancer and whose lungs were filling with fluid. Initially, she was to be intubated and placed on a respirator, but she changed her mind, deciding instead to live her last hours breathing air on her own, unassisted. She was in her early 40s, and her appearance in our unit had consumed our team’s emotions that day. It didn’t help matters when her son and daughter, ages 10 and 8, came in to say goodbye to her in the evening—we all knew this would be the last time they would see her. Each of us in turn, doctors and nurses, sought refuge off the main floor to check the hitch in our breathing or cry outright in private. Her husband escorted their children away and returned a couple of hours later with her best friend, now carrying a CVS bag. As I was doing my rounds, checking vitals on patients to dutifully report back to Dave, I glanced in her room and saw her husband standing, hunched over her bed, holding a clipboard as she wrote something. I made it back to our conference room. “Hey Dave, what’s going on in there?” I asked, gesturing to her room. By this point of the day, I had proven myself to be so utterly helpless, I no longer even worried about asking Dave completely idiotic questions. He was my lifeline, my only source of truth. If I had even time to go to the bathroom, I probably would have needed his assistance with that, too. He looked at me blandly, but without prejudice. “She’s writing out cards.” “3 5 cards?” I asked. I had a pocket full of them, each with a different patient’s information written. The only cards I could picture. “No, birthday, holiday cards—those types.” Birthday, holiday cards, graduation cards, cards for every occasion she could imagine. Cards for bar and bat mitzvahs. Cards for Halloween. Cards for the next 10 years for her son and daughter. Cards so she could be a part of their lives. Cards because she was so proud of them. Cards so she could live those years with them over the course of her last night on earth. Cards so they would never forget her. I was up all night, caring for others and watching her stay up all night, writing, sometimes her JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y VOLUME 28 NUMBER 36 DECEMBER 2