I had heard tales of night float: a formidable rotation for interns as they tended to patients they often weren’t well acquainted with, managing crises until their regular team could step in at dawn. Given this reputation, I was taken aback to discover a night float week on my calendar as part of my internal medicine clerkship, a fundamental rotation for a third-year medical student.
My initial patient was a very unfortunate woman in her thirties who, after being diagnosed nearly ten years ago with a rare congenital abnormality of her pancreas that necessitated surgical removal, faced complications that had left her with little of her stomach, intestines, and even her spleen. She had never truly recuperated, now frail and malnourished. Just last week, she experienced a pneumonia incident and was admitted to another nearby hospital for treatment, but just yesterday, after departing the hospital against medical advice, her blood cultures had identified a perilous and drug-resistant organism: Pseudomonas aeruginosa.
After reviewing her documentation, I headed to the emergency department (ED) to gather further history. Accompanied by a supervising resident, I initially couldn’t believe I was at the correct bed: the woman before me appeared no younger than sixty! However, after confirming her identity and date of birth, I began my interview, a daunting endeavor as she spoke with considerable effort in a barely audible whisper. The idea that she was so ill as to need an ICU admission crossed my mind repeatedly. As we moved on to our physical examination, I recognized a finding I had only read about before: cachexia, the wasting of the body due to severe chronic illness. After a brief consultation with my resident regarding her active medical issues, I completed my admission note and returned home for the night.
Mr. H entered the ED the following day: an elderly gentleman presenting with shortness of breath and “lumps” protruding through the skin of his chest. My heart sank as I accessed his medical records: Three years prior, he had been diagnosed with stage IV lung cancer, with metastases infesting not only his lungs but also the bones of his spine and hips. His oncologists were aware that a cure was unattainable, but they offered him chemotherapy infusions aimed at providing a better quality of life for whatever time remained. The infusions had been effective: the tumors had decreased in size. But that was two years ago, and he hadn’t seen a doctor since.
Even without reviewing images from our ED CT scanner (affectionately referred to as the “donut of truth”), I had a strong suspicion of what Mr. H’s masses would turn out to be. The images validated my concerns, revealing abnormal lung nodules with dense, necrotic centers. One mass had even eroded the bone of his clavicle. Additionally, clots were restricting blood flow to both lungs.
This time I roamed the ED corridor searching for signs of cachexia. The fat around Mr. H’s temples had diminished, creating a scalloped appearance, and as he extended his hand in greeting, I noticed the swelling of his fingertips: temporal wasting and clubbing, both common indicators in advanced lung cancer. The interview was tough: Mr. H often needed redirection (and even claimed at first that he had no prior medical conditions until prompted to recall). As I began to take my leave, a thought suddenly occurred to me: “Does he realize he still has cancer?”
The thought was all-consuming. I quickly tried to remember the mnemonic taught to medical students for sensitively delivering bad news and felt relieved when SPIKES came to mind. It started with selecting an appropriate setting, but one glance around the ED made it clear that there was no chance of finding a private room for this conversation. I began:
“Mr. H, what is your understanding of why you are feeling short of breath and have these masses?”
He did not really know or have any theories.
“I reviewed your previous records and imaging from here, and I feel that we might be able to determine what’s happening. Would you like me to share that information with you now?”
Yes, he wanted to know.
“I regret to inform you, but I have some unfortunate news. It appears that your shortness of breath and these lumps indicate a recurrence of your lung cancer. The cancer also increases the likelihood of blood clots, which it has, obstructing blood flow to your lungs.”
Mr. H was silent, finally breaking the pause with a long sigh and, surprisingly, a thank you. He appreciated my directness in conveying the situation, and we chatted for a few minutes about his journey with cancer to that point. He then inquired about what would happen next, and I explained that the next step would be admission to the oncology-focused internal medicine team to discuss the remaining options that aligned with his goals, whether they related to quality or longevity of life. I also mentioned that I would not be part of his primary care team moving forward, but that I wished him well. Tightly holding