Reflections on A Big Heart

This week, I diagnosed a young boy with leukemia in the ED. He came in with his parents, sent by their primary care doctor because he had been coughing for a month and the doctor was concerned about his heart size on his chest X-ray. I met the family before we had even loaded the film into our hospital system. We laughed about the show our patient was watching on TV and I did an exam with pleasant chatter with the family. He was alert, playing, breathing comfortably. I walked out of the room reassured, and told the attending he had no problems with his heart. The attending, however, was clearly more worried than I was - "maybe he has a faint murmur, maybe I hear an extra sound in the heart. Let's worry about this."

Ten minutes later, everything went downhill the moment we saw the X-ray. Nothing was wrong with his heart, but there was a large, terrifying thing in his chest. Thirty minutes later, our phones started ringing off the hook with the laboratory calling to report back critical laboratory values on the blood samples we had sent. We sent the patient for a CT scan, and shortly thereafter I called the oncology team for help.

The look on the parents faces when I prepared them for the bad news was one of disbelief. They couldn't understand anything I said - their lovely, healthy boy's life was going to be turned upside down in the course of an evening.

As the data rolled in, there was one part of my brain processing it medically, scientifically, even. That part was interested and eager to know what the data is and what it meant, thinking already about the next data pieces that we needed and the next steps to take. There was another part of the brain saying "fuck" with every new abnormal lab value, each one trickling in with anticipation as the abnormal values are verified by the laboratory before release. The next thought is, "what am I going to tell this family?"

I also have a vague sense that I feel a decrease in mental capacity, analogous to trying to do a high concentration task after having a small bit of alcohol. I think to myself that I should be careful because I still have a full panel of patients I am simultaneously caring for in the ED. The mild bronchiolitis in the next room seems unimportant in comparison, but I still need to focus that they get the right care and to avoid a judgement error simply because their neighbor is becoming a high acuity situation.

Hours later, when it was time to send the patient up to the oncology floor to start treatment for leukemia, the mother reached out and hugged me. I couldn't help but feel that it was because I must have looked like I needed a hug too.

I've been thinking about the scenario, the diagnosis, and the hug. It feels unsatisfying having delivered a diagnosis and sending them out of the ED for care. It feels wrong that we traversed from point A, health, to point B, diagnosis, together, and now I'm no longer needed. I want to visit them, but that would be selfish. I am certainly not family, they have much larger issues to deal with, and they are in capable hands. I console myself with the idea that this was a time for me to expand my repertoire of experiences, to practice skills in human connection that I will certainly need again, and to recognize the mental toll of an emotional experience that I am still working through.