was a curmudgeonly 60-year-old ex-Marine who hated everything.
In Vietnam, he had been a prisoner of war and was awarded the
Silver Star. After the war, he worked as a tow-truck driver and
started drinking heavily. His wife left him, and he was not on
speaking terms with his son and two daughters. Cliff had lived
his life as a tough guy and now, faced with the diagnosis of terminal
cancer, he had few words.
Cliff didn't have a primary care physician, so I inherited him
when he was admitted to the hospital where I worked. He had come
to the emergency room with difficulty breathing. When I first
tried to examine him, he told me to wait because he had to go
out and have a cigarette. His chart said, "60 y.o. Heavy smoker
with likely lung CA (cancer)." I showed him the chest X ray, which
revealed a "white-out" pattern in the entire left lung and a partial
white-out pattern in the right. A white-out pattern is an abnormality
that indicates an inflammatory process. "It looks like cancer,"
I said seriously, "but we won't know for sure until we do some
more tests." Cliff just sat on the gurney looking at the floor,
his chest heaving with each breath.
I got the usual consultants involved. The pulmonologist performed
a biopsy that came back showing primary lung cancer, and the oncologist
said there was no hope. At that period in my career, I also worked
part-time on a palliative care unit at a different hospital, so
I admitted Cliff there. Because he had such a grim prognosis --
less than six months to live -- he would receive only comfort
care. Initially, Cliff was an extremely difficult patient: He
complained all the time, made sexist remarks to the nurses, called
the AIDS patients "homos," refused to take his medication, and
even smoked when his oxygen tank was nearby (a real fire hazard).
The nurses didn't like him, and they complained regularly to me.
I didn't enjoy Cliff's gruff ways either, so it was easy to commiserate.
moved Cliff's car when the hospital administrator complained,
saying it looked strange for one of the patients to
be working under the hood of a car dressed in a hospital
"johnny" with a cigarette hanging out of his mouth.
One day during my rounds, three months after his admission to
the unit, Cliff insisted on having a chest X ray. "I'm supposed
to be dead, for Christ's sake," he responded when I asked why
he wanted it. And he had a point. Instead of getting worse, Cliff
was getting better. We attributed his improvement to better nutrition
and to the fact that Cliff was making peace with his estranged
family. He had met his infant grandchild for the first time. His
ex-wife was genuinely concerned and called every few weeks for
progress reports. I even gave Cliff permission to have his 1963
Buick Tempest brought to the hospital parking lot, where he worked
on it for hours at a time. I moved the car to the employee lot
out back when the hospital administrator complained, saying it
looked strange for one of the patients to be working under the
hood of a car dressed in a hospital "johnny" with a cigarette
hanging out of his mouth.
Cliff had his family bring in big bags of M&Ms, and he passed
them out to all the nurses in little paper pill cups. He sorted
them by color. To his favorites, he gave cups filled with red
M&Ms, because he said they represented truth. To those he didn't
like, he gave cups of blue ones, which he called "fake" M&Ms.
The nurses who got the blue ones just laughed and called Cliff
The new chest X ray showed significant improvement, so I called
the oncologist and asked for his opinion. "Kevin, all I can say
is that sometimes we see this," he said. "Temporary improvement
before the inevitable demise." Another month passed, and Cliff
asked for a weekend pass to spend some time at his lady friend's
house. "Of course, I don't really give a hoot what you say cause
I'm goin' anyway," Cliff informed me. "And, hey, I need a 'script
for some Vitamin V." "You mean Viagra?" I asked in disbelief.
"Listen, Sherlock, just leave it at the nurses' station," retorted
Cliff. And I did.
When Cliff returned early Monday morning, he was his usual cantankerous
self. "I didn't know you pretty boys got up before nine," he shot
at me. I took Cliff into his room and shut the door. I told him
that after he had asked for the Viagra I suspected there was something
wrong. I mean, four months ago he had been at death's door. Now,
although still debilitated, he was obviously stronger.
Over the weekend, I had gone through his four-volume chart, searching
for an explanation. Why was he still alive? I reread the pulmonologist's
report, the pathology report confirming the cancer, and the oncologist's
opinion that the cancer was too advanced for meaningful therapy.
The last section of the chart contained lab results. When I discovered
Cliff's PSA level -- a measure of prostate cancer progression
-- was the highest level I had seen in my career, I stood up abruptly.
I couldn't believe it. This meant Cliff had prostate cancer that
had spread to his lungs, not primary lung cancer. The difference
was huge, because we had treatment for prostate cancer.
After my conversation with Cliff, I hastily called all the consultants.
Nobody knew what to say. We were all at fault for missing the
PSA count. The doctors all asked if I thought Cliff would sue.
Cliff was readmitted to the oncology unit, where he underwent
surgery, radiation therapy, and chemotherapy. His chest X ray
normalized, and he breathed without supplemental oxygen. Both
the prostate and lung cancer appeared to be in remission, so he
was discharged from the hospital. He moved into a new apartment
and went back to his old job driving the tow truck.
Cliff never sued. He just went on with his life. He said he was
a better man because of cancer. After the correct diagnosis was
made, the same consultants treated him. We all had a team meeting
with Cliff, and we discussed the "mistake." Cliff just said, "God
knows we all screw up sometimes, but you jerks really screwed
up royally here." When the pathologist started speaking uneasily
about a possible lawsuit, Cliff cut him off and said, "Try thinking
less about your own butt and more about your patients" -- and
with that comment he ended the meeting.
Several months later, I was at K-Mart buying a mop when I ran
into Cliff and his lady friend at the checkout. Cliff was buying
a case of motor oil, two cartons of cigarettes, and several large
bags of M&Ms. As we chatted in the parking lot, Cliff reached
into his shopping cart and pulled out a bag of M&Ms. He grabbed
my hand, put the bag into my palm, and held on for a few seconds.
"The bastards are still making assorted colors, so you'll have
to handpick the red ones," he said with a wink.
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