My first “real” patient was dead before I even walked into his hospital room.
I had been assigned to the Oncology ward as a first-year intern in San Antonio at the Audie L. Murphy Veterans Administration Hospital. Named in honor of the most highly decorated American war hero in the Second World War, the Audie Murphy is a huge feeder hospital for all the veterans of South Texas, and this is where my story begins.
It was July 1. Significant across the entire country because it represents the start of the new residency year. This is also why a patient should avoid presenting for medical care to training institutions on June 30. Residents must train on someone, and the new day dawns for every program on July 1. Every year.
Word must have gotten out because the VA Heme-Oncology service had a mere three patients. The numbers worked out perfectly to allow each intern on our team a patient of our very own.
I strode (that is the only word for it) down 5B, to the nurses’ station and logged into the computer to review his chart. I had vowed to be an expert on my one patient. I wanted to know more about my patient’s history than his own mother or wife.
After an abnormal mole appeared, he had been diagnosed with melanoma two years previously. It was surgically excised, but he appeared to have fallen off the radar for a couple of years post-biopsy and surgery. This was his death warrant. Perhaps he rationalized it was “just a skin cancer” and a small one, at that. Or maybe he did not like the treatment options at the time.
However, he did eventually make his way to the Oncology outpatient clinic two years later, and after labs and scans were performed, it appeared the melanoma had metastasized throughout his body. A day later, Fate connected us and I became his intern.
Once I felt completely proficient with his chart, I entered into his room to the sound of buzzers and alarms going off simultaneously. It sounded like the cockpit of 727 airplane crash-landed in that room, or what I imagined one might sound like. I instantly realized these alarms had been going off for so long they had become white noise. I tentatively reached over to him, and touched his arm. He certainly was not cold, and he did not appear to be in rigor, but this was not a patient who could be heroically coded.
I turned around and walked slowly back to the nurses’ station, where there was a single unit clerk secretary sitting at a computer. I asked her where the nurses were, to which she responded, “Dolores is on a smoke break.” I felt lost and confused, and returned to the team room where I thankfully found the fellow. He was a kind man who had been practicing internal medicine before returning to train in Oncology. I explained the situation, and he asked, “Have you ever pronounced anyone before?” To which I responded that I had seen a little death and dying in medical school, but that I had never personally coded anyone myself. He said he would teach me. And he did.
Next, I had to do the unthinkable. I had to call the patient’s family. He did have a family. Where were they? It is best to have these conversations in person, but since he was all alone, I was forced to use the telephone. After a man’s voice picked up. I asked to speak to the family listed as next of kin in case of emergency or death. He said, “Speaking.” My words were something to the effect, “I have some very sad news about your father. It seems that he lost his battle with melanoma and passed away today. I am very sorry for your loss.” I braced myself for some kind of violent reaction, or sobbing, and I was not exactly sure what I was going to say or do next. Instead, he first was silent. Then he responded stoically, making it easy for me.
Over the next two years as a medicine resident, I would pronounce more deaths from the lesson my fellow taught me. But I learned that telling the family is the harder part, and it never got easier.
Ironically, melanoma would become a recurrent theme in my both my professional and my personal life. I chose dermatology as my specialty. I stood on the sidelines, and watched as my mother’s father survived World War II and stormed the beaches of Utah on D-day, only to battle melanoma and lose. My own father would be diagnosed with melanoma on his calf, and eventually succumbed to metastasis in 2015. In 2018, my sister Kelly was diagnosed with melanoma and passed away in 2020.
Yes, melanoma was a recurrent theme in my life. It became a teacher of sorts, instructing me about lessons not only as a dermatologist, but as a grand-daughter, daughter, and a sister. Things would get very personal along the way.
But eventually the student became the master.
In honor of Melanoma and Skin Cancer Awareness, get your full body skin exam annually or bi-annually if you have a history of skin cancer. Perform a self-check once monthly using the ABCDE criteria for moles and melanoma as established by the American Academy of Dermatology. Avoid tanning beds. Wear daily physical block sunscreen, and reapply if you are out of doors longer than two hours.