The Before and After

We sit at grouped desks, eyes on blinking green pagers then back to bright screens. It’s now the last year of my residency, and I’m admitting and cross-covering patients on night shift. Just as I finish putting in orders from a consultant, my pager buzzes with an admission. I call the Emergency Medicine resident.

“Room 631,” he says. “She’s a 67-year-old female with previous MI, diabetes, and tobacco use. Presented after a low-impact motor vehicle accident. It was a hit and run, those bastards. Anyway, Trauma cleared her, but she still has some chest pain. Needs a cardiac work-up. Her CT chest and abdomen are pending.”

I ask a few clarifying questions then start the familiar trek downstairs. The lights are dimmed, hallways empty. Soft tones alarm as I walk, signaling some minor derangement of vital sign or EKG lead displacement. Those tones persist, even in the silent stairwell.

I reach room 631 and introduce myself. Ms. Adams lies in bed, with starched blankets pulled to her chin. She has a stylish bob cut, her short bangs interspersed with wisps of gray. Her daughter Sarah sits at her bedside and launches into the events of the day. I ask about pain and associated symptoms. Other than mild pain at the seatbelt site, Ms. Adams feels fine.

I routinely ask about weight loss, and the answer catches me off guard.

“Yeah, she’s lost a lot in the last few months.” Sarah says. “Maybe 50 pounds or so. It’s like she has a vision of eating, then it disappears.”

Sarah begins describing the recipes she has tried as I walk over to the computer. The CT scans are back, and I double click.

The black reads, “There is a 2.8 cm right lower lobe nodule, with other nodules scattered throughout both lungs. There are multiple lesions in the liver, spleen, and pelvis, concerning for metastatic disease.”

I read it again.

I look over to Ms. Adams, as she talks to Sarah. They chat about the July heat and what they’ll bring to Sunday dinner. Sarah’s son Cole is bringing his new girlfriend.

I want to give her more time in this place, in the before. When it was just a bad day, with a minor trauma, a trip to the hospital with routine tests and scans.

I stand there, letting the before drag on. My mind envisions the after.

The disbelief as they hear the words, see tumors on the screen. The ensuing tests, treatments, side effects. The inevitable decline. The grief for loss of the life they had planned.

I see Sarah, caring for her mother as she weakens.

Sarah, holding her hand at the bedside.

Sarah, standing beside her grave.

I force the image out of my mind. Sarah senses a change on my face and looks at me, hesitantly. I walk back to the bedside and sit down.

The words feel heavy as I speak them.

The after begins.

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Correspondence to Laura B. Vater MD, MPH.

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Names and details have been changed to protect patient privacy.

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Vater, L.B. The Before and After. J GEN INTERN MED 35, 1889 (2020).

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