Natalie is Alive

She has been married and divorced and has spent all of her 27 years in a small town in the foothills of the Sierras. She is two years my junior but acts far older. I think of her maturity as evidence of an enormous will to live. It's clear to me that she decided long ago she could tough anything out. In this, too, we are alike.

But Natalie and I are different in one big way: she has just been diagnosed with a very aggressive, very rare, metastatic cancer.

When I met her, it was late at night. I was on call. I was tired, but she was more so. She was pale and obviously weak. She knew she had a mass in her belly as we could feel it on physical exam. She also knew that whatever abnormality her earlier CT scan had found was beyond the resources of her local hospital. That's why she was here in Sacramento, the closest tertiary care center, admitted to my general medicine team.

Her scan showed masses throughout her abdomen and pelvis. Though this is never a good sign - cancers in one place can often be removed, while widespread cancers are harder to treat - the going theory was that Natalie had lymphoma. As cancers go, lymphoma isn't so bad. It's more responsive to chemotherapy than other diagnoses we were considering.

Natalie didn't know any of this. The theories floating around in the call rooms and hallways on that initial hospital night were only the beginning of hours and days of conversation behind the closed door of her hospital room. There is some rationale to this: no one wants to suggest a diagnosis, especially a life-threatening one, when there is not enough proof to back it up. But I felt, even at that early date, that in her shoes I would want to know more.

Four hospital days passed before she was able to get into the operating room. Hospital bureaucracy, miscommunication, and scheduling difficulties dragged out the process. So for four days Natalie waited in her bed, with nothing much to do but think. Her parents waited too, dividing their time between their shabby hotel room and their daughter's hospital bed. And I waited, trying to complete the many tasks expected of me as a third year medical student, all the time wondering what was going to happen to her.

Over the course of these days, she was transferred from my team to the surgery service, but I continued my daily visits. I was unable to take her off my mind as quickly as she was taken off my service. She finally had her surgery - an exploratory laparotomy - and though I had to be in class at the time, I promised her parents I would find them as soon as I returned.

I stopped the surgeon leaving the hospital after the procedure and asked what he had seen. He had found, and cut out, the mass we had felt on physical exam: a grapefruit size mass on her left colon. He also saw many smaller masses in her lymph nodes and on her liver. By preliminary reading, the mass was determined to be a rare type of colon cancer.

"These are the cancers that give cancer a bad name," he told me, grimly. He said that if she responds to chemotherapy, she will live for a few years, but the cancer will likely return. If she doesn't respond, she is unlikely to live more than a few months.

I wasn't sure if her parents would want to see me after hearing this news. What words of comfort, what answers could I provide? I imagined that in their eyes, I was just one of many "white coats" that flitted in and out of their daughter's room over the past few days Would seeing them do me more good than it would them? Regardless, my need was urgent. I wanted to make sure they were okay.

So I found them, and quickly read their faces for signs that they wanted to be alone. On the contrary, they looked happy to see me. Perhaps just a familiar face was comforting, but they seemed like they wanted to talk. I joined them in the small room that the hospital often offers to families in their position.

They seemed to be tolerating the news quite well. They had hope that their daughter would be lucky. They talked about "miracle cases" and how doctors don't really know that much anyway. Having been steeped in the dry percentages and statistics that saturate our medical education, I was sure they were wrong.

"You're right," I said, "you never know what's going to happen."

Over the next week I visited Natalie every day. I spent a lot of time thinking about how I would feel in her position, what I would want to do with the time I had left, and how lucky I was to not have to decide just yet. I'm not sure whether these daily visits were for her benefit or my own. I believe she appreciated my company, but these check-ins allowed me to process, slowly, what was happening to her.

Participating in her care was different than reading about her disease in a textbook or practicing the difficult conversations we might have with a simulated patient. I couldn't turn the page or go to my next class. She and her illness were all too real. She was not a disease or a prognosis, but a young woman still living, breathing, and thinking.

While my thoughts were filled with her medical management, hers were filled with going home to see her kids, to eat pancakes with them, and to read stories to them. While I was thinking about where she would be in a year, she was only thinking about where she would be tomorrow.

After one day off, out of the hospital, I returned for my daily visit. Her bed was empty, with clean sheets made up for its next guest. She had been discharged that day and I never had the chance to say goodbye.

There are many things I wanted to say to Natalie. I wanted to tell her how much she impressed me, how much she affected my life, and how I would remember her. Most of all, I wanted to tell her what I think she already knew: that instead of thinking she could die at any moment, she should remember that at every moment, she is alive.

rmtelerant@ucdavis.edu