The word I couldn't bring myself to use

The author had much in common with his patient. And the patient had much to lose.

By Glenn G. Gray, MD
Radiology Resident / New York City

As I slap on the viewbox a sheet of film studded with 15 tiny T1-weighted images of the brain, the little black box attached to my belt screams once again. I am a senior resident on the last neuroradiology rotation of my residency. I pick up the phone and continue to hang sheets of film.

"Doc," the familiar male voice of the chief technologist says. "Got an ER case on the CT table."

I continue to hang films, unfazed. Usually the tech calls after an outpatient has had a scan, to see whether I want to check the study before the patient gets off the table. "How's it look?"

He hesitates. "Think you'd better see this one."

"Yeah?" I say. I stop hanging films.

"Yeah, better come check."

The tone of his voice indicates that this is a serious matter. I say, "Of course," and hang up.

The CT control room is quiet. Bob the tech guards the door, his hands tucked in his pockets, his face stone. We make eye contact, but do not speak.

I approach the monitor, which is filled with a single axial image of a brain. I adjust the contrast and scroll through the images. The abnormality becomes apparent.

There is a large area of decreased attenuation in the left temporoparietal region. Although I can't see it without contrast material, I'm certain there is a tumor lurking in that blackness somewhere and I'm seeing mostly edema. The text in the corner of the image reveals the patient's age, sex, and name: a 31-year-old male named Scott Larsen. (I'm not using real names.)

I peek over the console to see the patient lying on the gantry. He is well-dressed and slim. He looks like a regular guy. I can't help thinking he is only a few years older than me.

The next step is to give IV contrast. Bob has already drawn up the syringe. A transparent, blue-tinged clipboard holding a blank consent form sits on the table next to the console. I pick up the clipboard and step into the scanner room. I stand over Scott Larsen, who is still lying on the gantry, arms at his sides, his head surrounded by the puffy foam lining of the head-holding device. A chinstrap limits his head motion. Only his eyes move.

"Hello, Mr. Larsen," I say. "I'm Dr. Gray."

"Call me Scott," he says. Although he smiles, his pale blue eyes are concerned.

"I'd like to give you an injection of contrast," I say. "Have you ever had it?"

"Don't think so," he says.

"Any allergies?"

"Nope."

"There's a rare chance you could have an allergic reaction."

"No problem."

"Just got to mention that."

"Right-o."

"The contrast helps show things a little better."

"Yup."

"We give it all the time."

"Fine with me," he says.

It is evident I could tell him his body will explode once I inject the contrast and he would still agree to its administration. I think he suspects that since contrast was not part of the original exam, this change in plan cannot be good news. He says, "Where do I sign?"

I hand him the clipboard and a pen. "Here."

He holds the clipboard over his head and quickly signs his name. "Thanks," he says, smiling.

"Thank you." I hand the clipboard to Bob, who then hands me a plastic basin that contains a horse-sized syringe full of clear liquid contrast, a tourniquet, several squares of gauze, and a tea-bag-size packet enclosing an alcohol swab. I proceed with the injection.

As I slowly push the viscous liquid into Scott's left antecubital vein, I say, "So what's been going on?"

"Not much," Scott says quickly. "Just a couple of headaches."

"Since when?"

"Couple of days," he says. "Got a little worse today. I went to work, told my supervisor. She suggested I check it out."

"So here you are."

"Also, the wife said I pronounced a couple of words funny."

"How so?"

"Like 'production,' or something like that. She said I slurred it. Sound okay to you?"

"Pretty clear to me."

"Good."

There is a pause. "Okay, contrast is in," I say as I remove the needle from his arm and place a piece of gauze over a drop of deep red blood. "Ready to go."

"Great, let's do it," he says. This is faked enthusiasm.

Bob and I dart into the control room. Bob assumes his position at the console, looking like an airplane pilot before takeoff. With his right index finger, he presses a slew of buttons that send the huge CT machine into action. I stand next to Bob; all eyes are fixed on the monitor.

The lowest images look normal. The first hint of edema begins in the inferior left temporal lobe, and with each slice the area of abnormality enlarges. A few cuts later, the ugly, irregularly enhancing mass is revealed. It is the size of a small peach. The center, the pit, does not enhance. Tissue necrosis. My heart sinks.

There are many things this could be, I think. Most likely, it is a glioblastoma multiforme. It could be a single metastatic lesion, or even lymphoma, but these are unlikely.

The exam ends. Bob enters the scanner room, lowers the gantry, and unstraps Scott's head and body. Scott jumps up from the table, straightens his shirt, and brushes several strands of gauze from his trousers. He claps his hands, then rubs them together as if to say, "Now what?"

After seeing enough on the monitor, I brace myself and enter the scanner room. When Scott stands, I see he is my height, with hair the same color and cropped in the same style as mine. He looks as if he could be my brother. His eyes are wide.

"So, Doc," he says, "see anything?" His movements are curt, deliberate. The tone of his voice is positive, too positive, and it indicates a deep discussion is not necessary.

I take a deep breath. Although I'm not his primary doctor, I want to tell him something. I know he suspects a problem. "Well," I say. "Yes."

"Okay," he says and nods. "That's all right, Doc." The energy in the room changes. The pace of our conversation accelerates.

"Well, it's something," I say. "Something's there."

"Well, yeah. All right." The head nods faster.

"Where you going now?" I say. Scott gazes through me.

"Bad?" he asks. My question hasn't registered.

"Don't quite know yet," I say.

"Um," he says, and scratches his right eye. "I was gonna go home."

"Who's your doctor?"

Scott doesn't answer right away. "Gotta see my kid."

I follow his train of thought. I ask, "How old?"

"Five."

"Great age. Boy or girl?"

"Girl. Samantha."

"Pretty name."

"Pretty girl."

"I have a little girl, too."

"Girls are great."

"I know," I say. "Same age. Name's Monica."

We look into each other's eyes and smile.

There is a long, uncomfortable pause. "Dr. Swanson," Scott says. "My doctor. It's Swanson."

"Right," I say. "I'll call her."

"Sure," he says, and then, as an afterthought, "She's real cute."

"Dr. Swanson?"

"No, " Scott says, smiling. "My little girl."

"Oh."

"Looks a lot like my wife," he says softly. "Growing up fast."

"Mine's 5 going on 15."

"Tell me about it."

After an awkward silence, I say, "I'll look at the films closely."

He looks in my eyes. "Real bad?"

"Don't really know yet," I say and shrug. "Got to develop the films. Look at them more."

"I understand."

"So don't leave just yet."

"Want me to stay?"

"Until I talk to Dr. Swanson."

We now stand facing each other, about two feet apart. Bob watches from the control room.

"Definitely something?" Scott says.

"Yeah." I don't want to use the word tumor, not here, now. "Gotta look again."

"Sure, " Scott says. He starts pacing. "I'll stick around."

"Right outside's okay."

He makes quick, jerky movements with his right hand. His left hand is now tucked in his pocket. "Out there?"

"By the desk." I point with my right hand. "Right where you came in."

"Thanks, Doc," he says, and extends his hand for a shake.

I do not see his hand immediately so he pulls it back, just in time for me to extend mine. We try again, and this time we get it right. We shake hands. I say, "No problem."

Scott Larsen turns and exits.

I call Dr. Swanson. After discussing Scott's case, I hang up the phone and stand staring at the wall. I pick up the receiver and call my wife at home. I tell her I want to have a quiet family dinner when I get home from work. I say something about savoring every moment with the kids. She says, "Fine, honey."

I go back to the reading room, sit in front of the viewbox, and start dictating a huge stack of films.

Polly Miller, ed. Glenn Gray. The word I couldn't bring myself to use.

Medical Economics

2000;3:153.