The Case of the Lima Bean
"Matthew, go see this lady about her breast mass," says my attending physician at the clinic where, as a third-year medical student, I'm doing a family-medicine rotation.
Okay, I think. I've done my ob/gyn rotation; breast masses are no big deal.
I don my short white coat, freshly baked from sitting in the back of my car as I drove to work on this oppressively hot morning. As I sling the stethoscope around my neck, I feel my inner voice (my constant companion amid the stresses of medical school) gearing up, ready to offer insights, questions, distractions....
Knock-knock, open the door, wash my hands with Purell for the first time today, do the wavy hand-drying motion.
"Hello! My name is Matthew Webb. I'm a medical student at USC, and I'm working with the doctor today," I say with a dimpled smile.
That's the usual protocol: dimples and smiles for the women, a firm handshake and "Sir" for the men.
I see a ninety-three-year-old woman, comfortably dressed in a bright blue button-down shirt, white pants and sensible tennis shoes, smiling back at me.
"Well, hello young man," she says sweetly, reminding me of my great-grandmother Lorene.
Lorene lived in Colorado, and my family lived in California. As a kid, I got to see her only every other year, but my father always talked about her, so I felt like I knew her well. She always wore tennis shoes, saying, "Those damned fashionable shoes hurt my feet."
"I have a lima-bean-sized mass on my right breast," the woman says nonchalantly.
Okay...breast mass equals breast cancer in an elderly woman like this, I think, then wonder, What's her name again?
Lorene always had honeydew and Pepsi for me--my favorite snack as a kid.
Since this lady has jumped right into it, I should too. I log onto the computer and start typing as she talks.
"The mass appeared two months ago," she says. "It was pea-sized, but now it's a lima bean."
Lima bean...G6PD enzyme deficiency...we learned in hematology that people who have that deficiency can develop anemia and jaundice from eating fava beans...lima beans are the same as fava beans, right? Wait, wait, pay attention, Matt. She didn't eat any beans!
"It is firm, mobile and not painful," she continues. "There are no other masses in my left breast or armpits. Oh, yes, and I had a right mastectomy for breast cancer four years ago."
Keep your cool, Matt. She has a cancer recurrence for sure...though I really don't know that. But what if she does have breast cancer? What treatment would she have? Radiation and chemo would kill her! Her life will be so much worse if we blast her with drugs and radiation....
Calm down. My role is to be the student. I am not the doctor.
Hell, when Lorene's breast cancer came back, she said, "Well I've lived a good life; I think it's just my time." As a child, I knew Lorene would die soon, but that was okay. Everyone dies, and she got to choose how she left.
This lady is not Lorene...I think she said her name is Jones or Smith...something like that.
Huevos rancheros was the meal Lorene bought me for breakfast, the week before she died.
I focus intently on the computer screen, asking more questions about the lima bean and typing away.
When I finally look up at the woman, she is completely topless.
How the hell did this old lady get undressed without me noticing?!
"Enough talking, just take a look at the damned thing," she says.
Jesus Christ, what is her name? I can remember my grandma's name--why not hers?
I admire her no-nonsense attitude. I guess she feels she has no time to waste.
So I roll over on the little doctor stool and just go for it. She is correct: the mass is firm, movable and about the size of a lima bean.
I'll need to do a full breast exam, check for lymph-node enlargement, nipple retractions, discharge....
The door opens, and my attending walks in.
"Ummm...Well, I guess you're already doing the physical exam."
He's specifically told me not to undress the patients before he comes in. I feel the blood rush to my cheeks; I'm blushing as if my parents have caught me canoodling with a girl.
This lady is sixty-five years my senior! my inner voice protests.
"We'll need to do a full breast exam," says the doctor. While we're at it, I give him the history of present illness.
"What do you think we should do?" he asks.
"A biopsy for sure, especially in the setting of a history of breast cancer requiring a mastectomy," I respond.
"Correct, very good, Matthew."
Gold star for The Matt. Score!
Then, as Mrs. Whoever She Is gets dressed, she tells me a story.
"You know, I was an ICU nurse many years ago. I used to have fun with you medical students. When I was working on labor and delivery, I would carry the preemies in my nurse's apron to keep them warm. Before a medical student would show up to examine the newborns, I'd wrap a saline bag in a blanket and place it in the crib. When the student discovered that the baby was missing, I would yell, "You lost the baby?! You're going to be kicked out of medical school!" The student would run around the ward, looking for the baby in cupboards and under tables. Just as he was about to lose it, I would show him the newborn in my apron."
I laugh aloud, appreciating the joke--and the reminder: in the hospital, nurses are in charge. Worship the ground they walk on.
She's definitely my grandmother. Lorene could always make me laugh.
We set her up with an appointment for a biopsy.
I look up her actual name (it's been right in front of me the whole time, there in the electronic medical record), and we prepare to part.
"Goodbye, Mrs. Smith."
She's a cool lady...She knows that her breast cancer has likely recurred, but she's happy anyway. I guess she's accepted that it could be her time to go.
I wave goodbye.
When my parents and I left Lorene at the end of our last visit to Colorado, I sat in the backseat of the car and looked out the window at her standing on the porch.
Lorene waved goodbye, and I waved back. I knew that I would never see her again.
I smile, remembering Lorene and feeling thankful that she died happy, and that I got to see her before she passed on.
"Matthew, go see this man about his hypertension."
About the author:
Matthew William Webb is a fourth-year medical student at Keck School of Medicine of the University of Southern California. He is applying to pediatrics residency programs and hopes to become a pediatric oncologist. "I became interesting in writing as a way to humanize my patients and to remind myself that they can teach me about so much more than medicine."