Something More

The name on the front of the chart was Tom. In truth, I cannot remember his last name. Tom’s age wasn’t exactly known. He was probably in his mid-forties with a receding hairline to his afro. The chart also listed the home village. The name was long, and I didn’t recognize it, but then I don’t know most of them so I skimmed over it. I did know that Tom came from the area known as, “Middle bush”, which is pretty much any area not on the coast of the island. He seemed to have a wife and children though I didn’t really check. I don’t know what he did for work, or if in fact he did do anything other than tend his vegetable garden, and care for any pigs he might have owned, sustaining a hand to mouth existence. He wasn’t from a kastom traditional village or anything like that so he dressed like a pretty average guy on Tanna, wearing T-shirts and long shorts that were perpetually grubby from the dust and volcanic ash. While he may not have dressed differently, he did look different. It wasn’t obvious at first glance but as you got closer to him you would have first noticed that he was underweight. Then, as you got close enough to talk, you would notice that something wasn’t right with his face. You’d probably notice the eye first. His left eye was turned in, like it was perpetually trying to look at the bridge of his nose. Then you probably would have slowly realized that something wasn’t right with the left side of his face. The jaw was roughly the right shape but there was a lack of symmetry compared with the other side. The left was bigger, much bigger, and when you heard the difficulty he had speaking you would know that something bad was growing there. 

I think that in our core, primitive reptile brain we have a reflex that’s hard-wired in. It’s a reaction to the recognition of some signs of disease when you see it, a recoiling from it, and I think evolution made it flourish because it pulled us away from anything that might be contagious. You feel it when you see certain signs of illness, even when you may know intellectually that there is no risk of transmission. For physicians, this reaction gets hammered down over time like a nerve that’s goes dead. I don’t know what it’s like for other doctors, but every now and then I can sometimes still get an initial flicker of it, if only for an instant.  Psychologists have established a strong link between how symmetrical a person’s face is and how attractive they are perceived to be. Conversely, over the years I’ve noticed how a marked lack of symmetry in the face, from disease or trauma, reliably provokes this reflex in most people, sometimes even myself. 

 

I felt that flicker the first time I saw Tom on the ward. I don’t think he noticed, and I’m sure he had seen much worse. He had come to hospital because it had become too painful to eat. Tom had a cancer on the left of his face. It had wasted his body, disfigured his face, destroyed the nerve that pulled his left eye to the side leaving nothing to oppose the one pulling it to the center, and now the cancer had become infected. As awful as this sounds, it’s far from unusual here on Tanna. We’d been getting a couple of cases similar to Tom’s every month, many of them even much worse. Tom actually looked fairly normal until you got up close.  

 

At our hospital nurses do most of the admissions and the physicians will review the patient on the ward later. The first paragraph from the nurse pretty much told the whole story. Tom had a growth that had slowly progressed over almost 2 years before he finally went to Vanuatu’s capital on another island to seek medical attention. He obviously had had some surgery because he had a scar at the site, but he couldn’t tell us much more about anything else that happened there. The only other thing he remembered was being told was that there was nothing more the doctors could do. Trying to get any records from the capital is futile so we don’t bother any more. 

 

We were very busy that day and I pretty much just skimmed over the rest of the meager admitting documentation such as his social history or family history. His situation was obvious and so were our treatment options, both poor, so best to get on with doing what we can. We don’t have much to offer terminally ill patients here. At home, this area of medicine is a discipline unto itself, but in Vanuatu our offerings are pretty basic, mainly trying to fix any complications of the illness that we can, such as secondary infections. There’s nothing like prescribing Tylenol to fight cancer pain to make you feel inadequate in your treatment plan.

 

Tom was with us for about a week or so. His infection settled and he could eat small amounts of soft food. He said his pain became controlled but no matter if he said it was good or bad, I never saw any difference in his demeanor from day to day – stoic, but not in any angry, defiant way. I’d probably describe it as…….calm.

 

Each day I saw him we talked for a just a couple of minutes about how he was doing. These interactions were genuine but brief and relatively unremarkable. This whole month has been very busy at the hospital so between the time pressures and the language gap, I wouldn’t say I rushed, but I didn’t linger. I can at least say that I did show him what I figure is always the very minimum I can do - ask him, with my full attention, “How are you?”, and mean it.

 

I was able to do some investigations for Tom. A chest X-ray showed metastatic cancer lesions in his lungs. The ultrasound I did showed the same in his liver, big ones. Tom was going to die. It would probably be gradual, but it wouldn’t take too long now, especially once he could no longer eat. Tom would do what all the terminally ill patients here do, go home to their hut and be cared for by their family until the end.

 

The morning I discharged Tom was in the middle of a very unusual 36 hour stretch for me at the hospital. There were quite a few serious things to deal with, a couple of them just a bit too extreme to write about here. Suffice it to say I was in a bit of an altered state by the end of it, the kind where you know your brain needs a little time and distance before it can process what just happened. On top of this was the impending visit to the hospital that day from Vanuatu’s new Prime Minister. He was just elected a few months ago and is the first leader the country has had who originates from our island of Tanna. This is quite a big deal for people here as Tanna has a bit of a reputation for being a backwater of Vanuatu, and for being full of what they call Man Tanna, the Vanuatu equivalent of redneck.

 

The hospital was buzzing with excitement and activity. All the hospital staff were there, dressed up in their best clothes. Flowers were hung from the ceilings and from trees around the grounds. Even the road leading up to the hospital had been lined with flower petals on both sides. It was quite pretty. I took special note of a few balloons hanging over the front entrance. Consumer goods are pretty limited here and I had never seen a balloon on Tanna before.

 

The visit was fairly brief and perfunctory. More of a quick tour and a photo shoot than anything. The Prime Minister seemed nice and I had a chance to meet him and his cabinet. I wanted terribly to ask him if he could get the health ministry to finally pay me at least some of my outstanding salary, but figured I’d better hold back. Still, it was hard not get a little caught up in all the excitement.

 

The visit wound down after about half an hour. We went out back behind the hospital to take a few group photos and then the Prime Minister left with his entourage. Everyone was milling about, excitedly comparing and exchanging the pictures they had taken. I was in the midst of figuring out how to send a photo via Bluetooth when I happened to look up. A lone figure walking quietly down the petal lined path away from the hospital caught my eye. It might have been how calm he was amidst all the commotion, cutting through it like a stone protruding from a river of running water, or maybe it was the four brightly coloured balloons in his right hand.  His back was to me and in front of him stretched the falling coastline leading downhill to the beach and then the vast ocean and horizon beyond. I knew it was Tom, and I knew that I was watching him walking home to die.

 

My first thought was, “What could possibly make a man in that situation take the time to acquire those balloons?” My second, of how surreal this scene was - him walking away amidst all that excitement, through the crowd and the decorations and the picturesque backdrop to it all. My third was that I wanted to capture the image. I took out my camera but then stopped. It didn’t seem right to take the picture without asking so I called out his name. He stopped and smiled and came toward me. I asked if he was going home and he said he was. I told him simply that I wanted to take his picture. What he did next struck me at the time, but in the moment I didn’t know what to make of it. He tidied his shirt, made his back ramrod straight and lifted his head high and proud. It surprised me. I wouldn’t have expected a man under those circumstances to do that. I took the photo.

 

As I went to say thank you and goodbye I felt regret. I knew that there had been nothing wrong with my medical care for Tom. It had been…...” fine”. No one would have said I should have done anything different, but the unavoidable fact was that I knew I could have given more, and now I wished that I had. More what? I don’t know. Compassion? Time? I really wasn’t sure, just something…….. more. I tried to let him know by the way I shook his hand, putting my other on his shoulder and saying as kindly as I could, “Good luck. You can come back if you need to.” By his response, I’m pretty sure he understood what I was really trying to say. We turned and parted ways, each of us going off in our own different directions.

 

To be honest, ordinarily I would never write something like this for so public a forum. It’s just a little more personal than is entirely comfortable for me, and I always worry about the perception that I’m trying to glamourize things. However, as I sat here tonight, having had some time and distance to let the day’s events marinate, I think I came to understand what happened when Tom got ready for that photo. I think he was trying to say, “I’m still here. I don’t have to hide. I’m still human enough to care about presenting myself the best that I can.” I also think that he truly wanted me to take that picture, thinking that maybe, if he made it good enough, I might show it to others, and the more people that saw it, the more powerful his statement would become. I’m still here. I don’t have to hide. I’m still human. When I realized this, I knew I still had a last chance to do something more for him, and the idea wouldn’t let me go until it was done. It would start with this:

 

The name on the front of the chart was Tom……..

 
 

 

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Originally this essay ended with that photo I took of Tom; standing tall, balloons in hand. Showing it seemed like the whole point of the exercise. Ultimately though I felt that patient confidentiality prohibited me from publishing it, even if that patient lives in the middle bush of Tanna island and even if I know in my gut that he would have wanted it there. I removed the picture, though I desperately wanted to show it, and to as many people as possible. Hopefully after reading this you will also wish that it could have remained. While it's not the ending I envisioned, perhaps it's fitting that all of us are left wanting just a little something more.




Sean