The smell of cigarettes lingered after he left the room. We were following up after Howard was admitted for newly diagnosed diabetes in diabetic ketoacidosis (or DKA). DKA is when the cells in the body start to break down protein and fat as a fuel source because they are unable to get carbohydrates due to lack of insulin. The byproduct are molecules called ketones that create an acidotic state on the body which can be life threatening. This is often the first sign of type 1 diabetes where insulin is not present. Howard was in his late 60s. It was weird that he would develop diabetes at this point in his life. Type 1 diabetes is usually found in teenagers.
Howard was a great guy. He was practically deaf so our visits were filled with me yelling to try to get him to understand me. Then he would look at his wife who was a great translator. She translated by yelling louder and talking a little slower. For some reason he always understood her. He was a “good ol’ boy” who worked hard as a maintenance man prior to his retirement. Now he spent his days at the casino where he had apparently won and lost “thousands” of dollars. He continued to smoke two packs of cigarettes per day despite my urgings to have him quit now that he had been diagnosed with diabetes.
Over the next few months, Howard, his wife and I became friends as we saw each other often to get his diabetes under control. He was an already thin man but he was slowly losing weight despite our efforts and success in controlling his diabetes. When we finally had his A1c (diabetes marker) in an acceptable range and his weight continued to go down, we decided to look into it more closely.
Initial basic lab work was unrevealing. We had to keep looking. Upon further more in depth questioning he stated his only mild complaint was a vague discomfort in his upper abdomen worse when he ate. A clue, I thought. I ordered an ultrasound.
The ultrasound returned showing a normal liver and gall bladder but the pancreas was obscured by gas. A common and frustrating problem. The common bile duct was slightly dilated. His weight had continued to go down a few lbs over the 2 weeks it took us to get the ultrasound and lab work. I had to look further. We moved on to a CT scan. It was scheduled and the result returned a week later. I reviewed them before going into the room.
The results were devastating. The scan revealed a large mass in his pancreas very concerning for cancer. The progression now made sense. His diabetes was the result of the cancer destroying the normal cells that usually produce insulin. As it progressed it started to cause pain and the tumor was consuming most of his calories causing the weight loss. The mass had started to compress the bile duct making it dilate from increased pressure. I referred him and after seeing an oncologist the diagnosis was solidified: Pancreatic cancer.
Pancreatic cancer is probably the most aggressive of cancers and a diagnosis is essentially a death sentence. Only 23 % of people survive past 1 year and most don’t make it past 6 months. I was devastated. Howard was such a nice man and more importantly, he was my friend. I saw him back after the diagnosis and we had a conversation about hospice. He and his wife agreed that they did not want any intervention. They just wanted him to be comfortable.
The visit was emotional. We prayed. We cried. We hugged. The they went home. The smell of smoke stayed on my white coat the rest of the day, a lingering reminder of my close relationship with Howard. At the end of the day I shrugged off the white coat and hung it up, a symbolic gesture of the coming close to our friendship. Taken away not by choice but by an ugly disease.
Howard died about a month later. His wife had become my patient as well and I saw her a few months after. She was a shell of her old self, still dealing with his death. Most of the visit was spent reminiscing of Howard and how much we missed him. We both just wanted to see him again. I would yell at him and have his wife “translate” and we’d laugh… Losing him was tough. I can’t imagine what his wife was going through.
There is an emotional cost to having relationships and investing in people. However, if I had the opportunity I would do it again. What is the meaning of life? Why are we all here? I have a feeling it has something to do with the relationships we have with other people. Going to work, educating ourselves, and staying in shape are all wonderful things, but they pale in comparison to the investment of pouring yourself into another person. It is truly an investment because you will gain back interest and dividends from it. I encourage you to find someone to invest in today. You won’t regret it.