The most private treatment room in our Emergency Department happened to be the only space available when she arrived. I could see her through the open door, a middle-aged woman perched on the edge of the stretcher. She was impeccably dressed in a classic style that spoke of old-school manners and affluence. But she still wore her winter coat and thick scarf despite having been in the hospital building for over an hour. Slender fingers plucked nervously at the hat and gloves on her lap. I smiled as I entered. She avoided my gaze, preferring to study the floor.
I glanced at the Triage notes. Lena was 56 years old. She arrived complaining of pain in her chest and shortness of breath. Normally those statements would send her directly into a cardiac work-up, but words alone can deceive. At first glance, she looked healthier than most people who came to us. There was no other obvious evidence to suggest either urgency or a heart problem, although the subtle anxiety in her gestures suggested that she had reason to seek help. The triage nurse felt that we had the luxury of time to discover Lena Fogol’s problem. My instincts agreed.
“Hello. I’m your nurse, Mary. What brings you to Emergency today?”
“My son.”
I smiled inwardly. It was one of the oldest jokes in the ER but clearly Lena was unaware. She slowly lifted her gaze to the closed door behind me. “Do you know where he is?”
“In the waiting room,” I told her. “He can come in to sit with you after we’ve had a chat and I do a few simple tests.”
People often show mixed emotions when they are close to revealing their darkest secret to a stranger. Lena looked vulnerable, haunted, and sad.
“We need to get you out of these layers and into a hospital gown so that the doctor can examine you.” Lena sighed and carefully removed her coat.
“It’s so cold in here. Could I keep my suit on?”
I stalled before answering, making an exaggerated show of recording her pulse, respirations, and temperature. People are always afraid in the ER. They are frightened by the everyday world of doctors, nurses, needles, blood, medication—even hospital smells and trays of cold oatmeal. Some arrive with expectations that will never be met. The saddest of all are those who have ignored or denied the signs of illness, delaying treatment and putting their health in jeopardy.
At that moment, Lena’s fears—whatever they were—prevented me from helping her.
“I’m sorry. We can’t examine you properly if you’re fully dressed.”
She looked into my eyes then, and I softened. “Let’s leave the change of clothes for last, and I promise, I’ll get you a blanket from the warming cabinet. Okay?”
“Yes.”
“Your chart says that you’ve been having chest pain and shortness of breath. Do you have any pain right now?” I pulled my stethoscope from around my neck and inserted the earpieces but her left hand captured my wrist before I could move the instrument toward her.
“No! I don’t have any pain.”
“That’s good, but could I listen to your heart and lungs anyway? It’s important.”
Lena took a moment to think about that before withdrawing her hand from my arm. She whispered something that I didn’t hear.
“I’m sorry, could you repeat that?”
Her head snapped up in a flash of anger. “I’m telling you. There’s nothing wrong with my heart and lungs.”
“You seem very sure about that,” I said carefully.
As a gesture of reassurance I gently touched her right shoulder. Lena jumped away as if my hand was on fire. She fell across the stretcher onto her left side. “Don’t help me! Don’t…I’ll…I’ll,” she stopped abruptly, steadied her breathing, and managed to sit up again.
In that moment, Lena surrendered to the situation. She waved me away and began to unfasten the buttons of her jacket. Instead of a stylish blouse to match her suit, I was shocked to see that she wore a thin T-shirt with faded stains. Layers of thick padding were visible beneath it. They covered half of her chest.
“I might need help now.” And so we worked together, slipping her left arm out of the cotton shirt and then pulling it over her head. Lena could barely lift her right arm. I gently tugged the shirt until it fell into my hand.
My eyes were on the six-inch-wide bandage encircled her ribcage, holding extra large surgical pads against the right half of her chest, from collarbone to waist.
Lena nodded.
I began to unwrap her secret.
The outer pad fell away as I loosened the binding. A nauseating stench rose immediately from within. It looked like two more layers of thick dressings lay against her chest.
More accurately, they were inside her chest. Surgical pads filled the place where Lena’s right breast and ribcage should have been.
She sat stoically until I removed the rest of the bandage. Then, her story tumbled out.
“I didn’t tell anyone. I didn’t want my youngest to worry. He had to finish school, to start his life. I thought that it was just a little sore, a nuisance that would go away…”
Advanced untreated cancer had not only taken her right breast but also a large section of skin, muscle, and bone. A few small areas of pink lung tissue were visible and dotted with ominous black spots. The hole in her chest was a ragged, seven-inch circle more than one inch deep.
Until that moment, the triage nurse and I had believed that this woman was reasonably well.
How was this possible?
I found it difficult to imagine the pain of such a wound and impossible to comprehend how Lena had endured the slow decay of her body.
“How long has this been…developing?” I asked.
Lena’s expression shifted from shame to guilt and then profound sadness. “The little sore opened up about a year ago.”
“Did you see a doctor?”
“No,” she said. “I don’t…I didn’t want to know. I have so much to do. People depend on me. I just wanted it to go away.”
She bowed her head and lowered her voice.
“It’s too late, isn’t it?”
I swallowed hard, trying to maintain a professional demeanor. “I…I can’t say for sure. You’re going to need some tests. Several specialists will see you to figure out a treatment plan.”
Suddenly, my words seemed inadequate and my assessment felt like an unnecessary burden. I had seen and heard enough to reasonably describe her condition for the chart. Further details could be left to the physicians and surgeons who would do everything that they could.
“Let’s cover this with a fresh dressing, get you into a gown, and I’ll get that warm blanket I promised you.”
When she was settled I asked, “Are you ready to see your son?”
Lena said, “I know. I have to tell him now.”
From the nurses’ station, I watched a tall young man enter Lena’s room and close the door behind him. I wondered how his mother would explain this and how he would react.
As I began to write my note in her record, an ER doctor entered the room. She stayed only minutes. I was half-way through my description of the wound when Lena’s name winked out on our active patient board. Two interns whisked her out of the ER, probably to a bed upstairs where a cancer team was waiting. Lena’s wardrobe was unceremoniously stuffed into two plastic bags in the stretcher’s carry basket. Her son walked alongside with his eyes fixed on the floor.
As with most people who come to the ER, I never learned what happened to Lena, but certainly her prognosis was very poor. I do know that in twenty extraordinary minutes she taught me about the importance of everyday choices and the power of fear. Our encounter made me a better person, nurse, and health advocate. She would never know that, but to me, Lena was unforgettable.
