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an online version of the magazine Fall 2004
Learning Curve

Role Reversal

Dan Munoz
By Dan Munoz,
School of Medicine, '04
From the start, I had a feeling this one would be different. “What brought you into the emergency room this evening, ma’am?” I asked Mrs. Jones (I’ve changed her name), a woman in her early 50s who had been rolled back in a wheelchair to ER bed 15. She apparently was too weak to walk.

With a pleasant smile but a tired voice, she responded, “My potassium is low and I have pneumonia.”

Unclear as to how exactly she could have self-diagnosed with such oddly specific precision, I asked her a few more questions. Her son helped fill in the details. Soon, a more complicated picture began to emerge. Relatively healthy until four or five months prior, Mrs. Jones began feeling inexplicably fatigued. Each day she felt progressively weaker, less able to do the things she liked. Stairs became more difficult to climb and falls became more frequent. Her weight went into a downward spiral. Something was not right. After several doctor visits, and a battery of tests and procedures, a frightening answer surfaced. She had cancer. And it had already spread to her liver.

Then, earlier today, Mrs. Jones had gotten a call at home from her doctor. A CT scan from the day before, done as part of the routine staging process for her cancer, showed possible pneumonia. In addition, blood work from earlier in the week had reportedly shown her potassium levels to be low. Her low potassium, likely a result of her particular type of cancer, was not new. And according to Mrs. Jones, it was the clear reason for her fatigue.

Rather than go to their local emergency room, the Joneses had decided to travel across the state to Hopkins. With an appointment to see a Hopkins oncologist in a few days, they did not want to risk missing it. Her son handed me a copy of his mother’s CT scan from the day before. I told them we would run a few tests. Forty-five minutes later, my resident and I had some encouraging results. “Your potassium is fine and your CT scan doesn’t show any obvious evidence of pneumonia,” we reported, after reviewing the films with the radiologist on call and performing some initial blood tests.

“So I can go home?” Mrs. Jones exclaimed. It sounded more like a victory declaration than a question for us.

Before we could respond, her son interjected, “Do you mind if we talk outside?” His eyes telegraphed that this discussion was not yet complete. He walked out into the hallway with us and in a soft but firm tone began to share his worries. “She’s in denial,” he explained. “She latches onto other issues and focuses exclusively on them. She focuses on her potassium and attributes her fatigue simply to that. Anything but her cancer. She doesn’t get how sick she is. She doesn’t get how difficult it has gotten to take care of her.”

He paused. “We’re overwhelmed. My father is not capable of taking care of her. He’s dealing with his own medical problems. And he has to work. Without his health insurance, we’d have no way to get her the care she is going to need. And I can’t be there all the time either. If I hadn’t stopped by the house this morning and found her in the bathtub, unable to get up, she would have spent the whole day there.”

There, on vivid display before us, was the stunning maturity of a 28-year-old. In the absence of anyone else—a spouse, a parent, someone older in the family capable of taking on a leadership role—he took on his parents’ denial to face the undeniable facts. After he’d spent almost three decades looking to his mother and father for guidance and advice, for protection and for shelter, his role reversal was powerfully evident. He was now involved in dealing with an enormously difficult decision, a more torturous choice than most people his age commonly face.

We stepped back into the room. With a loving calmness and candor, in front of two virtual strangers, he presented the reality to his mother. He explained how difficult it had become to care for her, and how increasingly ill-equipped he and his father were to accomplish that task. He told her that he loved her and would respect her wishes, namely to go home. But he shared with her his pain of seeing her like this and his admission that he felt overwhelmed by the home care she required. He paused, and then with a hint of unsteadiness whispered, “Mom, I think you should stay here.”

It was one of the gutsiest displays I had ever seen. Rising above his sadness and the generational impulse to defer to his parents, Mrs. Jones’ son looked his mother in the eye and told her the hard yet inescapable truth. He was respectful but direct. And despite our presence, he did it on his own. I could not avoid wondering whether I would have the same courage were it my mother.

In that moment, Mrs. Jones’ son became a parent sooner than he had ever planned, and in a setting devoid of joy or promise for the days ahead. And that, along with the sadness I felt for a family facing a devastating diagnosis, was both inspiring and humbling.

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 Circling the Dome
 Medical Rounds
 Annals of Hopkins
 Learning Curve
Johns Hopkins Medicine

© The Johns Hopkins University 2004