The Maroon Baseball Cap

Author: Tara Pilato ’17

From the hospital bed trapeze swings a maroon baseball cap, nestled alongside a watercolor-splatter silk scarf.

“How are you doing today?” I vaguely hear my attending say.

Our patient, N, responds haltingly: “Today was . . . an ok-ay day. I think? I was able . . .  to use the bathroom.”

N’s story is the sort of tale feared by the average, WebMD-following, Doctor-Google-using everyday American. A few months ago, the young, 34-year-old woman was bothered by eye irritation and tearing. Several appointments with a primary care provider, ophthalmologist and retina specialist later, she was asked to undergo a PET/CT scan.

The diagnosis? A choroidal metastasis. Numerous, nodular brain metastases, including two in the cerebellum. Thoracic spinal lesions. Lung metastases. Leptomeningeal disease.

The treatment? Whole brain radiation.

Some days after completing a round of radiation, N was admitted to our hospital due to constipation and urinary retention. While her primary cancer had not yet been identified, she ended up on the GI-Oncology service, as a biopsy taken from one of her numerous lung metastases was apparently suggestive of a GI malignancy. She arrived overnight; the brain metastases were unchanged, and our hospitalist team feared cord compression. N was urgently started on further lumbosacral spinal radiation. As I read over her history in the handoff, and met her the next morning, my heart jumped into my throat: I recognized that I wouldn’t be able to adequately compartmentalize my emotions to take her on as one of my patients.

“Oh, yeah? It’s great to hear that you were able to walk some already today, I heard physical therapy came yesterday . . .” floats my attending’s voice, fading in and out of my primary consciousness.

On the wall next to the bed stands a small wooden crucifix.

On the whiteboard, a written mantra:

“N Wife Mother Sister Daughter! Here to Fight! Against! Cancer!”

Several wedding photos, taped up. Long, luminous blonde hair, and bright eyes: how N had looked prior to treatment.

A pencil-scrawled note, outlined with hearts, in a second or third-grader’s handwriting:

“I hope you feel better soon, mommy!!”

During N’s two weeks with us, I scoured her chart, wanting to know more about her story, wishing I was brave enough to sit next to her and ask about her life. There wasn’t much to find in her chart: other than a Cesarean section, she had no significant past medical history. N delivered twin boys, now 8 years old. By this time, she was unrecognizable from the pictures taped to the whiteboard. N spoke out of only one side of her mouth, a symptom that began approximately a month ago. Her speech was labored, and her thoughts didn’t always connect often, her husband often had to fill in the blanks. A few times, I saw N work with physical therapy in the hallway outside our workroom. N’s gait was grossly ataxic due to the metastases in her cerebellum. Her husband trailed quietly behind her; I don’t think she was aware of his silent sobs.

N’s mother travelled overseas to take care of her in the hospital. Although she did not speak a word of English, the mother knew about our rounds every morning, and prepared her daughter for the team’s visit. Watching her mother aid N in doing the simplest of tasks, such as guiding a toothbrush-gripped-hand towards her mouth, is an image I won’t soon forget. N’s mother would also help her manage the aggressive bowel regimen prescribed by our team, and somehow make sure nursing was aware if there were any issues with her daughter’s foley. Once my team entered the room to speak with N and her husband, N’s mother would dart outside the room, waiting.

Every day, the plan was the same: further radiation. 10 to 14 treatments, depending on her response. Although it was likely too early to tell, the cancer in N’s spine and brain showed no signs of shrinking. Every day, I quickly left the room in front of my residents, choking back my emotion.

During the second week of N’s hospital stay, her husband began standing outside her room, waiting to speak to us before we entered. He wanted to hear our plan before stoically entering the room and helping us present it to his wife. On hospital day 10, my attending wished to plant the seeds of the goals-of-care discussion with the family. Outside the room, she told N’s husband, “the risk-to-benefit ratio of further treatment is very small. I want your wife to know this. We need to tell her she has limited time.”

In N’s room, I am back in the present. I hear the channels flicker between the cheery music and “Come on DOWN!” of the Price Is Right, and the news barrage of the impeachment hearings.

My intern lowers the volume, as my attending asks N several questions. Eventually, she inquires whether N would like to go home for the weekend: “We want you to think about spending time with your family. While all of our time on this earth is finite, we fear yours is more limited than most.”

“How much . . . time . . . do you think I . . . have?” N asks.

“We hope it will be longer, but worry it may be weeks to months,” quietly replies my attending.

I sense N’s husband’s shoulders swiftly crumple, as my nails dig into my palms.

I affix my eyes to the plain maroon baseball cap hanging above the bed, and the watercolor-silk scarf wrapped next to it.

As a lowly medical student on this subspecialty service, I did not speak up much. I felt insignificant, smaller than an insect in the sadness and emotions enveloping every patient’s room. During several of the end of life, “do not resuscitate” discussions, I would have liked nothing more than to melt onto the floor and trickle away into the floor vents covering the heating ducts.

Questioning my team’s decision-making process or medical management felt insincere; the real questions I wanted to ask would make my tears overflow. Every patient had an incredible story of lives lived fully, courageously and beautifully. It was difficult to go home every day, remembering the majority of patients on my list might not be alive to see the new year.

I was not brave enough to ask N to tell me her story; I’m positive she would not recognize my face. I was afraid of failing to successfully compartmentalize my emotions, and of being just another stranger barging into the darkest hours of her life.

I hope one day to be courageous enough to recognize N in the faces of my future patients, and help to give their darkest hours the smallest bit more light.

Tara Pilato’s essay received an honorable mention in this magazine’s 2020 Young Alumni Essay Contest. She graduated with a B.A. in music performance (viola) and a supplementary major in pre-health. She is now a fourth-year medical student at Weill Cornell Medical College in New York City.