With friends like that …

Mrs. Silverman was not one of my success stories. I was an intern when we met the morning after her admission for a hemorrhagic stroke. She was massive, lying in bed with her flesh spread around her like old-fashioned petticoats. (When she died, a year later, she had shrunk to half that size: a skeleton draped in way-too-large skin.)

Mrs. Silverman went home from the hospital in a double-wide wheelchair, her off-kilter smile reminding me that I’d done virtually nothing for her except control her blood pressure and get to know, and like, her. Over the ensuing months, as the blood that had crashed into her skull — a destructive, uninvited house guest — gradually retreated, her warm smile became less lopsided. Her smile was contagious — seeing her in the outpatient clinic was like visiting with a friend who always cheers you up. Then Mrs. Silverman started losing weight. As the pounds disappeared, I decreased, then discontinued, her blood pressure medication. Inexperienced fool that I was, I congratulated her. Together, we’d cured her hypertension! The crooked crescent adorning her face expanded with pride.

Eventually — much later than it should have — it hit me that effortlessly losing so much weight was not a good sign. I questioned her: Did she have a cough? No. Fever? No. Blood in her stool? No. Except for an aching arthritic shoulder and weakness from her stroke, she felt fine. A shoulder x-ray revealed mild arthritis. I gave her ibuprofen and began the onerous and invasive processes that would, over the coming weeks, exhaust her while accomplishing little. Physical exam, breast exam, pelvic exam — normal. Mammogram, chest x-ray, barium enema — also normal. Blood tests — nothing but mild anemia. Meanwhile, the shoulder pain worsened; the ibuprofen hadn’t helped.

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I switched her to another NSAID, explaining that I did not want to use anything stronger until I knew what was causing the pain. Mrs. Silverman accepted the new, and useless, NSAID with her usual grace. (Years later, that decision still haunts me. What harm could possibly have come from relieving her pain with an opioid? She had no history of substance abuse, and, though we had no diagnosis yet, the source of the pain was obviously something serious.)

When a third NSAID didn’t touch the pain, which was now waking her nightly, I repeated the shoulder x-ray. The arthritis was unchanged, but something had taken a huge bite out of her first rib, which was just visible on the edge of this film. I was baffled: she’d had a normal chest x-ray one month ago. I pulled the month-old film. The lesion was obvious. How could we have missed it? Easily: all of us (the radiologist, clinic attending and I) had made the common but inexcusable error of focusing so hard on the normal lungs and heart that we’d ignored everything else, including her tattered rib.

If you’d knitted a skeleton out of wool, hung it for a summer in a closet full of moths, then photographed it, that was what Mrs. Silverman’s bone scan looked like. Innumerable bones had innumerable chunks missing. Mrs. Silverman had metastatic cancer of some unknown primary.

I started her on morphine, and her gratitude made me cringe with guilt from having allowed her to suffer unnecessarily all those weeks. “I’m sleeping again,” she exclaimed, smiling her now gaunt, but still radiant, almost-full-smile.

“I’m so sorry for your loss,” I said to Mrs. Silverman’s daughter after the funeral (neglecting to mention everything else I was sorry for).

“She always thought of you as her friend,” she answered, “and she always felt she was in such good hands.”