Being a well-trained and experienced neurosurgeon, I immediately noticed the dull gray nail protruding almost 1 cm out from Mr. Jones’ head.  The shaft had pierced his scalp through his fine and neatly trimmed hair immediately behind his left ear. The remainder of the 8 cm spike was embedded in his parietal lobe.  Congealed blood encrusted his pinna and coated the side of his neck. Aside from disorientation to place and time, he was in good neurologic condition. 


Mr. Jones had long ago retired as a foreman of facilities maintenance at a college campus, his eldest son, a stout middle-aged fellow with darting blue eyes, informed me.  He remained active and independent with the continued passion for carpentry. “He goes down to the garage every day and makes really nice furniture, really professional stuff.”  The octogenarian had fallen, suffering a nail gun accident also involving two nails to his left chest. “My mom found him down there when he didn’t come up for dinner”.


Synchronized members of the healthcare delivery team efficiently whisked Mr. Jones from the emergency department and conveyed him to the operating room.  A combined thoracic and neurosurgical procedure ensued expeditiously, resulting in the successful extraction of all foreign bodies. Although the clinical presentation was dramatic, the technical aspects of the surgery were mundane.  Mr. Jones was seen convalescing on the ward with neither focal neurologic deficits nor cardiopulmonary complications. 


On the second postoperative day, I found the genial patient sitting in a chair, charming the nursing staff.  Mrs. Jones, dressed in a powder blue track suit, her frizzy hair dyed black, fed him clear broth, carefully examining each spoonful through her thick spectacles.  “Another neurosurgical triumph”, I thought.


The etiology of the traumatic event, two shots to the heart and one to the brain came into focus when Mr. Jones’s long-time family physician made rounds that evening.  Dr. Smith, features drawn tight, explained to the hospital team that Mr. Jones harbored a newly diagnosed malignancy at the base of his tongue. The consulting oncologist had offered the patient an extensive disfiguring surgery, coupled with a tracheostomy and a PEG, followed by debilitating chemotherapy. 

When the anguished Mrs. Jones inquired if her husband had any other options, the oncologist blithely explained “that’s the standard treatment.  There is no way to cure this type of cancer, but we can give you a few extra months.” 


Dr. Smith, a slender, attractive woman in solo practice whose white lab coat bulged with electronic devices and medical paraphernalia succinctly summarized the rationale for Mr. Jones’s suicide attempt.  “He’s a proud guy. He didn’t want to go out that way. He didn’t want his grandkids to see him like that.”


The discussion between the oncologist and the patient was bereft at the option of palliative care.  No one had suggested Mr. Jones might enjoy the time with friends and family during the months while he still had minimal symptoms.  No one had told him that when the time came the symptoms could be controlled while the cancer took its lethal course. No one advised him of the possibility of a shorter life on his own terms.  The treatment alternative that would have been most palatable to the patient and his family had never even been offered.


“I don’t think the medical profession did Mr. Jones or his family much of a service,” Dr. Smith quietly said.  She walked away looking down and shaking her head.  


Sometimes we are so enamored with our own treatment preferences that we neglect to consider options which may be a better fit for our patients.  Sometimes we are so eager to tackle an obvious problem and declare a victory that we fail to dig deeper and explore alternatives which would potentially contradict our favored narrative. 


The first thing I noticed when I met Mr. Jones was not the cause of his problem but a symptom. Discovering what was wrong with the picture required seeing more than what was on the X-ray.