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A picture worth (even more than) a thousand words


The author learns that the value of close communication between doctor and patient-whether through words, appearances, or movements-has no price, no measure of productivity.

For me, the image of a round-faced man struggling for breath in a hospital emergency department (ED) had hung in the reaches of my mind for more than two decades, until it flashed before me again in an office hallway on an otherwise uneventful afternoon. Such a picture illustrated one of the reasons why it's good to be a doctor-sometimes, I have the chance to save someone.

Tony was in his 40s, dark-haired, and muscular, with a winning smile. A regular patient in my family practice, his mild hypertension was well-controlled, and his only other health issue was a pacemaker, which had been inserted years before I met him to manage an irregular heart rhythm.


As he arrived one afternoon for a routine visit, I saw him walking down the hall toward the exam room. His gait seemed unusually tentative and slow, each step carefully measured.

Most striking was the appearance of his face-it was purplish and his head appeared to be larger than normal, distorting his familiar smile. I sensed tension replacing his usual relaxed aura. Our eyes met, and immediately we seemed to tell each other what was wrong without saying a word.

I flashed back 25 years earlier to my internship, to an evening in the ED, when a man in his 60s arrived with respiratory distress. Other than his shortness of breath, I noticed his purple face and "big head." His look of fear cried out, "Please help me, I'm going to die."

A chest x-ray confirmed his dire state. He suffered from superior vena cava syndrome (SVCS), a medical emergency. In his case, a lung tumor was causing blood to back up from obstructed flow to his heart. Untreated, it could kill him. I had never seen a patient before or since with SVCS.

I walked into the exam room and after saying hello, my next words to Tony were, "Big head."

"Yeah," he agreed. "It's not getting any better."

The words "superior vena cava syndrome" came from my mouth, it seemed, before I had formed a sentence in my mind. I wasn't sure of the cause, but I told him I thought I had seen his problem once before. And I thought Tony had SVCS, basing my diagnosis on that picture forever etched in my mind from years ago.

"What is it?" he asked.

"It's something blocking the flow to the large vein draining blood from your head, and it's serious," I said.

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health