Friday, October 10, 2008

From Old Blog - The Big C

The Big C
They were doing an exploratory abdominal surgery where they open up the abdomen to see if they can find what is wrong. And they found it. An adhesion. Scar tissue from a previous surgery. This is what had been causing this 78 year old's sharp abdominal pain. This is what was causing her discomfort, her nausea, her stomach distention. This caused her small bowel obstruction. With the slice of a blade - it was cured. Medicine is truly amazing.
Before closing her up, the surgeon explored the abdomen for any other potential abnormalities. And there it was - a...lymph node. Larger than expected. The path report came back...
Squamous Cell Cancer
Poor lady. While she was in recovery, her family was told the news. Indepth discussion amongst them and the surgeon lead to a decision at the request of the family: Don't tell the patient until the primary source is found and the options are known.
(When a lymph node is positive for this type of cancer, this in most cases means the cancer has originated from somewhere else and has spread into the lymphatic system)
The surgeon called me with the news on my patient.
Squamous Cell Cancer. Primary cancer location unknown. Patient unaware per family's request.
Now that is a tough situation to say the least. I mean, this lady is one of the absolute sweetest patients I've ever had - an absolute sweet heart who came to the hospital for nausea and abdominal pain. Her symptoms improved dramatically after the surgery. Soon, she was eating again, and felt ready to go home.
Further workup the next day and the source was found - cancer of the esophagus...throat cancer.
I talked with the son that evening who assured me that that night was the night. The family had arranged to meet with one of the other doctors on the case and together, they would tell her the news. He couldn't bring himself to do it alone as he originally planned.
I emphasized that it was vital she be informed as soon as possible so that we could get an oncologist (cancer doctor) on board and he could examine her and review her options.
When I came back early the next morning, I spoke with the son who said that the doctor never showed up and she still didn't know. I asked if he'd like me to tell her with him present.
"Yes, please."
Now that I think back on all my patients since med school to now, I cannot remember ever having to tell a person that he or she for certain had cancer. I do remember telling a patient that she more than likely had kidney cancer (but it wasn't confirmed). That was quite similar now that I think about it. I guess it just does not get any easier. I also remember as a med student having a patient with liver cancer, but the doctors told him. In both of those cases, for whatever reason, those two patients died within two weeks. They were really really sick. Their sickness and hospitalization was directly related to their cancer - unlike this situation.
Anyhow, this was me. I was the doctor...I am the doctor. It's up to me to tell my patient that she definitely without a doubt has cancer.
I call the chaplain. I think it very appropriate he be there as I tell this lady...the one who has improved everyday since surgery...this sweet lady who only wants to go home since she feels tell her she has cancer.
I walk in the room with the chaplain. The son is there. He knows the plan...and so I begin.
The one thing I do remember learning in medical ethics is that once you say the word CANCER, the patient likely will not hear anything else.
"Ms. Smith**, I just want to give you an update of what all is going on..."
I take it step by step starting with what they found during the surgery and as soon as I say the C word, she screams, "CANCER!! Oh my goodness! Oh my goodness! No! No!" and she screams and cries, cries and screams. I pause. Thank God the chaplain is there. Thank God her son is there. I give her time as I hold one of her hands. Her son has the other hand. I explain the rest of the findings and where we go from here. The chaplain leads us in prayer.
And just like that, her life is turned upside down. A curveball thrown at her.
Options for her include what's called palliative chemo. Anything palliative means it may help but it certainly won't cure. Her and her family are still deciding what to do.
Makes me wonder.
If she had never gotten the small bowel obstruction and came to the ER for nausea and abdominal pain, the positive lymph node would have never been found, a search for cancer would have never been started, and the fact that she had cancer would not have ever been known.
But was it a good thing that the cancer was found...or would she have been better off never knowing?
(**Names and some details changed to protect identity

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