26 April 2010

Seriously, God, knock it off. KthxBai

I got a bad feeling from the 43 year old man in Bed F.  The triage compliant sounded like one of those bloody "not an emergency but it's more convenient so I'll just use the ER" things that never wind up involving any real pathology:  4 months of abdominal pain and constipation.

I had to suppress my initial snarky instinct "so what makes it an emergency today?"  There were clues that this wasn't a lame nothing presentation.  One funny thing was that this guy had never been to the ER in the last five years.  Odd.  Usually people who come to the ER for something trivial do so repeatedly.  And he was a nice guy -- very normal, with a pleasant wife at the bedside. Also a bad prognostic sign - the bad stuff happens to the nicest people, as a rule. I reviewed the records from clinic and he had been seen multiple times there with no clear diagnosis.  He had been seen by primary care, GI, and even by a spine specialist (due to back pain that seemed associated with the abdominal pain).  The poor man was really hurting, and I commented that he was looking thin.  He reported a thirty pound weight loss, and also some bloody mucous in his stools.  I did a rectal exam and felt a hard, smooth lateral mass.  The patient remembered that the spine guy had mentioned an "enlarged prostate."  Not likely, I thought, unless your prostate is not where it's supposed to be.  I put him in for a CT scan.
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The results did not surprise me.  A rectal mass which was almost certainly rectal cancer, with liver lesions consistent with metastatic spread.  I had the terrible conversation, dropped the bomb on them as gently as I possibly could, and admitted him for the work-up and pain management.

What a day.  Fortunately, it's really really unusual to make a diagnosis like that in the ER.  Maybe once or twice in a year.  I deal with a lot of bad stuff, so it's not unusual for me to have to break bad news, but usually it's the final act, not the opening, where I play my role. 

The next day had a bit of excitement.  A 60 year-old man came in with an acute stroke.  Pretty classic -- sudden onset of left arm paralysis, with some strange seizure-type activity.  The radiologist called me and informed me that the CT showed a right posterior middle cerebral artery stroke with edema.  I called the stroke team and prepared for thrombolysis.  But the neurologist and I were both concerned about the degree of edema (which is typically a late finding) in such an acute event and we decided not to push t-PA.  That was a very good call, it turned out, because the clotbuster drug would have almost certainly induced a lethal hemorrhage in the tumor which happened to be causing his symptoms:
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Then two days later, there was the woman with abdominal pain. I forget why I scanned her, but the result was the same.  Her liver looked like swiss cheese with metastases, and the culprit turned out to be a mass buried in the tail of her pancreas:
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I got to have the "You have cancer" conversation with her, too.  The neurologist had been kind enough to break the news to patient number two above.

By this time, I was feeling pretty snakebit, as you might imagine.  Three cancer diagnoses in three shifts.  Am I cursed?  More precisely, what is it about me that is cursing my patients?  Gruntdoc advised me to simply stop ordering scans.  I was tempted.  But it continues.

The next one was a real tragedy.  37 year old man, with a six year old and a three year old kid at home.  Younger than I am, with kids the same age as mine.  Smoker.  Persistent cough, hemoptysis and weight loss.  The radiologist described his lung cancer as "clover-leaf shaped." It was not a lucky clover, alas.  It too had distant spread.
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That was one of the hardest conversations I have ever had, on par with the time I diagnosed a little girl with neuroblastoma.

And the cavalcade of cancers continued.  I followed these up with a sixty-three year old woman with vaginal bleeding.  She was on coumadin and so it was thought she was over-anticoagulated.  But when her hematocrit got all the way to twenty-three and she fainted, she came to me.  I got the pelvic ultrasound that showed a 4 cm vascular mass in the uterus which is almost certainly endometrial cancer.
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That's all in about, I dunno, a ten-day period.  FIVE new diagnoses of cancer, almost all of them very bad indeed.  It's about three years' worth of cancers for an ER doc.

Really, what the HELL.  This is just not right.  And it's not like most of them required me to be particularly clever or were difficult diagnoses.  I just happened to be the guy on shift when these poor folks came in.  Not that it matters -- sometimes a difficult diagnosis is really satisfying to figure out, but when the diagnosis is cancer there's no pleasure in it and it casts a pall over the entire day.

So I would like to give notice to the heavenly randomizer that I have exceeded the limit of statistically probable diagnoses of cancer for the foreseeable future.  No more, please, or I'm going to have to conclude that you're a malevolent bastard after all.

Thank you for your attention to this matter.


  1. So very sorry for all the patients, family, and you.

  2. Maybe there isn't one.

  3. yah, almost seems to be contagious these days. I hate finding cancer in the ED. 2 in one shift last week-one was a kid. : (

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  5. I thought in cases where bad/terminal news had to be delivered it was deferred to someone else in the hospital. But, then I ask myself, "Who else would that be but the ER doc?" I have deep sympathies for all those afflicted and for what you have to endure when facing them. Especially in the cases when the diagnosis wasn't expected.

  6. With pt. #1, is there any explanation for why the three previous docs had all missed this obvious dx? More and more this seems to be why people come to the ER - because they can't get basic workups from their primary MDs.
    -whitecap nurse

  7. is that the actual scan of the guy with rectal cancer? it seems not.

  8. Sheesh! I feel very sorry for these people, but also for you. What dismaying and depressing discoveries to make, followed by the shared pain of breaking the bad news.

  9. Like whitecap nurse is saying, I was wondering too if these people are going to the ER first and not to primary MD's. I wonder if some of them even had a primary or if they ever had check-ups.
    This is a very bad streak for you, I feel sorry for of the patients that get this news.

  10. Holy smokes. It must be really hard to do this kind of work. I ran across your blog because my Mom was recently diagnosed with cancer - by an ER doctor - and I was randomly googling for information. It's really useful and interesting and heartwarming to see what it's like for the people on the other side of the curtain. Thanks for your work, and for writing about your work.

    By the way, my Mom's cancer is terminal, but she is 84 years old and she is already a 40-year cancer survivor. (She lived through stomach cancer, although her stomach didn't.) She is cheerful and resolute and unafraid. Her life has been an inspiration to her family and friends. Her death will be too.


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