End med 2

I saw, by far, one of the worst skin lesions in my short time at the hospitals yet. A pleasant elderly woman came to the clinic today, battling the mid-stages of dementia. She had recently had two skin cancers, two different skin cancers, removed from her forehead. Her surgical wounds had healed up nicely. Unfortunately one of her cancers progressed and had started eroding away at her cheek. The lesion was reported to be over 6 cm. It was even starting to erode away at her ear and a part of her ear looked like it was dangling by a thread of tissue. She wasn’t in any pain, thankfully, it’s just that the lesion was ulcerated and was oozing blood and fluid, so it was a mess. The only thing they can do, apparently, is irradiate it, hope that it heals well and hope it doesn’t get any bigger.

I enjoyed my time in medical oncology. I thought it could be interesting before I got into it, and after seeing it, I’m convinced that it is still on my list of “maybes.” I’d naturally have to come to terms with not being able to halt the progression of a lot of cancers, but the field is really cutting edge and breakthroughs are being made all the time. I feel like it is a specialty that can give people a lot of hope, but one that can also crush all hope when we have to explain that a patient is palliative and all we can do is treat symptoms. Not that I think that that is the worst thing possible, I’ve even thought about going into palliative care but that was a short thought and I haven’t seriously considered it, yet. Naturally it isn’t easy explaining to a patient that all we can do is help make them comfortable until the end.

I am writing my presentation and report that are due at the end of the week. Then, all I have to do is wonder what the next two years of medical school will bring me

The human side of medicine

I spent the morning in medical oncology. I was handed a chart and told to go talk to the patient and find out how things were. We glanced at the most recent biopsy report. It read "invasive ductal carcinoma, nuclear grade 2 of 3." If that scares you, it's supposed to. I was seeing my patient post-surgery for removal of the lump and dissection of her axillary lymph nodes (the ones in her arm-pit).

I enter the room. Her and her husband are visibly worried but they agree to be seen by me before the staff physician. She seems to be doing well. The two of them are very pleasant people, and they even crack a few jokes. She looks perfectly healthy aside from the staples that are still present in her almost-fully healed wound. They ask me if I have the results from her surgery. A part of my heart sinks. She already knows that she has invasive cancer but the surgery and axillary dissection are the only way to stage her disease. I tell her that I have some results but that I don't know if we have the most recent results from her surgery. I leave to get the staff physician.

It turns out that the results from the surgery aren't available yet. So she has to wait another two weeks; she's already waited two. The staff doctor explains that's all we can do for now because he can't begin treatment without the results.

Later that morning, I see a patient who was being very difficult with the other student, the resident and then with the staff and me. He's not satisfied with all the waiting that he's been put through; I wasn't there for the whole story. This is a patient who's caused another doctor to refuse to see him anymore. He's very angry and I understand that having a diagnosis of invasive colon cancer isn't the greatest experience in one's life but I've met plenty of very sick and dying people who manage to remain pleasant through till the end. What I'm basically saying is that I don't think it's the way this man has been treated or his illness that is making him miserable.

During the interview, the doctor explains that since he's failed the last two rounds of chemotherapy that there's no point in combining them and there's no point in doing anything until we see results from his CT scan (which hasn't even taken place yet). He tells the doctor that he's contacted doctors in an American hospital who say that what he's proposing, to combine the regiments, is legitimate. This patient is basically trying to dictate his own care. I fully believe that patients have a say in their care, but when a doctor tells you something is pointless and thinks it could only do harm, I feel that one should probably heed the doctor's advice. That is, of course, my humble opinion.

I saw another patient, a woman with colon cancer as well. She was, by far, one of the most pleasant people I've met in a while. My classmate had a good choice of words to describe her, my favorite of which was "Charming." This woman has disseminated herpes zoster, which basically means she had shingles all over her body. Despite this, she was still pleasant and polite with us. What a breath of fresh air after the last patient.

Today, I saw my staff be compassionate with the pleasant patients and turn his back on the unpleasant one. I'll say this: I don't know the whole story with the miserable patient. A part of me still feels a little dirty having seen what transpired in that examination room and how that man was treated. Will I ever know if it was justified? Probably not. Can I learn from it anyway? You bet

Oncology

Today we started a two week stint in oncology. Our first day we started in radiology oncology. You know when you hear about people getting blasted with focused radiation to treat various malignancies? Well that's what we were supposed to be seeing: the first presentations, the follow-ups, the complications, the improvements, etc.

Begin 9am in the resident's room where we are told that there isn't much to be done today despite being scheduled for the whole day. We force introductions upon the resident who seemed reluctant to tell us her name. Since two of us get stuck without anyone to follow who's actually seeing patients, we head to the lead-lined basement where the irradiating takes place. Here, we actually see how the patients are set up using their tattoos and lasers in the wall and machine to line them up in all three dimensions. The actual irradiating part takes less time than the setup most of the time. As interesting as it was, and despite the fact that every patient is different and requires a different setup, we realize very quickly that the radiation technicians are busy and have their own student to teach so we go search for a doctor to follow.

We get rejected with a shy smile and a slightly empathetic "Soon" from the other resident who forgets to explain to us that she has no patients to see until we ask what's happening. An hour before things are scheduled to wrap up, we are sent to lunch only to return in two hours.

Upon our return, this time all four of us are completely ignored. There's no test for this rotation, just a paper and a presentation but the residents are using the computers in the residents' room (makes sense, doesn't it?) and we discuss the weekend, the local restaurants, and the big debate whether or not to write a foreign medical licensing exam. One student decides he's going to leave, but backs out and jumps in on my action with a patient.

We interview my one patient of the day. He's a man with lung cancer. He reminded me so much of my grandfather before he fell ill. It was everything about him: the shape of his face, the big glasses, the clothes, the way he talked, his expressions. His prognosis wasn't good. The cancer had been eroding his ribs for at least a year now. There at least weren't any signs that the cancer had spread further, but sadly it's only a matter of time. The thing about lung cancer is that it just really doesn't respond well to any treatment we have, so the best thing to do is to not smoke, but that's a public health issue that I won't delve into right now.

We present the man's case to the doctor who goes in and sees the patient. Turns out there's a waiting list for radiation therapy. I cannot imagine how frustrating it is to have a malignancy and need treatment and then be told that there's a waiting list for radiation. At least chemotherapy doesn't have a waiting list. After seeing the patient, we head to the doctor's office to talk about the case. He rants a little about how he would rather be treated in Brazil because of our waiting times. We talk a little bit about staging cancers and that's it for the day.

We grumble. Make mental notes of everyone's names so we can give appropriate evaluations on our time well wasted (one patient in a whole day is not acceptable really).

Tomorrow we're off to the medical oncology department, which, from what I hear from fellow students, is a much more student-friendly environment.

Let's hope

The Stroke Unit

I know, I've neglected my blog again. "Bad blogger!" you say, and I can't deny it, my cyber-etiquette never was perfected. I leave MSN on "Away" all the time, whether I'm home or not. I drop conversations because myself and the other person have run out of things to say, but alas, I am not alone for no-one on my MSN has good cyber-etiquette.

But I digress.

My addiction to caffeine has reach horrendous levels. Why the sudden change in my abuse of the world's most commonly abused substance, you ask? Probably from a lack of sleep and a pattern of behavior that I have adopted that involves staying up until 2 o'clock of the a.m., awaking at the un-godly hour of 6:00 and jump-starting my mind with two cups of what I like to call "The Elixir of the Gods." Quite the ring to it eh?

Ok, I know you all want to hear my cool medical stories eh? Well, you're in for a treat because I actually have some this week.

My two weeks began in Neurology and I quickly discovered that all of the inpatients that we would see were situated on the hospital's stroke unit. These unfortunate souls are usually the only people with physical findings. They make excellent teaching cases, but some of them break your heart.

So the first patient we see is a woman who came to the hospital with progressively worsening weakness. She couldn't get out of a chair or climb the stairs. This weakness eventually spread to her shoulders and even affected her to the point where she couldn't swallow properly anymore. A fascinating case, but a tough disease to have, albeit a treatable disease with possibility of a good recovery. Dermatomyositis was her eventual diagnosis if you care to check it out.

Ok, so I said I was on the stroke unit, so let me tell you about the first stroke patient we had. This woman had complete paralysis of the right side of her body. She was very pleasant with us and let us all examine her rigid muscles on her paralyzed side and see the hyperreflexia that had set in. Her possibility of recovery wasn't great, but at least she could do some stuff still.

The most tragic case I saw during my whole rotation was one that reminded me of the first stroke victim I saw a few months ago. This woman had an aphasia. I suppose she didn't just have an aphasia she had two. A little hard to assess because when a patient has Broca's aphasia. This basically means they can't talk. She couldn't even grunt, nothing, nada. What's even harder about this poor woman is that she had a significant lesion in Wernicke's area as well, which produces what's called a fluent aphasia. If someone had a pure Wernicke's aphasia, they wouldn't understand a word you were saying, they wouldn't be able to read, and their speech would be complete gibberish. Now imagine, this woman I saw can't speak, and is having a very hard time understanding anything. She can only understand simple commands like "Close your eyes" but anything more complicated like "Point to my watch" gets lost in translation so to speak.

Of course, there's always hope for recovery, but it requires determination. Just like trying to get muscle strength back with physiotherapy, this woman is going to require extensive work with speech therapists. It's hard though when a patient doesn't understand anyone because they have no idea what is going on all the time.

On a different note. When I was shadowing a radiology resident on-call, we heard the surgeons talking about a man who jumped off a third-floor balcony and his only injury was a ruptured scrotum. It still makes me shudder. No, I didn't get to see it, but the story is that his testicles were completely exposed.

With that, I'm off to enjoy another mug of the Elixir of the Gods and study neurology.