Spiked

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **  
  
Today was opening day of the 2013 NFL season. Thousands of NFL players and NFL fans geared up to watch the Dallas Cowboys play the NY Giants. Today, I sent a Redskins fan into the game of his life. 

I met John in the emergency department. He was a healthy looking middle-aged man, dressed in a Redskins jacket and blue jeans. His chief complaint seemed rather benign. He experienced rectal bleeding for about a week, which he attributed to hemorrhoids. After further questioning, he did recall having some nagging abdominal pain, but stated it was probably gas or constipation. Come to think of it, he had been having some trouble defecating, but that could be related to hemorrhoids too, right? I continued the physical exam, only finding exactly what he told me -- blood in his rectum.

Per protocol, I started the regular workup for a gastrointestinal bleed. I ordered a CT scan to rule out possible perforations. The ER physician pulled me aside. Her eyes were suspicious. "I have a bad feeling about this one", she whispered. 

I read the CT report. His stomach, liver, spleen, kidneys, even his pancreas were unremarkable. The colon, however, was not. I sensed the dread in the radiologist's voice as he dictated the remainder of the report. "Suspicious mass, possible adenocarcinoma. Recommend further testing."

John didn't have cancer. He was a healthy man. He ran 5 miles each morning through the Virginia hills. He ate a "balanced" diet, except for a few Sunday beers and pepperoni rolls while watching the football games. There had to be another explanation. Had he been constipated? Perhaps he had an obstructed bowel. Or maybe he had appendicitis. Or an inflamed bowel. Did he drink from any country streams? His symptoms may be caused by a bacterial infection. Could he have had intercourse with men? Perhaps he inserted a foreign instrument into his rectum? I was desperate. The answers to all of these questions were negative. 

We scheduled John to undergo a colonoscopy to biopsy this "suspicious mass". I talked with him briefly before the procedure. We joked about the cleaning out process involving a bottomless container of GoLytely liquid. He was prepared, but visibly worried. We sedated him, and completed the colonoscopy, snagging a suspicious piece of tissue along the way. A preliminary examination of the biopsy was significant for adenocarcinoma.

The Society for Translational Oncology recommended the SPIKES method for delivering bad news, especially that of malignancy.

• Set up the environment. Ensure privacy, involve family members. Limit interruptions, and connect with the patient. Ask "are you comfortable?", "are there any other family members or friends you would like to be here?"
• Perception. Find out what the patient's understanding is of the medical condition, testing, and possible diagnosis.
• Invitation to choose the method of disclosure. "How would you like me to give the information about your test results?"
• Knowledge. Give a shot in the dark first, such as "Unfortunately, I have bad news to tell you...", then pause. Avoid being extremely blunt, especially when the prognosis is poor.
• Empathy to emotions. Observe the patient for signs of shock or sadness. Identify the emotion, and the reason for it.
• Strategy and summary. Ask if the patient and family are ready to discuss a treatment plan. Then, summarize the information given.

I stood in John's hospital room. His eyes diverted from the football game, and placed on me. His wife placed her novel on the bedside table. Should I be the one to break the news? John had only met me a day ago. And I was only the family doctor, the middleman. I was neither the radiologist who spotted this lesion, nor the surgeon who actually visualized it, nor the oncologist who would treat him. I couldn't answer his questions regarding treatment options. 

I recalled my grandfather's anxiety while waiting for his own diagnosis. I recalled my own angst about his care and the way his physicians broke the news and prognosis to him.

So, like a losing quarterback with time running out, I spiked.

Memoratus in Aeternum

Mid-October has been a special time for me, since 2002. I am currently on the verge of sitting for my first "Step" in licensure, and felt it prudent to reflect upon how I arrived at a career in medicine. 

The year 2002 started off normally for my family, a close-knit group of 4-mother, child, and grandparents. Of these, my grandfather seemed the healthiest, save for a few bouts of gout every year. He led a healthy lifestyle, getting frequent exercise with his shepherd/husky mix, chopping trees, shoveling snow and visiting neighbors. He would fatigue quickly, so made a habit of taking daily naps. In late January, my astute mother noticed his ankles were edematous, and made an appointment with his PCP. The PCP prescribed diuretics and advised to follow up.  Shortly thereafter, my grandfather mentioned a nagging pain in his left side. My mother asked for a CBC, which was never completed. My grandfather was tested for heart failure, diabetes mellitus, and various other common ailments. Trips were made back and forth from the doctor; finally a CBC/peripheral blood smear was done, and a diagnosis was made- Chronic Myelomonocytic Leukemia; an extremely rare leukemia with no cure, and no detectability until the "crisis" stage, though commonly associated with chronic gout and splenomegaly.

My grandfather was referred to an oncologist, and began getting blood transfusions. He was put on a few blood-boosting medications and full-time oxygen. He tried to lead life as normal, continuing to cut branches and untangling the dog from the snarls of the oxygen tubing. When he felt well enough, he attended my dance performances, and we even went to see Mel Gibson's "Signs", although he was embarrassed to tote the heavy oxygen canister though the theater. I accompanied him to his blood transfusions, taking careful mental notes of the nurses too busy with birthday celebrations to notice that his oxygen canister was empty and rattling, or too engrossed in watching "The Price is Right" to remove his automatic blood pressure cuff after discontinuing his IV. I watched my strong, 6'3", 230lb grandfather slowly waste away, while trying to maintain normalcy in our lives.

The entire family worked hard to help him heal. In an effort to limit his fluid retention, we cooked low-sodium, low-fat foods, which were labeled and charted to ensure he was getting enough nutrition without harm. My mother purchased a CraftMatic bed for him, so he would be more comfortable and wouldn't use his precious energy trying to sit up in bed. He listened to self-hypnosis tapes and meditated daily, to focus his energy on healing and controlling proliferation. His oncologist seemed to be uncomfortable discussing his prognosis, and advised against splenectomy, due to my grandfather's insurance and age.

By the end of September, and with little encouragement from the oncologist, he decided that treatment was futile. "Save the blood for someone else," he said. "Someone who really needs it".  The oncologist offered to refer for splenectomy, but he was weary and resigned by this point. We discontinued the sodium and fat controlled foods, and made his favorites- lobster tail, hot dogs, shrimp. He passed away in his CraftMatic bed on Oct 17, 2002, missing his birthday by 6 days.

Every patient knows a story like this, either experienced personally or heard from others. Every doctor knows a hundred of these stories, shared in medical journals or by colleagues. Did a medical error occur? Patients and families may emphatically agree; Physicians may not feel the same. My point in writing is not to place blame, gripe about the state of healthcare, or lament that not enough was done to save my grandfather.  Perhaps the disease was caused by years of exposure to benzene from working in a pharmacy laboratory. Perhaps the cause was due to inhaled cigarette toxins, and he hadn't quit in time to prevent damage. Perhaps there is no attributable cause. Whatever the case may be, I believe that a plan is set out by the Most High, and for whatever reason, I needed to experience this loss, this suffering, in order to become a more observant, empathetic physician. I am so grateful for the time I spent with my grandfather, especially while he was most vulnerable. I am grateful for the lessons I learned through this process. When I approach the computer on Wednesday, I am confident that the spirit of my beloved grandfather will be with me. 

I love you and miss you, GVS.