In the midst of this coronavirus pandemic, as our positive cases continue to climb (and our unresulted tests do too), I had a patient today come in for something unrelated.
Heās an older gentleman, in his 80s. He had some abnormal lab tests last week - a double-digit bilirubin, and a quadruple-digit alk phos - for which his cardiologist stopped his amiodarone. He saw his PCP today who saw the labs, looked at his newly yellow skin, heard his complaints of fatigue and poor appetite (but no pain), and had him directly admitted to the hospital - to me.Ā
For those med students reading, he sounds like a textbook case - pancreatic cancer.
For me, he sounds like my mom. She was admitted to the hospital for back & abdominal pain and weight loss. Her GI doctor called me, a state away in my last year of med school, and told me to come to the hospital. I get there, 3 trains and a taxi ride later, and see the hospitalist has left her number. I call from my phone, and with the poor reception in the hospital, all I can make out isĀ āpancreatic malignancy.ā My mom is sitting on the bed, a foot away, and I donāt know if she knows this yet. So I ask,Ā āIs that what you think this is?ā and hear a definitiveĀ āyes.āĀ
I hang up the phone, and turn to my mom, and ask her, just like I was taught in med school,Ā āWhat have you been told about whatās going on?āĀ
She tells me, āThey think itās something with my pancreas, it might just be inflammation.ā
I tell her,Ā āMom, they think itās cancer.ā
She cries. I cry. Neither of us stops crying for quite a while. Her first question for the oncologist is,Ā āWill I make it to her match day and graduation?āĀ
Between all the chemo, the nausea and vomiting and diarrhea, the begging her to eat, the intolerable side effects, the second line chemo, the failure of the second line chemo, and finally, finally the decision to do home hospice - and all the horrors we dealt with therein - I still think the most awful part was having to tell my own mother that she had cancer, because none of the doctors who saw her were willing to do so.
And now, almost two years later, I look at the man in front of me. He knows heās doing poorly - he described the last two weeks asĀ āa steep decline, like a ski slope.āĀ
I ask him,Ā āWhat have you been told about whatās going on?ā
He tells me,Ā āMy doctor thinks itās something with my liver or my pancreas. Some kind of rubin?ā - I smile, say,Ā āBilirubinā -Ā āYeah, thatās it! Anyhow something with that so he wanted more tests. I donāt know if itās my liver, or if itās cancer, or what.ā
A small part of the knot in my chest unwinds. I explain, the best I can, about how thereās something blocking the flow of bilirubin, which is why it backed up.Ā āIt could be a stone from your gallbladder, but usually youād have pain then; thatās why weāre worried it might be cancer, maybe in the pancreas, blocking the bilirubin and causing these symptoms. Thatās why we want to get this CT scan, to see whatās going on, and it can show us if thereās a cancer.āĀ
He nods - he has an excellent primary care doctor, and he wasnāt blindsided by the news. He starts to ask a question, then stops himself, and says,Ā āIāll wait til we have more answers. Thank you.ā
Heās here alone. We have a 0 visitor policy because of the Covid19 pandemic. Iām wearing a mask, hiding half my face, because Iām worried Iām asymptomatic but infected and donāt want to spread it to any of my patients.Ā
But at least I told him the truth. I didnāt keep him in the dark, or dance around the diagnosis.Ā
Iāll see him in the morning. Weāll have some answers then. And heāll have more questions, and Iāll give him all the answers I can. I canāt do anything else.
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