Wednesday, March 24, 2010

The Hope Trap

So, I did some moonlighting the other day. Shocking, I know. This was for an Infectious Diseases group, and they usually have some pretty interesting cases.

This, however, turned out to be a day of super sad cases.

The one that sticks out in my head most is a 22-year-old girl with the rarest of rare cancers diagnosed about 8 months ago. She has metastatic disease to her abdomen and lungs, causing fluid build-up in each of these cavities. We have to put a needle in her abdomen and one in each lung space every so often to drain the fluid. It keeps reaccumulating because of the tumors.

We have an expert at our hospital, so she came in for a second opinion. There is one case report of another woman who had the same cancer (different point of origin, less metastatic disease) who was alive 7 years after getting this certain chemo regimen. So the oncologist said, "What have we got to lose?"

Obviously, her parents are hoping for a miracle. The patient had gotten one round of chemo, 5 days before I saw her. I was seeing her for a possible pneumonia, which was not really a pneumonia but actually just cancer in her lungs that looked like pneumonia. But, rather than risk being wrong, we were treating her for the slim possibility of an overlying infection. It wasn't helping.

Her next round of chemo is in 6 weeks. I don't think she'll live that long. I also don't think that her cancer is going to magically melt away after one round of's just so extensive.

Should we have even given her the chemo? Are we just feeding a false hope? It's hard not to be optimistic (even stupidly optimistic) when you look a 22-year-old girl and her parents in the eyes. You really want to believe that this might work, even when you know the odds are overwhelmingly against it.

I call it the Hope Trap.

We desperately want to give good news. We want to believe that our patient will be the exception to the rule. And I think that's ok, to an extent. However, we also, simultaneously, need to be preparing the patient and her family for the likely result of death. We need to assist in that transition - just in case. We need to make death an acceptable ending and not a failure. If - no when - she dies, it's not because she didn't fight hard enough or because the doctors did give enough medications or because the parents didn't pray enough. It's just because the cancer was too deep and her body got too weak. No one failed.

Death is the natural result of living, and I think we forget that.

Thursday, March 18, 2010

Timing is Everything

So, I just got home from the Zoo. Clinic was disastrous as usual. But, since it wasn't any more disastrous than usual, it seemed ok. I had to act as the attending on a few patients because we were short attendings. The clinic is definitely much better from that view, let me tell you. No paperwork, no phone calls, no making the sure the lab got the sample. Just give advice, sign your name, and next patient please. Not bad at all.

I saw my own patient this afternoon who is still an enigma. She's from the Middle East and presented with a monstrous liver cyst that we found on ultrasound and confirmed on CT. It's probably a parasitic infection that is often seen in that part of the world. However, we don't know how active it is, if that's really what it is, etc. She came in a month after we diagnosed her and announced that she's pregnant. Now, we're trying to figure out a) how do we diagnose what this thing is, b) do we need to biopsy it and how can we convince the surgeons to do that, c) do we empirically treat her with a drug that will likely harm the baby, d) do we take the chance of this thing rupturing as her uterus gets bigger - which would send her into anaphylactic shock and a chance of death for her and the baby. Oh, and did that CT scan she got 2 months ago...did that happen before or after she got pregnant? The timing is pretty close. That's a hefty dose of radiation, and I'm not sure a fetus would survive and if it did survive what kind of long term damage it would cause. I mean, the fetus would've been a few cells big at that time, so I can't imagine it would survive that blast of radiation. However, I got her to see the OBs tomorrow, so we'll let them track back for the timing of everything and see what their recommendations are.

So, now we're in this dilemma - diagnosis with a biopsy might harm the baby (not that I could convince any surgeon to get in the same room with her, let alone put a needle in her), treating without a diagnosis will probably harm the baby, taking a wait-and-see approach may lead to you recommend termination of the pregnancy? We don't even know what this is, for all we know it's a benign cyst with no risk to the patient at all, save the abdominal pain that will occur as the uterus grows.

I don't envy this woman and her husband, they have a big decision to make without a lot of information. Hopefully, in the next month or so we can fill in the holes so they can decide what's best for them.

Monday, March 8, 2010

Unlimited Energy

I'm back home, visiting my parents, sister and her husband, and my niece and nephew. My niece is nearly 3 and my nephew just turned 1. They are adorable. I love them to pieces.

They wear me out.

My sister has a long body pillow, like 4-5 feet long, and we found it yesterday. My niece loves it. We discovered a game today, which she calls "Hannah's Game." Hannah's Game is going to be the death of me.

We put the pillow on the arm of the couch. She then sits on the pillow, balancing, while I sit on the floor. We pretend she is getting off balance, and I pull her and the pillow off into my lap. That's fun, but that's not the end of it.

Next, I hold the pillow with her laying in it. One hand on her lower back, one hand under her legs. Then we count to three and I launch her and the pillow up on to the couch. She weighs about 30lbs, I'd guess. So, it's like military pressing 30lb. Over and over and over again. She shrieks with delight, and says, "I haffa do it again!" After about 20 rounds of Hannah's Game, I need a break! Fortunately, I can usually distract her with a less intense game while I recover.

I'm sure the afternoon will have many more rounds of Hannah's Game for us to enjoy. I'm hoping I can come up with an easier game for tomorrow, or I'm going to be one sore puppy.

Monday, March 1, 2010

Interesting Observation

I take a class on clinical controversies, which examines clinical trials and looks at what went wrong, what could be done better, etc. Last week we had a hematology-oncology attending come talk about 2 cancer studies. He made a comment in passing that really hit me.

We were talking about lung cancer, which is his specialty. It's the #1 cancer killer of both women and men. He said that most people, even doctors, are shocked when they hear that. He said breast, prostate, even colon cancer get a lot more publicity and research money despite causing so many fewer deaths per year.

He then said, "I think the numbers shock peope because whenever you read an obituary and someone dies of lung cancer it just says 'So-and-so died of cancer.' But, if they die of breast cancer, for example, it says, 'breast cancer.' Read the obituaries some time - if it doesn't specify the cancer, it's probably lung cancer. And if it does say lung cancer, they will go out of their way to say that the person was a non-smoker."

I never thought of that, but it really rings true. I think there's a stigma attached to lung cancer - like you did it to yourself (hence the quickness to point out if someone was a non-smoker). I also think people don't want to organize marathons or raise money around lung cancer because it's so preventable. There's a lot of blame attached to lung cancer, inherently. I never thought about it, but I know that when I hear of a smoker with lung cancer, I think, "Well, what did they expect." This doesn't mean that I give them worse care or that I treat them badly. It just means I have a little less sympathy for them. Same with alcoholic patients with cirrhosis. Maybe it's because we see these patients in such volume that you get jaded to the individual patient. You see them as another smoker with another lung cancer. It's just sad.

I think people probably do this with HIV as well. It's super easy to rally around kids with HIV - they are innocent in their disease. But people with multiple sexual partners, people who use IV drugs...those people are gambling and losing. I don't know why I have so much more sympathy with HIV patients. Maybe because people diagnosed with HIV in the beginning were "innocent" - no one knew how it was being passed around, no one knew who was going to get it. And these people were shunned, attacked, and left for dead. Literally. When I see a person recently diagnosed with HIV, like any other preventable condition, it makes me sad. I can't understand why they don't protect themselves.

I guess it's time for my pitch: Stop smoking, no excessive alcohol, no intravenous drugs, practice safe sex, wear seat belts and use sunscreen. Life ain't half bad if you can surround yourself with lovely people and act lovely in return. Might as well make it last.