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.

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