Thursday, July 22, 2010

An Old Enemy

Three days have passed since we performed the cervical node biopsy on our patient in Bed 12. Since then we have turned over nearly the entire service. We discharged a number of patients; we have a heavy load of consults from our surgical teams including 2 patients with acute pulmonary emboli that we are now treating with anticoagulants to prevent further clots from killing them. Both had very low oxygen saturations (45% and 70%) but with no ICU beds available, we have managed them on the overcrowded ward.

Today the biopsy results came back from the node biopsy – adenocarcinoma – moderately differentiated. Thought the node doesn’t tell us where it come from, it is nearly certain it is lung cancer with a very poor prognosis. The patient’s family also paid for him to go to Nairobi for a CT scan that reveal multiple masses in the central chest and neck with bony metastasis. A grim picture. We met with him and his family and discussed his limited treatment options and palliative care. Lung cancer is not very common here – much less than in the US. For an American doctor, it is easy to make the diagnosis based on his presenting story and initial laboratory studies because we see it so often. Lung cancer is the most common cancer diagnosis I have made throughout my career in medicine and it is a formidable enemy. There are some types that are more treatable than others, but many don’t have a great prognosis. As usual, the families were extremely grateful to have the truth of his diagnosis and prognosis. They have been to multiple facilities over the past month with no answer but now were relieved to know what was going on.

Charles had a particularly rough day with a patient of his who died very suddenly and with a very unclear picture which only after the fact could we piece together the likely cause of death. The patient’s sister showed up on the ward an hour after she died and collapsed to the floor, wailing and weeping over the loss of her sister. The patient had AIDS, TB and PCP infection that was being treated but a catastrophe occurred that killed her quickly. It was a real blow for Charles, August (the attending of the service) and for the nursing staff. We’ll save the case details for later as it would be an excellent case conference for teaching when we return.

Every patient we can discharge home healthy means a great deal here. So often, we are sending patient home with bad news, a diagnosis of AIDS or cancer, or they leave by the morgue. I can see why OB is something I have loved doing here in the past as most of the stories are joyous in the end. Yet, in these difficult cases, it seems that God’s grace is most evident in the families and the patients as they move into the uncertainty that requires faith, not facts.

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