Indexing Title:

HTURINGAN’s Medical Anecdotal Report [05-01]

MAR Title:  Second chances

Date of Medical Observation: 12 August 2004

Narration:

 It was my last year of residency and my last month rotating as a senior in the GS I service when a junior resident referred a woman to me.  She was in her sixties, burly with a smile plastered on her face.  She reminded me of Italian women, well-built, working all day in the kitchen, someone who had borne and breast fed a lot of children hence the sagging breasts and a body used to taking care of everybody else.  She had a mass as huge as her breast with peau ‘d orange in its entirety. She had matted axillary lymph nodes half the size of my fist and supraclavicular lymph nodes. She was a stage IIIC (T4N3Mx) in the least, off the bat.  When I see advanced breast cancer I always have this sinking feeling of seething anger and futility.  And I would begin the daunting task of explaining everything but first the litany “why oh why, did you seek consult only now?  Did you think it would go away.....”  I explained to her what it meant and as I was doing so I realized she was crying.  I tried to console her and told her we would do what we could and try to downstage the tumor which would need a significant amount of money.  And of course like many before her, she had none.

 The GS I consultant came and we referred the patient to him.  He said the same things to her, that at this point neoadjuvant chemotherapy is the option of choice if there would be a chance to resect the tumor once it responds to chemotherapy.  Prognosis was explained to the patient.   I asked her to wait for me while the consultant and I talked.  He told me that although the tumor can be extirpated, it would grow back at a rate faster than it grew if we touched it now without giving systemic treatment first, and all effort and intention no matter how meaningful will be futile.

 To help her get financial assistance, I wrote a letter to PCSO endorsing her as an indigent.  I computed the chemo regimen she needed, and told her to come back anytime for any paperwork that would be required of her to get assistance.  I saw her again after two months, she responded to the neoadjuvant,  the mass is now only as big as my fist and very resectable.  I informed GS I to schedule her.  Then she said something like if she could postpone her surgery next year because fung shui said its bad lack for her this year.  I scolded her that she was lucky to have responded so well with chemo and not to mess things up again.  She promised she will, but as I inquired from the team handling her case, she was lost to follow up.  I saw her again this year, the mass is now fixed and resection once more is not a wise option.

Insights (physical, PSYCOSOCIAL, ethical) ,Discovery, Stimulus, REINFORCEMENT:

 In an effort to help as surgeons, we must never lose track of our goal to treat and alas to palliate.  It is so easy to succumb to the temptation of putting a patient under the knife and justifying this by saying that this is the most cost effective way to help the patient because the best option is beyond ones financial means.  Ignoring the fact that in doing so we do her more harm than good.  It is not easy to balance the fate of another human being in the palm of one’s hands and yet this is what we are tasked to do with prudence.

 I kept playing the scene in my head over and over.  If I have scolded and frightened her more and not endorsed her to the next team, I would not have lost her.  I knew she was frightened to her wits.  What do you do when you were given a second chance and you let it slip away?  In retrospect I should have lent her courage she did not possess, only then could I utter that I have done my best.