Nobody ever tells you how hard it is to look a patient in the eye when you know that they’re going to die.
This is especially hard when the patient hasn’t yet come to that conclusion. Trying to keep a straight face and ask relevant questions is incredibly hard. Even more so when their daughter has just arrived for a visit.
This happened to me recently and without a doubt I think it was my hardest day in medical school.
Some background I think. I have to be careful with what I say as I don’t want the patient to be identified, but I’m pretty sure that there are hundreds of these cases in the south of the UK at this moment anyway.
I was looking for a surgical patient to take a history from and examine, preferably a GI case as I hadn’t managed to get one for a while and I was worried my GI was getting a bit rusty (don’t really count C.Diff as GI as they could have had anything before they were given the antibiotics). This usually means going to the surgical ward, finding the F1 (intern) and begging them to give you an interesting case. I was in luck. I knew the F1; he’d graduated from our medical school this summer and I knew him from a couple of sports teams. I asked for a case that he thought I’d be able to figure out for myself. He sent me to a bay.
Male. 60 years old. That’s all I was told.
I went through the usual introductions, consent and started asking what had brought him in.
His GP had referred him into the hospital for some tests last week because his itching had become so bad. He described it as like having fire ants under his skin constantly, nothing seemed to help it. There were bandages on his hands, presumably from the scratching. One of them needed changing, I made a mental note to tell the F1. His GP had also told him that his eyes were yellow. Why his GP had to tell him this I don’t know.. you could see they were yellow the second you walked to the end of the bed. His skin was also starting to show a yellow tinge.
That explains the itching.
Jaundice (Icterus) is caused by bilirubin, a breakdown product of haemoglobin (protein in your blood that carries oxygen). Your blood cells are constantly being recycled, hundreds of thousands die and are produced every day. The ones that die go to your spleen where the cells are cut up into their constituents, which are then ferried to the liver (in the blood) where they are broken down into even smaller pieces to be made into something else, or in the case of bilirubin excreted. This normally happens by secreting it into bile (which is stored in the gall bladder). You get jaundice when something goes wrong with this process, it can happen at any of the 3 points above (spleen, liver or biliary system). Probably the most common cause of jaundice in the UK is alcoholic liver disease. This damages the liver cells, meaning that bilirubin is not correctly dealt with and it builds up in your blood. I probably should have mentioned that bilirubin is yellow and it can cause horrendous itching when the levels of it get high enough.
So, we have a jaundiced male patient in the UK. Instantly you think of alcohol as the cause. It’s the most common. Except this man doesn’t drink. That’s always an interesting answer. Patients that gave up drinking the week before will tell you they don’t drink. When you ask when they stopped they’ll pretend to think about it for a few seconds and then tell you last week. The same goes for smoking, it’s why you should never write “non-smoker” in the notes, it doesn’t mean anything. However in this blokes case he was quite adamant that he hadn’t drunk a drop of alcohol in over 20 years. I believed him. He also didn’t smoke.
That throws a spanner in the works.
I go down the gallstones pathway, asking questions about pain and food. He’s not in any pain, just a bit of backache that doesn’t seem to be going away.
That’s when it sank in.
I asked about diabetes; he was diagnosed as diabetic 6 years ago. He then told me he’d had half of his pancreas removed 20 years ago.. that explains the diabetes.
I asked again about pain. Just to be sure.
He was sure. He’d had acute pancreatitis 20 years ago (the reason he stopped drinking) so he knew what pain was.
It’s at this point that I really started to panic a little bit inside. My brain had jumped straight to giving this guy a death sentence. There were still other possibilities.
“Sir, would you mind if I examined your abdomen?”
He consented, patients are really good with these things. I’d be wary about medical students examining me personally, but it really amazes me how willing patients are to contribute to our learning. On another side note, I read a great quote today: “To learn about disease without books is to go out into an uncharted sea. But to do so without seeing patients is to not go to sea at all”. I think that sums up the importance of seeing patients perfectly.
I did my usual abdo exam. But for the first time since I’ve started medical school, I really wanted there to be nothing to feel. I liked this bloke, even though 10 minutes ago he was just a name on the ward list, he was a nice guy, with a family. Then I felt it. It was slight, but there was definitely a mass. Right where it shouldn’t be.
“Shit.” I said in my head. It was at that moment his daughter walked in.
“Sorry Doctor, I’ll come back later should I?”
I explained that I was only a medical student, and how kind her father had been for letting me examine him and that I had all I needed.
I thanked the patient and went to see the F1. I think my face said it all.
“You got it then?”
I nodded and asked to see his CT scan.
There it was. A huge mass on the head of his pancreas and a smaller mass developing in his liver.
I’ve never been so disappointed to be right.
“He doesn’t know yet; the consultant is going to tell him this afternoon, that’s why his daughter has come in.”
I thanked the F1 for getting me the case, it will be good to write-up at least. As I walked out of the ward I past his bed, he smiled and waved as I walked passed, as did his daughter. I smiled and waved back.
I’m not an overly emotional guy, but I genuinely did have to fight back a tear at that. That poor blokes world was about to come crashing down around him. I’m pretty sure I passed his consultant on the next corridor, walking towards the ward. That smile that he raised for me might well have been the last one he manages for a while.
I know that death and dying patients is part and parcel of the job. I know that I didn’t see him die or have any part in his death, I didn’t even have to stand there and tell him the news. But that didn’t stop this draining me for days afterwards.It reminded me of my mortality, but it did more than that, it shocked me that a man who looked and appeared so well could have so little time left.
This was my first real encounter with death in this capacity, and sadly, death won.
Until next time.
I just wanted to say that this actually happened a couple of weeks ago. I hadn’t posted it until now because I wanted to make sure that the patient and his family knew before I posted this. I also learned yesterday that the patient had actually passed away about 10 days after I saw him. There’s also no pictures in this post, I normally put them in to lighten the mood, but I thought to do so in this case would be disrespectful.
I also don’t want to worry anyone reading this that they have pancreatic cancer. Thankfully it is not that common, but has very few symptoms. This website is an excellent source of information : http://www.pancreaticcancer.org.uk/ you should know by now that I don’t like using the internet for diagnosis!
There’s also this video: http://www.youtube.com/watch?v=6mcp3U9ci8c Watch from about 45 seconds. I think this sums things up from a medic/doctors point of view.