Monday, 3 August 2015

Healthy not healthy

No offense, but if you ever hear anyone start a sentence with “With all due respect . . .” and expect what follows to be respectful, then you’re an idiot.  No offense.  It’s one of those phrases that is intended to deflect disrespect and immunise you from blame.  Whenever I hear it (or it’s bastard cousin “I don’t mean this in a bad way, but . . .”), I wish that the person would just be an adult and come out and say whatever offensive thing is on his mind rather than veiling it in a shroud of dismissal.

“Sorry not sorry” is similar - you are sort of apologising in advance, but at least when people use this one, they know in advance that you’re not really sorry.

So what the hell does any this have to do with Gerald (not his real name©)?  With all due respect, stop being so damned impatient and complaining so much.  You’ll just have to wait and see.  No offense.

Being on call for general surgery is usually mundane.  Since common things happen commonly, I can typically predict at least one or two patients with appendicitis, perhaps one with an infected gall bladder, maybe a bowel obstruction, or diverticulitis.  Pretty normal stuff, really.  Very seldom do I see anything really bizarre, but it does happen . . . hence, this blog.  Gerald (as you’ve probably guessed by now) falls firmly under the category of "bizarre".

“So I, uh . . . I got this guy with this . . . this . . . thing.”

When an emergency physician leads off with that, I am guaranteed to be presented with something odd, so I sit down and prepare myself for whatever hideousness is about to be dropped in my lap.  My brain cogs immediately started spinning as they usually do:  What kind of "thing"?  A bleeding thing?  An infected thing?  A needs-to-be-removed-from-his-rectum thing?  The emergency doc continued, and I must say I was more than a little disappointed that it wasn't a rectal foreign body.

“So this guy is 70 and healthy, no medical problems," he went on.  "But he came here because his co-workers were telling him that he was starting to smell like a rubbish bin.”

Well that was . . . unexpected.  The cogs spun a bit faster.

“And, well, he has this . . . thing on his back.  It’s kind of, um, big.  And, uh, bleedy.”

Bleedy?  What the . . . That's not even a real goddamned word!  The cogs spun yet faster.

“So I don’t really know what to do with it, so I’m hoping you do.”

The cogs flew off the machine.  Fucking greeeeaaaat.

I got to the hospital a short while later, and Gerald was sitting on his stretcher, smiling, chatting with his neighbour, and looking absolutely fine.  However, I could immediately see (and smell) why his co-workers had been concerned.  As I walked in an odour like death punched me in the face like walking into Ronda Rousey's fist (Ronda - call me).  The nurses were all wearing surgical masks, but the look on their faces told me that even that wasn’t nearly enough.  Having removed dead colons before (stories to come in the future, I promise), I’ve smelled worse, so it didn’t bother me quite as much.

“Hi, Doc!  How are you today?” Gerald greeted me with a big, warm smile.

Nauseated, I almost said.  I chatted with him for a few minutes, somehow resisting the urge to retch.  He told me that he was never sick a day in his life, took no medicine, had no allergies, and had never had surgery.  “I’m just a healthy guy.  I haven’t been to the doctor in 50 years!”

Considering the stench, that last part didn’t surprise me one bit.

He certainly didn’t look sick, but his fetid odour told me otherwise; healthy people don’t smell like a garbage dump.  When he removed his gown and turned around, what greeted me reminded me of this:



He had a mass on his back at least 20 cm in diameter.  It was cracked and bleeding in places, draining pus in other places, and it smelled like it belonged in a horror movie.  All around it were numerous smaller dark lesions, each around 1-2 cm.

Weeeeeeeell this isn’t good.

Within the first 0.253 seconds of seeing it (I timed it), and even without a biopsy, I was 99% sure that this was a large melanoma and that all the smaller lesions around it were satellite lesions, signs that the melanoma was spreading.

Gerald was quite clearly not the perfect specimen of health he thought he was.

It took a bit of encouragement and convincing before Gerald actually believed that there was something seriously wrong with him.  I informed him that, assuming my suspicion was correct, he would need an extensive surgical resection followed by a large and difficult reconstruction, best done by a team of specialists at a university hospital.  Despite maximum efforts, it was still nearly a certified guarantee that his melanoma would kill him in the next few months.  “But Doc, I’ve always been healthy!” he kept arguing, somehow still in disbelief.

No, Gerald.  You haven't been healthy for many years.  You just didn't know it because you've been ignoring the fact that your body has been screaming at you for all this time.

Gerald inspired me to coin my own new phrase: Healthy not healthy.

See, I told you I’d get to the point.  Sorry for making you wait.

Not sorry.

36 comments:

  1. I have to ask - couldn't he SMELL it? I know that my parents don't have as reliable a sense of smell as they did when they were in their 40's and 50's, but I doubt either of them would be able to overlook the smell (and the blood, pus and assorted debris on the bedclothes, running down the drain, etc.).

    How in the world did it not HURT?

    Wednesday

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    1. Some people can deny, block, transcend, compartmentalize and incrementally get used to normally-unbearable things when facing reality threatens their self-image or scares them witless.

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    2. I'm still staggered by how readily people overlook, ignore, minimize and grow accustomed to the unacceptable. I shouldn't be though, given how I earn my bread and butter.

      It reminds me of one of the folktales I read when growing up - the one where someone helped Death (out of a tree? pulled out of a river?) and in return Death promises to send him messages prior to coming for him. Guy gets very ill, Death appears. He protests. Death reminds him that he sent him all sorts of messages (fever, weakness, etc.). I don't think it was Italo Calvino's "Italian Folktales". Maybe "Russian Fairy Tales" collected by Alexander Afanasyev?

      Wednesday

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  2. The curious (nosy?) side of me was a little disappointed that you posted a picture that reminded you of the mass instead of an actual photograph. :)

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    1. Google "fungating tumour" and you will see more than you would ever wish. You have been warned, very gruesome.

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    2. I googled it despite your warnings... I regret it lol. But thank you :) :)

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    3. Anonymous and Melissa, thanks to your warnings I'm able to resist. Just.

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    4. If you have any doubts whatsoever, you really should resist because it absolutely cannot be unseen.

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    5. Anonymous, you are correct lol

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    6. Continue to resist. If you succumb to temptation, at least don't do it whilst eating or shortly thereafter.

      Physicians (and plumbers) earn their money. Sometimes, they REALLY earn it and it's still not enough given what they see, smell and have to bail. Or worse.

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    7. Why, why did I google that?!?!?!?!? That's not OK.

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    8. I googled, found the pics...and finished my pizza. The visuals aren't that horrific but I'm just as glad I didn't have to *smell* them. My question is, why would anyone ignore something like that for so long? Some of the pix I found were of huge open wounds where the patient couldn't have *not* seen them. Yes, denial are fear are strong motivators, but to have parts of your body rotting off and still say "oh, there's nothing wrong"--that, I just don't understand.

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  3. "...assuming my suspicion was correct, he would need an extensive surgical resection followed by a large and difficult reconstruction, best done by a team of specialists at a university hospital. Despite maximum efforts, it was still nearly a certified guarantee that his melanoma would kill him in the next few months."

    As a cancer survivor who plans on NOT going through a second round of treatment should my cancer return, this is of great interest to me. Would this man's prognosis be any different if he just chose to have in-home hospice care and pain management until his cancer kills him? I find myself second guessing whether the misery of surgeries, extended hospital stays, chemo and whatever else they would throw at him would really add any benefit or just make his last few months even worse than they need be, especially since he seems to be relatively pain free at this point.

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    1. Yeah, chemo is rough. Never had cancer, but know people who have, and even after the cancer is gone they're still reeling from the effects of the treatment for a while. It's probably worth it if you're young and have a few decades, but if we're talking a few years or months like this guy, I'm not sure what benefit medical procedures would really be.

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    2. Doc isn't an oncologist though. If he believes it to be cancer, his safest bet is to refer the patient to an oncologist or a facility with oncologist who can help him.

      Doc is simply giving his opinion to us on what the patient may need. Doc can't advise the patient of those options because that's not his area of medicine. An oncologist will give the patient all of his options, including do nothing.

      I work for a medical malpractice attorney in the states, and if a doctor who is not trained in the area of specialty you need gives you advice on treatment options, they open themselves up to a malpractice suit.

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    3. Amber - I am not a medical oncologist, but I do my share of surgical oncology (including breast cancer, skin cancer, and various GI cancers).

      Anon - His life expectancy may not be any higher, but a surgical resection would help control symptoms, including bleeding, pain, infection, and odour. Your point is an excellent one, however. Sometimes the right thing to do is nothing.

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    4. My home state has determined that statistically, with terminal cancer, palliative care is actually more effective in prolonging life at better quality than aggressive treatment.

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    5. That's the thing about statistics - they tell you everything about a population but almost nothing about an individual case.

      At 60 my mother had bowel cancer metastasized to the liver. That's pretty bad and there was a genuine decision to make as to whether to go with treatment or just to have as many good days as possible. She went with treatment and last month turned 79. She plays volleyball twice a week with the "over 50s" sport group. Her odds of that are about 1 in a thousand.

      There are statistics, but then on a personal level, you just never know.

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    6. one of my grandmothers fell, and there wasn't enough sound bone in her hip to pin pack together. a that time, the automatic reaction to cancer was chemo and radiation, and as I recall, there was something about my grandfather using a different car to get her to her appointments. she survived to their 50th anniversary and died soon after. in that case we knew.

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    7. @ Ugi..very true, you just never know. My own mother was diagnosed with colon cancer at 79. It appeared very localized, and her oncologist was of the opinion that surgical removal of the affected area might indeed "get it all." That worked. No spreading or recurrences, she's been cancer-free since, and celebrated her 90th birthday earlier this year. :) Point being, there's no single "right answer" for everyone, regardless of age, overall general health, whatever. IMHO, Doc B. did the right thing by giving "Gerald" his opinion, but suggesting he follow up with specialists (who, hopefully, will be able to give him the info needed to realistically assess his best options). .

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  4. I don't know if this fits anywhere on your blog but I wanted to send it along. He was a nice guy. I know his office well and I don't relish boxing it up for his family.

    http://www.washingtonpost.com/national/health-science/louis-sokoloff-nih-scientist-who-created-technique-to-detect-and-treat-major-brain-disorders-dies-at-93/2015/08/03/8c7c5442-396d-11e5-9c2d-ed991d848c48_story.html?tid=hpModule_9d3add6c-8a79-11e2-98d9-3012c1cd8d1e&hpid=z10

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    1. Annnnnnnnnd there's the off topic post.

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    2. Please note it was approved and posted by DocBastard. It's not as though it just magically appeared without his participation.

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    3. Please note that you are (probably) not John Benton. As long as you are not posting your weird fetishes on her, DB is pretty lenient. I think it's his Ken personality shining through.

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  5. the good news is that with advances in medical technology we have very good odds of living long enough to die from cancer.

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  6. One of the worst smells I have come across in nursing is cancer, although a different kind. End stage colon cancer complete with a GI bleed secondary to the cancer. Can't imagine someone not recognizing there is a problem until it has reached the point of smelling like a not so freshly dead body. Tasha Bennett

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  7. I found this interesting article on Prof. Pope's site:

    http://medicalfutility.blogspot.com/2015/08/medicare-care-choices-model-hospice.html

    This seems like an option worth exploring. It would provide an alternative to the either-or scenario, or,as Sen. Wyden characterized it, the "crossroads" dilemma. Currently, in order to access hospice benefits, patients have to "give up" on curative treatment.

    As Ken stated, there's significant evidence to support the conclusion that palliative care can contribute significantly to both duration and quality of life for patients faced with a terminal illness. Allowing patients to access hospice care services (either at-home support, or in a designated residential facility) *while* continuing curative treatment may benefit both the patient and family in many situations. It may also have the effect of saving some $ for the publicly-funded programs, since hospice care is less costly than full-time hospitalization while receiving treatment.

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    1. If we could get out of the "all or nothing" mentality the human race seems to spend much of its time in, there is no limit to the improvements we could make.
      but Hospice really is an end-of-life-care organization, and by my understanding, at least for local branches, trying to expand their coverage will overextend them.

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    2. Good point, Ken. In areas with limited hospice resources, this would be an issue. While this plan would also represent an opportunity for hospice organizations to increase their service-generated revenue, Medicare itself doesn't pay enough to really cover a provider's true operating expenses, much less generate enough additional funding to "grow" the operation (by adding staffing and beds for inpatient care, and/or more workers for home hospice care).

      Still, it might benefit those hospice operations that are directly hospital-affiliated, since use of hospice service reduces the need for more-expensive ER services and in-hospital-unit days. More patients and families can be served if the organization can minimize its financial writeoffs.

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    3. here, as I recall, hospice doesn't HAVE service generated revenue. my understanding from the contact I have had with it is that they do not charge for services.

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  8. This sounds almost exactly like my grandfather. Since he was around 16 he'd been smoking close to a pack a day and only when he was pushing eighty did that become close to a pack a week. He never went to go see the doctor and he never took any regular medications so my family joked that he had great genes (he did), that he was "a tank". Nevertheless, his lung cancer spread quickly.

    It is so important to keep healthy habits and most importantly to listen to your body. My pappou had difficulty breathing and terrible coughs years before he received his diagnosis just as the man in Doc's post smelt and bled for who knows how long before he consulted anyone.

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    1. Yes, my great grandmother made it to her 90's before her smoking habit finally caught up to her and made her die of lung cancer. I think she got treatment for it and died anyway.

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  9. I want to thank the person who suggested to go look at fungating tumours. Not two weeks later I happened to look at myself in the mirror and said, "Hey - my breast doesn't look quite right." Then I realized that it didn't FEEL quite right either.

    I've now been diagnosed with Stage 2 breast cancer. SOMEHOW I missed the message that women with dense breasts are more likely to be diagnosed with breast cancer and as my breasts are lumpy anyway it took some time before I figured out something was truly amiss.

    My point is this - I'm terrified of the health care and life insurance industries in the US. Yeah, they SAY they can't hold my health against my children when it comes to acquiring health insurance, but I don't trust the companies or their underwriters as far as I can push them off a cliff. So if it hadn't been for those horrible photos, I probably would have ignored this and just upped my life insurance and eventually gone out to drink myself into a stupor in a snowstorm. But those photos convinced me to get it checked out and now I'm shopping around the health system for a group who really know what they're doing and have tight connection to Johns Hopkins University.

    I'm not looking forward to the chemotherapy, surgery or possibility of radiation therapy. But it sure beats those fungating tumour photos!

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  10. I'm glad you caught it fairly early and wish you all the best in your recovery, Anonymous 11 September.

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    1. Thank you! I'm happy to report it's 100% sensitive to estrogen and progesterone, the growth rate is moderate (15-20%) and the FISH results show I'm HER-2 negative. One pathology consultation tomorrow, oncologist on 15th, genetic counseling & blood draw on the 18th and second surgeon to consult on 21st.

      Good thing I FEEL well because it's damned hard work being a patient!

      I really hope I don't have to undergo radiation in addition to chemotherapy. Chemotherapy will affect my memory more than enough, radiation therapy may jeopardize my job once I'm given the all-clear to resume it. I have a great boss, but I'm really worried I may not have a job to return to afterward if this stretches past 3 months.

      Everyone is replaceable and I earn the larger salary, plus carrying the health insurance.

      Delete
    2. I am so glad the situation sounds promising, all things considered. Happy thoughts for no radiation and a quick turnaround.

      Delete

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