Haunted.

Her image is burned in my memory.  Smiling and appearing happy.

How do you reconcile that image with the next one of her coffin being lowered into the cold ground?

How do you move on when a colleague, a classmate, a friend, a mother is taken from this life in a moment of violence?

How do you stop thinking and imagining what those final moments of her life were like? Did death come quickly? Did she suffer? Was she afraid?

How do you honor her memory when now the focus is on the man accused of her murder? Purple arm bands and purple pins just seem so futile.

How do we ensure justice is served?

 

Near the End.

She stepped over the threshold of their home, a visitor.  Through the doorway the hospital bed was visible and the hiss of the oxygen tank audible. She heard the patient’s voice speaking in his native tongue, French. His son whispered in her ear that he was talking to family abroad. She stepped into the room and put her bag and coat on a nearby chair.  He waved to her, finished his call and gestured for her to come closer.  She took his hand in both of hers and squeezed.  He thanked her for coming.

The hour passed quickly. She learned that his wife, having been always very demure and quiet in the office, was quite the spitfire at home.  His wife chastised him for wanting an ounce of red wine when he was barely eating any food. Though he was hungry at times, he could only eat a few mouthfuls before the nausea set in, this despite being on the appropriate medication to aid in controlling his nausea.  She explained that slowly his need for food would diminish and that would be okay.  So long as he could enjoy sipping on water, juice, or wine, that would likely be enough.  She learned that he enjoyed doing puzzles.

At one moment, he looked her in the eye and asked if she could help him go.  Tears welled up in his eyes.  Then in the next breath he said he wasn’t ready.  She reassured him that these emotions were normal.  There would come a time when he would become less aware of what was happening and so she reminded him to say the things that needed to be said now while he still had the chance.

She forgot about the tea that had been offered and accepted.  He told her to drink it before it got cold.  He asked for water, then said he was tired and wanted to rest.

She said goodbye and squeezed his hand again.  She said she’d like to visit again soon. He said he’d like that.

Thursday Mishmash

I love aliens.  Little green men.

Like this guy:

It all started with a little television show called The X-Files. I was obsessed.  Of course aliens are real and have been visiting our planet for decades! Of course the American government covered up the events in Roswell, New Mexico.  Now, before my fellow physician colleagues out there call for a psych consult, let me be clear that I don’t really believe any of that.  Sure, sometimes it’s nice to think that we, humans, are not alone in this vast universe, but I certainly don’t believe that we are being visited on a regular basis by other intelligent creatures from far away galaxies. Nor are select individuals being abducted from their homes and experimented on in spaceships.  (Though, as an aside, have you ever been in an MRI machine?  The bangs and clicks those machines make are startling similar to the sounds that abductees often describe. I’m just saying.) The concept of “We are not alone” is an intriguing one.  One pervasive human trait is our fear of being alone.  I think we pair bond for that reason (and of course to reproduce, but really I think, to avoid being alone).  How can we be the only intelligent life in the universe? What makes us special? Was it happenstance? Divine intervention? A fluke?

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Speaking of mish mash.  On a trip to Montreal about 8 years ago, husband did some research on where to eat and what to do in the city.  He found a little greasy spoon outside the city that had a wonderful reputation for something called the mish mash. Apparently this was the place to go to for a hangover breakfast. And that’s exactly what we did.  The restaurant was called Cosmos. Run by a Greek family, the house specialty was the mish mash – fried mashed potatoes, bacon, sausage, eggs and anything else you wanted, all mashed up together.  Seriously, it was one of the best breakfasts I’ve ever had.

Shockingly, we found out a few years ago that Tony (top) was killed in his home, his son a suspect in the murder. So sad and tragic.

tonycosmo

cosmo

mishmash

 

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I started this blog in September, 2011.  I was a month away from starting back to work after my second maternity leave.  I felt like I had learned so much from experiencing pregnancy, childbirth, and postpartum depression that I realized how much it helped make me a better doctor and wanted to share some of that experience.  Little did I know that three and a half years later, I’d still be writing and would have close to 350 followers!  It’s been fun being able to see where all my visitors are from. Some of you are thousands of miles away, others are just hop, skip and a jump from my back door, and some are from cities I’ve never heard of! Some of you are active contributors, others merely quiet observers.
Thank you all again for visiting.

 

First, do no harm …

Yesterday, a news story came up on my FB feed.  I’m still thinking about it and trying to figure out how I feel about it.  I decided to write about it, hoping it might help me process my thoughts.  It’s about a 29-year-old woman with stage 4 brain cancer (glioblastoma, the same kind of tumor that Dr. Greene (Anthony Edwards) on ER had) and she is going to die on November 1.  She lives in the U.S., in a state where, apparently, there are laws in place that allow patients to take their own life when terminally ill.  She states she’s not committing suicide, rather, she is taking control of her illness and deciding when and how she will succumb to it, not the other way around.  Most of the comments posted after the article are all like, “Wow, what a brave woman”, “Good for her”, “I’d do the same”.

Really?  I was kind of surprised that no one seemed to question the ethics here.

I can’t even begin to imagine what this woman is going through. To be diagnosed at such a young age with terminal cancer, it’s truly heartbreaking and tragic. One of my colleagues said she’d probably do the same if she were in that situation.  I’m really not sure I would, to be honest.  Or maybe I would? How can one ever know until faced with the reality?

I have three children.  This young woman has none.  Would her decision change if she had kids?  How would you explain to your children that you are going to end your own life before the cancer gets a chance to?

Death is a natural part of life – granted, dying at 29 doesn’t seem all that natural.  Dying at 90 on the other hand, does.  Still, we are all going to die, none of us can ever know when or how, that is, unless we are diagnosed with a terminal illness and even then, no one really knows how long we have.  Last spring, I visited a patient dying of prostate cancer. I saw him about 12 hours before he passed, peacefully, at home, surrounded by his family. When I spoke to his wife the following morning, she struggled with the fact that she was asleep when he died.  I wondered if it would have been easier for her to witness his death? I’m sure it would have been difficult regardless.  To the very end, my patient hoped and prayed for a miracle.  It was never stated, but you could see it in his eyes. He didn’t want to die; he didn’t want to leave his wife and children. He should have had more time. He kept fighting to the very end.  I admired him for that.

I have a hard time knowing that this young woman is going to actively end her life. That she picked the day she was going to do it, much like one picks a wedding day.  It’s two days after her husband’s birthday.   She has been told there is no cure, that her final days will be spent in pain, perhaps with multiple seizures and it’s not something she wants her family to witness.  I understand that, I really do, but there are ways of helping dying patients be more comfortable in the final stages of life.  It’s the whole reason Palliative care exists.  The process of dying has to remain a natural part of life, once we start helping patients to die, we no longer adhere to the Hippocratic Oath, in my opinion.

First, do no harm.  A physician, in good conscience, cannot be a party to the death of another human being. I can already hear those on the other side of the argument – NOT assisting a patient to “die with dignity”, causes harm.  I don’t believe it does and I don’t think this is what Hippocrates had in mind when he wrote the Oath.  I don’t wish for any individual to suffer on their deathbed, far from it. Medicine has come a long way in the past 150 years – expected death can be painless for the vast majority of patients.  I think we are actually inviting more harm to patients, their family, and society as a whole if we decide that assisted suicide, euthanasia, dying with dignity – whatever you want to call it – is okay.

It’s just not.

 

Life Imitates Art.

I have always been a sucker for disaster movies.  If I’m laid up on the couch sick with the flu, or just need a go-to movie to watch, my husband always knows which film to put on.  Hollywood doesn’t disappoint – there are many to choose from, be it in the form of natural disasters like comets and asteroids threatening the Earth, or solar flares, or climate change causing another ice age – I have my pick of movies that I can watch over and over and over again.

There’s a certain suspension of reality from the movies I’ve listed below – how likely is it that we will see another ice age? I mean, really.  How likely is it that a comet or asteroid is suddenly going to be discovered that will hit us in just the right way to cause an extinction level event?  I always joked that if such a thing were to ever happen, I would want a front seat to watch it.  A giant asteroid hurtles towards the Earth and will destroy the planet?  Yes! Sign me up for a front row seat to watch it enter the atmosphere!

 

 

 

 

 

 

 

 

 

 

 

But then there’s the other kind of disaster movie.  The movie about a virus, spreading throughout a population.  There’s only been a few that I can think of, probably because it hits a little too close to home for most people.  You know the movies.  You’ve seen them.

These movies are a little harder to watch, especially Contagion.  Why?  I think that’s pretty much self-explanatory.  The likelihood of a virus causing illness and spreading quickly, infecting and potentially killing people, is well documented in human history.

The Black Death (aka the Second Plague) killed an estimated 75-200 million people in the 14th century.  It was caused by a bacterium called Yersinia pestis and was carried by rats.  Also known as the Plague, it ravaged most of Europe, and took almost 150 years for Europe’s population to recover.  The Plague recurred on and off for the next 500 years, causing smaller outbreaks in Spain, France, Sweden and Russia.

 

Smaller pandemics of cholera, typhus, measles and smallpox have been reported throughout the past 1,000 years:

  • The Italian Plague killed 280,000 people in the 1600s
  • In Southern New England, 30-90% of the population of the Wampanoag people died of leptospirosis
  • In the 17th century, the Great Plague of London killed an estimated 100,000 people
  • In Asia/Europe, in the early 1800s – the first cholera pandemic killed over 100,000 people
  • The second cholera pandemic, in the mid 1800s, killed another 100,000+ people in Asia, North America and Europe
  • In 1838, over 100,000 people died in the smallpox epidemic of the Great Plains
  • The third cholera pandemic affected Russia killed 1,000,000 people in the span of 8 years, between 1852-1860
  • 20,000+ people died of a typhus epidemic in Canada, in 1 year in 1848
  • In 1875, 40,000 people died of measles in Fiji
  • Worldwide, in 1889, 1,000,000 people died of a flu pandemic

The 20th century alone saw some of the world’s worst pandemics.

  • The Spanish flu decimated the world’s population after WWI, killing an estimated 75,000,000 (75 millon) people, in 2 years!
  • In 1957, the Asian flu killed  2,000,000 people worldwide.
  • 1 million people died in 1968 of the Hong Kong flu.
  • 15,000 people died in India, in 1974, of cholera
  • More than 30,000,000 people have died of HIV/AIDS since 1981

The 21st century is almost a decade and a half old.  We have seen our fair share of outbreaks. Nothing as devastating as in the past, thanks mostly to sanitation, vaccination, antibiotic and antiviral medication, but outbreaks nonetheless.  One might argue that the world is due for one.

  • In 2003, SARS killed 775 people, mostly from China, Hong Kong and Canada; it spread to 37 countries from China
  • The 2009 flu pandemic (H1N1) killed about 15,000 people worldwide.

And this brings me to the real reason for this post.

For months now, news of the Ebola epidemic in West Africa has filtered through my Twitter and Facebook feeds.  The numbers of infected are astounding. I’ve seen estimates that by January 2015, over 1 million people will be infected, half of whom will die.  Ebola, historically, has had 90% death rate.  During this recent epidemic, about half of people infected are dying.  But that is still 50% case fatality rate.

So, what is Ebola? And why is it so deadly? Well, Ebola is a virus.  It’s actually quite pretty, I think.

My knowledge of virology is limited to a few hours of lectures on viruses from medical school.  It has an RNA-genome and it is kind of long for a virus.  Like most viruses, Ebola enters a cell by attached to that cell’s protein coat and fusing with it.  Once fusion of the two occurs, the virus empties it’s contents in the cell and the RNA attaches to the host cell’s RNA and takes over. Instead of the cell making its own proteins, it now has instructions from the viral RNA and starts making copies of the virus.  Once those copies are made the virus attaches to the cell’s outer coat, buds with it and leaves the cell.  By this time, the cell usually cannot function anymore, and so it dies.  The new virus copies get into the bloodstream where they are free to infect other cells and the cycle starts again.  The host immune system cannot keep up with this invader.  The virus makes special proteins that interfere with the hosts’ defenses and leaves the host vulnerable.

The Ebola virus especially likes the cells that line the blood vessels, as well as certain cells of the immune system and the liver.   After infecting these cells, it damages the integrity of the vessels, leaves the immune system’s defenders weakened, and damages the liver’s ability to form clotting factors.  The host then starts to bleed internally, hence the reason Ebola virus infection is also known as hemorrhagic fever.  The host bleeds internally, eventually causing death.

By the grace of God, if you so believe, Ebola virus is not airborne.  This means that it’s not present in the air and cannot be transmitted from being coughed on, sneezed on, or breathed upon.  Infection with Ebola occurs when bodily fluids (blood, feces, urine, emesis) from an infected host are mixed with a healthy host.  Most of the people who have gotten sick in Africa were family members and health care workers caring for the sick, and sadly, the dead.  The WHO recommends avoiding contact with the sick whenever possible, regular hand washing with soap and hot water, and discourages traditional funeral rites of washing and embalming the bodies of the dead.  The virus can be killed with heat (heating for 30 to 60 minutes at 60°C or boiling for 5 minutes).  Quarantine remains an effective method of controlling the disease.

I’ve often joked with friends and family that the world is due for a pandemic.  It’s been almost a hundred years since the Spanish flu pandemic.  The seasonal flu is nothing to joke about – the very young and the very old, still die every year from regular, joe-schmoe influenza.  There is a vaccine developed every year against the strains that most likely will be in circulation.  Since 2009, the vaccine now protects again H1N1 as well. Our office is getting ready for our annual fall classic – the Flu shots are arriving tomorrow and we are starting “flu shot” clinics next week.

But something in the news recently has me a bit worried. Earlier this week, it was reported that a traveller from West Africa boarded a plane in Liberia and landed in Dallas, Texas.  Asymptomatic at the time, he passed through whatever checkpoints were in place and entered U.S. soil.  A few days later, he started getting sick and presented himself to the local ER.  He told the triage desk his travel history, was seen by a doctor, given a script for antibiotics and was sent home.  He returned to the hospital 4 days later, very ill, and was diagnosed with Ebola virus.

Yes, folks. Ebola virus is now in North America.

I have one question.

How the FUCK did this happen?!?!?

Why are planes from West Africa being allowed to land?  If such a plane does land, why aren’t those travellers being immediately quarantined and monitored for symptoms?  Have we learned nothing from SARS and H1N1?

I wouldn’t want to be that triage nurse in Texas who took the travel history information from the Ebola patient and failed to forward it along to the attending physician.  I’d like to think that physician, had he known his patient had recently been in Liberia where there is an Ebola outbreak occurring, would have immediately notified the Centers for Disease Control and Prevention (CDC), and locked down his hospital. But no, that physician apparently didn’t know of the travel history, the patient didn’t bother to mention it again, and he was sent along his merry way to infect his family and God-knows who else.

Apparently, the man went back to the apartment complex where his family lived, started getting progressively more sick, was actually seen vomiting outside the building before being taken back to the ER where he was eventually diagnosed.  Does this not alarm anyone?  When I read the news report to my husband, he made an interesting observation. One that actually is a bit frightening.

Who cleaned up the vomit which likely was teeming with Ebola virus?

Did a dog come by and lick the vomit? Did that dog go back to his owners?  Is the dog sick? What will Ebola do in a new host species? Has the virus mutated? Can it become airborne?

According to that report yesterday, 18 people have been identified as being in contact with this individual.

Today? The Texas health departmentt said there were 100 potential contacts.  “Dallas County officials said more than 80 had direct or indirect contact with the patient.”

Well, which is it?  Indirect contact shouldn’t be a concern with Ebola, right?  Only direct contact, like family members cleaning up vomit or feces, or wiping the face of their sickened family member; or the maintenance worker of the apartment complex told by his bosses to clean up the vomit outside the building?

Today it’s 100.  Tomorrow it could be 1000.

Is this the beginning of next pandemic I joked earlier I thought we are due for?

In those two movies I love to watch, Outbreak and Contagion, the CDC takes control of local health departments and gets the epidemic under control.  Is life about to imitate art?

For all of our sakes, I certainly hope not.

 

 

 

 

 

 

 

 

 

Through the valley…

In the next few days, a family is going to lose a parent, a sibling, a friend, a partner, a lover. This is a family who has come together at the end, in grief and in love.

I witnessed a small piece of this today.

With a heavy heart I knocked softly at the front door, taking note of the “No Smoking, Oxygen in Use” sign.

Upon entrance into the home, the sound of the oxygen tank was heavy in the air.  A hospital bed could be seen down the hallway in the living room, and lying in it, my patient.  I forgot how one looks during the final hours of life. It caught me by surprise and a lump formed in my throat.  I approached the bed and touched my patient’s hand.  I said hello, as the personal support worker washed my patient’s feet.  I am not religious but was instantly reminded of Mary Magdalene washing the feet of Jesus as he hung on the cross dying.   The living room was transformed into a makeshift hospital room.  Bedpans, sheets, syringes, bottles of medications, all visible on the bookshelf and lined up meticulously, within easy reach. But this was someone’s home – unopened mail on the coffee table, hospital brochures on dying at home scattered underneath.  Half-read books on the couch, an afghan and pillow rested in the corner.

Surreal doesn’t even begin to describe it.  The family and I talked, mostly about their loved one and the events of the past few weeks, but also about their plans after the funeral;  the trip they will take this summer, to scatter the ashes; the arrangements for the funeral.

I walked for a while after the visit.  Trying to clear my head. Trying to imagine what that family is going through, watching their loved one dying in front of them. I wished, for just a moment, that I was religious.  Maybe believing in God would help me understand this process of death, what it means and what it leaves behind.

Yea, though I walk through the valley of the shadow of death, I will fear no evil: for thou art with me; thy rod and thy staff they comfort me.

 

Letting Go.

It’s been a difficult day.

One patient whose wife has terminal lung cancer came to see me today.  I plan on doing a home visit later in the week.  He came for his own medical issues, but we talked about his wife.  He put on a brave face but he is devastated.  Married for 36 years, second marriage for both, this wasn’t supposed to happen to them.

Another patient, in a long-term relationship, just isn’t “feeling” it with her partner anymore.  She hasn’t for a long time, yet remains in the relationship and complains regularly of episodic pain which has been investigated more times than I can count.  Her tests always come back normal.  She left her partner last year for a time, actually started dating someone new but then returned to the long-term relationship.  It would appear that the break really didn’t do much for her.  She still doesn’t know what she wants, yet isn’t ready to take the final steps.

Both of these people have to let go, in different ways.

At some point in all of our lives, we have to let go of something, or someone. Whether it is in death, or simply a parting of ways, it’s not easy.  I struggled to find the words for the gentleman whose wife is dying.

And I just got word another patient has likely entered the final stages of his journey and is now actively dying.

All of this in one day, within a few hours.

I need a drink.

I feel completely overwhelmed with my job today.

I need to let these people go.  I can’t take this home with me.

Husband is coming to pick me up. He won tickets to see an early screening of Godzilla. I need mindless entertainment tonight.  Thank goodness my mom can stay with the kids.

 

House Call.

From the time of antiquity,  healers, physicians, medicine men have treated their patients in the home.  In the United States, up until a century ago, a visit to the home was the standard way of delivering medical care.  Today, things are much different.  A study published in the New England Journal of Medicine in 1997 looked at the frequency of house calls to the elderly.  Shockingly, less than 1% of Medicare patients received house calls from physicians.  I suspect that this remains the case.

And let me be clear, what I am addressing here are the home visits by a patient’s primary care physician, not the walk-in clinic doctor opening up a house call business.

 

The days of your family doctor coming to your home instead of you going to their office, are largely over, I think.   Although my colleagues still make house calls, mostly for their elderly and housebound patients, as well as those dying at home, it’s not very often, and I can usually hear them grumbling about it. “Ugh, I have to make a house call.”

I am proud to say that I have made a few house calls, albeit not many, but when I feel it would benefit my patient, I make the effort.  Granted, I have a much younger patient population than my colleagues, so the opportunities for home visits are few and far between.  I expect this to change as my patients age.  I was interested to find out what the state of house calls is in this country, so I looked it up.

In 2010, family physicians in British Columbia were surveyed about house calls. The sample size of physicians who completed the survey was small.  After all, who has time in their busy practice to fill out a survey among all the other paperwork?  In this study, 73 surveys were completed (250 were sent out).  Of those completed, 87.7% stated they had done at least 1 house call in the past year; 31.5% did house calls at least once a month and 16.4% did them at least once a week. What I found interesting was that when the study authors looked at the physicians in two groups – those who graduated from medical school before 1990 and compared responses to those who graduated in 1990 and after, they found:

The 49 physicians (67.1%) who graduated from medical school before 1990 were no more or less likely to have done at least 1 housecall [sic] in the past year than the 24 physicians (32.9%) who graduated in 1990 or later (n = 42, 85.7% vs n = 22, 91.7%; χ2 = 0.53, P = .47). However, 11 (22.4%) physicians who trained before 1990 did housecalls at least once a week compared with only 1 (4.2%) physician who trained in 1990 or later (χ2 = 3.92, P = .048).

Younger physicians are doing about half the house calls their older counterparts are doing and even less are doing them once a week.  The tide is turning, indeed.  Even more interesting, is the report from the National Physician Survey:

The National Physician Survey reported that, in 2010, only 47.8% of British Columbia (BC) family physicians offered their patients housecalls and 0.9% described housecalls as a specific area of focus in their practices.2

Family doctors seem to prefer to see their patients in the office, not in their patients’ homes.  I can understand why – it’s more convenient to stay in the office, travel time in the city can be a nightmare, and remuneration may leave something to be desired.  After all, in the time it would take to travel to visit one patient, a physician could see 5 – 10 patients in the office.

A lot can be learned from visiting a patient at home.  For example, an 85-year-old woman who has had multiple falls in recent months;  she can’t come to the office because she’s in a cast after having broken her ankle.  You, as her physician, decide to take the visit to her home.  Upon walking in the door, it’s quite evident why she’s falling a lot – the floors are lined with ratty carpets, even you almost trip on your way in!!  The patient’s daughter is also present for the visit and instead of discussing the fracture, the visit is spent discussing removal of the carpets!

I made a home visit this week to a patient who is dying of cancer.  I called her husband last week and asked if she was well enough to come into the office.  She has a team of doctors looking after her, one of whom is a palliative care physician who makes home visits every few weeks.  A visit with me at this point is purely supportive in nature as her palliation is being tended to by the specialists.  Her husband said that, while they do make it to chemotherapy appointments, and other specialist appointments, it takes a tremendous toll on his wife and he didn’t think she’d be up for an office visit in addition to their weekly outings.  I knew he wouldn’t suggest a home visit – most of the time the last thing a patient wants is to impose on their physician.  So, I gently asked if she wouldn’t mind a house call.  The pause on the phone was telling.  “That would be wonderful for her,” he said.  “She would enjoy that so much.” He sounded a little bit surprised that I would offer.

Seeing a patient in their home environment is one privilege of family medicine I didn’t expect.  Once you step foot into their home, they cease to be “just a patient”.  You bear witness to their real life, to the home they have made, to their hopes and dreams, to their sorrow and sadness.  My patient and her husband welcomed me into their home, offered me a delicious cup of coffee and we talked.  We talked about her cancer and her pain; we talked about how chemotherapy was going;  we talked about the cat I saw roaming in the backyard; they told me how they met in Spain thirty-five years ago; and we talked about their four children. I saw the hope flicker in her eyes when she talked about the chemotherapy that helped her pain and maybe, just maybe, is shrinking the tumors. I saw the courage in her husband’s eyes as he tended to her needs and fluffed the pillow she had behind her back.  I saw the profound sadness in her eyes as she struggled to find the words to describe what it’s like to plan her own funeral.

Most family physicians don’t do house calls anymore.

I am not one of them.

 

Cancer Blows.

Prior to my maternity leave, one of my patients had been diagnosed with pancreatic cancer.  She was set up with specialists, I reassured both her and her husband that they were in excellent hands with my locum and promised to be in touch with them as soon as I could.  My locum has been keeping me up to date on this particular patient as well as a few others.  This patient had major surgery a few weeks ago to remove the tumor and reportedly has been doing well.  I read the operative report today.  She had a procedure known as the Whipple.

The Whipple is a complicated procedure.  I saw one performed once as a medical student and all I remember is holding a retractor for a very, very long time.  Generally speaking, pancreatic cancer is not a good cancer to be diagnosed with – I mean, no cancer is, but this one in particular can kill a patient very quickly if it’s not caught early.  Thankfully, I believe my patient’s tumor was found early and according to the operative report, the Whipple procedure was considered curative.  Curative!! If I believed in God and Angels, I would say she definitely has an Angel looking after her.

Cancer is one of those illnesses that, I believe, touches all of us in one way or another.  My mother had breast cancer, diagnosed 12 years ago while I was still in medical school.  My mom was one of those women who always did self-breast examinations because she was prone to developing cysts.  I remember when I was a lot younger, she went in for day surgery to have a lump removed.  It was benign, but ever since then I always remember her feeling her breasts, always checking for something.  Well, on one of those checks, she felt something different.  Her family doctor couldn’t feel it; the radiologist couldn’t feel it; the breast surgeon couldn’t feel it.  But my mom did and the mammogram proved it. She had a lumpectomy about a month later and it was proven to be contained within the breast with no evidence of spread to the lymph nodes.  She had 5 weeks of radiation therapy, took Tamoxifen for five years and is considered cured.  Her having breast cancer does not necessarily increase my risk as she was post-menopausal at the time of diagnosis, but I still plan on being vigilant and likely will get my first mammogram next year when I turn 40.

Husband’s father was diagnosed with bladder cancer at the age of 62. Like most individuals diagnosed with bladder cancer, he presented to his doctor with gross hematuria (frank blood in the urine).  His tumor was small, localized and initially treated with an immune-stimulating drug called BCG (made of the bacteria that causes Tuberculosis).  It seemed to work at first but several months, maybe a year later, he developed acute renal failure and it was discovered that the tumor had spread outside the bladder wall and was blocking one of the ureters that drains the kidney.  I believe he underwent chemotherapy at that time, as surgery was no longer an option due to local spread.  Sadly, he died about a year and a half after the initial diagnosis. His risk factors were his age (>40) and his sex (male).  He never smoked, but he did work in the pharmaceutical industry as a pharmacist for many years back in Scotland, so it’s possible he was exposed to some chemicals back then.  We’ll never know.   As husband has just turned 40, I remind him periodically that he needs to go for his check up.

I remember a particularly difficult case I worked on during my family medicine training.  I spent two months on the Palliative Care unit. Palliative care is end of life care. More than that, it is medical care and treatment during the process of death and dying, not only for the patient, but for the family as well.  Difficult under any circumstances, but brutally awful in this particular case,which was a 44-year-old mother of two children, dying of colon cancer.

Colon cancer is one of those illnesses you think happens to a man in his sixties.  At least it was for me, as a medical student and resident.  But those two months on the Palliative care ward taught me otherwise.  Almost 10 years later, I don’t remember the details of the case, but what I do remember is that cancer can strike anyone, at any age.  My job as a family physician is to be suspicious and cognizant of that fact.  Anyone with symptoms of anemia, weight loss, change in bowel habit, vague abdominal pain/cramping, night sweats, regardless of their age – these are all red flags that need to be paid attention to.  Sadly for this woman, her physician lacked a certain amount of imagination and her tumor wasn’t discovered until it was too late.

I recently visited the RateMyMD website and looked myself up.  I was pleasantly surprised to see several new comments, and yes, they were all positive. (Giving myself a pat on the back right now!)  One in particular stood out.  This patient was new to my practice, having seen her husband’s physician for many years.  This physician was retiring and she sought out a younger, female doctor.  She got me. Apparently, at her first annual physical exam with me, I asked her about colorectal cancer screening.  She had never had a colonoscopy – it was never brought up by her previous doctor.  She had the “home testing kit” done every few years.  These fecal occult blood tests (FOBT) are designed to detect microscopic blood – blood not visible to the naked eye.  The thing is, not all tumors bleed, so the test might miss one.  Colonoscopy is the gold standard test for detecting colon cancer.  Guidelines for screening state that all patients > 50 years of age should have one every ten years.  However, this usually doesn’t happen because of wait times and cost to the healthcare system. Thus, the FOBT became a test to do in between colonoscopy.  Despite the guidelines, most physician will still recommend for all of their patients to have at least one colonoscopy.  Apparently, I talked about it enough at this woman’s appointment that she agreed to have one.  Turns out, I saved her life.  She had several precancerous polyps which were removed during her colonoscopy.

It’s a no-brainer, folks.  Screening tests work, be it mammography for breast cancer or Pap smears for cervical cancer.  If anyone reading this has a family history of cancer, or is of the age that a screening test is recommended, please get your screening done.  It really might just save your life.

When A Patient Dies.

A while ago, I posted about how it sucked that every time I go on maternity leave, one or more of my patients gets seriously ill right before I go.  I know it’s just part of the job, some of my patients are going to get sick and some are going to die. It just feels worse when it happens and I’m not physically present in the office to get the news.

Well, one of the three patients I was worried about dying while I am off, has died.  I got the news the other day that a lovely woman, a patient of mine for 6 years, has succumbed to her blood cancer. I knew it was coming based on reports I had been receiving from her specialists over the summer.  I just didn’t think it would happen 2 weeks into my leave.  I see most of her family but hadn’t seen them in quite some time.  Either they are relatively healthy, or more likely the case, they were busy with caring for their wife and mother.  In any case, I am now faced with the question:  Do I reach out to the family?

Normally, I wouldn’t hesitate to call the family upon hearing the news that a family member passed away.  But I am not working and I haven’t seen the family in almost a year.  A part of me wants to reach out, but I worry I may be intruding and perhaps it’s best to just let it go and address it when I see the family again.

And I have to ask myself,  am I reaching out for their sake, or my own?