F is for Cancer…. as in .. FUUUUUK, it’s cancer.

I saw my colleague’s patient the other day as I was covering her practice for a few days. It’s haunted me ever since. She was diagnosed with a bladder infection last week and I got the culture report back just before the weekend. I had to change her antibiotics. I spoke to the patient on the phone and told her if she still wasn’t better after the weekend to come to see me.

Well she did. While the bladder symptoms appeared to be improving she also mentioned how light-headed and dizzy she was and “oh yeah, by the way, I’ve lost about 10 lbs in the past month.”

Fuck.

I looked through her chart at her recent blood tests. Hemoglobin was normal but compared to 2 years ago, there’s been a 20+ point drop.

Fuuck.

Upon further review of her chart, I noted a family history of colon cancer in her mother and stomach cancer in her father. Both deceased.

Fuuuck.

Oh and she repeatedly refused to be screened with colonoscopy or fecal occult blood testing.

Fu—-

You get the drift.

She’s got cancer and it could have been caught early with a simple screening test.

WTF?! Moments in Medicine.

I’ve had a two “WTF” moments in my practice of family medicine over the past several months.  Still boggles my mind how unconcerned some people are when it comes to their health, or the health of their children.

Case #1 – A woman in her early 60s comes to the office with a complaint of chest pain.  It’s not sharp, it’s not dull, it’s “a very heavy, heavy ache, like pressure across my chest.”  It has been going on for a few weeks, sometimes once a day, sometimes more.  She also had a bit of shortness of breath with exertion but given she had asthma, it wasn’t new to her.  I have her do an electrocardiogram at the lab in the building and she returns with the result.

ecg

What do we see here??  Come on, I helped you out!  Those are ST-segment depressions, a sign of cardiac ischemia. She was given a baby Aspirin in the office and sent to the hospital for immediate assessment.  She left AMA (against medical advice) a few hours later.  Her white-coat hypertension was at its worst, her blood work was normal and the cardiologist wanted her to stay in hospital until he could arrange an angiogram.  Well, the thought of a hospital stay was not one this patient would entertain so she went home.  She was pretty adamant that she didn’t want an angiogram, she had heard from friends about “awful” complications and she just wouldn’t entertain the thought.  Instead, she wanted to pursue all the non-invasive testing she could to avoid it.  She was, quite frankly, in denial that her chest pain had anything to do with her heart.  She was convinced it was either her asthma or her heartburn.  Almost a month later, the nuclear medicine scan confirmed there was an area of decreased perfusion and angiogram was now the final course of action.  Her cardiologist kept telling her there was a 15% error rate in the test, but I couldn’t get the ECG out of my head.  Those depressions were real, and they were still present a month later, despite her not having another episode of chest pain.

(As an aside, a few days before her angiogram, news broke of the passing of James Gandolfini, of you guessed it, a massive heart attack.  Not a day went by when I didn’t worry that my patient would suffer the same fate.)

The story ends happily.  And I feel vindicated.  She had the angiogram which confirmed a 90% blockage of a dominant artery in her heart.  She had a stent placed and is doing well.  Yet, it still completely confounds me how it took over 6 weeks for her to get the intervention done.  Had it been me?  No way I would have left that hospital.  But that’s me.

Case #2 – At the end of a routine appointment, a father asks me if he can bring up something about his 2-year-old daughter (who is also my patient).  “It’s probably nothing, but I thought I’d ask since I’m here.”  It’s not terribly busy, so I tell him to go ahead.  He describes these “episodes” his daughter has where her eyes roll up, her eyebrows start twitching and she is “out of it” for about 15-30 seconds.  During this time, she is not responsive to outside stimulus.  She comes out of it on her own and returns to whatever it was she was doing.   I asked him how long this has been going on for.  He says a few months, but maybe longer.  Mom is the caregiver, so she’s seen it more.  Sometimes it can happen a few times a day.  Apparently the girl’s grandfather has epilepsy, so dad was thinking this could be seizure activity.

!!!&??@%&#^#&#(#&#^!&~!!!!!!!

I saw the child the next day.  Mother confirmed what dad had reported.  I called up our local pediatrician who saw the child a few hours later.  During that visit, she had a seizure witnessed by the pediatrician.  The child is now going on to have formal investigations and will see a neurologist in the next few weeks.  Apparently, mom just thought she’d “grow out of it”.

I have some patients who bring their child in panicked because a foot hurts for a day or two,  and here is a family whose daughter has been having seizures for months and it was only in passing that it was brought up to me.  Seriously?!

I just have to shake my head sometimes and think, What.The.Fuck?!

Ignorance is not bliss.

Growing up, I was fascinated with how my body worked.  I sought out books that explained how my eyes and heart worked.  My parents gave me a series of encyclopedias to explain the birds and the bees to me.  I wish I still had them.  Granted, it wasn’t the best way to learn, maybe that’ll be another blog post in the future, but those books were very important to me. I remember they were red, but that’s about it.  In any event, my point is that from a young age I was interested in how my body worked.  So it’s for that reason that it still amazes me how totally uninterested or clueless some patients are when it comes to their body.

Over the course of my career so far, I have encountered several patients whom after I see I can’t help but shake my head.  Really?  You didn’t think there was something wrong when you gained 15 lbs in your abdomen over the course of a few months?

I’ll share a few stories – remember, details have been altered or obscured so as to protect confidentiality.

There was that time when a 15 year old girl came to my office.  She came with her mother, who was concerned that she hadn’t had a period in 5 months.  She knew this because she made sure to look in the bathroom garbage once a month.  Mother said the teen was bloated and her breasts were leaking.  Really?  Didn’t take me long to figure out this child was pregnant.  How could the mother not know?  Denial?  How about the teenager?  After examining her privately and auscultating a fetal heart rate, the girl still denied ever having sex.  It was astounding to me.  It was also incredibly disturbing and sad.

Then there was the middle-aged woman who came to my office complaining of a 15-lb weight gain in her abdomen over the course of 3 months.  She wanted to know if there was a medication I could give her to help her lose weight.  Upon examination, there was a huge mass in her pelvis.  I didn’t even have to palpate it, but I did.  Thankfully, it was a benign ovarian tumour, but my goodness, how does one not know their body?  It was so obvious!  She didn’t look pregnant, she looked like there was something growing out of her pelvis!

Finally, the elderly woman who came in complaining of a rash on her breast.  This was no rash.  She hadn’t been seen for several years, and had always declined the preventive screening tests.  Turns out she’d felt a lump a year previously and ignored it.  Ignored it!  Those were her own words!  The cancer had eaten away half her breast.  Clearly this woman had a serious case of denial.

It truly amazes me how some individuals just don’t care or don’t want to know how their body functions.  It’s even more concerning when a patient suspects something is wrong but is so totally consumed by fear or denial that they wait months, or years, to seek medical attention.

A few months ago, I bought my daughter a puzzle.  A puzzle of the human female body.

I’ve already taught her that her belly button is also called an umbilicus.  She knows she has a heart, two lungs, a brain and lots of muscles and bones.  I want to instill in my children a wonder, a fascination, a love for their body.  I want them to know their bodies inside and out so that if there is ever something not right, they’ll be the first to know it.  It might one day save their life.