Monday, September 15, 2008

I become the patient

I came out of the shower and dried myself with a huge white towel. Something caught my eye. What was that on my back? It was dark, but I couldn't get a good look at it, even with all the mirrors in my bathroom. I'd never noticed it before.

A few days later, I became more worried. Could it be the dreaded melanoma? I had recently seen several patients die of metastatic melanoma in the hospital, and they were terrible, slow, painful deaths. I was rather young for such a thing, and I tend to wear sunscreen and keep out of the sun when I can. But there was still a chance. And if it was the real deal, catching it early was my only hope. If it invades more than 1 millimeter into my skin, my five year survival (the odds that I would live longer than five years) drops off a cliff. I couldn't let this go.

Since I couldn't see it well, I took pictures of it with my digital camera. I saw that it met all the ABCD's of melanoma. It was Asymmetric. Its Border was ragged. It was comprised of two or more different Colors. And its Diameter was greater than a pencil eraser. Shit. This could be bad. Should have used more sunscreen. I suddenly remembered the blistering sunburns of my youth. That time in Saudi Arabia when my skin was peeling right off my back. All those times I went water-skiing without sunscreen. Those blistering sunburn drastically increase your odds of skin cancer.

So I went to the Dermatology department to try to make an appointment. They asked to see my insurance card. Then they told me that the first available appointment was in late November. Really? I'm supposed to wait more than two months with a time bomb on my back?

That afternoon, I decided to take matters into my own hands. I would not wait that long if I could help it. I left the pediatric neurology clinic in which I was working, and headed towards the derm clinic. I tracked down the doctor I was after, and introduced myself. "Hi Dr. B! I'm me. You worked with my dad a while back. I have this thing on my back, and I think it might be a melanoma."

He was so nice. He immediately took me into a room so he could look at it. He thought it was suspicious, so a few minutes later, he took a biopsy of it. He asked for my pager number so he could give me the results as soon as he read the slides (he's also a dermatopathologist). Now I have quite a few stitches in my back, but at least I know that I, and the little piece of my back, are in good hands.

Monday, September 8, 2008

The Nile

A patient comes in today. Middle-aged man, slightly balding. He had headaches that just wouldn't go away. So we got a MRI of his brain. The official report hadn't come in yet, but the images were on the computer. So I glanced through them.

MRI is an amazing thing. With the click of my mouse, I can fly through cross sections of a person's brain, seeing it in exquisite detail. I can see, millimeter by millimeter, what makes you who you are.

As I flew through the cross sections, I started to see bright spots at the junction of the gray and white matter. There were ar least four to my untrained eye. I called over the resident (a junior doctor). He agreed. Lesions at the gray-white interface are pathognomonic for metastatic cancer. The patient's prognosis was dismal.

The resident and I went into the patient's room to tell him the news. His wife was there.

"The results of the MRI are not good," the resident told him. "We think you have cancer in your brain. The prognosis is not good."

He looked at us for a while, not showing much emotion. I tried to picture myself in his position, but couldn't. I had no idea what I would do or say or think.

He said, "Jesus will heal me!" "I'll be fine, 'cause Jesus will heal me!"



Denial ain't just a river in Egypt.
-Mark Twain

Crazy People

Mr. T came to the hospital to detox for his sixth time, and he was only 25 years old. He was taking large amounts of Valium, booze, and opiates, as usual. So we detoxed him, giving him meds that would make him more comfortable while he withdrew from the drugs.

He would come up to me, seemingly from nowhere, and beg for more. He said the withdrawl was unbearable. He hadn't slept for days. He was anxious. He was sweating. He felt like he was crawling out of his skin.

And then he started to pee blood. A lot of blood. Oh shit. And on top of that, he had a urinary tract infection. He had a history of kidney stones, which can cause bloody urine as they pass through. And he described in perfect detail the exact location and excrutiating pain a kidney stone can cause.

He wanted opiates for his pain. If it were anyone else, we would have given it to him.

So we got a consult from Nephrology. They said that the bacterium cultured from his urine usually didn't cause UTI's. We started him on antibiotics. A CT scan confirmed that there were stones in his kidneys, but unless the stones actually pass through, they shouldn't cause any pain.

Then we got a Urology consult. They said his bloody urine was almost certainly due to "self manipulation." This translates to him shoving a coat hanger into his penis, all the way through his urethra, and then into his bladder, and then whirling it around. All to get opiates.

We discharged him a few days later. He was supposed to go to an inpatient drug treatment program the very next day (we had set up everything for him). But he relapsed, again, and nearly died, again. So now he's detoxing at yet another hospital.

At first I was furious. Furious that he had misled us. That we had wasted thousands of dollars for needless tests and consults. Money that could have probably saved several lives elsewhere in the world. All because this idiot was a druggie.

And then I felt sorry for him. Genuinely sorry. I wondered how a person would have to feel to do such a thing. To fake kidney stones with a coat hanger just to get some drugs. Never before had I realized the power of addiction could be so strong. So strong as to take over everything that you have been, or ever will be.