No one enjoys diagnosing cancer. Everyone particularly hates making the diagnosis in young people. Little kids are the worst even though they do not understand what is happening – it is Mum and Dad, Nanna and Granddad and the sibling and other relatives who bear the brunt of the shock and heartache. But these poor littlies still suffer the agonies and tortures of treatment that adults suffer – the only difference is they do not understand why. Teenagers usually know enough about cancer to realise what an appalling situation it is to be in.
In the ED, strangely enough, we diagnose a lot of cancer. People come to us with bleeding from the bowel or intractable headaches or chest pains or broken bones from pathological fractures or coughing blood and so on. These problems are all emergencies – in the eyes of the patients at least. After taking a history and doing an examination we have rapid access to laboratory tests, x-rays and CT scans. A diagnostic process that may require several visits to the GP over a week or two, after a week or three wait for an appointment, can be fast tracked into a few hours. And immediate consultation with appropriate specialists or transfer to a tertiary hospital can be arranged the same day.
Troy was seventeen and enrolled at TAFE doing a personal trainer course. He had been doing a lot of cricket training of late, especially bowling, and he was left hand dominant. He attended with his Mum. Both were intelligent, pleasant, likeable people. Troy complained of left chest pain, constant, radiating around the chest and worse when he bowled a cricket ball or took a deep breath. He said it had started after the intensive cricket but his mother disputed that and said he had complained of it frequently for the better part of a year.
He looked quite fit, had a mild scoliosis in the chest (curvature of the spine). He had no neurological signs and no abnormal sounds in the chest but it hurt him when I applied rapid compression to his chest side-to-side. His ECG (electrocardiogram) was strangely abnormal to the degree I asked nurse to do it again – with the same result. I requested a chest x-ray and was dismayed to find it grossly abnormal. The radiologist suggested an immediate CT scan of the chest and there was the diagnosis.
Troy had a tumour the size of a mango sitting in his chest behind and to the left of his heart. It was encroaching into two inter-vertebral nerve outlets thus causing the pain radiating around his chest. The radiologist was of the opinion it was an advanced non-Hodgkin’s lymphoma - a form of cancer. It was my duty to inform Troy and his mother.
Such tasks are painful to all involved. I take the view that there is no point in beating about the bush – the patient must be informed of exactly what we have found and of the most likely diagnosis. But this must be done clearly, gently, with compassion and empathy, and without delay. This I did.
Two worlds fell apart before my eyes. Troy was obviously shocked. His mother broke down crying with her face in her hands. Troy rapidly regained his composure, hugged his mother and told her, “Mum, don’t cry, I am going to beat it!” Then followed the questions and answers. I informed them of what good news there was – the tumour appeared to be above the diaphragm only and that rapidly advancing treatment modes have dramatically improved the survival rates of this disease.
Then followed the arrangements for Troy’s transfer to a teaching hospital. His Mum left and a bewildered and confused Dad arrived. I walked him through it all. It was another hour or so before the transfer arrangements were completed. Dad volunteered to drive him rather than use the ambulance. I was busy with another case when the time came for them to leave but they waited until I was free, both shook my hand and thanked me most sincerely for my efforts. It is those moments that distress me immensely yet deliver the greatest intrinsic rewards in medicine – patients expressing sincere gratitude even though I had delivered them the most frightful news.
There is an interesting sequel to that day’s events. Six months later Troy, his mother and younger brother arrived back in the ED. Troy had broken a bone in his foot in a minor event on his bike. It was easily sorted out. His mother carried a folder containing, as it transpired, all the medical notes and laboratory reports about Troy’s lymphoma. She wanted me to see it and I duly perused the contents. Then the mother got my complete and undivided attention as she described how she felt when I first told them Troy’s tentative diagnosis. “I wanted to get up and slap you across the face as hard as I could. I suddenly hated you for what you were doing to us. But a few days later, when the specialists told us the full extent of Troy’s illness, I realised you had actually saved his life. You didn’t send us away like some other doctors had. Troy would have died if you had.” That caused me a certain amount of introspection. I am satisfied her reaction was a consequence of the message, not the messenger.
We had been wrong in our initial assessment of the extent of the disease. In fact it had been a Grade Four, (very widespread), Hodgkin’s lymphoma with a poor prognosis. Troy had undergone six months of chemotherapy and a recent PET scan had found no evidence of tumour. He is not out of the woods yet but he is as optimistic as ever. I feel he will beat it.
Only a week before Troy another young man of about twenty years presented with a small, tender lump in his thigh just below the groin. He appeared athletic, fit and well. Examination confirmed the small, tender lump under the skin of the thigh but also a mass of tender lymph nodes in his groin and there were others in one armpit. There were a couple of minor abrasions on his lower leg but nothing that could be considered a focus of infection severe enough to cause such a reaction in the lymph glands. There was nothing else to find in a thorough examination. Taking a more detailed history added only the fact that he had lost four kilos in weight in recent weeks for no apparent reason.
His chest x-ray was normal but his white cell count was grossly elevated. I went to the laboratory and had a chat with the scientists and asked them to examine a blood smear. This revealed some abnormal white cells of a non-specific nature – that is to say they were not normal cells but not the cells seen in leukaemia or other sinister diseases. I then rang a haematologist – a specialist in disorders of the blood and lymphatic systems. He agreed there was cause for concern and agreed to see my patient at his clinic a few days later.
Sitting on the side of the emergency ward trolley I explained the situation to the patient as best I could. It was awkward, (the telling, not the sitting), because I could only tell him I suspected he might have something serious going on but I did not have enough information to make a firm diagnosis. He asked what was the worst case scenario. I had to tell him it would be a form of cancer such as leukaemia or a lymphoma. He appeared philosophical about it saying, “Oh well, I’ll just have to wait and see what the specialist has to say.”
I heard no more for a couple of weeks then ran into the specialist in the hospital and asked about this patient. He informed me that when he saw the patient the glands were barely palpable, the lump in the thigh had gone and the white cells had returned to normal. We don’t know what had caused all of this but I was delighted the worst case scenario had not eventuated.
The hospital rang me the other day and asked if I could come in to help out in a very busy period with two doctors short. On arrival I took over the care of an elderly gentleman – among several other patients. He had presented with pain in the right hip, present for several months with increasing severity but had reached a stage where he could no longer ignore it. He could not put foot to floor now because of severe pain but was pain free at rest. He did not look at all well and told me he was being treated for aggressive cancer of the prostate as well as lymphoma and both were “in remission”.
His wife was with him and asked if I thought the pain could be due to cancer. It would be a pointless lie to say no, so I told her it was possible but there were other possibilities also including a fractured bone. And that was what the x-ray revealed – he did have a fractured neck of femur. It was not of the type that occurs with a fall but more of a gradual giving way of very osteoporotic bone.
I took the x-rays around to the operating theatres where I knew an orthopaedic surgeon was working. My timing was impeccable as he had just finished one case and was waiting for the next to arrive. He looked at the films while I told him about the patient. His considered opinion was that the patient needed surgery to insert a “pin and plate” to stabilise the fracture. Failure to do so would inevitably result in the bone shearing through into a complete fracture that would be very difficult to deal with and leave the patient with a very poor quality of life in the time left to him. The concurrent prostate cancer and lymphoma reinforced the need for surgery rather than being contraindications.
Patient and wife accepted, with equanimity, what I had to say. However, he was very surprised when I said I would arrange transfer to another hospital, where the surgeon performed such surgery, by ambulance. He wanted to drive himself. “How on earth can you drive a car.” I asked.
“Well, it is a bit awkward, but I use my left foot on the accelerator and brakes. It takes me a while to get in and out too.”
It took the best of my powers of persuasion to convince him that an ambulance would be much more satisfactory. Then I had to work through how we could get his car home. He had driven it to the hospital and his wife did not drive. We eventually arrived at a mutually acceptable solution, the ambos turned up and away he went. His wife thanked me and apologised for his intransigence. I smiled, thanked her and told her apologies were not necessary.
From time to time I have a medical student tagging along behind me. I enjoy having students with me and making whatever contribution I can, not only their knowledge base, but also to their “life experience”. By that I mean I deliberately expose them to such situations as informing patients, such as young Troy and his mother, of dreadful diagnoses. I had a student with me that day – a mature age Emergency Department nursing sister who had decided to do medicine and was at the end of her third year. Despite her work experience she had never participated in such discussions previously. With permission of patient and mother she observed what took place. Afterwards we sat down and discussed how I went about it and the respective reactions of patient and mother. (The mother had given no indication of her anger with me.)
A few days later she had the opportunity to participate in a similar discussion with another doctor. This time the patient was a man in his fifties who had come in blue in the face and very short of breath which he said had come on while mowing the lawn. In fact it had been building up for some time. His body’s compensatory mechanisms had become exhausted when mowing the lawn. I was not looking after him but, as he was an unusual but classic case, we doctors had a discussion about it and reviewed the x-rays together. These showed a large tumour in the apex of his right lung. It was undoubtedly lung cancer – he was a heavy smoker – and the tumour was compressing the veins that bring blood back from his head and right arm. His doctor invited the student to participate in the process of informing him and his wife of the dreadful diagnosis. After that he was sent off to a teaching hospital for urgent surgery to decompress the veins.
I occasionally allow myself a wry smile when I feel I should show a student something mundane but which, to me, is interesting. But, when I look for them, I find they are engrossed in trying to interpret a CT scan of the brain or are observing treatment of a convulsing drug addict in one of the resuscitation rooms. Diseases such as scarlet fever, (I saw a case just recently), quinsy, scabies, embedded corneal foreign bodies, foreign bodies in the ears or noses of children, a basal cell carcinoma on the face of woman, hand-foot-and-mouth disease in a child –these are some of the afflictions that first present to the GP – or the ED. Most of these young doctors are going to finish up as metropolitan GPs and these are the conditions they will have to diagnose and treat. They will have a better chance of success if they have seen at least one case previously. In general practice the will not do much CT brain scan interpretation – it will be done for them by radiologists - and, unless they move into the country to practice, they will do precious little resuscitating.
Shingles is another case in point as it does not always present in its classical form but it does often present in cancer patients – a most undesirable complication to their disease. It is caused by the chicken pox virus which, after a child has that disease, may settle and reside for many years, in the dorsal nerve roots in the spinal column. At a time of its own choosing, usually when the patient is severely stressed emotionally, physically - or both – as in the case of cancer victims, the virus decides to multiply and migrate down the sensory nerves to the skin where it forms vesicles (blisters) and causes severe pain. It can be treated with anti-viral medication provided such treatment is commenced within 72 hours of the onset of symptoms. So, if the doctor does not recognise the affliction at first presentation the boat will be missed and the cancer patient will have yet another burden to carry.
A diagnosis of cancer does strike fear and dread into most patients. It is, indeed, a dreadful diagnosis. Roll on the day when the scientists will have found better cures than those we already have for most cancers – and cures for those we cannot cure now.