Tuesday, January 27, 2009

Suspending Disbelief

When one's 'only' health problem is smoking it's easy to delay coming to the physician. After all, what's the worst it could be? The gentleman in this picture was very sick by the time I saw him. He had been struggling to breathe for days and had a pulse on presentation of 140 with sats in the upper 80s and a respiratory rate of about 40. A few more hours and he would have been intubated immediately.

His EKG showed a right heart strain pattern and I reflexively ordered treatmment for pulmonary embolus (along with a bunch of other stuff). As it turns out having a PE would, perhaps, have been better than having this XRay.

This guy was very anxious and only partly because of his difficulty breathing. This Xray was quickly followed by a chest CT scan and it detailed in three dimensions what we see here in two dimensions. This gentleman has a consolidated pneumonia on the right side and areas of trapped air and fluid which will probably turn out to be secondary to an underlying malignancy.

It happens with relative frequency that I am the first person to diagnose cancer in the ER, probably because folks so rarely have primary care physicians these days and so rarely take care of themselves as they should. The strange bit about this particular shift was that I diagnosed three new cases of cancer in about 18 patients. It was a bad day to have me as a physician.


  1. "It happens with relative frequency that I am the first person to diagnose cancer in the ER"

    Impressive, diagnosing cancer without path

  2. Spoken like a snot-nosed surgeon who the EM doc has to tell what and where to cut...

    Mass + smoker + post-obstructive pneumonia = MOST LIKELY diagnosis is cancer. Sheesh.

  3. anonymous,
    you are correct AND an asswipe. based on the likely diagnosis of this patient i did spend about fifteen minutes with him and his wife talking about the high likelihood that he had cancer. then there was the dude with the antral gastric mass and lesions in the liver which could have been a bezoar with an indidental finding of hepatoma etc... whatever.

  4. Sorry you've got to break the news so often 911. Had a 14 y.o. female come to our ER for the "flu" recently. Her slide looked like a damn zoo & she was mecca bound in a jiffy with 80k whites and something like 65% blasts. You think people have any inkling (especially in your case, not so much in the girl's) what's coming when they stroll in for SOB or the flu?

    Also, I've been mum lately but I have to say that the political posts as of late are about as germane as you can get with respect to American healthcare. I see people posting the lament that "I loved it when you were a medical blog....now my little heart's been torn asunder." What's more central to medicine than how we run & fund the entire fuckin' system? Those political posts deal with topics that affect or will affect all of us. But you already know that.
    Good job.

  5. Hey annonymous,
    you gelded coward, I'll go 9-11 one better and make a histological diagnosis...its a Small Cell Cancer...
    and tell me you're not an Internist...
    or an academic....probably an Academic Internist

    Frank Drackman

  6. RubyRidge, I love you. T'would make for a great book...nag, nag...

  7. Thought you might like this -- http://www.fresnobee.com/state/story/1158156.html Coalition of CA ER docs filing suit about the whole unfunded "treat everybody" mandate.. which is of course getting very little press coverage.

  8. Anon #1 here:
    Nice language guys.
    Ever had the "no you don't actually have cancer that the ER doc told you that you had" talk after the path came back? I have. Just because a quacks and waddles doesn't mean it's a duck (even though I agree it most likely is). It is good that you coached it in "most likely" 911 that wasn't what happened in my cases.

  9. Chantix also known as Varenicline Tartrate, is a prescription medicine given to patients seeking to end their smoking addiction. Chantix operates without using any nicotine and helps in getting smoke free but nowadays some negative reviews stating suicide attempts by chantix consumers have raised a question on its efficacy.http://www.chantixmagic.com

  10. Are you serious? You mean the conversation where you tell the guy no in fact its not cancer, we'll treat you and you'll be fine. Must be tough to have to break that kind of news to patients.

  11. Anon,
    Please return after mastering English. It seems to me that having the converstion with a patient where you tell them they do not, in fact, have cancer would be a good one to have and one that would allow you to poke fun at us 'glorified nurses'. I'll give you a holler for my next cric, fuckstick.

  12. You know 911 do you really think calling someone a "fuckstick" is evidence of mastery of the english language? My point is that even if it "obviously" looks like lung cancer it may not be. I don't argue it probably is, but I have seen anything from benign processes to cocci mimic lung cancer (and that patient presented very ill like yours did by the way). Rare but it happens. Actually one of the "happy" patients was so thrilled he wanted to sue the ER doc (clearly it didn't go far but that is not the point).
    Good luck on your next cric, you certainly don't want me there (seriously).

  13. The strange bit about this particular shift was that I diagnosed three new cases of cancer in about 18 patients. It was a bad day to have me as a physician.
    No, it was a VERY good day. Caught prior to major malignancy is a good thing!