(Warning for unhappy topics ahead. CW: disease, cancer, poor prognosis)
“Numerous”, “plethora”, “many”, and a whole host of other vague terms are not what you want to see in a radiology, pathology, or surgery report. Physicians, especially the ones who go into those specialties, tend to be fairly exacting, precise, and unequivocally clear in everything they do. It’s been a few years since I was working for the surgeons that specialized in cancer-related plastic surgery (a very specific field), but there are a few patients that will stay with me for years to come.
One of the most amazing technologies in medicine is the PET scan. “Positron Emission Tomography” scanning. The basic outline of the procedure is that the patient is injected with a sugar compound that contains a medically safe, mildly radioactive isotope attached to metabolically active sugar. Tumors are greedy little monsters and devour glucose in the most voracious and inefficient way. This is used to our advantage because more of that isotope will end up in the tumors, making them light up like Christmas trees. The PET scan will make a 3D image of the entire body which highlights any areas that are consuming sugar at a higher-than-normal rate.
There are a handful of tissues and organs that consume extra glucose compared to others, but it’s usually easy enough to discern between the normal physiologically active tissue and the tumors. In the surgical practice where I had worked, it was standard practice to get one of these scans prior to surgery for any melanoma that was beyond a certain stage on biopsy. The scans were usually negative besides the area around the melanoma, but every now and then, they were unfortunately positive.
There is one radiology report that sticks in my head; one phrase in particular:
“Numerous pulmonary metastases.”
Normally, the radiologist reading the scan will be very specific about the number, location, and relative size of any metastatic tumors beyond the original cancer site. That was not the case here. The report came in late on a Friday afternoon, just before we were closing the office for the weekend. The surgeon who had ordered the scan had finished in the OR hours ago and was out of the office on Fridays, but he responded quickly when I forwarded the report to him.
I remember the patient. A lovely, kindly, older gentleman with a warm smile despite his fears going into his surgical consultation appointment. The surgeon called the patient to discuss the results and directed us to cancel the surgery that had been tentatively scheduled for the following week. There was a flurry of orders to get the patient set up with the oncologist that specialized in non-surgical melanoma treatment because the extent of the disease was so far beyond surgical management.
It was all very routine for us despite the profoundly negative implications for the patient’s prognosis. It was entirely too easy to forget that this was a real person with family and friends that would be impacted by this disease.
Dehumanization through apathy through overexposure.
The alternative can be worse though. If you don’t learn to compartmentalize; to separate yourself from the tragedies of your patients’ lives; it will eat you alive. There are little details of so many cases that echo in my mind when things are quiet for a little too long, or if I’m too tired or too stressed to keep the memories at bay. Compartmentalization is a critical survival skill in medicine, but it is hard to escape the memories formed before the skill gets developed.
This case will be one of those for me.
“Numerous”.
Not even worth trying to count.
It wouldn’t matter. It wouldn’t make a difference to know the exact number because once you pass a certain threshold, it’s a forgone conclusion.
In this case, the only thing that could be done would be to try to get the patient’s own immune system to go after the tumors because it would be so far beyond impossible to treat it surgically or with radiation. There have been revolutionary advances in chemotherapy and immunotherapy, so the prognosis wasn’t set in stone technically, but statistically….
That warm smile from a kindly gentleman who was just a bit afraid at his consultation will forever be paired with that quote from the PET scan report:
“Numerous pulmonary metastases.”
Unfortunately, I fully expect to see an ever-increasing number of cases like this. Healthcare accessibility is about more than just money. Lives are on the line here because there are so many conditions and illnesses that have a wildly different prognosis depending on when you catch them. Part of why primary care is so important is that patients need to have someone to check on the little signs, symptoms, and lab values that can be heralds for serious problems down the road. An ounce of prevention is worth a pound of cure after all.
For this patient, catching the melanoma early would have meant treating it before it got the chance to metastasize. For cancer in general, early diagnosis is the best tool we have for increasing survival and improving the quality of life after diagnosis and treatment. Unfortunately, many cancers are insidious little demons that will smolder in silence without causing noticeable symptoms until it’s too late.
With the recent cuts to Medicaid and the impending closure of critical access hospitals and clinics in remote rural communities, I fully expect to see more patients slumped on Death’s doorstep because of problems that could have been prevented, treated, or cured had they had access to reliable primary care. I don’t know how many people will die because of this callous disregard for human life from the current government, but I know the lives lost will be “numerous”.
It will be heartbreaking and horrible, and incredibly difficult, but we need to count those lives lost. It would be all to easy to compartmentalize and just run with a faceless, nameless estimate of casualties, but in this situation, we cannot compartmentalize, we cannot generalize, we need to count and name every life lost and demand justice for every single one.
The Huge Horrible Bill has already passed and rural clinics and hospitals are already closing, but you can still demand change and accountability from your representatives. Emails are good, phone calls are better, physical letters are hard, tangible evidence of your demands for justice. Look up your representative here, and support critical services like the USPS by mailing your demands to them.
Stories like this patient’s are going to be specks in the avalanche that will be smothering our already struggling healthcare system, but sharing these stories and raising awareness of this problem are critical parts of the solution. Share this story, share the stories from your family and friends, because I guarantee you know someone who has been directly affected by delays in diagnosis and care. We cannot sweep them under the rug and hide our eyes, ears, and hearts from their lived and died experiences.
Thank you for writing this!