Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

A Memorable Patient

I have been thinking about some of my more memorable patients these days. I especially remember one of my younger surgical patients from when I was a junior resident. I was on the Colo-Rectal surgical service, which was one of the more interesting rotations that you can have a resident. Colo-rectal surgeons handle just that, diseases of the colon and rectum that have to be treated surgically. One of the nice things about the service is that the colo-rectal attendings were among the most personable and knowledgeable of my junior years. They loved to teach and they loved to have us involved in their cases at every step.

One day, a gentleman presented to clinic for the final scheduling of his upcoming surgery. He was a young man (less than age 40) with a very low rectal tumor that we knew was cancerous. His presentation had been rectal bleeding and when his primary care physician found the tumor (it was palpable on digital rectal exam), he immediately referred the gentleman to our clinic for workup and surgery. At this point, the workup was complete: CT Scan, blood work and chest film. We reviewed everything and the patient was scheduled for AM admission, given pre-op orders and sent home to report back to the hospital two days later.

Two days later, we greeted the patient and his wonderful wife in the holding area. They had followed the prep instructions to the letter and he was cleared by anesthesia for the case that we would be doing. We had planned an abdominoperineal resection which involves wide excision of the rectum to include the lateral attachments and pelvic attachements and the creation of a colostomy. In the performance of this procedure, abdomen is opened and examined to see the extent of spread of the disease if any. Since we had a CT Scan that was two weeks old, that showed no evidence of spread of disease to other organs, we were confident that we would be able to remove the tumor, fashion a colostomy and get this patient on to recovery.

To have a colostomy at such a young age is life changing but to die of rectal cancer would be a tragedy and thus the patient was eager to get the surgery over with and get on with chemo and his recovery. He had been very eager to learn about colostomy care and life with this procedure. We open the abdomen and to our shock, the cancer had spread to his liver. As I moved my hand over the liver, the extent of the numerous tumors was quite evident. We all scanned the CT to see if we had missed something but we had not and neither had radiology. The tumor did not show on the CT Scan.

At this point, I helped my chief resident close the abdomen while our attending went to deliver the devastating news to this patient’s wife. The cancer was unresectable and the patient had little chance of living more than a few months with the extensive liver involvement. The next day, we ordered another CT Scan and sure enough, there were multiple tumors throughout the liver in addition to the tumor in the rectum which really hadn’t changed much in size.

The next two days, I rounded on this patient and wrote notes. I made sure that his pain was under control and I met many of his relatives who were just wonderful and very grateful for everything that we had done for the patient. I felt horrible because we all wanted to do more but there wasn’t anything more that could be done from a surgical standpoint. On post op day 3, the patient was ready for discharge from the hospital. He was scheduled to see a wonderful oncologist and the possibility of enrollment in an experimental protocol was there but still, it was difficult to see this situation.

A week later, the patient came back to clinic for removal of his surgical clips. His incision was well healed and he joked about the small shave prep that had been performed. His lovely wife said that every day she had with her husband was a gift because he had been badly injured in an accident three years earlier and given little chance of survival but he did. She said that she was so happy to take him home and that he was a well-loved man.

I heard that this patient died peacefully at home six months after the surgery. His wife sent us an obit notice and wanted us to see that she had directed all donations go to the American Cancer Society. She thanked us again for the great care and the time that she had with her husband. Those words stung then and they still sting as I think of that lovely family from time to time.

It is always patients like this patient that remind me to give my best always. We don’t know if we will be the last physician or the physician that will make an impact on our patients. This patient gave me so much by just putting his trust in our team. I see him often when I have to deliver bad news to a family or to a patient and I hope that he is at peace. His wife said that his death was peaceful and that his 10-year-old child was with him as was his mother and father. I can only hope that all of my patients can leave behind their disease in peace when the time comes. I am certain that the oncologist made sure that he was pain free as much as possible.

It’s this time of year when I think of some of my more memorable patients. The ones who show me how to live by being a great example with their lives. I am a very fortunate physician.

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14 December, 2007 - Posted by | colo-rectal surgery, general surgery residency

5 Comments »

  1. The patient should have gotten a Pet-scan before going to surgery. This would have shown the cancer had spread to his liver. Sad that the doctor did not order this procedure done and the patient had to be cut open find out he had cancer in his liver.

    Comment by rick | 14 July, 2009 | Reply

    • To Rick:
      This patient had undergone a CT Scan one week before the scheduled surgery. The CT Scan was read as clear by two radiologists. The tumor was aggressive hence the surprise that the liver was affected at the time of surgery. Had there been evidence of tumor on the CT Scan, there would not have been a surgery.

      Comment by drnjbmd | 17 July, 2009 | Reply

  2. To Imran,
    If you have a poor undergrad GPA, you really want to do some post bacc work to get that uGPA higher. While public health is interesting, an MPH isn’t going to help you get into medical school. A better choice if you need grade enhancement would be informal post bacc work, a Special Masters Program (go to the AAMC site and do a search) or a formal post bacc such as the one at VCU (in Virginia).

    You can always pick up your MPH while you are in medical school (can do this after third year) or while you are in residency (many residency programs such as Preventive Medicine, Community Medicine or Aerospace Medicine) have MPH programs built in.

    No matter how low your uGPA, you can do some “damage-control” and retake those classes that you did poorly in. If you apply to DO schools, they substitute your more recent grades for your previous poor ones.

    Study well for the MCAT and apply to medical school. Pick up your MPH later and should be fine. I have an acquaintance who had a uGPA less than 2.0. He totally took a new bachelors degree, applied to DO school and is now finished with residency. It can be done.

    Comment by drnjbmd | 26 June, 2008 | Reply

  3. First of all I wanted to say thank you for this great blog. I am one of those students who basically tanked my first 2 years in college but having been working extremely hard to get myself back on track. I have always found community health and public health interesting as well as medicine. I know my chances of getting into medical school are slim to none so I am thinking about going to get a masters in public health or community health. If I get in and do well, will this have no bearing on when I apply to medical school?

    Comment by Imran | 19 June, 2008 | Reply

  4. Wow.. inspiring.

    Comment by Max | 22 December, 2007 | Reply


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