My first patient to be diagnosed with cancer

“I feel very dizzy when standing,” was Ms. A’s* chief complaint. She originally came to the ER for sudden onset double vision and severe balance issues. After briefing myself, I took the stairs to the fourth floor and found her.

When I arrived, Ms. A was the only person there. She was wearing a silver visor and a crisp white shirt. As a native of west Texas, she loved her BBQ, local football, and farming. After I went through my usual routine and gathered her history, I proceeded to the physical exam.

I listened to her heart, breath, and belly sounds, then palpated with my fingers her cervical and clavicular lymph nodes. What I read from the primary team’s note matched what I felt … a hard and slightly mobile mass in the left clavicular region: Virchow’s node. It is known to be a strong indicator of abdominal cancer. I processed this in my mind while I did my best to not look worried. It didn’t work.

“Hey, Ms. A. have you noticed this small lump next to your collarbone?”

“Ah, yes I have actually. It showed up suddenly about a week ago. Doesn’t bother me though. Do you know what it is?” she replied.

I told her a white lie: “I’m not sure what this is, but we will look more into it today and hopefully get an answer.”

“No worries, do what y’all got to do; I don’t want no stone untouched. I feel strong and great so hopefully, it’s nothing. Just get my eyes and balance right and I’ll be on my way,” she said with a smile.

An incidental CT scan completed two days prior showed a small bowel tumor with metastasis to her liver. Subsequent scoping of the duodenum did not show the tumor and gave me some sense of relief. But I knew this was not a definitive answer.

The next morning after we finished rounds, I stayed with Ms. A for her FNA (fine needle aspiration) of her clavicular mass. She was as nervous as was I, and I told her to look towards me and squeeze my hand as hard as she wanted. As the FNA proceeded, Ms. A revealed to me that she lives alone and often gets around by asking neighbors to help drive her to and from town. At home, she uses a walker and often has her neighbors help her with housework. Unfortunately, one neighbor took advantage of her and vandalized her home. She was robbed of all her valuables a mere day into her hospital admission and was notified by police.

“I was told by a friend that everything was stolen. Funny thing is that I don’t feel outright bad about my lost possessions. I value my connections with people much more than material things. But it was still shocking that someone I knew would do that to me.” She trailed off.

I asked Ms. A if she would like to see a social worker, but she said everything should be alright.

“I just want to get my eyes and my balance right and go home, things can’t get any worse for me right?” she said with a laugh.

The next day, I visited Ms. A and she told me that her primary team is discharging her since her vision and balance have both improved substantially. She then asked me about the biopsy results, and I was honest with her.

“The results could be malignant, but we don’t know for sure yet.”

“If it is malignant, can chemo do the job?”

“If that’s the turn we take, then yes chemo is certainly an option.”

“If I need chemo let’s do it. I just want to get out of this bed, go home, and take care of things. You know me and I told you this before, I hate sitting on my ass all day.”

“Every time I saw the group of doctors and students each morning I always noticed you. You always took the time to talk to me even though I know you are busy.”

“Would you feel jealous if I spent more time with another patient?”

“Of course!!” We both laughed together.

“You know, if it does end up being cancer I’m in a good place. I’ve been blessed to have lived a long life. I’ve made no enemies, always looked out for my friends and family, and kept God close to my heart. He’s guided my path from Day 1 and I know that whatever is next there is purpose to it.”

The morning after, as we were nearing the end of rounds, I walked past Ms. A’s room. I casually asked my attending if he knew what the results were.

“Her FNA came back positive for advanced pancreatic cancer. There is not much we can do for her at this stage besides chemo.” I felt a hand placed on my shoulder.

The hardest thing about medicine is that after we care for patients and they leave the hospital, we almost never know how things end up. Did they truly get better? Will they make it to their follow up appointments? Do they have a support system at home? Will they make it to their next chemotherapy or dialysis session?

Regardless of the illness or disease a patient is faced with, we are all human beings regardless of race, religion, color, creed and sexual orientation. By truly listening to every patient’s story we come to understand that we connect on that fundamental level. We remember again what drives us to become physicians. We become better advocates for our patients. Most of all, we never forget that human suffering is a phenomenon that can happen to any one of us at any moment in time. Understanding suffering starts with their story.

Ms. A was my first patient to be diagnosed with cancer and I will never forget the experience we shared. When I look back at all the patients that I have had the privilege of talking to since I started clinics, Ms. A will always stand out to me for her kind-hearted tenacity.

* Identifying information changed.

Ton La, Jr. is a medical student and student editor, the New Physician.

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