Medicine: My First Brush with Cancer

I am proud to announce that in the last 2 weeks, I have figured out how to get from South Building to 4-West, not just what a sign-out is but also how to do it, and settled neatly into my spot at the bottom of the medical totem pole. I still do the 180 outside every elevator, though. I don't think I'll ever be able to kick that ritual. I followed my very own patient from a quivering wreck on Dilaudid in the ER through to happy, ambulating discharge 4 days later, and although everyone else on my team got a handshake, I was the only one who got a hug (I'm unabashedly proud of that-- and it was a big, badass guy, not a touchy-feely little old lady). I feel integrated. I feel like I am actually making a difference.


Midway into week 2, I was asked to "look up" rare coinfections with Lyme disease (namely, Babesiosis and Ehrlichiosis for those who care for such pedantry). Ehrlichiosis presents with fevers, myalgias, thrombocytopenia (low platelets), and elevated liver enzymes. I don't believe I will ever forget the symptom complex for Ehrlichiosis, because a patient came in that very morning with a symptom complex and history of present illness so definitive for Ehrlichiosis that we might as well have watched the tick bite him. He was our Ehrlichiosis patient. Or was he?

We began the standard treatment regimen with doxycycline and sent his blood out for serology at a lab in Utah-- the only lab in the country that performs the blood test for Ehrlichiosis. His fevers and joint pains went away, and then returned with a vengeance. Despite the appropriate treatment, his blood labs continued inexorably on their negative course. He was in pain, a pathetic body on the bed, sweating and asking us daily why we couldn't do anything. We increased his pain medication. We gave him laxatives. We increased his pain medication some more. We waited for the serology to return, to confirm the diagnosis we were so sure was true.

Our patient's condition continued to worsen. Confidence in our diagnosis waned to hope against hope, because by this time, we had widened our differential diagnosis and set up plan B: if our serology for Ehrlichiosis came back negative, we would have to start thinking cancer. We would go where the money is and biopsy the bone marrow. Our patient had stopped looking like the classic case of Ehrlichiosis and started looking just like an atypical presentation for leukemia or lymphoma-- and we had ruled out almost everything else.

One morning, his daily blood count came back with "atypical lymphocytes" on the smear (under the microscope). A marrow biopsy was performed the very next day. As we began preparations for transfer to the Hematology-Oncology service, our Ehrlichiosis serology fell by the wayside, forgotten. I don't even know what the results are, if they ever came back; I assume they were negative, but it really didn't matter anymore.

It was almost a blur how quickly he was gone from our service, whisked up by Oncology into a world of immediate chemotherapy, considerations for bone marrow transplantation, and months of suspense about whether he would live or die. I would have imagined that a patient diagnosed with cancer would need weeks to come to terms with the diagnosis before he could begin to undergo chemotherapy. In reality, things move at a breakneck pace; there was barely time to turn around, blow a kiss, and wave before this huge change took over his life. But time is a mysterious beast; inside my patient's mind, life may have turned to slow motion. I don't know.

I think I learned 2 important lessons from this patient's case. The first is a principle I was taught in the abstract last year: YCMTDIYDTOI. What the heck does YCMTDIYDTOI mean, you ask? Well, its name illustrates its principle: You Can't Make The Diagnosis If You Don't Think Of It (and you certainly can't figure out what this acronym stands for if you don't already know it-- and think of it). The best clinicians have been said to use pattern recognition, but sometimes patterns are not the be all and end all of diagnostics. Solving problems in the real world is totally different from solving textbook cases in my first and second year lectures, where anyone who had pneumonia came in with a cough, a fever, and a dullness to percussion over the right lower lobe. You have to start somewhere-- but from there, you must grow.

The second, and more important, lesson I learned from this patient is that cancer is never expected. Nobody comes into the hospital thinking "I must have cancer." It is sobering to know that at any point, any one of us could walk in with a fever and some aches, and walk out with a diagnosis that might change our lives. The line between health and illness is finer than I had ever appreciated, and every step we take on the side of health should be a thankful one. When we do cross that line, we won't know how far we've gone-- whether we'll be cured in a week with antibiotics, or whether life will start being measured in probabilities of survival months. The journey is seldom in black and white, and it is always frightening and confusing. It's a good lesson for me to have learned now, because I will spend the rest of my life escorting my patients along that road.