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|2012 YP Award Essay 2|
2012 Winner - Essay 2
The Doctors Company Foundation Young Physicians Patient Safety Award
Sometimes a patient experience is so moving that it changes the way we practice as medical professionals. I had the fortune of meeting such a patient during my junior surgery rotation in 2011. The patient was a 60-year-old woman originally from the East Coast who moved to be near her daughter and son-in-law. She had been recently diagnosed with nonalcoholic steatohepatitis (NASH) and presented to the hospitalist service midway through my rotation with hypotension and ascites. After 4 paracenteses and fluid boluses to control her blood pressure, she was referred to the transplant surgery service on hospital day 6 for liver transplant workup. During the workup a CT scan of her abdomen showed a lesion in the pancreatic head that was suspicious for malignancy. Carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) were both elevated, and thus the surgical residents recommended that surgery be performed to remove the lesion before further evaluation of her liver transplant. She reluctantly agreed and a Whipple procedure was performed. She was immediately moved to the ICU after the procedure, as the surgery had several complications. In the ICU her condition stabilized for a short time, but shortly thereafter she started to bleed from her incision sites and developed bacteremia. By post operation day 4 her creatinine rose from a baseline of 1 to 4.2. Despite fluids and aggressive resuscitation measures she developed shock and died on post operation day 9.
I followed the patient the day she was transferred to the surgery service as part of my transplant surgery subspecialty rotation. She was outgoing, personable, and despite her illness had a positive outlook about her future. She would tell me “I can’t control the fact I have this disease. All I can do is thank God for everything He has done for me in my life.” As a third year medical student I have the luxury to spend significant time with my patients and hear their stories. We would talk about the activities she enjoyed, which included making fudge every month. She sounded disappointed, because weakness prevented her from making fudge that month for her friends and was a source of significant morbidity. Her spirits improved greatly when the transplant team started evaluating her for a liver transplant. Her daughter just welcomed their first child and the patient’s first granddaughter. She was fighting to stay alive so her granddaughter would know who she was. “The transplant is my only chance at being a part of my granddaughter’s life” she would say. The morning we informed her of a possible pancreatic malignancy was the only time I saw her frustrated. She asked out loud, “What have I done to deserve this?” We did not have an answer for her.
I identified with the patient’s frustration and uncertainty on a personal level. I was diagnosed with Focal Segmental Glomerulosclerosis (FSGS), an autoimmune renal disease, just before I was about to apply to medical school. It was a shock to me, then a 22-year-old person about to graduate from college and in the prime of my life. I looked up research that showed that a majority of people with this disease end up needing renal transplants or dialysis. The prospect scared me, but gave me greater resolve to live my life to the fullest. This was the same sentiment I observed from the patient—that despite her end-organ disease she was determined to enjoy the remaining years of her life. The transplant would allow her to do that. When she would talk about her granddaughter I inevitably would think about my own life and its prospects. I had just proposed to my fiancé a couple of weeks before I began following the patient so thoughts drifted into my head about my future family. “Would I be around to watch my children grow up?” What would my wife do if I died and left her alone?”
After surgery the excised specimen was sent to pathology for analysis. The day after she died I overheard the residents discussing the results: benign pancreatic adenoma. I was visibly upset—I thought to myself that she went through all of the surgery and post operation morbidity for a benign adenoma. The residents did not seem too upset however, as they mentioned “At least we got to practice a Whipple.” The next Friday during the surgery department’s weekly Mortality and Morbidity (M&M) conference the PGY4 who performed the surgery presented this case to the department. As the resident presented the case, the Chairman of surgery promptly noted that the laboratory tests our team had used to decide that the tumor was probably malignant were not reliable indicators of malignancy. “Elevated CA 19-9 and CEA don’t mean anything” he said. “I’ve got a patient dead on my service because the resident operated on a benign lesion.”
Pancreatic cancer is difficult to diagnose and there are no reliable diagnostic tests other than biopsy. I looked up the laboratory tests after the M&M conference and found that CA 19-9 can be elevated in patients with bilary/hepatic disease, and CEA is not sensitive or specific as a pancreatic adenocarcinoma tumor marker. Looking back, we did not perform a percutaneous biopsy of the lesion before surgery and the decision to operate was made on the two lab tests only. The patient’s liver disease and resulting poor coagulation studies were not taken into account before undertaking such a complicated operation. Considering the patient’s overall health condition when deciding on a plan to diagnose or treat disease is paramount.
As residents and medical students, we have a finite time to hone our skills before we will be expected to practice independently. However while we are trainees, we also have an obligation to ensure our patients are receiving appropriate medical care. I believe the resident saw this pancreatic lesion as an opportunity to practice a difficult surgical procedure instead of thoughtfully concluding that the procedure was the appropriate one for this patient. In essence, the resident treated himself, which resulted in shifting the goal of her care from liver transplant to operating on an interesting pancreatic lesion. The consequence in this case was death.
Though this case resulted in a bad outcome, I find personal solace in this experience. Living with disease is a daunting task. As a medical student I try to distance myself from my patient’s emotions, while at the same time I am often having thoughts about my own disease. She showed me how to maintain a positive outlook despite living with disease and displayed a courage I hope to one day attain. I am grateful for my opportunity to get to know her, as the lessons she and her hospital course taught me will remain with me throughout my professional and personal life. ¨
*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.