July 18-19, 2011. Medicine: CANCER

Staying late to take call, my team started to get new admissions from the emergency department. One patient had come with coughing blood and shortness of breath X 5 days. I sat with one of my residents reviewing his records. Then we hit his chest x-ray. It looked terrible. White messy stuff everywhere. We looked at each other – what in the world is this? We tossed around ideas – a vasculitis (inflammation of vessels), infections (although we didn’t know one that looked like this), metastases from cancer? The thing is he was 29 yo. Hard to get such nasty looking lungs when you are 29, and it didn’t look like the diseases I knew (I knew it wasn’t TB).

The next morning before rounds our attending was very impressed with the lung film. “Wow, what is this??” He exclaimed upon seeing the film. We told him the top ideas – atypical pneumonia, vasculitis, maybe mets, but he reports no pain anywhere else. Later in the conversation our attending says, “of course, a guy this age, what should we check out just to be safe if we think mets?” I respond “his testicles.” “Exactly,” he says, “just to be sure.” (Testicular cancer hits mostly 20-40 yo).

In his room we went through a bunch of things with him. Finally we casually asked him to pull up his gown. My heart sank. I could not believe what I was seeing. His testicle was the size of a grapefruit. I knew immediately he had testicular cancer that had spread – it was likely in other places too – bone, liver, brain, lymph nodes.

We all examined it and walked out of the room. One resident said that it seemed mostly like fluid though, not a mass. I agreed that it was interesting, BUT we already know its cancer because we saw the film; it fit EXACTLY the clinical picture. I would soon learn that this idea of the “clinical picture” is reasoning new drs (and some old ones) seem to not have. Why would we think for a second that this wasn't testicular cancer? We saw the scary xray, we thought 'this is crazy,' then we said the only thing it might be is mets from a big testicular mass. We then saw just that – a big testicular mass! How could we make an argument now that he has a mass of only fluid (not cancer) AND mets from somewhere else at the same time? The odds of that would 1,000,000 to 1. Yet some people do one test and let it lead them totally astray. Little did I know that over the next few days this would become a bigger and bigger issue.

We ordered blood work for HCG, AFP, and LDH, and ultrasound of his testicles, and a CT scan. All looking for cancer.

I decided to follow him as my patient since I intend to go into oncology as a specialty. Later in the day I returned to chat. I just sat down and watched some TV with him. Seems stupid but I knew he needed someone to help with this stuff, and not one family member had visited. I also didn’t know if he understood exactly what we thought was happening.

After a few minutes the Urologist dropped by.

He introduced himself to both of us, then told me to grab some gloves so I could do the exam with him. I did just that.

Then, like a real teacher, he walked me through feeling the testicles and then checking the rest of his superficial lymph nodes.

“Ok, Rico, I’ve gotta check out your prostate” he says. Rico rolls over.

Urologist looks at me “Get over here and get in on this too” he says. Now, seems odd to most, but this was exactly how you have to teach in the hospital, particulary when it comes to sticking your finger up a patient’s ass. The last thing you want is him to ask “Matthew, would you like to stick your finger in this guy’s ass?” But he knows you gotta learn. I walked over.

“How many of these have you done?” He asked me.

“One.” I was trying to talk so Rico couldn’t hear me.

“Ok, well, you’re about to get number two,” he says cheerfully. His prostate was normal.

We took our gloves off and he broke the news to Rico.

“You have testicular cancer that has spread to your lungs. We will need to remove the testicle soon and you will need extensive chemotherapy.”

Rico took it all very stoically, asking only a few questions. It did get revealed that only a few years ago a Dr. noticed a lump in his testicle and scheduled a surgery. At the time, Rico was told it was from lifting heavy objects, and when the pain went away, he skipped going for surgery. Turns out it was cancer, and now its destroying his lungs.

After the urologist left I went up and broke the news to my team; Rico knows the deal, he has cancer as far as we can tell (the true diagnosis comes back when a biopsy from his lungs returns). I said goodbye to him and went home. I wanted to give him a bit of time to digest what we told him. 29 years old. My age. Cancer.