July 19, 2011. Medicine: RICO

The next day I made it my job to just hang out with Rico. We had gotten the CT back and there was a very large lymph node. On rounds that day I went straight to the attending to suggest we do a brain scan. He thought and said, "yeah, I guess you're right, we should."

One resident thought it unlikely.

"Just to be sure" I suggested, thinking I knew full well there would be mets. How could there not be at this point? We know many testicular cancers go to the brain, and this one has already destroyed his lungs.

Two out of the three markers in his blood were very high, telling us it WAS testicular cancer. These markers are simply never this high for anything else. The ultrasound was ambiguous – it looked like lots of water the physician reading it said, with some strange nodules.

I sat in his room and explained everything to him from how cancer spreads to what type I thought he might have and what that might mean. Hell, I even told him about My mother’s disease and about Lance Armstrong.

“I’m really sorry to hear about your mother’s disease” he said. I felt like an asshole for even bringing it up.

He opened up to me and told me things I never would have imagined. He came from Chile originally, with his brother to work. They both stayed. All the other family was in Chile. A few years ago he was scared of the surgery and was told it was a hernia; cancer was never mentioned. I asked if he had gotten ahold of his brother, as I had seen no family since he got there (and to make it worse he had been on isolation ‘til we ruled out TB).

“My phone is dead man, he doesn’t know.”

I was shocked. I let him use mine but he didn’t recall the number – like most of us it’s just programmed in and we never actually dial it. He told me had a blackberry, so I went off in search of a charger.

Looking for the charger it hit me: This kid stopped by the hospital with a bloody cough to get checked out. We isolate him only to come back and tell him he has cancer. His phone is dead and he can’t get his one relative here. Tell me a worse nightmare.

None of the nurses on the floor had one. Into the residents room I walked, “It’s for a patient, not me,” I say to a room of 20-30 young doctors. “But does anyone have a charger for a blackberry so he can get his family?”

“What is this, a hotel?” one yells. Another mocks me.

“Yeah sure, admit it if its for you!” Another says.

I just walked out. I could’ve killed everyone that opened there mouth. I searched on.

Amazingly, one of the nurses had one in her pocket for reasons like this.

I got him the cord and he got his brother. We also had a chance to talk more as it charged. When I left to check on another patient and came back, the social worker was leaving.

“What was that all about?” I asked him.

“The social worker – telling me they’ll pay for this visit but for nothing else since I don’t have insurance. No follow up, no treatments.”

“Wait, Rico, why don’t you have Medicaid?” I asked.

We looked at each other.

“You aren’t a citizen here are you?”

“No.”

He went on to explain all about how it works. Making a living, not getting deported etc. Not following up with a surgery for a hernia a few years ago now made sense. Being so stoic in front of us now made sense. He didn’t want to get deported.

“Rico, you HAVE to get chemotherapy,” I told him.

He looked over at me, as if all along he knew he wouldn’t get it.

“Without it you’ll probably die.”

He looked at me, eyes moist. I reiterated it.

“Rico, the film is awful, you have cancer all over your lungs. Now we have blood markers back, and we found another lymph node that is huge. You have cancer. You need chemotherapy or you will die.”

A long conversation followed. I explained it all to him. He was calm but understood it.

“You are going to get the chemo, Rico,” I told him. “Somehow you will.”

I left and talked to both our team and the Oncology floor. It was decided that he would get admitted for each Chemo treatment so that it could be paid for. Meanwhile, I overheard a surgeon on the phone saying he saw the ultrasound and it didn’t look conclusive so he didn’t want to operate. I could’ve smacked this guy. Blood markers through the roof, chest film with METs, testicular mass, and para-aortic lymph node (the correct ones from testis). And he was stuck on one ambiguous ultrasound. He delayed the surgery for at least a day. I only read it in the chart – he never told the patient and he never told him he could eat (he had been fasting all day for the surgery). It was disgusting patient care.

I walked down and told the patient, then asked the nurse to bring the poor guy some food. Finally, his brother arrived and I explained it all again: Medicine, Surgery, Oncology, and Urology are all were working on it, I told him. Then I told them both everything I knew about it, every test we had run, every conversation I had about it. "Likely cancer, and likely bad," I said. "How bad? We’ll know when we get the pathology, but people beat this all the time," I told them. "All the time."