Thursday, July 01, 2004
Denial is an amazing thing
I talked my way into tagging along on weekend morning rounds on the family medicine service. I sit in on sign-out from the night float; the residents are very nice, but astonished that I'm doing this voluntarily. The clerkship director is attending (faculty rotates this gig). I'm trying to follow along, but still don't have normal labs memorized, etc. There are a couple cases that sound interesting, Asperger's adult with pneumonia; pulmonary fibrosis; liver failure; and a man with a sarcoma in his arm that needs amputating, but he doesn't believe he has cancer. The pathology report from a doctor visit back home read in Spanish, "sarcoma..." but hand-written on the same page was, "No Cancer." He believes the latter.
Sign-out's over; the residents go their ways (home and I don't know where). I ask the attending if I can follow her on rounds; she agrees. I see some patients, listen to some chests, and ask a tentative question or two.
I ask about the patient with the cancer and is there any way to save his arm. She says, "Wait till you see this guy's elbow!" She knocks on a patient room door and walks in; I look at his arms, and I don't see anything. I try to see something, so as not to look stupid. She speaks to the patient in Spanish and I'm not listening - I'm looking; still nothing to my eyes. She's leaving; I spin around to follow, disoriented. "Wrong room; they moved the patient. We'll have to track him down."
She finds his room from his chart at the nurse's station. She knocks; we enter. There's a middle-aged man seated right there by the door, calmly watching T.V. His left arm is wrapped in a chuck. This is the right guy. The attending starts speaking in Spanish. This time I'm listening. I'm internally embarrassed because I'm surprised by the fact that her accent is very good and she's very fluent; who the Hell am I to not expect such competence!
She is nonchalantly asking him how he's feeling. He's fine. How about the arm? It's fine. Anyway, it's time to take a look. Once unwrapped, there's what looks like a large lump of coal as big as my fist sticking out of a ragged, swollen, draining socket in the flesh of this guy's lateral left brachium just a little proximal to his elbow. He does not seem phased by the meteorite sticking out of his arm. I like to think that I contained my shock, while I concentrated on following their ping-pong match conversation. She is nonchalantly telling him that the thing on his arm is cancer. He just as nonchalantly says that it's not. She tells him that they will need to amputate his arm above the wound. He acts like he has never heard of such a notion and that it isn't that serious. This guy is cool as a cucumber.
We don gloves and palpate the skin adjacent the sarcoma. The skin is hard and hot. He doesn't seem to feel any discomfort. She tells him she believes that this is very serious. He is unswayed, but respectful; he even seems a little concerned for our unnecessary worry. We say our good-byes.
We leave. She tells me that he is told that it is cancer multiple times a day and that he calmly, but consistently denies it. A routine biopsy is down at pathology. Hopefully, he can see the "new" results from this report. But, who knows? Of course, you think of a psychiatry liaison consult. That's been tried. In his case, it's pure psychological denial, just like Uncle Sigmund said, about 100 years ago; meds don't work very well on stuff like that. I am astonished at a workingman's need not to be deathly ill and to keep his arms (his life), at all costs.
Sign-out's over; the residents go their ways (home and I don't know where). I ask the attending if I can follow her on rounds; she agrees. I see some patients, listen to some chests, and ask a tentative question or two.
I ask about the patient with the cancer and is there any way to save his arm. She says, "Wait till you see this guy's elbow!" She knocks on a patient room door and walks in; I look at his arms, and I don't see anything. I try to see something, so as not to look stupid. She speaks to the patient in Spanish and I'm not listening - I'm looking; still nothing to my eyes. She's leaving; I spin around to follow, disoriented. "Wrong room; they moved the patient. We'll have to track him down."
She finds his room from his chart at the nurse's station. She knocks; we enter. There's a middle-aged man seated right there by the door, calmly watching T.V. His left arm is wrapped in a chuck. This is the right guy. The attending starts speaking in Spanish. This time I'm listening. I'm internally embarrassed because I'm surprised by the fact that her accent is very good and she's very fluent; who the Hell am I to not expect such competence!
She is nonchalantly asking him how he's feeling. He's fine. How about the arm? It's fine. Anyway, it's time to take a look. Once unwrapped, there's what looks like a large lump of coal as big as my fist sticking out of a ragged, swollen, draining socket in the flesh of this guy's lateral left brachium just a little proximal to his elbow. He does not seem phased by the meteorite sticking out of his arm. I like to think that I contained my shock, while I concentrated on following their ping-pong match conversation. She is nonchalantly telling him that the thing on his arm is cancer. He just as nonchalantly says that it's not. She tells him that they will need to amputate his arm above the wound. He acts like he has never heard of such a notion and that it isn't that serious. This guy is cool as a cucumber.
We don gloves and palpate the skin adjacent the sarcoma. The skin is hard and hot. He doesn't seem to feel any discomfort. She tells him she believes that this is very serious. He is unswayed, but respectful; he even seems a little concerned for our unnecessary worry. We say our good-byes.
We leave. She tells me that he is told that it is cancer multiple times a day and that he calmly, but consistently denies it. A routine biopsy is down at pathology. Hopefully, he can see the "new" results from this report. But, who knows? Of course, you think of a psychiatry liaison consult. That's been tried. In his case, it's pure psychological denial, just like Uncle Sigmund said, about 100 years ago; meds don't work very well on stuff like that. I am astonished at a workingman's need not to be deathly ill and to keep his arms (his life), at all costs.
