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and i want it so much to be something else. aything else.

here’s the clinical picture. left sided tightness that spread across the chest. shortness of breath on physical exertion. occassional cough. rather benign symptoms really.

then the chest x-ray showed massive pleural effusion, so much so that the left lower lobe has collapsed. repeated pleural fluid tap reveals a little bit of abnormal cells, but nothing really diagnostic. but the fluids keep coming back. now the mediastinum is shifted towards the right side.

that is when thoracoscopy is decided upon. biopsy needs to be taken to be absolutely sure. the fluid is drained (the whole 1 L of them) and chest drain is left in place.

clue # 1; the parietal pleura is grossly thickened, nodular and looks infiltrated.
clue # 2; pleurodesis is undertaken, as fancy as it sounds, it’s just involves spraying talc-so that both viscera can come together and stuck to each other as it is supposed to)
clue #3; the patient suffered almost no pain, even when the talc is applied, there must be something wrong with the nerve in the pleura.

here’s a more wholistic picture. she’s so easy to talk to. she has an easy smile that makes her eyes sparkle. she’s genuinely interested to hear about myself; where i come from, how’s my training has been, what i am going to do later after graduation, etc, etc. she barely turns 50. she has a daughter my age, about to graduate in few months’ time. she’s a carer to her mother who has basal cell carcinoma of the lips, which is now on palliative care. she’s been fit and well all this while. she had unfortunate encounter with radiotherapy 9 years back when she was diagnosed as having breast cancer, and the treatment seemed to have settled it.she never smoke. she eats healthily. she exercises often. as she put it, she just want to have this sorted and get on with her life and never has to have any more needle being stuck into her chest again.

and she keeps saying. i’m so puzzled. even my doctors are puzzled as to what is going on. do you have any idea what is going on?  abnormal cell isn’t the same as cancer cell, right?

she was very close to asking me directly; is it cancer?

luckily, as of now, i can dodge all the questions and say; i don’t have a clue. i am not allowed to say anything. i’ll pass on your concerns to the consultant.
eventhough i have quite a good idea what is going on.

if i were to be the bearer of the bad news to her, especially of something as horrible as lung cancer, or any cancer really that is extensive enough to have spread to the pleura, i wouldn’t have a clue what i’m going to say. probably i’ll beg any of my colleague to do it for me. probably i’ll call in sick that day.

before i said goodbye, i gave her hands an extra tight squeeze, and wish her all the very best. and truly meant that.

we always say we’ll never appreciate what we have untill we lose it. we always know we are ever guilty of taking things for granted. most of the time we refer to our money, or our car, or our spouse, or even our legs and fingers. tangible, visible things that without it we’ll feel deprived, lonely and disabled.

dr barker arranged for us to follow anne-marie, a community occupational therapist for stroke patients doing house visits. before i actually got to meet the patients, my minds create images of bed-bound helpless people with drooling saliva and slurred speech. but what i encountered later proved me wrong.

first patient; she was sitting comfortably on the sofa sipping tea. apart from splinted ankle and a frame, nothing gave away the fact that she suffered a stroke 8 months ago. talking to her, i became more amazed. like any normal 60 year-old lady, she could maintain the conversation going, no problem at all. anne-marie said, inspect closer. than it strike me, she kept banging her right foot against the frame. once she even step on the other foot. she couldn’t put her tea on the mug holder on the first or second try. and when asked to solve simple, mundane everyday problems or tasks, she became clueless.

she realized her shortcomings. she even joked that most of the time she asked her husband where her right leg is. she actually suffered residual perceptual awareness and executive functioning deficit. 

second patient; he greeted us at the door. he’s a well-built 34 year old man, and do what every 34 year old man does; walking talking laughing drinking, etc etc. i was like, ‘where’s the real stroke patient??’ before the stroke, he was a high-flying businessman. travel around the world. made lots and lots of money. the typical type-A personality, the true go-getter. then the stroke happened. he went into episodes of depression and even mania. it took him 1 whole year to accept the fact that he has had stroke, and the stroke leaves him with a lasting deficit and he needs help. again, i was like,’what’s there to be depressed about, u r fit and healthy, man!’
(these are what went thru my head, not my mouth)

but in all actuality, he has such a short attention span and cannot retain much short term-memory. what a successful businessman to do now he can’t even remember what he read in the paper minutes ago. obviously he couldn’t go back to his old job. and i can just imagine how hard it must be for someone of his intellect to now be doubting himself, even entertaining the idea that he is stupid.

he said to us; ‘i picture myself to be in between 2 doors. one door leads to my past, and now after more than a year i’m finally able to shut it without regret. through that door is a man i once was. i put my job first, second and third in my life. another door opens into my future. and the man that will walk through that door will be one who puts his family first. there’s only so much money you will need, right?’

this might sounds a bit cheesy, but he said after all the help and support he has gotten, he finally becomes a man who sees tomorrow. and ning and i listened animatedly to his story, glassy-eyed.

these people have lost a subtle yet significant part of themselves to stroke. and yet with the support the get from occupational therapist, speech and language therapist, physiotherapist, psychologist and community nurse who works together as a team, and not to mention their own resilience and willpower, have enabled them to come to term with their loss and acquiring it back to some extent. no doubt, these exceptional carer providers display true altruism through their amazing work, but i am more than impress at the whole system that create and allocate resources to the team and enable these people to do what they do, the nhs of course. compared to what stroke patients and their carers in my own country have to put up with once being discharged from hospital, the difference is striking.

it’ s-me-ars, doc!
ohh right! i ‘ll have a look at the screen for you if you can just give me a minute. hmm..it says here you haven’t had one done ever. you should, you know? it really is important. especially for women your age, it needs to be done every 5 years. it is very simple and will be over before you know it! what happen is we will have a little swab down below with this tiny brush and we’ll send it to the lab. the result will come to you in the post in 2 weeks’ time. and 99 percent of the time it will be absolutely normal and it will give us a piece of mind. but even if it doesn’t, we detect it early before it gets nasty so that we can do something about it. now my dear, if you’ll be so kind as to pop onto the couch and undo your pants as i get all things ready, that will be great.
Doctor, IT’S ME EARS!

look as though the doctor’s ears need fixing too! soo yeah, despite whatever grand thing they wow us in er or house or anything similar; doctors who slit the patient’s neck open (cricothyroidectomy), or stabbing the patient’s chest (relieving pressure in open pneumothorax), or shocking patient in cardiac arrest, the most important skill would probably be listening. (except for dr house maybe, because all his patients lie). it is not an impressive skill, but difficult nevertheless.

learning to listen probably saves as many lives as drugs or surgery or any other treatments. from the doctor’s perspective it will save one from embarassing moments like this. but on the more serious side, it helps spot the diagnosis, detect underlying depression/suicidal intent and even better, prevent  mistakes.

it never is something i’m good at. i can easily snap out of the conversation whilst taking history. probably things will be better in coming years. or else i’ll opt for surgery. better to have a sleeping patient who doesn’t speak. or critical care maybe, where i’ll only meet them when thay are too poorly to talk.

but i guess this is one of the hidden advatage of studying here. patient’s ideas, concerns and expectations tend to matter more. you are expected to be more than a robot that spill out ‘unpronouncable’ medical terms. you have to find out how they are managing at home so that proper support can be arranged when they are discharged. you are expected to put the patient at ease. you are expected to introduce yourself, ask for their consent for even the slightest thing, and smile and say thank you afterwards. so basically you learn to be human. not just some arrogant doctor who demand respect just because he/she knows what pyrexia means. not a so-full-of myself arse who don’t even bother to look up when the patient enters the room let alone smile, just because he/she has got a medical degree and the patient doesn’t.

so after all this gruelling 5 years and beyond, even if i still don’t know what the hell neurofibromatosis means, i hope i can bring home with me one lesson; to be human.