I’ve meant to write about so many cases these past two weeks. Yes, because of course it’s contributing to my growth as a future physician, helping me find what I’m comfortable with and what kind of doctor I’ll be, but also more selfishly because they will make for some amazing CaRMS stories. (Apparently we need to have at least 2 patient stories prepared for all 6 canmeds roles so that’s a lot.)
Names have been changed, and some details have been changed–some added, some altered–to protect patient confidentiality.
Cara is young and healthy, but develops severe pelvic pain that brings her to the ER. The physicians there do their routine bloodwork, which includes a beta HCG. They inform her that she’s pregnant. Cara and her husband are ecstatic. It’s a surprise, of course, but it’s nothing that a pair of young healthy 30 year olds can’t handle. They have the rest of their lives ahead of them. Now they have an additional life to add to their pot of youthful vitality.
Cara’s pain continues. She doesn’t mean to be a brat, but she really can’t take it anymore. A month since the news, she visits the emergency again. They do a full workup of x-rays and investigations. Except… this time… it’s not as simple as walking away with the pain medications and that presumptive diagnosis. Because pregnancy shouldn’t be this painful all the time, should it?
The ER doc is going with ulcerative colitis. Sure there’s no family history but what else could it be in someone young and blissfully pregnant?
Cancer. It could be an incredibly, horrifically, devastatingly unlucky case of colon cancer. It could be one of those cases that present in its last stages, with metastases in nearly every organ of her body, mets that she never noticed due to the wonderful distraction of the new life inside of her. Pain that she dismissed as pregnancy aches, or just didn’t feel at all. It could be cancer that her beautiful body chose to ignore while creating a home for this baby, proving scientific miracles do exist and even cancer-ridden bodies can indeed conceive. Perhaps even worth publishing a case study out of. Just as rare, though in an ironically complete opposite way, is the fact that a young female in her 30s can develop full blow colon cancer with no family history and no genetic abnormality. In fact, so unfathomable that this case report should definitely be published, if it weren’t so insensitive to ask a family such a self-interested question.
Cara is informed that the source of her unyielding pain is not the life inside her, but widespread cancer. It is everywhere. It is the explanation for the very minimal weight gain she’s observed, absolving her of the guilt of not being a good host to her fetus. It is the reason for her complete lack of appetite, rather than the pregnancy cravings she expected. It is why she’s been absolutely exhausted, dragging herself to work, telling herself she still has months to go before her mat leave starts, when in reality the cancer will demand she never work another day in her life.
She has almost no choice in the matter. Her body will not be able to carry a baby to term when in such a catabolic state. The cancer will suck up every last calorie. She obviously will have no therapeutic options–chemo, radiation–if she remains pregnant. She and her husband make the decision to terminate.
Almost immediately afterwards, Cara sits down to discuss her treatment options. She says yes to everything. She would leave no path untrodden. She would leave no road for the cancer to find its way back to her. She undergoes chemo at all costs, no matter how tired, nauseous, and dysfunctional it would make her. No surgeon would go near her, and radiation wouldn’t work when the cancer was so widespread. So she puts everything she had into her chemo.
And she continued to do so, for years and years. When one regimen would stop working, her doctors would offer her another one. And another, and another. They never seemed to give up hope, so she didn’t either. She continued to live her life, too; bungee-jumping, sky-diving, mountain-climbing, dirt-biking, she continued being herself.
Until one day, after her last course of chemo had proven ineffective and the disease continued to show progression, they didn’t offer her any more options. They sat across the desk from her and explained that they had run out of things to suggest as a second-line or 5th line or 10th line option. In a last ditch effort, they mentioned some offhand comment about the possibility of a clinical trial, knowing in their heads that no one would include a patient as sick as her in their trial who would colour their research with her 100% likelihood of pending mortality.
So she came to us. Palliative care.
to be continued