Sunday, May 12, 2013

On Being a Patient

written June 2008

Bridge players say, “It’s better to be lucky than smart.” That means that in an impossible situation, where you can’t possibly make your contract, for a variety reasons everything works out. In medicine that can often be true. The diagnosis may be puzzling to you and all the consultants but in some mysterious way you stumble on the answer and you become a genius. Or the illness has a dire prognosis and then, for some unknown reason, the treatment works and the patient once again enjoys good health.

Look at me. Four years after a partial pancreatectomy for adenocarcinoma of the body of the pancreas I’m overweight, glowing with health and with no evidence of recurrence of a uniformly fatal cancer. OK so there is a less than 5% survival rate of patients with the disease, but that number is pretty close to rare. And how did the fact of my still being alive come about? That is the lucky part: it was because of an operation for another serious condition that gives me bragging rights about still being alive.

On a morning in mid-January 1996 I suddenly developed intermittent claudication. I had no other symptoms than severe cramps in both calves when I walked less than 10 feet. Inasmuch as nothing else bothered me, I did not visit a physician till the following day when I kept a previously made appointment with my orthopedist. I mentioned my new symptom to him and he examined me, finding that I had no pulses in my femoral arteries or below. He offered a Doppler study but I knew that palpation had given me enough information and told him that I planned to see my vascular surgeon the next day.

That visit confirmed that I probably had a blocked aorta and I would need an aortogram followed by laparotomy and vascular repair. I was agreeable and asked if the plan could be put off for 10 days until my sons returned from their skiing vacation. 48 hours had passed after what was obviously a serious vascular event but my surgeon calmly assured me that further delay was acceptable. I had enormous confidence in him, he probably had seen and operated on a couple of thousand patients with what I had and if he said I could wait, then it was OK to wait.

Ten days later I had an aortogram and repair of the distal aorta for obstruction by a large cholesterol plaque which had been dissected off and formed a flap over the bifurcation and obstructed blood flow. My postoperative course was marred by the nasogastric tube which eroded the edge of my left nostril. That healed promptly when the tube was removed.

I returned to practice. Four years later I had the first in the series of obstructions of the small bowel due to adhesions formed by the surgery for my dissected, obstructed aorta. At each event I was hospitalized for two to four days. Diagnostic studies always included blood count, urinalysis, and blood chemistries; also chest and abdominal X-rays and MRI of the abdomen. I always had to endure the torturing nasogastric tube.

It was during the episode of obstruction in January 2004 that the MRI of the abdomen showed a suspicious mass in the body of the pancreas; comparison with the MRI made in December 2003 confirmed that the mass was indeed new. Partial pancreatectomy was done February 2004. My oncologist recommended six months of chemotherapy. He admitted it was probably unnecessary, just one of those elements of “doing something.”

In October 2006 I had another and my last episode of small bowel obstruction. My surgeon lost no time in deciding that enough was enough; he lysed a number of adhesions and repaired a ventral hernia (a result of the surgery for the cancer).

It was one of my sons who pointed out that if I hadn’t had the dissecting aortic aneurysm, I wouldn’t have had abdominal surgery which may have saved my life at the time. If I had not had the abdominal surgery, I would not have had peritoneal adhesions. If I had not developed peritoneal adhesions, I would not had had several episodes of small bowel obstruction. If I had not had small bowel obstructions, I would not have had serial MRIs for comparison and the serial MRIs provided information to a sharp-eyed radiologist to detect an early, operable, curable cancer.

Yes, it’s better to be lucky.

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