The disease that we all fear, cancer. ER docs treat cancer patients frequently. At the hospital where I work, there is a very active cancer center. Side effects of radiation and chemotherapy include vomiting, dehydration, and infections. Our oncologists and primary care doctors send cancer patients to the ER for treatment and possible admission.
On occasion, I have made the diagnosis of cancer in a patient who came to the ER for a seemingly unrelated problem. Chronic coughs, vomiting and diarrhea, abdominal pains, headaches, seizures, strokes, skin lesions, nose bleeds, and fevers may all be the first presenting symptoms of cancer. In my thirty years of ER practice I have diagnosed leukemia, brain tumors, melanoma and other skin cancers, lung cancer, breast cancer, ovarian cancer and oral cancer.
The diagnosis is usually a surprise to me and devastating to the patient and his or her family. As a resident during the late 70's, I examined a 27 year old woman for the presenting complaint of a "breast infection". This young mother of three was 6 months postpartum. Her left breast was hard with a pebbly feel known as peau d'orange. The nipple was retracted and I easily palpated several hard lymph nodes in the left axilla (armpit). There was no doubt that she had advanced breast cancer. She was only a couple of years older than me. Her mother accompanied her and was watching the patient's children. Being young and very inexperienced, I blurted out the diagnosis and told her I would set up for her to see a surgeon. When she started crying I offered my sympathies and almost ran out of the room.
Recently I examined a woman in her 60's who presented after a syncopal episode. She had a sudden unexplained loss of consciousness. I ordered the usual labs, EKG and head CT. She was very lethargic and her speech was slurred. The CT showed a large mass with some bleeding. There was swelling of the brain. A malignant brain tumor in a healthy woman who "fainted". I arranged for transfer to a major teaching hospital. The family and I spoke at length of the diagnosis. I offered a sympathetic and encouraging message. In my advanced years, I also cried along with the family.
A toddler with frequent nose bleeds is usually caused by vigorous use of the child's index finger in his nostril. The beautiful little boy on the stretcher looked too pale and I noticed petechiae and bruises. My worst fears were confirmed when his CBC showed ALL (acute lymphocytic leukemia). The child was transferred to a pediatric hospital. The cure rate for this form of cancer is excellent, but knowing what he and his family would have to endure gave me nightmares for weeks after.
A smoker with a chronic cough is a common complaint in the ER. The usual diagnosis is bronchitis or pneumonia. On a number of occasions I have viewed the x-ray and found a lesion that looked like lung cancer. The word cancer comes from the Latin and means crab. The central body and the "legs" of the crab are an apt description of the shape of a lung cancer on a chest x-ray. Despite the warnings on every pack of cigarettes, the addictive power of nicotine traps the smoker. In each case, I try to be honest but offer hope and sympathy.
Ovarian cancer is too often diagnosed only after it has become advanced. Chronic pelvic or lower abdominal pain is sometimes seen in the ER. An ultrasound or CT may make the diagnosis. A sore testicle or a lump in the testicle may turn out to be testicular cancer. ER docs must keep these diagnoses in the differential of patients with pelvic or scrotal complaints.
Radiation and chemotherapy can impair a cancer patient's immune system and lead to life threatening infections. A cancer patient with a fever is a call to action. Cultures are obtained from the patient's blood, urine, stool, sputum, throat, skin lesions; a chest x-ray is done; and the patient is given broad spectrum antibiotics. Although this is ER medicine by the numbers, it is imperative to remember the anxiety and emotional well being of the patient and family.
We all have friends or family members who have cancer or who have died from cancer. Some of us are currently being evaluated or treated for cancer. Walk, bike, swim etc "athons" are held to raise funds for cancer research for "the cure". I would urge my readers to keep current on the latest research. Cancer is a complex disease. Early diagnosis and preventive behavior are still our best hope. Get recommended screenings, don't smoke, eat a healthy diet, keep your weight down and know your family history of cancer.
Having a strong faith, keeping a optimistic outlook, laughing, and being active are all helpful in dealing with a personal diagnosis and treatment of any cancer. Friends and family are vital in the battle. We are all mortal. My father died of renal cell carcinoma. When he received the diagnosis and grim prognosis, his comment to me was "at least I know what I will die from". He was in hospice care at the end. He died at home with his family at his bedside. I hope I can face my mortality with such grace and strength.
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