Today, Christine Le and I saw Dr. Chen's outpatients. They were a mix of patients with anemia and cancer looking to follow up.
Patient 1 had microcytic anemia, specifically iron deficient anemia. Hemoglobin decrease from 12 to 9 three weeks ago. Dr. Chen stated that if Hb is under 8 mg/dL, patient will be dizzy. Dr. Chen also suspects bleeding from GI. Iron deficiency anemia is determined by bone marrow aspiration and ferrum supplement was given 2 years ago.
Dr. Chen has been using recent evidence on combining Herceptin (trastazumab) with other chemotherapy agents has been very successful. Many of the treatment plans he uses comis combined with Herceptin.
Patient 3 was a 62 yo female presenting with fever. She had left breast IDC grade 3, ER+ T2N2 Mx. After her 4th round of CTX, her platelets decreased and she does not feel well in general. She asked if she had to continue CTX after her recommended full course of 8 rounds. Dr. Chen said that there is always a possibility that she may have to do more rounds. He tells us that he always explains all the options and complications that may occur for patients if they choose to undergo chemotherapy. Many of the patients are conservative in their approach to treatment, often hesitating chemotherapy and surgical intervention. Unfortunately waiting a week, month, or a year can have dire consequences for cancer patients. Cancer can progress rapidly. This patient also presented with leukopenia (under 500) due to CTX. She was given prophylactic antibiotics.
Patient 6 presents with HER2/neu 3+ left breast cancer IDC, T2N0 with liver and bone metastases. She had a mastectomy 3 years ago and is on monthly zometa and weekly paclitaxel and herceptin regimen. Dr. Chen told us that she was not referred to him directly after her mastectomy and expresses that he would have begun adjuvant CTX if she had been referred directly. Unfortunately, due to some hospital error, she was not and her cancer has progressed.
Patient 7 was a 35 yo female with mental retardation, depression, and rapid deterioration of nasopharyngeal cancer with lung and bone metastases. She was supported by her sister walking in. Dr. Chen stated that she was able to walk fine when they last saw her a week ago. Dr. Chen suggested hospitalization but patient and patient's sister refused. Dr. Chen said that where they choose to let her pass away is up to them, and it may be more peaceful for her to be surrounded by loved ones in a familiar place than in the hospital.
Patient 9 was a 53 yo female with hepatosplenomegaly. She has had poor appetite with CTX treated with paclitaxel and herceptin. The CEA/CA 153 ratio was 67/663. This ratio is important in monitoring the treatment of cancer.
Patient 12 was a 65 yo female with ill defined mass in the central pelvis and sigmoid colon cancer with multiple liver metastases. She came to Dr. Chen for an opinion and he suggested palliative chemotherapy, taking his time to explain risks and benefits. He also warned them that they should take take action within 1-2 months as treatment options will decrease later on. Dr. Chen told them his opinion and the family still decided to go to a different hospital for a second opinion. Later he told us a little about his philosophy. He said that he only gets $100 per patient OPD and said that the patient seemed like they were not willing to listen to his opinion, therefore he cut short his explanations when it seemed like they stopped responding to him. For the sake of his time and money, he needs to make sure he is not putting too much time on a family and a patient who will disregard his plan anyway. I thought that was an interesting thought and one of the many concerns that a doctor who has to see 17 patients in outpatient clinic in the morning should address.
During rounds, we saw a patient with pending liver failure who had colon cancer and hospitalized for urosepsis and abdomen distension. Her ultrasound showed liver tumors. Dr. Chen suggested no chemotherapy and that she needed hospice treatment. He ordered vitamin K and a blood transfusion. Since she is on empiric antibiotic treatment, many bacteria in her gut will be killed. These bacteria make Vitamin K. Intrinsic clotting factors such as 2,5,7, and 9 need vitamin K as a coenzyme to effectively clot blood.
--
In the ED, student doctor Vincent Chou and I saw a 60 yo patient with prostate cancer come in with a subdural and subarachnoid hematoma due to a MVA. The neurosurgeon was called in for consultation on surgery. The neurosurgeon stated that he will probably not be conscious even if they stop the bleeding and decrease the intracranial pressure due to an elongated and damaged brainstem. There is bleeding on both sides of the brain, making surgery more complicated and less likely to have a good outcome if it was a unilateral hematoma. The number one priority for a brain hemorrhage is to keep the intracranial pressure low. Stopping blood flow is less important since there is only so much blood that can leak out into a compartmentalized space. There was also a herniation into the brain stem from the temporal lobe. The neurosurgeon suggested temporal lobe resection to relieve the pressure and stop the herniation into the brain stem. However this was not recommended since there is bleeding everywhere and it would exacerbate the hemorrhage.
Before it was mandated that motorcycle helmets be worn, Dr. Liu said that these kind of cases occurred all the time. He said he often got 3-4 of these cases per day as an intern 10 years ago. It was devastating to see the doctors tell the family what their options were, and that he would probably not come out of coma. Fortunately the doctor was very clear about the options and what surgery could offer them. Although they did not decide on anything (watch and wait or surgery), the patient will be kept on medication to sustain his vital signs while they discuss their options. The neurosurgeon suggested that the family decide on what to do if an emergency arises, and if they want to sign a DNR. He reassured them that signing a DNR does not mean that they will give up on the patient and 'do nothing'. He gave an example of a comatose patient whose family signed a DNR who eventually woke up and recovered fine. It is interesting to see the methods that doctors use to reassure patients or change a family's perspective based on anecdotal stories like these.
No comments:
Post a Comment