The following is a little disturbing and a little technical. Feel free to ask questions.
B calls me the other night - the resident who always caps the service by midnight. "You gotta come down to the ER. Now. You'll never see this again."
I head down to the ER. We talk for a while about the patient who's probably in fulminant hypovolemic shock, with a side order of rhabdomyolysis and a sprinkling of sepsis for a while - the usual ICU type orders, thyroid, old records, why-did-someone-operate-on-his-brain kind of thing. It's almost routine, although I never quite get over the heart-thumping anxiety of someone saying "ICU". He's beginning to stabilize, after four liters of IV saline, antibiotics, and a hint of Levophed to bring his blood pressure up. He can open his eyes and mumble, at least. Then she pulls on my arm.
You gotta come see this. You gotta.
We don N-95 respirator masks (the orange "duckbill" TB masks you have to be specially fitted to wear) and step into the room.
Patient is a late-fiftiesh male, past psychiatric history of schizophrenia, with a ten-year history of a lesion on his left cheek, approximately 2 centimeters across at the time of this examination. He notes a four-year history of intermittent swelling of the extremities, progressively developing nodules (left ear, right ear, chin, chest) and diffuse rash. He presents to the ED tonight with a two month history of swelling of his head and a two-week history of progressive weakness and inability to walk, culminating in the inability to raise his head without lifting it in his hands due to his weakness. He complains of neck pain. He has previously been evaluated for this but has refused diagnostic biopsy. He declines Western medicine treatments and has been using vinegar on his lesions and herbal remedies prescribed by a preventive health doctor whose name he does not recall.
I don't mind herbal treatments, folks, but somewhere along here I wish he would have noticed that he was getting worse.
I'm looking at a man whose bald scalp is swollen and pitted by edema, fully half an inch deep throughout. His head appeared nearly twice the appropriate size. On one ear he had a 3/4 inch growth that looked like nothing good - cauliflower surface, protrusions, edema around it, good blood supply. The other ear was completely deformed - nearly replaced by more of the same. And there was nothing but swelling around his jaw, his neck, his chest, his arms...
And I'm staring at an inch-wide spot on his left cheek that looked like someone had pasted a picture of malignant melanoma onto his face. And all I could think was "He's going to die."
CT scans of head, neck, and chest had been done by the ER. I started with the cross-table and anteroposterior X-rays, and that was where things got really bad, because all I could see was shoulders and skull. This man has no spine. I said it out loud, I think. B nodded. "Look at the CT scan." Everywhere, from the base of the skull to below the clavicles, the normal configuration of the vertebrae was replaced by swirling masses of soft tissue and thready remnants of bone. The tumor, whatever it was, had not only eroded the bone but almost completely replaced it. He couldn't lift his head - not from weakness, but from lack of muscle attachments to move his head around.
Later, Neurosurgery and I sat at the chart talking. "I don't know how this man isn't dead," he said, shaking his head. "There's nothing there. If he sneezed he'd kink his cord and die."
He's considering having the back of his skull fused by means of steel rods to the intact vertebrae at his waist, so that he doesn't do exactly that. We're waiting on pathology. Nobody knows exactly what this is, but it's not good. We're banking on metastatic melanoma, with a lifespan measured in weeks remaining. He wants us to give him a B12 shot so he can move his neck again, then go to Florida, eat health food and be cured. He refuses to hear the discussion about code status - feigns sleep, orders us out of the room, or changes the subject - and every time someone says 'cancer' he acts like it's the first time. "Oh no, Doctor. It can't be that. Nobody's ever told me that before." We don't know if he's crazy, or toxic, or in denial, or a lot of things, but running a Code Blue on this man would be like trying to intubate macaroni - and inevitably fatal.
Our current plan is to get him a diagnosis, some pain medications, and Hospice. If he wants to go to Florida, we figure it's better than dying here in the snow. What can you do?