Looking for loopholes

On Sunday, we admitted a new patient to my team, a young, kind of hip lady with an 8-month history of progressively worsening abdominal pain, fever, night sweats, and weight loss. All signs pointed to pancreatic cancer, which generally has a very poor prognosis. So it was a little confounding when the initial CT scan failed to show a pancreatic mass.

My team spent about an hour and a half discussing her differential diagnosis–the list of diagnoses she could possibly have–with two different attendings. It occurred to me at a certain point that I so badly wanted this woman not to have cancer that I was reacting defensively to assertions that she did. I was looking for loopholes that didn’t exist. Somewhere in between the lab values and the symptoms and the films and her consuming pain, I was sniffing for something that didn’t stink. Maybe it’s tuberculosis, I said. Or Crohn’s.

“Maybe,” said my resident, “but it’s so unlikely. Like, the gastroenterology people devoted most of their note to discussing which kind of cancer it was most likely to be, without even really considering that it could be anything but a malignancy. And they’re specialists.”

She was right. In this situation, I am very much a learner. I am learning how to broaden both my clinical and my emotional thinking about patients–learning how to think of lists of problems in one minute, and how to cope with the reality of those lists in the next. It was an effort, but I crammed into my head the idea that our lady had cancer, and I stayed with it for the whole day.

Today, she had a special pancreatic protocol CT and a fancy endoscopic ultrasound. Neither of them showed a mass. In fact, neither of them showed much of anything wrong with the pancreas. We now have a patient with abdominal pain, fever, night sweats, and weight loss who doesn’t have abdominal lymphadenopathy, and who more than likely doesn’t have pancreatic cancer! FUCK yeah!

Maybe it’s tuberculosis. Maybe it’s Crohn’s. Big damn deal. We have medicine for that.

See? I’m learning.

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