October 29, 2018

I saw a patient recently that has made a lasting impression on me, so I would like to share that case with you.  One of my new PA colleagues came to me for advice.  He was seeing a patient for a recent episode of epistaxis and had noted blood dripping out of her Eustachian tube on flexible fiber optic nasopharyngoscopy and wanted my opinion.  I repeated her exam and noted not only blood in her Eustachian tube meatus and hemotympanum, but I also did not see the origin of her epistaxis. This was unusual; not that we couldn’t see the nidus of her epistaxis, as that is actually common, but that her epistaxis had been so severe that it passed up her Eustachian tube and we still couldn’t find the vessel responsible.  After evaluating the patient, I was concerned that cause of her epistaxis wasn’t the usual dryness and perforating vessel in Kiesselbach’s plexus, so I recommended that she have a CT of the face and neck with contrast.

After that visit, I didn’t think about her again until a couple of weeks later when my colleague received a page from radiology about the patient.  She was there for her CT of her face and neck and they noticed an abnormality of the left upper lung incidentally imaged with her neck CT.  They recommended she have a dedicated chest CT which he added while she was still in the CT scanner.  He mentioned this page to me so we reviewed her CT imaging just after it was completed.  Her chest CT showed a 5cm left lung apex mass with possible invasion into the ribs and enlarged hilar lymph nodes; her neck and face CTs were normal.

About 30 minutes later this patient arrived in the office without an appointment relaying to my front office staff that the CT technician told her she should be seen soon to review her CT results.  As I had a cancelation, I added her to my schedule.  I have to admit that no matter how many times I give patients bad news, it never changes how hard it is or how much it ruins my day.  During that visit I not only told a patient that she had a very large lung mass that had an extremely high chance of being a cancer, I also had to tell her that it appeared to have already began to spread locally.  I took my time, explained and showed her the CT images, and outlined the next few steps in her care.

This is where the visit took an unexpected turn.  The patient, whom I just told likely had advanced cancer, looked at me and said “Thank you. This has turned out to be a good day.”  To which I replied something along the lines of: “That is an unusual response to the news I just shared with you, I don’t think I have ever had a patient say that to me.” It just slipped out of my mouth, but it was the truth; I had never met a patient who not only thanked me for telling them such bad news, but I certainly never had a patient tell me that it was a good day.  She smiled and proceeded to tell me that she has been having back and shoulder pain for months and none of her other providers could explain why.  She had a feeling something was very wrong, but couldn’t figure out what was going on in her body.  Next she said that she believed that her nosebleed was meant to be so that she could find out why she was having these other problems.  She left my office in good spirits and I left the exam room in a contemplative mood.

Later that night I sat pondering this experience and began looking within myself.  Could I face such a diagnosis with understanding and acceptance?  Are all things “meant to be” as she said?  Should I look at the difficult times as an avenue to something better?  So many questions were raised, and to be honest, I did not find many answers; but what I did find is a new lens to look at my life through that I never had before.  As I stated at the beginning of this story, I shared this patient story as it made an indelible mark on my life and I hope sharing it will also make a difference in your life.  I challenge you to take a moment to look at your personal, work, and professional life from a different lens, as you may be as surprised by what you see also.