“We’ll Do Everything We Can”
Sometimes, to save a patient, doctors must move beyond textbooks and embrace the ineffable
By Patrick Tripp
December 4, 2017
Late Friday afternoon, I was called to the ICU to see Mr. S., a 65-year-old man recently diagnosed with lung cancer. The tumor, oozing blood, rested on the carina, where the central airway, the trachea, divides into the two main stem bronchi, the large airways to the lungs. With the flow of air obstructed by the tumor, he needed the mechanical ventilator to keep breathing. A few days earlier, he’d arrived at the emergency room with fever and shortness of breath. A chest x-ray showed “consolidation,” an opaque, fluffy patch of white against the black air of the surrounding lungs. Doctors diagnosed pneumonia and sent him home with antibiotics. The next day he returned, coughing up blood. This time, a CT scan of the chest showed a mass almost 10 centimeters in diameter in the middle of his chest. The x-ray had missed it, blocked by the heart and the developing pneumonia. The tumor completely obstructed the left main stem bronchus. With no air moving in or out of that section of the lung, it had collapsed. Mr. S. was taken for bronchoscopy, in which a flexible fiberoptic scope is used to examine the airways, and a biopsy was taken to verify that the mass was in fact a tumor. With Mr. S. sedated for the procedure, the scope went down the trachea until a soft, fleshy mass was identified, extending in uneven blobs. Pierced by the biopsy needle, the tumor started to bleed. This almost always happens.
But this time, the bleeding did not stop, and Mr. S.’s oxygen level started to drop. A thoracic surgeon was called, for rigid bronchoscopy, used to remove an obstruction or control bleeding. Looking through the scope, he saw the bronchi filling with blood. Here his note in the electronic medical record said, “Patient’s oxygen saturation dropped from 70 to 60, and he wasn’t ventilating.” He suctioned blood clots from the airways, used a laser to stop the bleeding, and removed the bulkiest parts of the tumor, allowing Mr. S. to breathe. The oxygen saturation monitor showed his blood oxygenation levels returned to greater than 90 percent. With the bleeding under control, if only for now, the scope was removed. Mr. S. remained on the ventilator.
Later in the afternoon, the pathologist issued a preliminary report: under the microscope, the appearance of the cells taken from the mass was consistent with the impression of the CT scan and the bronchoscopy—lung cancer. That’s when the thoracic surgeon called. He recounted the story of Mr. S.’s two trips to the emergency department in two days, the x-ray, the CT scan, the biopsy, the bleeding, and how he, the thoracic surgeon, had been called precisely at the life-threatening moment, when Mr. S. began to desaturate. “We don’t have staging yet,” he said, meaning the work-up scans to show the extent of the cancer, whether curable or incurable, had not yet been completed. “But the way he looks, I thought you should see him.”
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Patrick Tripp is a physician and an associate professor of radiation oncology at the University of Pennsylvania and the Philadelphia VA Medical Center.