The Choices Patients Make

Pin-Chieh Chiang -- Last Friday, I had just finished my last surgery for the day when one of the O.R. nurses gave me a heads up that an emergency operation was just added. It was a case of a 57 y.o. female with a ruptured viscous, and the case was listed as an exploratory laparotomy with sigmoidectomy and colostomy. In the rush of things, I didn’t get a chance to learn more about the patient’s history. What I did know was that she had presented to the E.R. with abdominal pain, nausea and vomiting, and an abdominal film had shown air bubbles under the diaphragm.

As we started the surgery, the other two surgeons discussed this patient’s case. She had had symptoms of abdominal pain for at least a year. On a CT scan a couple of months ago, it was discovered that she had colorectal cancer. Then, what really perked up my ears was that apparently this patient was already scheduled for surgery this day, but had canceled earlier in the week. It was obvious to the surgeons and me that this patient has just been avoiding and putting off surgery for a while now.

This surgery would teach me about more than just medical science; I was also forced to ponder the nature of doctoring and disease. I’ve always had problems understanding what was going through the minds of patients like her. Why would they delay medical attention for a condition so severe?

This patient reminded me of another case I saw during my first surgical rotation. This other patient was over 80 years old and presented to the office with a breast mass. When I went to do the breast exam, there was a huge mass eroding through the skin of her left breast. Her left breast anatomy was very distorted with the nipple completed inverted and axillary lymph nodes were very palpable. I asked her how long ago she had first been able to palpate a mass in her breast and she told me 1 year. She sensed the “why?” question that was in my mind, and without being prompted she explained that she felt like she was already over 80 years old anyway. The reason why she was referred to surgery this time around was for symptomatic relief; the mass was causing her too much pain.

During the rest of the ruptured viscous case, I pondered why such patients push off medical care for so long. It would be so easy for me to just blame the patients themselves for being careless with their own health. During the exploratory laparotomy, we found foul smelling pus throughout her abdominal cavity. There was an abscess near the posterior wall where the colon had perforated. Towards the last 45 minutes of the surgery, the patient became very hypotensive and was resuscitated with fluids and pressors. After the surgery, she remained in the O.R. for further resuscitation from septic shock and was directly taken from there to medical ICU.

At the end of the surgery the head surgeon made some comments that were very enlightening. She told me that she never passes judgement on her patients. Perhaps both of these patients wanted to spend more quality time with their loved ones versus subjecting themselves to aggressive treatment. Maybe there are no wrong decisions.