Wednesday, April 25, 2007

Two words we don't tell you

Have given up on the cardiovascular system for tonight and am now drinking red wine out of my official Drug and Alcohol Services "Count your drinks for good health" cup. We wave these at patients at the Driver Assessment service to try to frighten them into sobriety. It does not work at all. But the cups are nice.

I am in a slightly odd mood today, because today Mr Jarusnich, our drug dependent and often very difficult to manage bodybuilder
(Opening dialogue last visit:
Me: So, how are things?
Him: Well, you lot are still forcing me to take ecstasy and fantasy instead of giving me enough painkillers...

and later on

Me: This private detox facility you're going to...
Him: Yeah, they're much more understanding about the screaming and the violence and the throwing stuff around. They understand that it's not your fault.)

... Mr Jarusnich is no longer with our service. Well, he's not with me, anyway. He was banned for life from the local pharmacist (who has taken a restraining order out on him after Mr Jarusnich again threatened to kill him) and because of that can no longer be seen by us.

And although the visits with him were frequently difficult, and although he was one of our clients whose mental illness, in the broadest sense of the term, made him very, very high risk, I feel I will regret not seeing him. I think we kept him alive, and although meetings were frequently difficult for all concerned, and satisfactory for no-one, each time he moves practitioners or services is like another spin of the chamber, another step closer to the time when he finds some deeply dodgy doctor who will give in to his threats and accusations for long enough to prescribe him something that will kill him.

Anyhow. Yesterday in the ICU I heard two of the words that doctors use to conceal stuff from patients. These are terms you should watch out for if you don't like being spoken about as if you are not there or shouldn't be informed.

The first was while we (the four members of the ICU team and the seventeen members of the surgical team) were gathered at the foot of the bed of Mr Dolor, a middle-aged man with an acute exacerbation of his chronic pain. Mr Dolor was on a number of pain medications - including, oddly, morphine (an opiate) and buprenorphine (an opiate antagonist, something that stops opiates working) - and was having these attacks of what looked and sounded in a lot of ways like very severe pain. The surgeons were suspicious because there was lots of screaming and crying and rolling around but no rapid heart rate, no sweating, normal blood pressure, and only a very mildly abnormal Xray.

Also, and I may be being harsh, surgery is the most materialistic of the disciplines. To some surgeons, if it can't be grasped with a pair of forceps it doesn't exist. This is, of course, why they can work such miracles, but it also means that when presented with patients like Mr Dolor they can become wary.

"I feel the predominant lesion here is supratentorial" said the new surge reg, and there was a bit of snickering around the end of the bed and everyone moved on.

Supratentorial literally means above the tentorium cerebelli, the membranes that separate your cerebrum from the lower parts of your brain. So, when a doctor says your problems is supratentorial s/he means "all in the mind" - and s/he doesn't want you to know that that's what s/he thinks.

The other word, or phrase, is "mitotic lesion". It came up while we were gathered at the end of the bed of Mrs Oat, a cheerful woman who was just getting over her pneumonia. There had been something unusual on her chest X ray, we had ordered a CT scan, and subsequently a biopsy by bronchoscopy (Dr White had stuck a tube down into her lung and sucked up a bit of whatever it was shouldn't have been there) and sent it off to the lab to look at what it was.

Throughout the entire diagnostic process we had become more and more suspicious and Mrs Oat, as her pneumonia resolved, had become more and more cheerful. She smiled and waved at us every time she saw us.

Late one evening we got the pathology report. Small cell cancer, aggressive looking, extensive. Median survival was maybe months, maybe a year. The next day, at the ward rounds, I spoke to her treating doctor.

"Have you seen the path report?" I said, quietly.

He glanced at her and nodded. "Mitotic lesion" he said.

Literally "mitotic lesion" means when your cells are dividing something has gone awry. When doctors use it it means cancer. Specifically, when doctors use it in front of you it means they think or suspect or know you have cancer but they don't want to tell you about it.

Anyway. On that happy note - shall post and do comments soon.

Thanks for listening,


Anonymous Dr Rant said...

Smoke a "blue cigar" for me...always found ICU the most rewarding part of my EM training...second to Aplliative Care with which I feel it has many similarities.

In our little ICU, we had a photo of that young kid from 'The Sixth Sense' ...our ascot and motto? "I see dead people".

Best song for MET calls - 'ICU Baby' (Groove Armada). Always made me laugh that, arriving on ward 8, to some massive PE post op patient humming 'ICU Baby, shaking your ass'. That, and programming the AED to speak Japanese rather than the awful American twang language module.

Anyhow, good to know you're well

Dr Rant

7:02 PM  
Blogger lauritajuanitasanchez said...

Damn, there goes any chance I have of using my favorite strategy...DENIAL! I don't have cancer, but if I suspect I do and go in for testing, I'll be on the lookout for your mitotic lesion. Damn it! :)

3:20 AM  

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