My yellow eyed patient

I finally took the time to figure out how to post pictures, so I hope to start contributing more to the blog. We are all going to start trying harder since Sarah is leaving today and she has been the heart of our blog thus far. This picture is from a few days ago, but I want to tell you about this man. Thus far, he is the patient who has had the most impact on me and, although I can't say for certain yet, I think he is the patient I will remember most after leaving here. He came to clinic last Tuesday a week ago. About one month ago, the whites of his eyes and his skin started to turn yellow, he developed severe abdominal pain, and began to have difficulty eating because his stomach hurt so bad and he vomited when he tried to eat. He has lost 20 pounds in the last month. By the time he came to our clinic, he had already been hospitalized three times in the last month and was treated for three different diseases without any relief . . . they were nowhere close to getting his diagnosis correct and did not even send him for proper lab work. I am not sure why this is . . . it may be because they knew there was nothing they could do, so they just treated him for other things just to be doing something for him. He came to us in desperation. After reading through his records, hearing his symptoms, and performing his physical exam, I knew there was something very wrong with his liver or another organ that affects his liver. The problem is, we only have a few blood tests here and cannot do liver tests in our lab here. Towards the end of my interview with him, he looked at me and told me he felt very weak and could not eat or drink and wanted to know if I could admit him and give him IV fluids. I consulted with the doctor I was working with and we decided it was best to send him to another hospital to get his lab work as soon as possible, so I had to tell him no, which I really did not like. I thought about this man a lot over the ensuing days . . . I just couldn't stop thinking about him asking me for such a simple thing and having to tell him no. I realize that I have not been practicing in this environment very long and that is was probably the best thing to do since we could do nothing for him here to treat his disease, but it was still very hard to send him away. I did not think I would ever see him again. Well . . . on Thursday of that same week, I was working in clinic with Sarah. Two people work side by side in each clinic room. I was not paying attention to the patients she was seeing that morning because I was focused on my own. After reading a patient's chart, Sarah nudged me because she recognized my writing from the note I wrote in his chart earlier in the week. I looked up at the patient she was seeing and have never been so happy to see bright yellow eyes in my life! Sarah sent him my way. He showed me his lab tests which showed there was indeed something severely wrong with his liver (his bilirubin was nearly 20, an obstructive process for those of you who know what this means). He told me he was in such severe pain that he could not sleep at all the last two nights. I admitted him for pain control and IV hydration. I also had the idea that I would be able to orchestrate him getting other tests or treatment at another hospital while he was here. After he got to his hospital bed, I went and talked to him for a long while. I told him that he most likely had cancer in an organ in his stomach (liver, gallbladder, or pancreas) causing his symptoms. This diagnosis is a death sentence for almost everyone here because there is nothing we can do . . . no surgery, no chemo. These cancers are even hard to treat back home. I told him he could try to go to another hospital to see if they could do more tests or offer him more treatment (I thought that he may have stones that our old ultrasound machine did not catch, which are treatable, unlike cancer). This was probably not the right thing to do though. This man may be seeking money from all of his friends and family for money to travel to hospitals and for treatment and he may be spending a great deal of his last days travelling to get this treatment. I should probably have told him to go spend time with his family. It is not easy to get around here . . . only the wealthy have cars. He does not have a car. I guess I will never know. I told him this because he was a young, healthy man otherwise and this diagnosis was so unexpected to him and I just thought we might be missing something . . . even through he was stoic and brave, I could see his shock and sadness and desire to live. It was hard to see him go. I sent him home on our typical meds for cancer treatment . . . phenobarbital (a seizure medicine that takes the edge off pain), ibuprofen, and elavil (for sleep). For those of you who don't know, these medicines are nothing at all compared to the pain medicine we give for cancer pain in the U.S. . . . absolutely nothing. To end this story, my patient told me that his wife wanted to "greet me." I went to the courtyard to meet her. I talked to her for a bit and ended up telling her what I thought her husband had (which you don't do at home without permission from a patient). I later told him this and apologized and he said, "It is okay. She is my wife and needs to know." She had no idea . . . she thought it was an ulcer. Tears welled in her eyes, but she very bravely thanked me and told me she did not have any questions when I asked. She then gave me the two loaves of bread she had brought with her for their journey home (she is a breadmaker). It is rude to not accept gifts here, so I accepted it. It was very hard to see this man go . . . it is hard to see a man who was healthy and strong one month ago head off with his beautiful young wife knowing there is nothing I could do for him . . . I couldn't even give him that much for the severe pain he is going to face over the next few months. His trust in me and his bravery and stoicism, as well as his wife's generosity made it even harder to watch him go. It was uncomfortable for me, but it was likely what was best for him . . . during my internal medicine rotation at WVU, I watched my patient who likely had the same type of cancer as this man sit in a hospital bed for 2 of the last 3 weeks of his life waiting to be stabilized so he could start chemo. He just wanted to go home to be with his family . . . he spent very little time at home because of all the tests we were running and procedures we were doing on him . . . it is just different here. I hope my patient went home to be with his family.