It was 4.30pm. I was getting ready to go home after a long day….
Zila barged into my room.
“Dr , sorry.. you have one walk-in patient. She looked so much in pain”
Zila let the patient in my room. The patient was in a wheelchair. She looked uncomfortable and frail, her thin torso bent forward, her hands held her tummy.
Urinary catheter bags were hanging from her back - she has bilateral nephrostomies. The urine in the bag looked so cloudy. She came with her husband.
A nephrostomy tube is placed into the right kidney to drain urine. Due to obstruction at the ureter, urine cannot be drained in to the bladder and causes the right kidney to swell up. the right kidney.
“This is not gonna be an easy case” i was talking to myself.
“How can I help you Madam?”
They were both non-local, they didn't speak English. The husband handed a thick file with blood results, referral letters and a few clinical summaries. I went through the documents.
“This is not good” I told myself. All the investigations were done six months prior. Acute kidney injury…seizure…..CT scan….. obstructive uropathy…..those can only mean one thing….and it’s not good.
“Sir, can I get your wife on the examination couch” I had to use Google Translate to communicate with them.
I examined her pelvis-a hard mass could be felt. There were rashes on her vulva. Not looking good. She was sooo much in pain that I could barely touch her. I couldn’t examine her internally.
I admitted her for pain relief and ordered a few investigations - blood workup, CT scan, and urine sample. She looked so much comfortable after the medicines that she was able to walk almost upright. The least I could do for her.
Although I think I knew her diagnosis, a histopathological examination of the lesion was still necessary to confirm her diagnosis, which would decide the kind of treatment she would receive. This meant she would need a sample taken from the growth on her vulva and her cervix - a tissue biopsy. This was done in the operating theatre due to her condition to not inflict pain on her.
CT scan result impression read:
Liver metastases….. bilateral uropathy…. Non functional kidney…… cervical mass…..
“Bad… liver metastases” I told myself.
Whatever the HPE result was going to be, this meant she had stage 4 cancer.
This meant it was not curable; she would not live long, she needed chemo & radiotherapy ….the side effects would be bad. But if she didn’t have those, the cancer would spread even further, which meant she would deteriorate faster….
After a few days, the HPE result was released .. as expected, she had squamous cell carcinoma of the cervix & vulva - in short, cervical & vulval cancer.
“She got not much time; she’s stranded here in Malaysia - no family members here”
I did it many times. That day, I had to do it again. Breaking bad news was never easy. Regardless of how often you do it, the same heavy, dreadful feeling will remain. I feel like running away from it. If I’m feeling this, definitely the patient would feel even worse. Guugolplex times worse !!
I took a deep breath and walked into the room where the patient was. She was sitting on her bed, watching something on her phone with her earbuds on. She looked comfortable. Her husband was sitting beside her, using a laptop; he looked like he was doing some work.
With a heavy heart, I broke the bad news. The patient and her husband looked numb.
It must be devastating to realise that her days were numbered, the uncertainty, despair..
I knew there was nothing I could say to make her feel better. I briefly outline the next step of treatment. At that moment, after hearing the bad news, there was so much to take in. I would return to her and explain the treatment when the news sank in. I left the room.
I couldn’t help saying it in my head.. this could have been prevented if she had gone for cervical screening (pap smear).. if only… but it’s not for me to judge… everyone has their own reasons… maybe she wasn’t aware.. in fact still many people aren’t aware of cervical screening..
This picture shows normal cervix, cervix precancerous changes (CIN1-CIN3) and cervical cancer. With cervical screening (pap smear) early changes can be detected before the cervix becomes cancerous.
Picture: https://www.sciencedirect.com/science/article/abs/pii/S1746809419303660
Cervical cancer is preventable…..the ONLY gynaecological cancer with a good and effective screening method. Preventable means if the cervical abnormality is detected early (precancerous stage), it is 100% curable, yes 100% curable! It is free at KKM facilities. But still, only 1 in 5 women go for screening..
The patient went back to her country after receiving a cycle of chemotherapy. Never heard from her since..
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