Vacation Angst

All of us need time away from our professional duties. A vacation is a wonderful time to recharge the batteries and take stock of where we stand in the currents of life.

As a physician, a leave from daily practice brings with it some concerns. There is always a group of actively ill patients. Although my covering MD colleagues are wonderfully skilled and extremely capable of dealing effectively with anything my patient population might present to them, I always have an underlying worry that they may not be as attentive as I to the nuances of the ill patient. This is not surprising as I also periodically ‘hold the fort” until a colleague returns. Additionally, available records never fully reflect the depth of understanding a primary physician has as it relates to a particular illness.

In any event, I recently needed time away with the plan to relax, read some interesting books and spend some time in Maine, as I have since childhood.

I arranged for excellent coverage with close and experienced colleagues who were quite willing to see the patients in the outpatient arena who were under active therapy for their various malignancies. I was very comfortable with that since a good part of management is formulaic and the expected potential toxicities are universally known by my colleagues.

But I was leaving an ill patient in the hospital at a time when the acute illness was not completely explicated. Thomas did not appear to be very ill but I was nervous about the course of recent events highlighted by the sudden appearance of a brisk hemolytic anemia that weakened him and worsened his known underlying chronic lung disease. He was easily short of breath and additionally had lost considerable weight and complained of pain in his belly.

By looking at his red blood cells under the microscope, I noted characteristic changes in their structure seen in an enzyme deficiency called G6PD deficiency. This inherited disorder is prevalent in the Mediterranean basin including Greece, Thomas’s birthplace. He also had been on an antibiotic known to trigger an attack. I felt comfortable that this was the cause of the rapid drop in his red cell count but it did not explain the weight loss and abdomen pain. I also was concerned about a second change in the red cells that I saw by microscopic examination. There was a small subset of red cells that appeared fragmented. This change can come from several ominous medical disorders, some rapidly deadly. I still felt G6PD deficiency was the major culprit for the anemia but I was happy he was in the hospital with plans for further testing of his abdomen while I was away. I left him in very capable hands but some worry lingered.

While away, I remotely entered his hospital chart to see what was happening and to my dismay, he was found to have masses in his abdomen that likely reflected some form of cancer with lymphoma most likely based on his known history of an autoimmune lung disorder and the presentation. But his gall bladder was distorted and I had a fear he might have metastatic gall bladder cancer remembering the appearance of a few fragmented red cells when I had examined his blood under a microscope. I knew that widespread cancer can inappropriately activate the clotting system leading to disseminated coagulation in the blood vessels. Red cells can be mechanically damaged when that happens leading to fragmentation and hemolytic anemia.

A biopsy was done and indeed he was found to have gall bladder cancer and a PET CT scan confirmed widespread disease. My capable colleague who was covering me began him on the appropriate chemotherapy. He seemed to improve but two days later he rapidly declined with worsening anemia, active clotting and organ failure in the setting of a falling blood pressure. Despite maximal support in the ICU he died at age 57. I was stunned.

While trying to enjoy my time away, I had this dreadful feeling come over me. I questioned the wisdom of leaving for vacation. Although Thomas was in the care of great doctors, could I have done better? Could I have responded more quickly to the rapid change in the clinical condition of the patient. Perhaps I am more attuned to blood changes and if I were at the bedside, could I have favorably changed the trajectory for this relatively young man? The lingering doubt of leaving an ill patient was palpable and frightening. Did I do something unethical? Was I wrong in my interpretations? Should I have stayed at his bedside and delayed “recharging my batteries”?

I do not have comforting answers to these questions. When I returned I reviewed Thomas’s illness and treatments and concluded his care was exemplary. I find some solace in this. I also noted he was found to have a deadly disease and even without the complicating blood disorder, his further life could be counted in months, not years. Nevertheless, I wrestle with the notion of whether any individual physician could alter the outcome in this setting. I believe it is possible.