To cure sometimes, to relieve often, to comfort always
by James Channing Shaw
view PDF: CORINA’S PRIDE
My resident, Rishaad, presented the case in the corridor: “This is Corina, a fifty year old woman with itching on her back, chest and abdomen. No other medical problems.” He presented his findings and working diagnosis.
We entered the examination room. Corina appeared healthy. I agreed that the hundreds of tiny, rough bumps over her torso were probably benign keratoses. Being the third consultant, we performed a biopsy and prescribed short-term symptomatic treatment, asking her to return in a week or so.
Outside the room, I explained that such an eruption of itchy keratoses could be a sign of internal cancer: the so-called sign of Leser-Trélat. “We’ll discuss it with her next time if necessary.”
At her next office visit, when Corina added that she was more fatigued recently, I divulged the rare association with malignancy but emphasized that it usually happened in older patients.
“I recommend that your family doctor update all your routine cancer screening tests: mammography, colonoscopy, ultrasounds, routine blood tests.”
“Maybe we could start with the blood tests here,” said Rishaad.
“Good idea,” I said. “That will speed things up.”
We left it that we’d call if any of the blood tests were abnormal. She thanked us for taking her problem seriously. That was Wednesday.
The next morning I received an urgent email. Corina’s white blood cell count came back CRITICAL: fifteen times normal, with blast cells.
“Oh my god, she has leukemia!” I thought. It was the sign of Leser-Trélat after all! She needed immediate treatment.
It was an hour before I finally reached her sister Clara, the emergency contact. I explained the blood test as confidentially as possible and recommended that Corina go to the emergency room immediately. When Corina called, she took my concern calmly. “I’ll be there in half an hour.”
My heart sank. I knew what was in store for her. At the same time, I felt relieved that she would be in good hands and receive the best treatment available. That was Thursday.
Monday morning, Clara (the sister) called me at home. “Hi Dr. Shaw, sorry to bother you. I’m calling to update you about Corina. Have you heard anything?”
“Last I heard she was in the emergency room and I assumed she would be admitted to University Hospital.”
“Yes, she went in Friday, but asked for a weekend pass to clean up her files before starting chemo.” Clara paused with a long sigh…“Early Sunday morning, she killed herself.”
Speechless at first, I eventually said, “Oh…my…goodness.” My mind raced; I thought she had been a good candidate for successful treatment. She had no signs of depression.
What on earth had happened? Neither of us spoke for a few moments. “She was a proud person,” said Clara. She went on to convey Corina’s appreciation for us having “at least discovered the cause.”
In reality, we had done nothing heroic. It was a twist of fate (or brilliance) that Rishaad recommended blood tests at our hospital instead of through the family doctor. The sign of Leser-Trélat had been a long shot. I could easily have been one of the doctors who didn’t perform any tests.
A week later, a thank-you letter arrived from Clara in which she expressed her bewilderment about her sister’s tragedy. I also had burning questions and invited her to contact me again to further discuss how all this could have happened.
Four months elapsed before we spoke again. I asked her to recount the events leading up to her sister’s death: Clara had joined Corina in the emergency room. For two hours, they searched ‘elevated white blood counts’ on their cell phones, fearing the worst. “We will need to repeat all this blood work,” said the officious nurse. The doctor saw her briefly, her blood was redrawn, and they returned to the waiting room.
Forty-five minutes later the nurse came through the door. “So I guess you know you have leukemia.” It was the first time the word had been mentioned! Corina was sent home without the E.R. doctor ever returning to provide context to the devastating diagnosis.
The next day, once the bone marrow sample was obtained and she had settled into her bed at University Hospital, an oncologist discussed her illness—acute lymphoblastic leukemia—and reviewed all the details, the chemo, stem-cell transplant, risks for infection, graft-versus-host disease and more.
The prognosis came across as grim, fraught with huge risks and uncertainties. Corina recalled her mother’s terrible death: breast cancer, pain, mental-status changes. She definitely did not want that.
Saturday morning she asked for the weekend pass. Chemo wouldn’t start until Monday morning anyway. Later that day, Clara called her sister: “I have just one favor to ask. Pretend that I am the one with leukemia and do what you would want me to do.”
“Don’t worry. I’ll do what needs to be done,” said Corina.
Dusk Saturday brought rain, which didn’t help with the gloom everyone was feeling. Some family and friends gathered for dinner, but talk did not come easily. At the end of the evening, Clara suggested that someone stay with Corina overnight.
Clara received the horrifying phone call the next morning. Corina had jumped from her twenty-second floor window. It turned out she had asked the friend to go home. “I’ll be fine,” she had said. “Let’s have coffee in the morning.” Police recovered copious Internet activity on treatments and prognosis of leukemia from her computer.
Throughout Clara’s story, she and I couldn’t come up with any real failures in Corina’s care. The emergency nurse’s delivery of the diagnosis epitomized bad communication but was not a medical error per se.
A week later, it suddenly hit me. There had been a failure. The failure of not providing comfort to a patient in need. The oncology team never introduced the option of palliation. With a new cancer diagnosis it’s always full speed ahead with aggressive therapy. If palliative therapy had been offered, she might have found peace in knowing she could be ushered pain-free to a merciful death during her remaining weeks. The panic that overcame her might have been averted. Instead, Corina was left alone in the dark, envisioning only two choices: horrific treatment with bad odds, or the violent and tragic alternative she ultimately decided upon.