Why Now? – April 9, 2015

A frail alabaster-skinned woman sat on my exam room table, the last patient of the day late on a Friday afternoon. The woman in the corner introduced herself as the patient’s sister. The patient, whom I will call Priscilla, slowly opened her blouse. She revealed a growth about the size of a human heart, but outside the central chest instead of inside, as if her heart had somehow flipped outside like an everted starfish.

“How long have you had that?”

“I don’t know.”

“Approximately.”

“More than 4 years.”

I looked at the sister. “Is there a reason you waited so long?”

“I can‘t force her.”

Priscilla spoke quietly. “I went to another doctor, a surgeon.”

“And?”

“She was a bitch.”

“What did she do?”

“She took a swab from it and sent me out. Said she would not remove it.”

Priscilla had a medical insurance only rarely accepted by any dermatologist—Medicaid—and her choice of providers was severely limited. We talked and I emphasized that she needed to get this off of her asap.

We checked her vital signs. Her blood pressure was elevated. Given her non-compliance with the tumor that had grown on her chest, I did not expect her to be taking care of herself, so having high blood pressure fell in line with her approach to health.

In textbook medicine, I would have sent her out and made sure her blood pressure was lower and she had all the best options to decrease her risk factors, including perhaps a general surgery under anesthesia. But this was far from textbook. I knew that it was highly likely that if she left now, she would never get anything done, and this cancer would erode into her chest and could kill her. Even now, I did not know if it had spread and would quickly be her demise.

With some persuasion from her sister, she agreed to have the operation and the proper consents were signed. The surgical room was prepared and she was prepped. As she lay down on her back, she had the visage of a frightened child.

I carefully explained to her what I was doing during each step of the surgical journey. I had to reach under the large mass and cut the pedicle that clung to her chest. As I performed the procedure, one blood-soaked sponge after another was used to mop up the profuse bleeding. Finally the giant growth gave up its hold on poor Priscilla. If this had been a fish, I would have had to toss it back in the water—it was far above the legal limit of size.

Priscilla was shivering and seemed a bit more pale. I had her sit up and put pressure on her wound so the gravitational flow of blood would not result in more bleeding. In a few minutes the flow of blood subsided, and I began the onerous chore of sewing up the defect where the tumor had grown and spread.

After the surgery she seemed to have a bit more color and I was hopeful that she would have a good recovery.

“God sent me to you,” Priscilla said.

“We have a ways to go,” I said. “We have to see what the biopsy shows. You need an MRI and your blood pressure controlled. You may need to see a general surgeon or plastic surgeon.”

“I need something for pain.”

I gave her a pain med, an oral and topical antibiotic, and complete instructions to her and her sister to head to the ER if she started having bleeding or any problems.

When I checked her before she left, she appeared as if her burden had lightened; she had shifted from a scared child to someone who at least seemed to be able to stand up a little taller.

The biopsy was reported as a 314 gram, 12.5 cm x 8cm basal cell tumor, certainly the biggest one I had ever removed. I saw her again a couple of weeks later, and her wound had started to heal. When I asked her about getting her blood pressure checked or a MRI, she replied, “I haven’t had time.”

Why now? Why do certain people wait so long to come see us when they must be aware they have a problem that continues to get worse? And then comes the great question of everyday life–What do we do next?

Here are other examples. A man came to see me who complained about a “growth on my arm.” When he was in the exam room, and my medical assistant gently pulled off his ragged home-rigged dressing, a profusely bleeding half-dollar sized skin cancer made its appearance. I mentioned the option to surgically remove it right then, and the patient agreed. But underneath the story of this nasty growth was a whole history of events that had occurred prior, in particular an extreme lack of money. I remember a woman who had waited over ten years to see a physician and when she showed up at my office, she had a basal cell cancer that covered almost her entire right cheek. “I didn’t have any money and just got insurance last month,” she said.

I saw an eight-year old girl in my office with severe atopic dermatitis. She had been out of school for three weeks and the mother had been off of work due to lack of sleep and trying to care for her child during much of the three weeks. Why did the mother wait three weeks?

And the horrendous cases often gain purchase in my mind, such as the 41-year-old man with AIDS that came to see me because he felt a bump on his buttocks and never did anything about it. When I examined him, he had a huge and irregular growth that I removed–a 12 mm deep melanoma–that had already spread internally, and despite every effort, eventually claimed his life. Or the 50 year man who looked at least 70 years old and had smoked two packs a day since his teenage years, and showed me a nasty growth that everted his lower lip. During his examination I noticed a swelling on his neck, and later found out he had spread of the cancer to the cervical lymph nodes and beyond.

A 48-year-old man rolled up his pants on his right leg and showed me a huge round growth that looked like it was about to burst. “I’ve had it 20 years,” he said. “But only in the last 5 years has it started to give me any pain.” The guy was really strange, with a sort of child’s pride in having kept this hidden for so long. If he had told me he had swallowed a grapefruit and it somehow got lodged in his upper thigh, I may have believed that he thought it was true.

The man covered his face with a drape while I worked on him, but his wife hovered nearby and was engrossed in the whole event. I opened the lesion with my scalpel blade and it turned out to be a large irritated cyst which gushed ounces of cheesy substance. The key was removing the shell of the cyst so it would not recur, and this took some time. His wife and I discussed the task at hand and he moaned with a squeamish cry every few moments.

“Any pain?” I asked.

“No,” he said. “I just don’t want to look.”

Even though I used an absorbable foam to fill the large deficit, an indentation remained when I finished the task of sewing him up. Over time the normal contour of the leg would hopefully come back.

A 32-year-old, Hispanic woman came to see me, accompanied by her parents. She asked about getting a growth taken off her lip. I asked how long it had been there, and she replied “ten years.” I performed a history and physical, and noted a raised red bump on her left upper lip, appearing as an irregular hematoma. The patient, who I will call Graciella, was mildly mentally retarded, and the family had moved to Tampa from a tough area in New York City about eight years ago. She remembered getting some rocks thrown at her one day by rowdy neighborhood kids. “I think one of them hit my lip,” she said, pointing to the raised bump.

“Why after all this time did you want this off?” I asked.

“I don’t know,” she said. “I’m just tired of looking at it.”

I had her sign a consent after reviewing the procedure with her and her parents. The mother appeared quite anxious, and the parents left the room prior to the procedure.

I numbed up the area, and Graciella seemed to handle everything without much distress. I used a scalpel to open the lesion and explored it with a dissecting scissors. Within a short time, I probed and found a solid object that resembled a small hematoma. Using a pickup, I was ready to pluck it into the biopsy bottle when I noticed something shiny. While my nurse put pressure on the wound, I pressed on the object with my fingertips. The bloody covering slipped off, revealing a tiny copper ball. It was a B-B! I dropped it in the bottle, and it landed with a little kerplunk.

“I don’t think you got hit by a rock ten years ago,” I said. “You got shot with a B-B gun.”

“A B-B?” she exclaimed. “Oh, my God! Momma, Pappa, come here!”

I told my nurse to have the parents come in. The mother was a bit hysterical when she heard the news.

“That’s a first,” I said.

I just shook my head in amazement. After ten years, the mystery had been solved.

Recently I had a 39-year-old Cuban man come in to see me because of what he thought was a cancer on his abdomen. “It has been there for about 16 years but now it is bothering me and it has gotten bigger.” I asked him about trauma or other history but he denied anything that may have contributed to the growth. I examined the raised area near his belly button, which appeared to be more cystic than solid, and told him I would need to take a biopsy. After he agreed the area was prepped and I opened it up. Inside I found a two-inch piece of suture wrapped around and twisted. “Oh yeah,” he said. “I had a surgery there 16 years ago.” The dissolvable suture had never dissolved and had brought on a skin irritation that had raised itself up and made itself known.

All health care providers have these kind of crazy stories. As physicians, we are often required to peel away other possibilities to get to the source of a patient’s medical problem and repair what has been disturbed or broken. And with each problem comes a whole story that has preceded the person’s appointment. Many reasons come to mind—-fear, frustration, denial, feeling vulnerable, lack of trust, symptoms that did not interfere enough with daily life, a lack of funds, a perceived or real paucity of available and timely care, limited transportation—all can contribute to someone not seeking a remedy. A Priscilla type exists in every medical practice, and we need to be aware that, for whatever reason, sometimes now is the right time.

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