A Surgery Tale
Joshua Dow, University of Washington SOM

A 58 year-old homeless man who lives in the woods comes into the ER. Get this. For the last NINE months he's had problems swallowing. For the last six months, he's been unable to swallow solids, and so he's been living off Slim Fast and a gallon of milk a day. (He's a homeless guy with a PO box to which these food stamps get mailed--this is new to me.) Interestingly, he's not malnourished; his albumin is normal--apparently milk's good for you. (For non-med students, albumin is a blood protein and it would be low in protein deficiency.)

Yesterday, he became unable to even swallow liquids, and so he comes to the ER today. The ER pages the surgery attending on call. I'm just a dumb med student, but I know what's coming.

Esophagram (also called a "barium swallow x-ray") shows a huge irregular mass in the man's esophagus, and in this email I've attached a picture that's similar to what his looks like. Contrast is barely seeping past the mass into the stomach. CT scan shows another mass in the man's right adrenal gland. Whatever's in his esophagus has now metastasized. EGD (a scope down the throat) and biopsy show cancer.

The metastasis makes this stage 4 esophageal carcinoma. I'm lucky. The attending does not ask me the obvious pimp question for making a dumb med student look even dumber: "What's the five-year survival for stage 4 esophageal carcinoma?"

I surreptitiously flip through my copy of "Surgical Recall" (a med student's soul on a surgery clerkship).

"Zero percent."

While looking at the x-ray, I glance at the man's name tag in the corner of the film. Today is his birthday. The attending and I go back to see the patient and explain to him what's going on. It's a busy call weekend, and we have to get back to the OR to do an appendectomy on someone else. As we leave the ER, I apologize to the man for how this must be a rough way to celebrate a birthday. He has thick glasses, long white hair, and a long frizzy white beard. He used to be a welder.

The man's hospitalization does have one positive outcome. His brother, who he hasn't seen in years, is in town this weekend looking for him--right now, just by coincidence. The brother checks the hospital, and the two are reunited. If the man hadn't been in the hospital, I don't think his brother would have been able to find him.

The next morning I round on the patient, and I ask him the question I had avoided asking him in the ER: why didn't he come in sooner? His reply: he wasn't sure how he would pay for a doctor.

In Canada, people don't even think about this. Everyone has insurance. Simple insurance. If you can't swallow, you go to the doctor. It's a no brainer.

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