• Users Online: 14154
  • Print this page
  • Email this page


 
 
Table of Contents
RESIDENT CORNER
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 529-532

Throwback to when it all started: Part two


Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission20-Jun-2021
Date of Decision26-Jun-2021
Date of Acceptance29-Jul-2021
Date of Web Publication10-Sep-2021

Correspondence Address:
K Alok Shetty
Department of Medical Oncology, Office 11th Floor Homi Bhabha Block, Tata Memorial Hospital Parel Ernst Borges Road, Parel, Mumbai - 400 012, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_146_21

Get Permissions


How to cite this article:
Shetty K A. Throwback to when it all started: Part two. Cancer Res Stat Treat 2021;4:529-32

How to cite this URL:
Shetty K A. Throwback to when it all started: Part two. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Dec 9];4:529-32. Available from: https://www.crstonline.com/text.asp?2021/4/3/529/325898



Case number three: A close brush with the virus-From the pages of my diary –April 19, 2020

As the pandemic seems to be coming to an end, I turned back the pages of my diary and reached the point when it all began.

The coronavirus disease-2019 (COVID-19) pandemic had gripped the world and pushed it into a seemingly never-ending limbo. Not so long ago, the first two cases of COVID-19 were identified among our own patients at our center. Since then, innumerable patients had been screened, but none had tested positive yet. As I had collected the swab from the last patient who tested positive for COVID-19, I often joked to my friend, that I could conduct training sessions on how to take swabs and how my efficiency was statistically 100%. (Statistics seem to be seeping into my system too!).

One of my batchmates who had come in contact with the first COVID-19-positive patient at our center was asked to self-quarantine and I was asked to take his emergency ward calls, which I agreed to, albeit (I must confess) reluctantly, considering my past experiences.[1] The hematology-oncology emergency duties were among the toughest duties in the hospital. One had to constantly juggle the allocated ward and the emergency ward, while remembering to breathe when pacing between the two. As residents, we often thought that an additional problem with hematology-oncology emergency duties was that the patients were often sicker, yet more salvageable. As we advance in our oncology training, our minds adapt to expend more energy on patients with conditions that are curable. As a novice, a few months ago, I found this blasphemous. However, as one starts practicing the Religion of Oncology, one's beliefs and practices change, so a curable patient means that one has to tread carefully.

What do hematology-oncology emergency duties entail? We have two sets of tasks. Patients who are ambulant or whose preliminary reports need to be checked are seen in an emergency clinic setup and directed further accordingly. Contrarily, those who are ill, non-ambulant, and need urgent attention are triaged into an adjacent emergency ward, where they are monitored with the help of the nursing staff, and administered urgent medications to stabilize them before shifting them to the ward or an intensive care unit. With the pandemic, the number of such patients had dramatically decreased. I remembered, how we spent up to six hours straight in the emergency clinic on a Saturday or Sunday, with a never-ending line of patients; but now, because of the pandemic, we had adequate time to put our lungs to use.

The COVID-19 pandemic had brought about yet another change. We now had a designated area called the “fever outpatient department (OPD)” where all patients who entered the building were asked whether they had symptoms such as fever and breathlessness.[2] Individuals in whom these symptoms were present were rescreened along with history-taking and an evaluation of their records to check if they were likely to have COVID-19. Patients were then directed further according to their screening results.

On Saturday, I finished my ward work earlier than usual in the afternoon and decided to take a quick nap to recharge myself. I rushed back to the emergency clinic after the afternoon siesta in my resident quarters. My friend and senior colleague was already there attending to patients with solid malignancies. As I sat down across the table from him, looking at the bundle of files, I picked up the first one. It was that of a middle-aged lady with diffuse large B-cell lymphoma - a form of nonHodgkin lymphoma. She had fever in the past week, following her fifth cycle of chemotherapy. Her records indicated that her last visit to the OPD was around 5 days ago and her fever had resolved. Her antibiotics had been discontinued and she had been given some analgesics for the body ache.

As I called out for the patient to come in, I wondered what had brought her back. She sat down with her shawl covering her head and a mask, her face; I quickly asked what ailed her. In broken sentences, she and her daughter attempted to convey that she had fever. The protocol had been breached, and the authorities had somehow missed directing her to the fever OPD. However, barriers had been breached too, and I now had to attend to her like any other patient. As a strong believer in at least basic history-taking, I requested them to get a translator. The daughter quickly managed to find another person who could speak both her native tongue and Hindi. With his aid, I figured out that her complaints were high-grade fever with chills, vomiting, and a bitter taste in the mouth because of which she was unable to eat.

My mind started analyzing things. Firstly, the treatment regimen that the patient had received was not really the most toxic one. Secondly, it was a little uncommon for someone with no comorbidities to develop febrile neutropenia after their fifth cycle. Thirdly, the fever had started on day 4 post-chemotherapy, which was an oddity in itself, as that was not the usual time for neutropenic fever. The patient had interestingly become neutropenic in the later part of the illness when her fever had relatively subsided. Fourthly, she had presented to the hospital on day 14 post-chemotherapy, which was the fag end of the neutropenic period, and an unlikely time frame for the fever to have persisted.

Something was amiss, and the pieces of the puzzle were not fitting. And then, I had to fit her chills into the puzzle too. I stared at her hemogram trend on the computer screen, hoping that a persistent stare would magically reveal some answers. However, none came. The only thing that could now help was probably a thorough clinical examination. I recalled a video in which our hematology head had said that a thorough head-to-toe examination, from scalp infections to paronychia in the great toe, was of utmost importance in a neutropenic patient. We residents often joked that examining a neutropenic patient entailed looking at holes at both ends and all the things in between.

A well-rehearsed baseline checklist flashed in front of me – oral cavity, chest examination, perianal tenderness, and peripherally inserted central catheter line tenderness. With this background, I set out to perform a thorough clinical examination. I checked her pulse to get a quick feel of the rate, volume, and regularity. I asked her to pull down the mask and looked into the oral cavity with the aid of a torch. A white speck sparkled on the inner surface of her cheek. Possibly oral candidiasis, my mind noted. I then stood up and placed my stethoscope on her back, what we called the bases of the lungs. With no effort, I could hear some crackling sounds in the infrascapular area. With a few more quick movements over the chest, I realized that the sounds were restricted to the right side at the bases. I touched her forearm with my palm again and felt that she was warm. I asked the nurse to quickly check her vital signs and revert. Meanwhile, I tried to diagnose her condition mentally and plan a further course of action. She probably had a right-sided pneumonia, I thought, which would explain most of her symptoms and signs. However, I was going to need a fresh set of labs and cultures and a chest X-ray. The nurse thrust the file back into my hand “Doctor, her sats are low, 89%.” The alarm was set off in my head. A patient requiring supplemental oxygen was a high priority. She would have to be sent to the emergency ward and started on oxygen immediately, followed by investigations, and treatment started on a “stat” basis.

However, considering her current state, I wondered whether she needed to be screened for the virus. Somehow, the prolonged duration of the fever seemed odd for a viral illness. I voiced my concern to my colleague across the table, who was already complaining that a pandemic was not the best time to be treating metastatic solid malignancies with aggressive regimens.

“Fever, low sats, chest findings – does she need to be screened?” I enquired. “Of course. Discuss with someone from the committee.” His affirmative reply gave me the necessary impetus. I called up my consultant who was a part of the hospital's COVID-19 management team and briefed him about the case. We decided to move her to a cordoned off area we had designated as the fever OPD and then to proceed with investigations. I conveyed to the patient and her attendant that she would be further tested and re-examined in another area. The nurse ensured that the patient was shifted to the fever OPD.

As I stood up to wash my hands, the translator asked me if the patient could drink oral rehydration solution (ORS). I ignored the question. He then rephrased it, “Can she have lime juice?” I am not sure if it was my anxiety speaking, but I chided him saying that these issues were not of primary concern and could wait and sarcastically added that neither the ORS nor the lime juice were elixirs of life. I have noticed that at the end of a counseling session regarding cancer diagnosis, which is often a life-altering one, the most frequently asked questions are “What caused the cancer?” and “What can I eat in the future?” Often a menu of fruits and vegetables is discussed. I try to answer these questions to the best of my abilities, but often direct the patients to our dietitians for better advice. I must confide that there have been moments when tired of the interrogation, I have jokingly replied that the patient could chew on anything other than my brain.

As the translator left, I scrupulously washed my hands and sat down. My senior and I wondered as to what would happen to us if this patient tested positive. The senior nurse from the emergency ward wondered if her juniors would have to be quarantined too; this would mean an additional burden on the rest of the nursing staff, as they were already running short of nurses because of the lockdown imposed in the city.

I continued to see a few more patients – one with a headache post-intrathecal injection, one with some paresthesia over his trunk post EPOCH (a chemotherapy regimen including etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin), and one with fever post a consolidation regimen for acute leukemia. In the meantime, we received news that the suspected patient had been shifted to the isolation ward and her swab had been sent for testing. I rushed to the ward, finished my pending work, and returned. I checked the X-ray of the suspected patient, and my heart sank for a moment. The X-ray was suspicious, and the odds of her being COVID-19 positive seemed higher. Nevertheless, I continued my work. I saw one or two new patients and checked on the reports of the previous patients, doing whatever was necessary to take care of them.

I waited for my senior to finish his work, and we both left for dinner together. Although by now, we were used to the food in the cafeteria, we believed that even if we survived the pandemic, the monotonous food would not spare us from martyrdom.

Over dinner, we quipped about the ongoing situation in the country and the hospital, about how everyone had an opinion, and also about the aftermath of this pandemic-how we would probably be swamped with patients from all over, once the travel ban was lifted. The future seemed dreary. I then went to change out of my scrubs, returned to my room in the resident's hostel, and took a hot shower. My siesta had me charged enough to do a bit of reading and listen to some music. Something was preventing me from falling asleep.

At around 3 am, I switched off my lights and lay on the bed setting my alarms. That was when a message flashed across the phone – “Patient ID**** tested positive.” My reaction would best be censored – a lump in the throat, a missed heartbeat, and that sinking feeling in the stomach again. I called up my senior colleague, and we roared with laughter at our predicament. We received multiple calls from the emergency ward and our consultants, hinting at a possible test and quarantine. I tossed and turned in the bed and then stared at the rotating fan on the ceiling. The outlines of the three rotating blades were barely visible and overlapping. Similarly, several questions swirled in the vortex of my mind. The first question that popped into my mind was whether I was safe. I could not recall the patient coughing, I had my N95 mask on, and I had definitely washed my hands. However, was that enough? I had not worn the visor-like face shield the institute had provided on that day. If I tested positive, would I be penalized for being reckless? Had I enthusiastically overexamined her?[3] There are a few conditions where enthusiasm in medical examination is discouraged; for instance, performing a per rectal examination in a patient with a fissure in ano (to be avoided as it would definitely increase the patient's pain), performing a chest percussion in a patient with atrial fibrillation, and eliciting the Moses sign in a patient with deep venous thrombosis are highly discouraged. For no other conditions could I remember being taught to examine less.

The virus had hit the soul of the physician in me. It has been an undying habit of mine to auscultate the lung bases of my patients, with one hand on their shoulder and the other on my stethoscope. Even though I know that it may not always reveal something additional, the act is almost always mandatory. It is what a professor I previously worked with referred to as “touch therapy.” It made the patients feel comforted and assured that they were being examined. I had performed an oral cavity examination for this patient. Was I wrong in doing that? The holy texts of clinical medicine have harped on the importance of this task, and not so long ago, as a teacher myself, I demonstrated to my students the innumerable signs of systemic diseases that lay hidden in the oral cavity. It was only ironic that this act could now possibly be considered an unpardonable sin. The biggest question was – “What if I get infected?” Besides the chances of me infecting other patients, I was probably staring at my own impending doom. What was it that I feared? Was it death? Death was an old enemy. When I was a physician, death was a perennial enemy. Often, I had kept him at bay from my patients, extending their lives; often I had snatched some of my patients' lives from his clutches back into this world; equally often I had lost many battles to him. However, as an oncologist, my relationship with death seemed to have changed, and I seemed to be making agreements with him more frequently. When needed, I had fought aggressive battles, but more often than before, I was fighting losing battles.

I found myself coming to terms with the fact that sometimes death would be kinder to my patients than the cancer they suffered from or the treatment that I would put them through. I have begun to understand that death is an inevitable passenger in everyone's life. However, at this point, I wondered if I would have to bargain with this old enemy for myself? What is it about death that scares us the most? Is it the process of it? Is it the fear of the unknown? Is it the fear of leaving all the lovely dreams behind – my parents whom I have not seen for more than seven months now, my favorite pop music star's concert which I one day wish to attend, and all those places which I have dreamed of traveling to? Would all my dreams remain unfulfilled because of a brazen act of performing my professional duties? I could not really singularly point to one reason, probably because I was not scared enough. I decided that I had to move on. I convinced myself that examining the patient could not be held against me. However, that missing visor? Well, to err is human and to forgive divine. As the divine in me began to calm my anxious soul, my eyes focused on the rotating fan blades again. The blades seemed to rotate relentlessly, as I slowly drifted into dreams of swabs being thrust up my nose and me being quarantined on an island with a pop music star.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shetty AK. Throwback to when it all started. Cancer Res Stat Treat 2021;4:347-9.  Back to cited text no. 1
  [Full text]  
2.
Joshi S. Coronavirus disease 2019 pandemic: Nursing challenges faced. Cancer Res Stat Treat 2020;3, Suppl S1:136-7.  Back to cited text no. 2
    
3.
Babu TA, Sharmila V. COVID-19 pandemic: Another nail in the coffin of the “dying art” of the physical examination. Cancer Res Stat Treat 2020;3:610.  Back to cited text no. 3
  [Full text]  




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
References

 Article Access Statistics
    Viewed372    
    Printed12    
    Emailed0    
    PDF Downloaded16    
    Comments [Add]    

Recommend this journal