Poor Prognosis

A telephone call (from a patient previously discussed) reveals some disturbing symptoms: almost no urine output for three days, as well as a completely inactive colostomy for four days. He is supposed to start chemo and radiation, but something seems to be going wrong. The cancer, spreading from the area where the rectum used to be, has erupted, and bladder or bowel involvement---not to mention lymph nodes---is only a breath away.

I drive over to the apartment house, homeless men hanging out in the vacant lot next door, brown paper bags concealing their recent package store purchase. A long line of people wait to order lunch at the McDonald's across the street. The smell of french fries wafts through the cold air.

Luckily, the elevator--which smells of Pine Sol--- has been fixed so I don't have to run up five long flights of stairs. He's laying on his side in the bed, sounds of traffic coming through the windows which are slightly open despite the chilly temperatures outside. His face is ashen, and he grimaces and then smiles wanly.

"Does it hurt?" I ask. "Not really." The number of morphine tablets in the bottles confirms that not much has been taken since Friday. Is he in denial, scared of the medication, or is there really not much pain yet? "Yet" is the operative word here. Yet. Promises of suffering to come.

Fever? No. Blood pressure and pulse? Not bad? Coloring? Ashen. Bowel sounds? Yes, but high-pitched. Tenderness? Yes, especially the lower right abdominal quadrant. Ileocecal valve, perhaps? But what about the lack of urinary output? Infection? Stricture? Cancer in the bladder? Yikes. I call 911.

The paramedics seem nonplussed. They've seen it all and this patient doesn't seem so bad. Sure, he can't lay down on his back since the huge gaping wound where his rectum used to be is quite uncomfortable---a wound that will never heal. I tell them he may look OK to someone who doesn't know him well, but he has to go to the ER, no questions. I write a long list of medications and a brief history: HIV, recent active TB treated for one year, diabetes, asthma and COPD, recurring rectal cancer with rectum removed thirteen months ago, patient well-adjusted to the colostomy, very reliable with taking meds.

We ride down in the elevator, my patient walking since the elevator is so small the stretcher would never fit. He's most comfortable on his feet anyway. I tuck him into the ambulance and promise to follow up later, returning to my car, calling the ER to talk to the Charge Nurse in advance of the ambulance's arrival, then call my office and ask them to fax a demographic sheet and med list to the ER.

A big sigh.

Turns out it's not really a bowel obstruction. The tumor in the rectal area has grown and is pressing against the urethra, restricting the bladder's ability to empty. The cancer will eventually break through the bladder wall and then all hell will break loose. The lack of bowel movement was most likely due to the pressure of the full bladder against the bowel. The tenderness in the right lower quadrant was stool stuck in the colon with nowhere to go.

How long do we have? Six months? We haven't even been able to start chemo or radiation yet, not that that's a panacea. It may buy us a few months, that's all. Cure? Impossible. Palliation? If we're lucky. Death by the end of 2006? Very likely.

And miles to go before we sleep.