Robbins Doesn't Tell the Whole Story

I was reading through prostate pathology in Robbins tonight and took pause after reading a few interesting facts. I know someone that survived what can only be described as a death sentence - in layman's terms, pretty much the worst prostate cancer you can have (Gleason 5+5, T4N1). This guy is, by no means, a terrible person - but he wasn't winning any kindness awards. But, as I said, he survived. The relevant Robbins quote:

"Any spread of tumor the lymph nodes, regardless of extent, is eventually associated with a fatal outcome, such that the staging system merely records the presence or absence of this finding as N0/N1."

I then thought of some other cases where people weren't so lucky. In my humble opinion, they got screwed. You'll hear about them again - they're not just 3 cases to me, they're friends.

A young football player feels a nagging pain in his thigh. Fast forward a few months and he's staring at an oncologist telling him he has a Ewing's Sarcoma (rare tumor with an incidence of 4.6 per 1,000,000 in the US). It's in his bones and lungs. If it was just in his lungs, that'd be the best prognosis possible. If it was just in his bones, that wouldn't be as good as just lungs, but still not the worst case scenario. Nope, he has it in his lungs and bones - the worst prognostic category. He's the type of kid that lights up a room, everyone's best friend, just the last person this should happen to. He died two years later at the age of 15. We were still in high school. Today I feel lucky that, at the time, I didn't comprehend the true magnitude of the tragedy.

Another young athlete is running on a treadmill at the gym. He's trying to stay in shape - he was an all-state swimmer in high school, but school and a job at a law firm keep him pretty busy these days. He has been dating a lovely girl since high school. Now in their senior year, they're planning to get engaged after he graduates. I met him at orientation before college started. We were friends for the next four years - he wouldn't hurt a fly. But, karma be damned, he passes out while running. His heart was out of rhythm, due to a congenital malformation of the musculature in his heart (congenital hypertrophic cardiomyopathy). He was pronounced later that afternoon at the age of 21. His death shook all of us up - he didn't see it coming, we didn't see it coming - it's probably not even possible that he could have known. He was just such a great guy. It shouldn't have happened. If people like this are the ones not making it, what does that leave for the rest of us?

Last, but certainly not least, a young woman volunteers to be designated driver for a friend as they go out for the night. On the way home, they're hit by a drunk driver. If it wasn't such a disgusting use of the term, I'd call the event ironic. Her friend awakens to the jaws of life pulling her from the wreckage. They extricate the driver's friend first. Aside from a concussion, the friend only has some bumps and bruises. But no good deed goes unpunished. In a particularly violent car wreck, the massive forces of impact can push the heart downwards, however the aorta is secured in place. This causes the aorta to transect. Of all the amazing things that the aorta does, I would argue that the most important thing it does is bring blood to your brain. Oxygenated blood sustains the neurons in your brain, keeping alive the cells that make you . . . well, you. I suppose it makes me feel slightly better to know she wasn't awake and didn't know that any of this had happened. Her chest was filling with blood, stealing beat after beat of life sustaining fluid. It was robbing her brain while simultaneously punishing her lungs with pressure as the cavity filled. She died that night, she never had a chance. She lived next door to me, we had started dating a few months before the accident. I still remember a shaky voice on the other end of the phone trying to explain to me what had happened - I couldn't comprehend what "we lost her" meant.

There are so many things that bother me about this. I can't help but ask myself why. An old man comes in and gets a terminal tumor diagnosis and is cancer free 5 years later. Three wonderful young people die in an instant, seemingly with no rhyme or reason. Their deaths were probably not even preventable - hypertrophic cardiomyopathy is tough to screen for in healthy kids, the driver in the car wreck didn't have any known underlying vascular pathologies, Ewing's Sarcoma is a random mistake in cell division that just happens. Part of it is feeling powerless. As I continue to learn more and more medicine, I continue to realize how hopeless these cases were. Metastatic Ewing's Sarcoma has a survival rate of less than 10%. Aortic transection has a mortality of 98%.

These three cases played into my decision to go to medical school, but they weren't the whole story. Call it what you want - god, fate, ying & yang, or just dumb luck. If there is some form of guiding principles controlling our day to day lives, I definitely don't think they merit worship.

So, naturally, we ask ourselves - what can we do? We can continue to sacrifice every day and night with our faces stuck in a book. We can read, re-read, practice, and study. We can spend our weekends and vacations in lab, trying to push back the frontiers of medical therapy. We can try to learn every disease, every therapy. We can memorize resuscitation algorithms and chemotherapy cocktails. We can promise ourselves never to miss this disease or that one, but we will.

We will fail, from time to time. We will fail because there are people we can't save, we will fail because we're human. We will fail and people will die. We'll have to watch the boyfriend crumple to a heap, we'll have to help parents say goodbye to their dying son, we'll have to tell a family that there was nothing we could do.

So we again ask ourselves, what can we do? The best answer I have come up with is to keep caring. We can work ourselves to exhaustion and learn every medical fact that is known. But when we're playing against a loaded deck, the only thing we have left is to care.