Week 11: Life And Death

          Well that was an experience I’ll never forget…let me fill you in on the events of my second standardized patient lab (again, the ‘patient’ I will speak of is a paid actress, hired by my PA program to act as a patient).

          I arrived at the standardized patient lab, with eleven other students, ten minutes before my scheduled appointment at 9:00 am. Each of us was instructed to stand outside of one examination room, and review the medical history chart of our patients-to-be. As indicated by the information on the patient’s chart, he or she presented one week prior with persistent headaches, and, as a result, the patient was prescribed a head CT scan to rule out any unusual causes for the headaches. At this follow-up, 25-minute appointment, it would be our task to discuss the results of the CT scan with each of our patients. At 9:00 am, we were all instructed to knock on the doors of our respective examination rooms and meet our patients. So, I knocked three times and entered the room…

          When I entered the examination room, my patient, a middle-aged female, was pacing and breathing fairly quickly and heavily. I introduced myself as the PA, and she instantaneously expressed how nervous she was about receiving her CT scan results, so I calmly (as possible) told her to have a seat. After washing my hands, I sat across from the anxious patient, who told me that she was in a rush to get back to work and did not have much time to spare. I then looked her straight in the eyes (my heart dropping to the floor at this point) and informed her that the results of her CT scan were consistent with a Stage IV (highly invasive and aggressive) brain tumor…

          Gliobastoma multiforme is a highly malignant (Stage IV) brain tumor that is fatal in nearly all patients. Sources vary on the exact nature of the diagnosis, but symptoms are typically consistent with headache, nausea and vomiting, and focal deficits (symptoms that vary depending on the location of the tumor in the brain). The causes of such tumors are currently unknown, and the prognosis (outcome) for each individual varies. Generally, sources document that, without treatment, patients live no more than six months, with aggressive treatment (surgery, radiation, and/or chemotherapy), patients may live up to fifteen months, but very few patients live past two years upon the onset of their symptoms. Often, surgical removal of the tumor cannot guarantee total removal of all of the cancer cells. The tumor literally resembles an octopus, with a central core that spreads tentacle-like projections to other surrounding areas of the brain (this is what makes total removal of the tumor nearly impossible). And I, a 2.5-month-old PA student, had to break this news to my already distraught patient…

          After breaking the news to my patient, she sat silent, in awe, stunned by the results. She was shocked that her diagnosis was so serious after presenting merely one week ago with such mild preceding symptoms (her headaches), and was certain that the lab technician had mistakenly switched her scan with that of another patient. As uncomfortable as it was, I opened her chart, and reviewed the CT scans with her, showing her the location of the tumor and explaining the reasons for her associated symptoms. I would say about five minutes were spent explaining the nature of the tumor; the other twenty minutes were spent consoling the patient. She was very concerned about her husband and children, overwhelmed by the mortality rate of the condition, and unsure of the next steps to take. As I addressed each issue with her, she would occasionally drop her head down and start crying, but I was sure to stop talking at these sensitive moments and rather take time to console her. The point I stressed most was that she would not be alone when making all of the many difficult decisions; rather, she would have the undying support of her loved ones, and, equally important, myself. I wanted to ensure that she left the appointment with a bit of hope that her treatment course may vary from that of the general population. She seemed to understand that the condition was fatal, and she even asked me if she was going to die. I cringed inside when she asked that question, but again stressed that although the diagnosis is generally a fatal one, every patient is different and will therefore experience a unique course. When the appointment ended, I was instructed to leave the examination room, and wait outside for my critique…

          About two minutes after the completion of the appointment, my standardized patient called me back into the examination room. Her critique could not have been any more positive. She was impressed with my calmness (bizarre, because I was freaking out before entering the room!), and said that my empathy was clearly and sincerely expressed. She appreciated that I didn’t lose eye contact with her at any point throughout the communication, and that I wasn’t afraid to place my hand on her shoulder to console her (I had to do this about five or six times…I felt so bad for her, even though she was only acting!). So, as nervous as I was, the critique I received could not make me feel any better. This was probably the most intimidating and difficult task I have ever had to complete. Although these situations are not real, the actors and actresses make the simulations feel extremely real (not to mention the cameras in the examination room also watching my every move!). Although I was still nervous approaching this scenario, I did feel more at ease relative to my first standardized patient encounter. Maybe I’m getting used to this…or at least a bit more comfortable. Overall, it was a very tough morning to get through, but now at least I can unwind a bit with some studying. I am so relieved!

Question of the week: Examine the fingers of your right hand. These five fingers, together, contain how many of the 206 recognized bones of the human body?   

Last week’s answer: The largest nerve of the human body is the sciatic nerve.  

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