In a valley shadowed
Recently I had a patient that impacted me deeply. Not to say that many don’t make an impression, but some more so than others.
My patient was a 41 year old young woman who within the past 2-weeks had surgery to her neck. She presented to the ER some days ago with her husband due to nausea and vomiting.
Often post-surgical patients can have nausea and vomiting due to many reasons. The pain medication as well as the pain itself are among some of the reasons why patients may experience nausea and vomiting.
Though upon further investigation we realized that she had been suffering with nausea, vomiting and headaches for many weeks prior to her surgery. This was thought to be symptoms related to her neck issues that would correct themselves after surgery.
She was acting very sedate and somewhat withdrawn. Usually cervical (neck) patients patients are often discharged the same day as the surgery and do very well.
I also noticed the way she let her hand just kind of stayed where I placed it and her fingers has a mild inward curling quality to them suggestive of cerebral injury . There seemed to be a lack of self concern and in the way she appeared emotionally detached from the present inconsistent with a person of her age.
She complained of a headache and consistent nausea. She had been taking nausea medication at home that did nothing to alleviate her symptoms. She denied any pain to her neck.
The doctor and I discussed the fact that she may have taken too much pain medication per her demeanor but when we requested some urine, she stated she did not know if she could urinate.
So we discussed getting a CT of her head and one was ordered along with images of her neck to rule out any post-operative problems.
Well the report revealed some distressing news.
A tumor of the brain. Could be a glioblastoma!
More follow up testing for confirmation and then we would have to transfer her to another hospital for follow up care.
While she was having the MRI of the brain done, I went over to give her some nausea medication. The radiology tech showed me some of the images already taken and the tumor was clear to see.
We felt a palpable distress for this young woman.
The doctor and I had discussed the diagnosis and the prognosis. She told me of a colleague’s husband who had had a resection for glioblastoma and was doing well now some 2 years later.
We felt some hope.
As I walked back through the radiology depart toward my home in the ER, I said a quick prayer, “Dear God, please let this young woman be okay!”
The next workday the ER doctor gave me an update on the patient. The neurologist updated the ER doctor that a biopsy had confirmed she had glioblastoma and it was inoperable. He also said the patient was so confused.
We were filled with sadness for this lady and her family.
Glioblastoma is the most aggressive tumor of the brain. It is one of the most deadly types of brain cancer.
A glioblastoma may occur at any age, though they usually occur after the age of 40 years. There is a peak incidence between the ages of 65 and 75 years.
They occur more frequently in males with a ratio of 3:2 M:F and Caucasians are affected more other ethnicities.
The current standard of care, inclusive of consisting of surgery, radiation and chemotherapy is quite simply ineffective.
The survival rate of a person diagnosed with a glioblastoma is about 15 months.
Without treatment, survival rate is approximately 3–6 months. Though radiation and chemotherapy may prolong life, they greatly reduce quality of life. With this reduction in quality some patients decide against treatment to spend their remaining time the way they choose with their family.
Research has found that each glioblastoma is different and developing drug therapies must be focused to treat each occurrence individually.
The Temporal Lobe
The temporal lobes aids the processing of speech and sound. It is also vital to the comprehension of language and speech.
Another primary role of the temporal lobes is in processing memory and emotion. The limbic structures of the temporal lobes are responsible for regulating emotions and the forming and processing of memories.
Patients with temporal horn injury may present in several ways:–
- with focal neurological deficits
- exhibiting symptoms of increased intracranial pressure, e.g., confusion.
- may have seizures
Treatment and prognosis
The treatment for glioblastoma includes:
- Surgery to remove the glioblastoma. Your neurosurgeon will remove the the glioblastoma if it is possible and beneficial to do so. Because glioblastoma grows into the normal brain tissue, complete removal is not possible. For this reason, therapy will include additional modalities focused to target the remaining cells.
- Radiation therapy. Radiation uses high-energy beams, such as X-rays or protons, to try and kill the cancer cells. During therapy, beams deliver radiation to precise points in your brain.
- Radiation combined with chemotherapy. For people who can’t undergo surgery, radiation therapy and chemotherapy may be used as a primary treatment.
- Chemotherapy. Chemotherapy uses drugs to kill cancer cells. In some cases, thin, circular wafers containing chemotherapy medicine may be placed in your brain during surgery. The wafers dissolve slowly, releasing the medicine and killing cancer cells.
- Drug Therapy. Chemotherapy as a pill form known as temozolomide (Temodar) — is used during and after radiation therapy.
- Tumor treating fields (TTF) therapy. TTF uses an electrical field to disrupt the ability of the tumor cells’ to multiply.
- TTF may be combined with chemotherapy may be recommended after radiation therapy.
- Targeted drug therapy. Targeted drugs focus on specific abnormalities in cancer cells that allow them to grow and thrive. Targeted therapy prevents collateral blood vessel formation to feed cancer cells.
- Supportive (palliative) care. Palliative care is specialized medical care that focuses on providing some relief from pain and other symptoms.
We care for patients every day. We do our best and often think of them and wonder how they are doing. Many times I have come home with a patient on my mind and cannot wait on the next day to get an update. Sometimes I do not wait and call my peers for an update.
Many we will soon forget.
There are however those who will always stay with us. You wish you could do more, help more, heal more…
You feel helpless and very human.
You feel sad, defeated and eventually hopefully you will reconcile that you are only human, incapable of really changing the outcome. All you can do is your job to the best of your abilities.
It is within your power to be empathetic, supportive then you must let go and let God.
The final decision is always his.
Emotionally there will always be those who remain with you, you will always recall specific details and you will always feel a little sad and helpless when they are called into remembrance.
Please pray for our patient.
Be safe and be well.