Archives of The Cheerful Oncologist, Volume 2

Ah, what a glorious duty it is to be the king! One delightful day last week as I paraded around the palatial rooms of my imperial domain, stethoscope in hand, I could not help but reflect on how pleasant the office is when running smoothly. Patients were moving from room to room with fluid precision like a snake gliding across a cool river. Telephones were being answered promptly, the “blood machine” (we do use the vernacular in medicine, you know) shimmied and hummed, spitting out lab results as if it had no prior recollection of past meltdowns, and my dictations were crisp and articulate, if not artificially enhanced by a tasty cuppa from some exotic valley. In short it was a good day at the office. Taking a last look around, I went to my desk and fired up the computer.

Little did I know that the mystic seismograph labeled “Crisis Alert” was about to start oscillating like a Tilt-A-Whirl on a Saturday night.

As I reviewed some research data I had been searching for I became aware of some vague hollering in the back of the office where the treatment room was located. Suddenly a nurse burst into my room and cried out “We need you in the back now!”

In this era of new and powerful chemotherapy and biological therapy every oncologist in the world knows what that command means - it is the bugle call of a sudden complication called a hypersensitivity reaction. I ran back with the staff and found one of my patients sitting bolt upright in a treatment chair, red-faced and clutching his chest. Was he having such a reaction, or was this a sign of something more ominous, like a myocardial infarction? Was it a pulmonary embolus? Aortic dissection? Especially funny joke?

It is predicaments like this that give doctors their reputation of grace under pressure, not to mention changing a few hairs from blond to ash. Fortunately I remembered my superior training and the first thing I did was to take my own pulse. Next I interviewed and examined the patient, which I have always thought was a nice way to break the ice during an emergency compared with say, standing on a chair and yelling out “Rampart! Start IV with LR!” or other dubious comments. The precious seconds ticked by and my patient still moaned and grimaced. I had to make a decision now on whether to treat him here, or transport him to the hosptial emergency room. The facts in the case could be catagorized as follows:

Symptoms of a hypersensitivity reaction: chills, flushing, dyspnea, wheezing, nausea, hypotension.

Symptoms of a major coronary event: dyspnea, chest pain, back pain, wheezing, hypotension, nausea, arm/jaw pain, syncope.

Symptoms my patient was exhibiting: chest pain, back pain, dyspnea, generalized distress.

It didn’t take a session with an IBM mainframe to place the puzzle pieces together and come up with a plan. Let’s remember folks - we doctors are skilled in the art of leaving no stone unturned when it comes to finding a diagnosis. Why is that, one might ask? Well, given the menacing cloud of litigation that doctors practice under these days, one would understand with Zeus-like clarity why I rushed this patient to the emergency room. The decision was justified if one notices the overlap between my patient’s symptoms and those of a major perturbation of the old ticker. Hypersensitivity reactions that are minor can be managed at the bedside by turning off the infusion and treating with Benadryl, corticosteroids, oxygen, IV fluids. Major hypersensitivity reactions (called anaphylaxis) are treated like a cardiac arrest - no head-scratching over that diagnosis, eh? My patient’s symptoms were atypical for an allergic reaction, and rather than assume that the most likely diagnosis was the actual diagnosis, I checked for other serious problems that could have lethal consequences if undiscovered.

In this case all’s well that ends well. After a thorough work-up in the hospital we determined that my patient was not having a myocardial infarction but just an unusual manifestation of a hypersensitivity reaction. La de da! So what if I went into supraventricular tachycardia as we raced down the hallway like Dale Earnhardt (requiscat in pace), flattening little old ladies on the way to the E.R.? Who cares if the doctor is scared out of his size 36 boxers as long as the patient has a full recovery? Am I right? Of course I am - the patient is the one with the disease, remember?

The only problem is - these darn reactions are making me a nervous wreck. My nurses are beginning to comment that my countenance reflects a certain lack of sangfroid normally found neatly stacked within. The next time I hear shouting don’t be surprised if I drop the dishes and run like the dickens - to the crisis, of course. We oncologists are hardy stock. We just don’t like surprises.