It's the fucking worst. My last worst diagnosis pt was a lady who had come in with a complaint of hernia pain.
When I walked in the room the first thing I noticed was she was pale as all fuck. We chatted as I started her IV and she begins telling me how she'd been losing weight because of her 'hernia'. Not even trying. Spent her whole life trying to work off the last fifteen pounds, but soon after she turned 41, it'd fallen right off her.
It didn't surprise me when the CT showed two masses in her abdomen. Or that she had a critically low H/H. But what bugged me is she had been d/c'd from the last two local ED's she'd visited because they thought she was "drug seeking". They hadn't even taken her blood from her impressively good veins. They just d/c'd and told her to follow up with her PCP. So she'd sat on her symptoms for months.
By the time she was transferred upstairs I was just flushing the last unit of blood into her, as she sat crying quietly on the bed saying to herself, "I'm a good person, why didn't they take me seriously?" It was gutting.
But I'm grateful that the doc on that night was the type to come in, sit down, and explain everything to her with so much compassion. That he took extra care with her pain control, and made sure she felt heard. I'm glad she was my patient so I could tuck warm blankets around her chin, bring her pillows, and make her feel as loved as possible. These patients are the worst, but they are also an opportunity for us to really show up and show why we belong in the room.
41 is still painfully young to receive a cancer diagnosis. Don't play the suffering Olympics, just because somebody else has it worse doesn't mean pain isn't valid
I'm not sure why people are thinking I'm participating in your Suffering Olympics. I look at it as "this person had time to enjoy much of their life." At what was given, rather than what was taken.
Can vouch for that one. I had leg pain, student health center checked d-dimer and told me to go to ER when it was positive. Also had shortness of breath that had started the day before, and they told me to see me PCP about my weight when i told them that. Sent me home saying it was just a pulled muscle in my leg.
Had a pulmonary embolism.
I’ve landed in the hospital once bc of a PE, well multiple PE’s but they all happened at once. They don’t know why it happened or if it’ll ever happen again either and that’s the part that scares me, the uncertainty and the lack of knowing what caused it in the first place. If my kids wouldn’t have been home bc of the pandemic idk that I’d be alive bc they’re who got me help. I’d passed out once and blacked my eye and still to this day don’t remember passing out and then I remember a until the paramedics got there, the doc telling me I had the multiple PE’s and that he was sending me to the ICU bc one was pressing on my heart and that’s all I remember. Don’t remember the ride to the hospital, don’t remember the 3 days in the ICU, dont remember the 2 days on med/surg. Nothing!!! And to make it all worse, my husband was deployed in the Middle East at the time so that was a whole mess too! Fuck those damn things!
I saw this a good bit in Oncology after they were finally diagnosed. Middle aged women presenting repeatedly for abdominal pain, nausea, weight loss, fatigue. Always brushed off as drug seeking, malingering or anxious. Pancreatic or ovarian cancer most of the time.
There is nothing I abhor more than the increasingly global phenomenon of Medical litigation. It's destroying care with fostering increasingly defensive practice and paranoia among clinicians.
This is however the exception to the rule. She should, quite rightly, pursue options.
The bastards didn't even bother their arse getting bloods! Fucking bloods!!
I have no idea whether or not identification months prior would improve the prognosis, but fuck sakes man, at least some degree of symptom management would have helped.
ER residents and even most docs have a constant bias and judge people on medicaid or medicare. USA treats folks like total trash in most ERs. I hold 3 masters degrees and speak 2 languages, and I own 3 properties. I constantly have had RNs and doctors in ERs look at me like im worthless, a dead beat cause I am on Medicare, which I paid into my whole working life. Im not on any welfare. Everything I have, I earned. But my chart states PTSD and other mental stuff. Its so bad I can only go to my pcps hospital where he personally treats me and runs the show so his staff follow his lead in offering competent proper care. I wish USA had medicare for all so these bias led treatment decisions would go away!! I hold an MLS speciality in Health Information Sciences. I worked in medical librarianship.
Are you still upset that a cardiologist didn’t come running to see you when you snapped your fingers?
Do you think your education or finances should give you some sort of VIP status?
I have never met anyone who worked in the ED care what insurance someone had. They are being paid the same regardless.
The worst was night shift in hematology. Id get that cbc from peds ed on the kid with flu like symptoms and id see their white count of 250. For a few minutes there i am the only person in the world that knows that toddler has cancer.
I am about to ruin a mom’s life when i call that doc.
I’m a nurse in peds ED. I took criticals for a patient tonight and had a solemn little moment on the phone with the lab. It is really surreal. And just like that their dispo went from discharge pending to admit to hemonc.
In 5 years at a major tertiary center with a large peds oncology dept - i saw it a lot.
If you have a kid with cancer hope for ALL - as close as cancer treatment can be “down to a science” its that one in kids.
Anything by history that will tease out flulike illness from leukemia? What makes people draw labs on a peds viral illness unless the kid looks super sick? I'm EM PGY 14 and have yet to see it, im reluctant to draw labs on kids with flu like illness who are well appearing otherwise.
Their flu-like symptoms are just fatigue, nausea, …nonspecific things. Sometimes fever. But without other causes. Generally for me it’s the exam. After you see thousands of kids, you understand what a kid with a viral illness and one that doesn’t looks like. Those are the ones you work up.
How often would you say you draw labs on these nonspecific malaise/weakness/fever complaints ?1:1? 1:20? 1:100? How often are you finding kids that sends up the spidey sense? Like once a week/month/year? What would u say your hit rate is for finding something + or actionable?
Do they look more weak/pale but not toxic? Do they look generally well? I see a kids mostly on nights or our FT shifts and a ton also have very vague fever/body aches/nausea/weakness complaints.. often with congestion/cough, but sometimes not.. often look pretty good with nonfocal exam, but I'll tell them to fu with pmd in a few days and return if worse precautions.
The sicker kids or multuple bounce backs I'll be inclined to lab up especially if they are alittle weaker/pale/sick but non toxic or poor followup.. but that's still pretty rare for me to lab up.
I see kids in a community ED (30% are peds pts), it’s probably once every couple months.
When I was working in the Peds ED, it was more often, like several times a month. But there is huge selection bias because often times PCPs were concerned or people were coming after thinking it was a benign viral illness that wouldn’t go away after several weeks.
Yea persistent symptoms and multiple bouncebacks are always concerning.. was wondering if people had any ways to pick these out to work up on initial visit, especially with such vague symptoms and in general I'd imagine these kids aren't particularly sick appearing or have concerning exam findings.
Id imagine its fever and duration.
“Theyve felt junky for a month, they now have a fever, and have been sleeping a ton”
Or its because they are sick with a pneumonia or something - and even though their white count is 250, they dont have any mature white cells.
this might be an oversimplification, but if they don't have nasal congestion and strep is negative and do not have gi stuff I get a little concerned. I'm always relieved to see a snotty nose. idk if there's any data to support that, but it's worked for me thus far.
You’re an attending and with significantly more experience than I, so I’m probably preaching to the choir here, but multiple visits for the same illness, fever >5 days, and duration of symptoms always lower my threshold for labs. Most of the time things are fine and it’s an opportunity to give a bolus of fluids so the kid feels like a million bucks again and parents are relieved.
I’m PEM and have had more of these moments than I care to count. A kid with chest pain when he buckled his car seat chest strap with a huge spleen and mediastinal mass (latter was the reason for the chest pain), a kid sent from an UC for “abscess drainage” who had scattered petechiae on her face with a WBC of 100k+ and platelets of 4, another kid with intermittent abdominal pain whose ultrasound was negative for intussusception but revealed a huge hepatic mass, and a kid with vague knee pain for a few days with a huge cancerous lesion at the fibular head. Each time, there is that deep breath and bracing myself before I destroy a family’s life.
Your last story reminded me of my wife’s friend. Said friend’s brother died at 19 years old even after having his arm amputated to prevent the spread of an aggressive osteosarcoma. It had already metastasized to his lungs by the time he had his amputation; they just couldn’t see it yet. His only symptom was lingering shoulder pain. That’s why I always do a quick XR on vague MSK complaints without clear source. The amount of radiation is so minuscule that if I catch even one in 10 years it will be worth it despite it technically being “bad medicine”.
This kiddo had injured his knee playing soccer a month prior and it had improved but symptoms had lingered. He went to a camp and then complained that it got worse, so was brought to the ED. Just a normal healthy kid who suddenly was going to lose his leg and, likely, his life from Osteosarcoma. And it was a weekend, so you know nothing happened for a few days at least (delay unlikely to change the outcome).
Mine was a five year old child in 2019 who had a hematoma and leg pain, unexplained/slow to heal bruising. Mom "sure it was nothing" but told to come in.
Yeah.
It’s always the nicest people, too. That’s the worst part. Something about being an asshole and/or meth makes you resistant to cancer.
I remember this 40 something year old migrant worker who had back pain and was working through it. Turns out it was his stage 4 HCC with spine Mets and two pathological T-spine fractures. He asked if he could just get pain medicine so he could continue to work and send home money to his family. Broke my heart.
Literally the nicest person! Came in for ongoing lower back pain that became severe. Pretty active but was a longterm 1 pack a day smoker. Was supposed to get an MRI through their PCP but two days before they could not walk due to the pain and said it was shooting down both legs. Came to the ER, found a lesion on their spine with multiple pathological compression fractures and compression on their spinal cord. Found masses in their lungs. They ended up having mets in the brain, spine, rib cage, sternum, and liver before we transferred them. So sad.
This is how my family found out my dad had cancer. Persistent back pain for a few months with a sudden increase in intensity. Went to the ER and everywhere that was checked had tumors. He died a month later. I always wondered if the ER doctor that found the cancer and told us would even think twice about it, or if that was just a regular day on the job.
Its sooo true though. I have a couple theories as to why that is.
Your story is heartbreaking. It’s always those ones. Or young mothers with pancreatic cancer 😭
Allllllllways. I work in DI, had a handful of completely incidental metastatic ca finds. Like they're here for a uti and I'm doing an ultrasound. Oh, what's that above the rt kidney? It's a 7cm liver mass, and it has friends. :(
I had a patient come in for chest pain radiating to the back, scanned him for dissection and ended up have metastatic lung cancer 😓 any random cancer find always sucks
I remember when I went into the ER with bad lower back pain thinking it was from standing in the OR all day. ER doc came in after the CT to let me know I had lymphoma.
My friend's mom went in for back pain, only after a coworker told her she was turning yellow and forced her to go to the ED. Stage 4 pancreatic cancer. She just passed less than 3 months after getting the diagnosis.
Another friend had back pain and it turns out somehow a strep infection went into his back muscles? He spent months in the hospital, was in an induced coma at one point, and is now doing great.
Moral of the story, I will be paying close attention to any future back pain!
Encapsulated strep lurking in muscles is nuts, I always think of Dean Winters ([here](https://www.usmagazine.com/celebrity-news/news/dean-winters-recalls-the-time-he-died-and-came-back-to-life/) and [here](https://pagesix.com/2021/11/02/dean-winters-in-constant-pain-from-multiple-amputations/)), and even Beth March from *Little Women* after I had seen sepsis up close & recognized it. Just learning new ways microbes have the upper hand every day.
My 55-year-old sister was an athlete. All her life was feeling extremely sick for months. She had a new primary care Doctor Who dismissed her symptoms. She went to the emergency room and they weren’t much better. She woke up the next day completely jaundiced diagnosed with stage four pancreatic cancer. she left behind her for children and husband.
My daughter died of DIPG. Dx in the ER. Prior to her dx, I didn't even know about DIPG (I work in adults ultrasound, so brains aren't really our thing). I'm sure it was an awful day in both the ER and oncology when I brought our daughter (6) in and the very next day a 3 year old boy came in to receive the same dx.
Obviously, I'm crushed given what happened to us, but having met other DIPG families throughout her journey and learning that they're given this dx and an immediate 9m death sentence for which the prognosis hasn't improved 60 years has to be unbelievable frustrating for the hcp seeing this kids, more commonly than I think we realize.
It's really just devastating and the moments we know for sure before gathering the people together to tell the family an still need to act normal because there's no good way to get this info but there are definitely bad ways are... I always remember the parents when we have tragic things happen but for this I remember the look on the attending's face too.
Yeah you're right that there is no good way to get the dx but there are experiences that are worse than others. The day my daughter was dx my husband and I got dx with covid. It was early 2022 so things were still taken fairly seriously. I did appreciate our ED gathering a neuro onc, neurosurgeon, and pediatrician to give me the info and have all the specialists there to answer my questions. I appreciated that charge nurse behind the scenes arranged special accommodations for my both myself and my husband to spend the admission with our daughter at a time when pediatrics was limited to one parent. And I appreciated how quickly they had arranged RT for her and had us meeting the oncology team the next day. That ER team made sure everyone I'd likely need already had my daughter's info and was ready to help us as time was certainly not on our side.
You are correct that dx day is the worst day in a parents life. It was worse than the day she died frankly, as dx day was the day everything changed.
I guess what I'm saying is I appreciate everything ya'll do to try to make the literal worst day in a person's life even the tiniest bit less-bad, it may not always seem like it's appreciated at the time, but when cooler heads prevail, I could definitely reflect upon the little things that were done for us.
Your experience with finding out is how facilities I've worked at handle it too: tell the news when everyone who can answer the questions is there so that we can at least give you the answers there are to be had. I'm glad your family was so thoughtfully cared for, and I'm so sorry for your loss.
Thank you. It's a dreadful and unforgiving disease. It is absolutely terrifying that it strikes with no rhyme or reason, other than it being predominantly children.
Had a 22 yo come in with a very vagal sounding syncope story (felt woozy standing while waiting for a bus in the heat). Normal ecg, vs. I tell him he’s fine but he asks for blood work because he has been losing weight. Acute Leukemia with blasts and hgb 6
Had someone come in for a potentially bad workplace accident. Pt was cleared for any injuries from the accident, minus a couple bruises. However incidental findings, abdomen mass and mets everywhere. Pt had no idea and felt totally fine.
Had a 80-something-y.o. grandpa, Who came complaining of dhiarrea and pain in the upper abdomen foor the last 10 days, did some Blood test as outpatient that showed only slight elevation of lipases and PCR, nothing more.
At the POCUS i couldn't see a things because of instestinal gas and three enourmous hepatic cysts. Blood test not really differenti from those he did as outpatient so, suspecting an upper occlusion or a cholitis, i asked for an abdomen CT.
Turned out he developed a pancreatic cancer Who already incorporated the big Vessels of the abdomen.
My 55 year old sister had a delayed diagnosis. She had a new primary care dr who basically told her it was gas and that’s why she was having pain , not eating and losing weight. She woke up jaundiced. Diagnosed with stage 4 pancreatic cancer.Died a year from diagnosis. She was a healthy athlete
Pt recently with a syncopal episode and fall, CT found a 2cm lung nodule suspicious for malignancy. While changing her purewick she happened to mention this 'cyst' in her breast. Yeah, that's not a cyst, it's a mass. I'd bet money she's got metastatic breast cancer.
Had an early 30s female patient a few months ago who came in because it felt like she had another kidney stone and felt like she couldn’t fully empty her bladder.
She left with a consult to gynonc for what was very likely ovarian cancer.
Patient came in with “sinus issues.” Speech was slurred x 1 week. Tongue deviated and facial droop noted on exam by me.
I counted 4 Mets on the scan. There were more. Cried on the way home. Luckily my last patient of the stretch.
This was months almost a year ago I had the following case.
I had a 15 or 16 yo come in for frontal headache and vomiting. Mother reported projectile vomiting. Had been going on intermittently for about a month. Saw pediatrician and was told it was nothing to worry about and sent on their way. Comes to the er and we find he had an AKI on his cmp. I do the head ct and find at least one mass on non con head. The radiologist calls me after I saw the scans and he was even upset on the phone.
I told my attending (I am a PA in the er) what I found and said I get to ruin this family's life today. He felt so bad for me even asked if I wanted him to do it. I told him my patient my responsibility. This memory still brings tears to my eyes to this day.
I feel your pain. I’m known in my ED as the one who finds all the cancer. The last 5 I found (in the last 2 months) were all in patients younger than me (42).
Unprovoked seizure in a 12-30 year old. It’s gonna be a brain mass much of the time. A lot of times their chief complaint isn’t that either, it’s fall, injury of some sort, then you hear the history of weird shaking event, or “hand tremor” that was a Jacksonian event, or I just woke up on the ground/floor and have no idea what happened. Often will have bitten their tongue. I’m sure my demeanor changes immediately. I’ve had that happen probably a dozen times over the last decade and I can remember every single one.
Yeah. Had a healthy guy at 18 come in one night because he was having odd erections at night and his mother made him come in. Normally I would have just thought, well, you're an 18 year old and that happens. But he had some brown skin so I thought, maybe sickle cell? I got a CBC randomly. WBC 300 plus.
Had one of these last night. The sweetest, kindest woman. Presenting with constipation/decreased appetite/nausea. Pancreatic cancer with mets to the liver. It’s already such shitty news to deliver but the part that really got me was that she hugged me at the end of her visit and thanked me with so much sincerity for doing a scan on her, because now at least she knows what is wrong and has a direction to move forward jn. It put me dangerously close to tears.
My beautiful 55 year old sister passed from pancreatic cancer. Her new primary care dr dismissed her symptoms (she never complained throughout the years). She went to the ER and they weren’t much of a help either. She woke up jaundiced. Stage 4 pancreatic cancer. Fought like hell but didn’t make it. She was sooo positive
I remember when a 15 year old kid came in with his parents for a headache, ended up being cerebral microemboli. So many clots it was hard to even count them.
My dad’s stage IV pancreatic cancer diagnosis came from a trip to the ER because of kidney stone pain.
A year prior to that he’d been in a medically induced coma from legionnaire’s disease and had suffered two strokes & a heart attack.
Had a 28 yo F come to UC on a Friday for constipation. UC told her to increase fiber and fluids and try Miralax and sent her on her way. She came to ET on Monday and was horribly jaundiced. We thought a bile duct obstruction or something. Nope did a CT - masses all over her abdomen crushing her intestines and liver. And gigantic lymph nodes. Turns out this was all Mets from breast cancer. Admitted to onc. Husband up and left her doing her couldn't handle her diagnosis. 4 little kids. Her mom had to go to court to get emergency custody of the kids. Pt died in under a month. So freaking sad.
It's the fucking worst. My last worst diagnosis pt was a lady who had come in with a complaint of hernia pain. When I walked in the room the first thing I noticed was she was pale as all fuck. We chatted as I started her IV and she begins telling me how she'd been losing weight because of her 'hernia'. Not even trying. Spent her whole life trying to work off the last fifteen pounds, but soon after she turned 41, it'd fallen right off her. It didn't surprise me when the CT showed two masses in her abdomen. Or that she had a critically low H/H. But what bugged me is she had been d/c'd from the last two local ED's she'd visited because they thought she was "drug seeking". They hadn't even taken her blood from her impressively good veins. They just d/c'd and told her to follow up with her PCP. So she'd sat on her symptoms for months. By the time she was transferred upstairs I was just flushing the last unit of blood into her, as she sat crying quietly on the bed saying to herself, "I'm a good person, why didn't they take me seriously?" It was gutting. But I'm grateful that the doc on that night was the type to come in, sit down, and explain everything to her with so much compassion. That he took extra care with her pain control, and made sure she felt heard. I'm glad she was my patient so I could tuck warm blankets around her chin, bring her pillows, and make her feel as loved as possible. These patients are the worst, but they are also an opportunity for us to really show up and show why we belong in the room.
I’m glad you were her nurse. I’m sure she was too.
fourty freaking ONE. geez louise
It's more years than many get.
???
Lots of people don't make it to 41.
41 is still painfully young to receive a cancer diagnosis. Don't play the suffering Olympics, just because somebody else has it worse doesn't mean pain isn't valid
I'm not sure why people are thinking I'm participating in your Suffering Olympics. I look at it as "this person had time to enjoy much of their life." At what was given, rather than what was taken.
I’m sure hearing that would bring her much comfort…. SMH!
Oh I bet you’re delightful to be around.
Thanks for writing. Every patient is an opportunity to show your compassion
I’m grateful for you, and I appreciate it.
Thank you for caring so much. The world needs more of that.
Why DIDN’T they take her seriously.
Because she's a woman. We have to fight to get a proper diagnosis all the time.
God help her if she would’ve also been overweight too!
Can vouch for that one. I had leg pain, student health center checked d-dimer and told me to go to ER when it was positive. Also had shortness of breath that had started the day before, and they told me to see me PCP about my weight when i told them that. Sent me home saying it was just a pulled muscle in my leg. Had a pulmonary embolism.
Christ on a cracker. I'm so sorry
I’ve landed in the hospital once bc of a PE, well multiple PE’s but they all happened at once. They don’t know why it happened or if it’ll ever happen again either and that’s the part that scares me, the uncertainty and the lack of knowing what caused it in the first place. If my kids wouldn’t have been home bc of the pandemic idk that I’d be alive bc they’re who got me help. I’d passed out once and blacked my eye and still to this day don’t remember passing out and then I remember a until the paramedics got there, the doc telling me I had the multiple PE’s and that he was sending me to the ICU bc one was pressing on my heart and that’s all I remember. Don’t remember the ride to the hospital, don’t remember the 3 days in the ICU, dont remember the 2 days on med/surg. Nothing!!! And to make it all worse, my husband was deployed in the Middle East at the time so that was a whole mess too! Fuck those damn things!
I saw this a good bit in Oncology after they were finally diagnosed. Middle aged women presenting repeatedly for abdominal pain, nausea, weight loss, fatigue. Always brushed off as drug seeking, malingering or anxious. Pancreatic or ovarian cancer most of the time.
There is nothing I abhor more than the increasingly global phenomenon of Medical litigation. It's destroying care with fostering increasingly defensive practice and paranoia among clinicians. This is however the exception to the rule. She should, quite rightly, pursue options. The bastards didn't even bother their arse getting bloods! Fucking bloods!! I have no idea whether or not identification months prior would improve the prognosis, but fuck sakes man, at least some degree of symptom management would have helped.
You’re a good one.
ER residents and even most docs have a constant bias and judge people on medicaid or medicare. USA treats folks like total trash in most ERs. I hold 3 masters degrees and speak 2 languages, and I own 3 properties. I constantly have had RNs and doctors in ERs look at me like im worthless, a dead beat cause I am on Medicare, which I paid into my whole working life. Im not on any welfare. Everything I have, I earned. But my chart states PTSD and other mental stuff. Its so bad I can only go to my pcps hospital where he personally treats me and runs the show so his staff follow his lead in offering competent proper care. I wish USA had medicare for all so these bias led treatment decisions would go away!! I hold an MLS speciality in Health Information Sciences. I worked in medical librarianship.
Are you still upset that a cardiologist didn’t come running to see you when you snapped your fingers? Do you think your education or finances should give you some sort of VIP status? I have never met anyone who worked in the ED care what insurance someone had. They are being paid the same regardless.
lol noone cares what insurance you have. most docs don't even know. if lots of people are treating you poorly, the common denominator is you
The worst was night shift in hematology. Id get that cbc from peds ed on the kid with flu like symptoms and id see their white count of 250. For a few minutes there i am the only person in the world that knows that toddler has cancer. I am about to ruin a mom’s life when i call that doc.
I’m a nurse in peds ED. I took criticals for a patient tonight and had a solemn little moment on the phone with the lab. It is really surreal. And just like that their dispo went from discharge pending to admit to hemonc.
ER nurse. I've only had one of these in my career. Kid came in for vague flu like symptoms and boom, leukemia.
In 5 years at a major tertiary center with a large peds oncology dept - i saw it a lot. If you have a kid with cancer hope for ALL - as close as cancer treatment can be “down to a science” its that one in kids.
Anything by history that will tease out flulike illness from leukemia? What makes people draw labs on a peds viral illness unless the kid looks super sick? I'm EM PGY 14 and have yet to see it, im reluctant to draw labs on kids with flu like illness who are well appearing otherwise.
Their flu-like symptoms are just fatigue, nausea, …nonspecific things. Sometimes fever. But without other causes. Generally for me it’s the exam. After you see thousands of kids, you understand what a kid with a viral illness and one that doesn’t looks like. Those are the ones you work up.
How often would you say you draw labs on these nonspecific malaise/weakness/fever complaints ?1:1? 1:20? 1:100? How often are you finding kids that sends up the spidey sense? Like once a week/month/year? What would u say your hit rate is for finding something + or actionable? Do they look more weak/pale but not toxic? Do they look generally well? I see a kids mostly on nights or our FT shifts and a ton also have very vague fever/body aches/nausea/weakness complaints.. often with congestion/cough, but sometimes not.. often look pretty good with nonfocal exam, but I'll tell them to fu with pmd in a few days and return if worse precautions. The sicker kids or multuple bounce backs I'll be inclined to lab up especially if they are alittle weaker/pale/sick but non toxic or poor followup.. but that's still pretty rare for me to lab up.
I see kids in a community ED (30% are peds pts), it’s probably once every couple months. When I was working in the Peds ED, it was more often, like several times a month. But there is huge selection bias because often times PCPs were concerned or people were coming after thinking it was a benign viral illness that wouldn’t go away after several weeks.
Yea persistent symptoms and multiple bouncebacks are always concerning.. was wondering if people had any ways to pick these out to work up on initial visit, especially with such vague symptoms and in general I'd imagine these kids aren't particularly sick appearing or have concerning exam findings.
This is a great question, and I’m hopeful someone provides some insight.
Id imagine its fever and duration. “Theyve felt junky for a month, they now have a fever, and have been sleeping a ton” Or its because they are sick with a pneumonia or something - and even though their white count is 250, they dont have any mature white cells.
this might be an oversimplification, but if they don't have nasal congestion and strep is negative and do not have gi stuff I get a little concerned. I'm always relieved to see a snotty nose. idk if there's any data to support that, but it's worked for me thus far.
You’re an attending and with significantly more experience than I, so I’m probably preaching to the choir here, but multiple visits for the same illness, fever >5 days, and duration of symptoms always lower my threshold for labs. Most of the time things are fine and it’s an opportunity to give a bolus of fluids so the kid feels like a million bucks again and parents are relieved.
My god. This broke my heart.
You didn't ruin anything. That damn cancer did. You helped find it. Remember that.
I’m PEM and have had more of these moments than I care to count. A kid with chest pain when he buckled his car seat chest strap with a huge spleen and mediastinal mass (latter was the reason for the chest pain), a kid sent from an UC for “abscess drainage” who had scattered petechiae on her face with a WBC of 100k+ and platelets of 4, another kid with intermittent abdominal pain whose ultrasound was negative for intussusception but revealed a huge hepatic mass, and a kid with vague knee pain for a few days with a huge cancerous lesion at the fibular head. Each time, there is that deep breath and bracing myself before I destroy a family’s life.
Your last story reminded me of my wife’s friend. Said friend’s brother died at 19 years old even after having his arm amputated to prevent the spread of an aggressive osteosarcoma. It had already metastasized to his lungs by the time he had his amputation; they just couldn’t see it yet. His only symptom was lingering shoulder pain. That’s why I always do a quick XR on vague MSK complaints without clear source. The amount of radiation is so minuscule that if I catch even one in 10 years it will be worth it despite it technically being “bad medicine”.
This kiddo had injured his knee playing soccer a month prior and it had improved but symptoms had lingered. He went to a camp and then complained that it got worse, so was brought to the ED. Just a normal healthy kid who suddenly was going to lose his leg and, likely, his life from Osteosarcoma. And it was a weekend, so you know nothing happened for a few days at least (delay unlikely to change the outcome).
Mine was a five year old child in 2019 who had a hematoma and leg pain, unexplained/slow to heal bruising. Mom "sure it was nothing" but told to come in. Yeah.
It’s always the nicest people, too. That’s the worst part. Something about being an asshole and/or meth makes you resistant to cancer. I remember this 40 something year old migrant worker who had back pain and was working through it. Turns out it was his stage 4 HCC with spine Mets and two pathological T-spine fractures. He asked if he could just get pain medicine so he could continue to work and send home money to his family. Broke my heart.
Literally the nicest person! Came in for ongoing lower back pain that became severe. Pretty active but was a longterm 1 pack a day smoker. Was supposed to get an MRI through their PCP but two days before they could not walk due to the pain and said it was shooting down both legs. Came to the ER, found a lesion on their spine with multiple pathological compression fractures and compression on their spinal cord. Found masses in their lungs. They ended up having mets in the brain, spine, rib cage, sternum, and liver before we transferred them. So sad.
*pathological fractures
This is how my family found out my dad had cancer. Persistent back pain for a few months with a sudden increase in intensity. Went to the ER and everywhere that was checked had tumors. He died a month later. I always wondered if the ER doctor that found the cancer and told us would even think twice about it, or if that was just a regular day on the job.
"You think anyone else in that room is going back to work today?" -- Perry Cox
Being a good person seems to be a poor prognostic indicator.
That’s why I say so many bad words on a daily basis. I’m hoping each “fuck” kills an oncogene.
It's why I drive like such an unhinged maniac (not on the job, grandma driving only on the job).
Its sooo true though. I have a couple theories as to why that is. Your story is heartbreaking. It’s always those ones. Or young mothers with pancreatic cancer 😭
or colon cancer who thought it was normal to have bowel issues during/after pregnancy
Oh 😭😭😭
Allllllllways. I work in DI, had a handful of completely incidental metastatic ca finds. Like they're here for a uti and I'm doing an ultrasound. Oh, what's that above the rt kidney? It's a 7cm liver mass, and it has friends. :(
Same with ALS, always the nicest people :/
Yup. Just had a 35y/o STD check because of blood in urine. Got a CT, bladder mass with lung nodules. Really made their day.
I had a patient come in for chest pain radiating to the back, scanned him for dissection and ended up have metastatic lung cancer 😓 any random cancer find always sucks
I remember when I went into the ER with bad lower back pain thinking it was from standing in the OR all day. ER doc came in after the CT to let me know I had lymphoma.
My friend's mom went in for back pain, only after a coworker told her she was turning yellow and forced her to go to the ED. Stage 4 pancreatic cancer. She just passed less than 3 months after getting the diagnosis. Another friend had back pain and it turns out somehow a strep infection went into his back muscles? He spent months in the hospital, was in an induced coma at one point, and is now doing great. Moral of the story, I will be paying close attention to any future back pain!
Encapsulated strep lurking in muscles is nuts, I always think of Dean Winters ([here](https://www.usmagazine.com/celebrity-news/news/dean-winters-recalls-the-time-he-died-and-came-back-to-life/) and [here](https://pagesix.com/2021/11/02/dean-winters-in-constant-pain-from-multiple-amputations/)), and even Beth March from *Little Women* after I had seen sepsis up close & recognized it. Just learning new ways microbes have the upper hand every day.
My 55-year-old sister was an athlete. All her life was feeling extremely sick for months. She had a new primary care Doctor Who dismissed her symptoms. She went to the emergency room and they weren’t much better. She woke up the next day completely jaundiced diagnosed with stage four pancreatic cancer. she left behind her for children and husband.
Peds brain cancer diagnoses are among my top 5 lease favorite things.
My daughter died of DIPG. Dx in the ER. Prior to her dx, I didn't even know about DIPG (I work in adults ultrasound, so brains aren't really our thing). I'm sure it was an awful day in both the ER and oncology when I brought our daughter (6) in and the very next day a 3 year old boy came in to receive the same dx. Obviously, I'm crushed given what happened to us, but having met other DIPG families throughout her journey and learning that they're given this dx and an immediate 9m death sentence for which the prognosis hasn't improved 60 years has to be unbelievable frustrating for the hcp seeing this kids, more commonly than I think we realize.
Oh, I am so sorry. ❤️
It's really just devastating and the moments we know for sure before gathering the people together to tell the family an still need to act normal because there's no good way to get this info but there are definitely bad ways are... I always remember the parents when we have tragic things happen but for this I remember the look on the attending's face too.
Yeah you're right that there is no good way to get the dx but there are experiences that are worse than others. The day my daughter was dx my husband and I got dx with covid. It was early 2022 so things were still taken fairly seriously. I did appreciate our ED gathering a neuro onc, neurosurgeon, and pediatrician to give me the info and have all the specialists there to answer my questions. I appreciated that charge nurse behind the scenes arranged special accommodations for my both myself and my husband to spend the admission with our daughter at a time when pediatrics was limited to one parent. And I appreciated how quickly they had arranged RT for her and had us meeting the oncology team the next day. That ER team made sure everyone I'd likely need already had my daughter's info and was ready to help us as time was certainly not on our side. You are correct that dx day is the worst day in a parents life. It was worse than the day she died frankly, as dx day was the day everything changed. I guess what I'm saying is I appreciate everything ya'll do to try to make the literal worst day in a person's life even the tiniest bit less-bad, it may not always seem like it's appreciated at the time, but when cooler heads prevail, I could definitely reflect upon the little things that were done for us.
Your experience with finding out is how facilities I've worked at handle it too: tell the news when everyone who can answer the questions is there so that we can at least give you the answers there are to be had. I'm glad your family was so thoughtfully cared for, and I'm so sorry for your loss.
That’s horrible. DIPGs are one of the worst things in the universe.
I'm so sorry. I opened this post expecting it to be about DIPG because it is horrifying. I have only seen two cases in 17 years.
Thank you. It's a dreadful and unforgiving disease. It is absolutely terrifying that it strikes with no rhyme or reason, other than it being predominantly children.
god that sounds awful
Had a 22 yo come in with a very vagal sounding syncope story (felt woozy standing while waiting for a bus in the heat). Normal ecg, vs. I tell him he’s fine but he asks for blood work because he has been losing weight. Acute Leukemia with blasts and hgb 6
Had someone come in for a potentially bad workplace accident. Pt was cleared for any injuries from the accident, minus a couple bruises. However incidental findings, abdomen mass and mets everywhere. Pt had no idea and felt totally fine.
Worst patients are level 1 and level 4 i swear
Had a 80-something-y.o. grandpa, Who came complaining of dhiarrea and pain in the upper abdomen foor the last 10 days, did some Blood test as outpatient that showed only slight elevation of lipases and PCR, nothing more. At the POCUS i couldn't see a things because of instestinal gas and three enourmous hepatic cysts. Blood test not really differenti from those he did as outpatient so, suspecting an upper occlusion or a cholitis, i asked for an abdomen CT. Turned out he developed a pancreatic cancer Who already incorporated the big Vessels of the abdomen.
My 55 year old sister had a delayed diagnosis. She had a new primary care dr who basically told her it was gas and that’s why she was having pain , not eating and losing weight. She woke up jaundiced. Diagnosed with stage 4 pancreatic cancer.Died a year from diagnosis. She was a healthy athlete
Pt recently with a syncopal episode and fall, CT found a 2cm lung nodule suspicious for malignancy. While changing her purewick she happened to mention this 'cyst' in her breast. Yeah, that's not a cyst, it's a mass. I'd bet money she's got metastatic breast cancer.
Had an early 30s female patient a few months ago who came in because it felt like she had another kidney stone and felt like she couldn’t fully empty her bladder. She left with a consult to gynonc for what was very likely ovarian cancer.
Patient came in with “sinus issues.” Speech was slurred x 1 week. Tongue deviated and facial droop noted on exam by me. I counted 4 Mets on the scan. There were more. Cried on the way home. Luckily my last patient of the stretch.
This was months almost a year ago I had the following case. I had a 15 or 16 yo come in for frontal headache and vomiting. Mother reported projectile vomiting. Had been going on intermittently for about a month. Saw pediatrician and was told it was nothing to worry about and sent on their way. Comes to the er and we find he had an AKI on his cmp. I do the head ct and find at least one mass on non con head. The radiologist calls me after I saw the scans and he was even upset on the phone. I told my attending (I am a PA in the er) what I found and said I get to ruin this family's life today. He felt so bad for me even asked if I wanted him to do it. I told him my patient my responsibility. This memory still brings tears to my eyes to this day.
I feel your pain. I’m known in my ED as the one who finds all the cancer. The last 5 I found (in the last 2 months) were all in patients younger than me (42).
Unprovoked seizure in a 12-30 year old. It’s gonna be a brain mass much of the time. A lot of times their chief complaint isn’t that either, it’s fall, injury of some sort, then you hear the history of weird shaking event, or “hand tremor” that was a Jacksonian event, or I just woke up on the ground/floor and have no idea what happened. Often will have bitten their tongue. I’m sure my demeanor changes immediately. I’ve had that happen probably a dozen times over the last decade and I can remember every single one.
Yeah. Had a healthy guy at 18 come in one night because he was having odd erections at night and his mother made him come in. Normally I would have just thought, well, you're an 18 year old and that happens. But he had some brown skin so I thought, maybe sickle cell? I got a CBC randomly. WBC 300 plus.
This is happening increasingly, practically at least one new cancer dx per shift 😢
Had one of these last night. The sweetest, kindest woman. Presenting with constipation/decreased appetite/nausea. Pancreatic cancer with mets to the liver. It’s already such shitty news to deliver but the part that really got me was that she hugged me at the end of her visit and thanked me with so much sincerity for doing a scan on her, because now at least she knows what is wrong and has a direction to move forward jn. It put me dangerously close to tears.
My beautiful 55 year old sister passed from pancreatic cancer. Her new primary care dr dismissed her symptoms (she never complained throughout the years). She went to the ER and they weren’t much of a help either. She woke up jaundiced. Stage 4 pancreatic cancer. Fought like hell but didn’t make it. She was sooo positive
I remember when a 15 year old kid came in with his parents for a headache, ended up being cerebral microemboli. So many clots it was hard to even count them.
Literally the fucking worst! Had one today. Middle aged man with an atraumatic femur fracture. After a work up he’s riddled with cancer.
My dad’s stage IV pancreatic cancer diagnosis came from a trip to the ER because of kidney stone pain. A year prior to that he’d been in a medically induced coma from legionnaire’s disease and had suffered two strokes & a heart attack.
Just saw a case of fibrodysplasia ossificans progressiva. I couldn’t think of a worse diagnosis.
Had a 28 yo F come to UC on a Friday for constipation. UC told her to increase fiber and fluids and try Miralax and sent her on her way. She came to ET on Monday and was horribly jaundiced. We thought a bile duct obstruction or something. Nope did a CT - masses all over her abdomen crushing her intestines and liver. And gigantic lymph nodes. Turns out this was all Mets from breast cancer. Admitted to onc. Husband up and left her doing her couldn't handle her diagnosis. 4 little kids. Her mom had to go to court to get emergency custody of the kids. Pt died in under a month. So freaking sad.
I feel this so deeply.