There is slight tracheal deviation to the right, the cardiomediastinal silhouette is completely obscured on the right and the mediastinal width is widened in the left lung field. The diaphragm right hemi-diaphram is obscured on the right, while the left diaphragm, costophrenic sulcus obscured on the right and visible on the left. In the right upper lung field, within the opacity, there’s a central lucency.
Given multi-decade smoking history, significant second hand smoke exposure as a child, primary lung cancer should be strongly considered in the differential diagnosis.
…are things I would say, if I didn’t know the identity of this patient.
This X-ray is from last year, from a person I knew, a person who treated me like a son. I haven’t looked at the X-ray for over a year. When his parents died, and left him some money, some of it went towards my education. I used a portion of that money to pay for medical school applications, the rest went to living expenses racked up while moving to New England for said medical school acceptance.
He grew up essentially poor and never had a chance go to college himself, so he always wished his kids would obtain more than he did. His parents owned a model battleship and cigarette shop, an admittedly strange business combination. In Japan, for a family business, it’s not uncommon to both own a space for business and use said space for quarters. The building, his home, was a two-story building with the family living upstairs and the business downstairs. Customers would bustle about, old men recollecting their pasts in miniatures whiles they chain smoked their new purchase. And really, at those times, the effects of second hand smoke were still unknown (to the public). In that house, his little brother and him grew up, it was only his little brother afforded a college education by his parents budget.
Later, he would go onto have two kids of his own. He would go onto encourage his daughter to go to college, she later went onto to get her masters. His daughter traveled to London, then to California, it was in the latter location that we got together. He was tech savvy, so he would be sure to keep up with his daughter several times a month via Skype.
Over time, we got closer. I started to think of him as another dad. When I was still planning on applying to medical school he supported my decision. Prior to medical school, when I had considered a PhD, he also supported my decision. His daughter told me that she had hated, vehemently, any of her previous boyfriends while in Japan. So, I just naturally assumed he’d have a death wish out for me. He didn’t. Instead, he embraced me as a son. He’d brag about my latest conference, tell his friends how I was working hard to make ends meet/further my goals. He even followed my blog and Twitter, at my blog’s inception I hardly had any visitors, so when I saw an IP address from Japan I knew it was him.
I’ll never forget his approving eyes while I would tell him my life plans.
Several weeks prior to the first X-ray shown above, I found out afterwards, he had been experiencing shortness of breath, and hemoptysis (coughing up blood). He walked into a mobile imaging service and got a chest X-ray, a place he usually went to for his yearly chest X-ray. The person who interpreted the image told him, in so many words, “Go home, it’s just pneumonia, it’ll be okay.” Now, I could write a whole other article on the ethics of the paternalistic nature of this decision, but that’s for another day; I could write another article on the fool heartedness of using an X-ray (with CT) to screen a high risk patient for lung cancer. He ignored the advice to just go home, bringing a copy of his X-rays with hm, he visited the hospital that he worked at as an maintenance electrician. They immediately checked him in, he was soon diagnosed with lung cancer.
They began radiation treatment, at the request of the family and patient to give it a good fight. The doctors, they pushed on with great outward reluctance. After a week of treatment, the impression of his X-ray improved somewhat:
However, a few days into his fight, his daughter called me. She told me that he had been talking about complaining to the mayer of the city about the hospital service. He’d often go on long nonsensical rants, stringing together figments of his past life with confabulations. When I was being told this, I was just a second year medical student, I had just learned of the term “delirium”. And, what little I knew of it, I knew it was a bad sign. Over that weekend, in the ICU, at some point of his course of treatment he likely developed a pulmonary embolism. During the night, he struggled for breath, in a bit of confusion ripped his IV and oxygen out, and died sometime in the early morning.
Then, I went back to school, along with my day, as if nothing happened. A few months later, I took my board exam. It was tough to do without him, I think I had imagined he’d be there to cheer me on like he did for the MCAT. Just like how proud I imagined he’d be at my graduation as a MD. Now, when I see my blog stats, I know the Japan location isn’t him – it was a hard truth to swallow. And it’s taken me over a year to slowly soak it all in – during that time, I lost my will to write, and blog posts inevitably slowed down.However, medical education doesn’t allow much time for personal feelings. Knowing about medicine doesn’t necessarily make people dying easier, if anything it makes it colder, more visceral, and unquestionably unforgiving.
It’s been a year now since he passed away, and it’s always hard to let go of your family and biggest cheer leader. As a medical student, as I learn how to become a doctor, I now always reflect that each patient has a rich back story unknown to me. But, their backstory is known well to all of those of love them.