Sunday, March 29, 2009

Getting the Finger from a Patient

A patient gave me the finger not long ago.

Not once, but twice.

How did that make me feel?

The first time, intrigued.

The second time, embarassed but relieved.

Here's why:

It started when her dematologist ordered an MR scan to "R/O glomus tumor" of the middle finger. In case you're not completely up on your small, rare, soft tissue tumor lore, here are a few facts: glomus tumors are usually small (often 1 - 2 millimeters in diameter), benign , rare (we only see a few a year), typically occur in the tissues under the nail bed, and can be exquisitely painful.

Looking for something this small is a real challenge -- even with current MR technology. Most MR machines are optimized to look at large chunks of human tissue -- sometimes as large as the abdomen on a 350 pound dude. In this patient's case, we were pushing the other extreme, and trying to focus all of the resolution of this giant machine down on a single finger. Tumors this small sometimes end up in the small gap between MR slices -- making them invisible. Even when things work perfectly, we may be lucky to see a lesion on only one image out of hundreds that we scan from that patient.

Despite these challenges, I enjoy looking for these intriguing little lesions.

To improve our odds of seeing this millimetric lesion, we gave her an intravenous injection of a gadolinium solution, which is designed to concentrate in tumor tissue, and make it stand out better against normal tissue.

Alas. We screwed up. My MR technologists omitted the critical sagittal image sequence that best shows the nail bed. To make matters worse, I didn't get around to looking at her study until she had already gone home.


It's painful to have to admit to a patient that you, a professor at Enormous Medical Center, have screwed up, and need her to come back in for another scan.

Painful, but we did it. She took off from work yet again, endured a new IV injection of gadolinium, and gave us her finger for another session in our scanner. However, we finally got the crucial sagittal images. This time, I was standing by the scanner and looked at her images before we ended the study.

The happy ending: we saw the tumor this time -- it was indeed so small that it only showed up on a single sagittal image. Small, but unmistakeable.

Afterwards, I showed her the key image, and offered one more abject apology for the extra imaging hassles.

Her reaction? She forgave us our mistakes, and was delighted to finally know what had been causing her pain for so long. We both left that encounter a lot happier than we entered it.

In the past few months, I've become pleasantly used to hearing a president willing to claim responsibility for his mistakes. Are my patients any different? Admitting mistakes to patients is not yet a universal practice , but it sure felt good this time, to me and my patient.

Finally, there is the concept of grace -- an ecclesiastical term for unearned forgiveness. Being a physician or a parent gives one endless opportunities to screw up someone else's life. Happily, kids seem to dispense a boundless supply of grace when this happens. Fortunately, some patients give it too.

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