42. The C Word

from an email received March 23th:

"I have an appt. for the 15th of April - but I have to say - I think it's crazy you have to wait so long for an appt. when its something potentially as serious as this is. I'm having a hard time concentrating on anything else. My father was recently diagnosed with cancer so this is making me crazy. I think three weeks can make a huge difference in whether or not someone beats a disease... or not!"

Two possible replies:

1. Explain that an abnormal Pap smear usually diagnoses "precancer," (dysplasia) not cancer, and that the progression from dysplasia to cancer takes years, so a three week delay really is acceptible. Three months would be okay. Three years not okay.

2. Offer an appointment tomorrow, my call day so it may mean some extra shuffling back and forth from the hospital to the clinic, but usually doable.

Number two of course. The time to talk about the difference between dysplasia and cancer or about the natural progression of the disease is BEFORE not after the results are known. But I'm not the one who obtained the Pap smear.

p.s., biopsy obtained during the appointment; she has moderate dysplasia (maybe 10% chance of become cancer over a few years). She accepted a procedure that will remove a button-size segment of the cervix, almost always including all of the dysplasia)

41. Diversity

Apparently bored by my discussion about antepartum risk screening (the result being reviewed estimated that the risk of Downs Syndrome was 1:35 so not a trivial discussion), a father-to-be said, "Doctor, can I ask you a question?"
"Sure," I answered.
"Are you a mulatto?"
"Must be; my hair's from Bathsheba, eyes from Thor and my deviated septum from Genghis Khan. It's my genetic diversity that promises a long, healthy life."

[the question was real, the answer sadly, was really something along the line of, "Must be, if you go back far enough..."]

40. Macrosomia

Macrosomia, literally "big body;" in my world, babies over 9 lb at birth (greater than 90th %ile). B. delivered a "macrosomic" baby two years ago, 9 lb 15 oz. Uncomplicated vaginal birth. Concerned that a second child might be larger, an ultrasound was obtained yesterday, two weeks before her due date. Estimated fetal weight: 5000 grams, or about 11 lb. For most babies, the head is larger than the shoulders so once the head delivers, the baby slides out. But macrosomic babies may have larger shoulders that get stuck, an obstetrician's nightmare: injured nerves, fractured clavicle, paralyzed arms, stillbirth; I've seen them all.

So one of my partners, who herself underwent two uncomplicated Cesarean births, gave her the option of skipping labor, going straight that same day to the operating room for a Cesarean delivery. She said yes. I was on call and delivered a 10lb 5oz baby boy. Would this baby have safely made it through the birth canal? Probably. Would I have counseled her differently? Probably. Would she still have chosen an elective Cesarean? ... Probably.

39. In My Country, part V

The ultrasound demonstrated not one but several "echodense" (i.e., sound waves don't pass through so white area on ultrasound) areas, consistent with collections of silicone. Not something one wants to surgically remove (the cure possible worse than the disease) unless symptoms increase. So, we like to call, "watchful waiting."