Take-home Message

Dealing with a neglected patient

(Fictional narrative by the doctor)

James Fleck, MD, PhD & João A de Andrade, MD

Anticancerweb 04 (05), 2019

Except for subtle changes in the rigid routine, it was hard for one to tell that night had fallen in that prison. A brief and eerie silence dominates the place as the sun goes down. The night crushes all the prisoners, leading to a solitary introspection and an acute confrontation with their harsh reality. Moans, screams and whispers have the same meaning, because nobody really cares.

Edgar was 47 and previously very healthy. During his three years in prison, he always carried himself with an exemplary behavior. Two months ago, he started complaining of pain in the left side of his chest wall after exercising. At first, changing certain routines was enough to avoid the pain. Over time, he began to ask for analgesics, first occasionally and then every three or four hours. The pain worsened when he took a deep breath, and he was getting more breathless every day. Eventually, the pain was so severe that he could no longer sleep, which made him very anxious and aggressive.

Despite the worsening pain, Edgar did not appear to be sick and those around him dismissed his complaints. He was examined by a prison doctor who failed to notice any abnormality in his physical examination and proceeded to prescribe stronger pain killers.  

Nothing helped and Edgar began to moan at night, disturbing other inmates. He was moved to an isolation cell in a remote area of the ward. He was told to be quiet, both by the guards and by the other prisoners. At night Edgar wrapped a blanket around his mouth to muffle his crying from pain.

That night he reached his limit. He began to sweat, despite the cold winter night. He tried to convince himself that this was not happening. He imagined that he was out of that place, still young and free. He remembered his father rigid and aggressive behavior and his mother's sweet attempts to save him from his old man’s wrath. He remembered his friends and all the Saturday nights that he spent high on the many drugs he experimented with. Suddenly, Leo's helpless face appeared to him. He could almost feel the fear of his victim, whom he had abducted and brutally murdered under the influence of cocaine. He pushed the image away, now thinking of Luana, his high school sweetheart, and all the fun they had together. The brief joy was interrupted by a sharp pain that almost made him pass out. He felt so desperate that he hit his head against the concrete wall as hard as he could. All went black… 

Edgar woke up when the sun hit his face through the small window. His face was covered in blood, he was confused and his vision was blurry. He tried to get up but felt very dizzy. Shortly after, he fainted again. Edgar was finally found and transferred to the local county hospital where a brain MRI revealed a subdural hematoma that was causing increased intracranial pressure. He had to have emergency surgery to relieve the pressure and avoid brain swelling and death. His neurological condition was unpredictable and he remained under close clinical observation for 48 hours after the procedure. He received medications to decrease the cerebral edema, and gradually improved his level of consciousness.

As soon as he was awake, Edgar was told that he was under specialized medical care in a public hospital. He was able to understand that simple information but it was not clear to him how or why he was there. The sudden severe stabbing pain in his left chest led him to remember what had happened. It was a reality he'd rather forget but it was impossible to deny. He touched his body, he was awake and tied to a bed. A police officer was sitting by his bed. 

Edgar called a nurse, asking for pain relief.

She assumed that he was having pain related to his surgery and promptly administered a dose of the prescribed analgesic, without even asking where the pain was located or how severe it was.

Torture resumed, as the painkiller did not give him much relief. Edgar became aggressive, pulled his IV and tried to get out of bed.

Before he had any chance to say something, he was given an intramuscular antipsychotic which obviously did not take care of the pain but made him very sleepy.

A physician on duty attributed the condition to post-traumatic stress disorder and made no changes in his treatment plans.

Few minutes later, Edgar was even more confused and agitated.

He was then physically restrained. His wrists and legs were tied to the bed.

He was considered to be a dangerous person, potentially suicidal, and there were also concerns about his prospects for neurological recovery. It was finally decided that he would not receive any sedatives or antipsychotics so that his neurological condition could be properly monitored. 

Edgar, feeling more clear headed, realized that he would have to take control of that situation if he were to survive.

Resigned, he managed to calm himself down and asked to see a doctor.

A consulting neurologist was called in. He approached the bed and after a simple physical examination concluded that Edgar was awake and fully oriented to self and his surroundings.

They start a conversation and finally, Edgar had a chance to explain where his pain was

The neurologist ordered a chest X-ray.

The image revealed a large tumor located in his left lung that was invading the bones of the chest wall.

The neurologist placed an epidural catheter allowing direct continuous spinal analgesics and Edgar felt, for the first time in many months, the much-desired pain relief.

Shortly after, Edgar was transferred to our University Hospital and admitted to the Department of Oncology under my care.

To be continued in PLOT 2…

*      Attention: The story 3 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 3 from the beginning, just click in the numbered links located at the bottom of the homepage.  

© Copyright 2019 Anticancerweb

 James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2019 (Editor)

Joao A. de Andrade, MD: Professor of Medicine and Chief Medical Officer, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Nashville, TN – USA 2019 (Associate Editor)