9th Clinical Simulation P1

Take-home Message

Listening carefully to the patient's history helps to build a good doctor-patient relationship, which promotes better understanding and acceptance of recommendations. 

(Fictional narrative by the doctor)

James Fleck: Anticancerweb 01 (10), 2022

 

Lyla was a communicative young woman. Smart, dynamic and creative, she had just graduated in architecture. She had established an affectionate relationship with Raul, a Peruvian colleague who had come to Brazil to pursue a master's degree in urbanism. They had common goals and naturally the affinity evolved into a relationship of daily coexistence. They started to live together, despite the short period of mutual acquaintance. It was a relaxed and uncommitted relationship in which they shared expenses, expectations, frustrations and joys. They were a couple of two young people, simulating an adult married life.

Lyla thought she was living in a mature love situation and precipitated a pregnancy. Raul was surprised by the situation and immediately took the opposite stance. He was 28 years old and had other plans for his life that predated fatherhood. He criticized Lyla's impulsive attitude, which he described as irresponsible and treacherous. He was explicit in recommending an immediate abortion. Lyla, dominated by the glamour of the motherhood, had already undergone an ultrasound and was carrying a photo of the embryo, despite being the result of a non-consensual conception. What for her represented a desired child, for him was an obstacle to the full exercise of freedom and professional growth. Lyla's parents were very sensitive people. Lyla was the younger of the couple's two daughters. Upon learning of the pregnancy, they welcomed her daughter and made themselves available to support her. There was no censorship or judgment, just resigned acceptance. The position of the parents was not based on any legal, moral or religious principle. It was purely affective. Even if Lyla decided to face this pregnancy alone, she would have the approval and commitment of her parents.

Despite her family's support, Lyla felt ambivalent. She dreamed of a situation of total acceptance. In her fantasy, Raul would celebrate the conception. She rebelled against Raul's attitude, blaming him for being selfish. She began to reject him and unconsciously transferred this feeling to her offspring. She untimely decided to have an abortion. Lyla talked to Therese, her older sister, and together they looked for a clandestine abortion clinic. It was a covert environment, located on the outskirts of the city and characterized by indifference and impersonality. There, they found other young women sharing the same unpleasant feeling.

When her turn came, she was ushered into a small room and instructed to remove only the bottom of her clothing. She was placed on a gynecological table and a vein was punctured in her arm. From that point on, Lyla became unconscious as she had been given an intravenous hypnotic medication. When she woke up about one hour later, she had abdominal pain and vaginal bleeding. She never had any contact with the doctor, being guided only by a supposed nurse to get dressed, as her complaints were considered normal and would go away in a few hours.

Lyla did not communicate her decision to her parents, as she knew they would not agree to the abortion. She left the apartment she shared with Raul and moved in temporarily with Therese. They were eight years apart and Therese had always been very protective of her sister. Therese was divorced and childless, worked as an investigative journalist, and was successful in her job.

The first twenty-four hours after the procedure were marked by deep prostration, intermittent vaginal bleeding, and abdominal pain. Lyla remained lying down and drinking electrolytes. She had not received any prescribed medication or guidance on how to proceed in an emergency situation. She felt guilty and assumed the physical suffering as a punishment for her thoughtless attitude.

Therese put off all her appointments and stayed at her sister's side to comfort her. Due to physical and emotional suffering, Lyla felt sad and often cried, expressing anger and nonconformity. Teresa gave her an anxiolytic she had for personal use, as well as painkiller drops, diluted in chamomile tea.

Lyla got a few hours of sleep. The situation got worse. The pain had taken on an uncontrollable intensity and was now accompanied by distention and stiffness in the abdominal wall. Vaginal bleeding became continuous and Lyla began to develop chills after a persistent fever. She couldn't get up as she was dizzy in the upright position. What had been described as routine and transient discomfort has taken on a serious proportion.

Therese took the initiative to transfer Lyla to an emergency room. When they got there, Lyla had passed out. She had low blood pressure and received drug support to stabilize her hemodynamic condition before a more accurate diagnosis was made. Several tests were performed, revealing a uterine perforation. Lyla underwent immediate surgery, requiring the removal of her entire uterus. She received a blood transfusion and antibiotics and remained hospitalized for a week. At the time of admission, Teresa had communicated to her parents and heard severe criticism for keeping them unaware of the situation. She felt guilty, but justified that she was protecting them, as abortion was an illegal situation in Brazil. The parents were retired judges, adhering to a legal doctrine they had practiced throughout their successful professional lives. However, they were affectionate parents, who put love above their convictions, welcoming their two daughters. Lyla returned to live with her parents and Therese resumed her routine.

This whole story was buried for over two years and only came back because Lyla was now being diagnosed with breast cancer.

At that moment, the whole family was there, in front of me, for the first appointment.

 

To be continued in PLOT 2 (raising action) …

 

* Attention: The story 9 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 9 from the beginning, just click in the numbered links located at the bottom of the homepage. 

 

© Copyright Anticancerweb 2022 

James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2021