Risk of living life to the max

It was a quiet holiday for me this year.

Unlike many who travelled during the December school holidays and over the long weekends of Christmas and New Year, I stayed in Singapore.

Those weekends were no different from any other weekend for me - seeing patients in the wards in the morning and answering calls as they came in during the day.

The clinic was closed for the public holidays. But in the late afternoon of New Year's Day, the resident medical officer at the hospital emergency room called, asking if I was prepared to accept a new patient with a history of metastatic breast cancer.

Cynthia, a 66-year-old American, was travelling with her daughter and family from San Diego, California, and they were planning to spend a few days in Singapore before heading to Bali, Indonesia. However, during the flight, she suddenly developed severe abdominal pain.

When they arrived at Changi Airport, her daughter, who had studied in Singapore, immediately took her to Mount Elizabeth Hospital.

I met Cynthia at the emergency room. She was lying on a trolley bed, in obvious distress.

When I felt her abdomen gently, she complained of severe pain throughout the entire abdomen. An X-ray showed that there was free gas under the diaphragm.

As any medical student would know, the phrase "free gas under the diaphragm" is bad news. Any gas in the abdomen should always be confined within the bowels.

The fact that there was free gas meant that there must be a hole in some part of her gastrointestinal (GI) tract. GI perforation results in a discharge of gas, as well as other intestinal contents, into the abdominal cavity.

The spillage of gastric contents and faecal material often leads to life-threatening infections. A computed tomography (CT) scan confirmed our fears that there was indeed a perforation. I immediately called in a specialist in infectious diseases and a GI surgeon.

Cynthia had been on active treatment for her metastatic breast cancer since September 2013. She had been receiving continual three- week chemotherapy sessions, followed by a one-week break, for 15 months. She hardly suffered any side effects from her treatment, except for a bout of severe diarrhoea which occurred just before Christmas. As her symptoms quickly subsided with treatment, she was deemed fit to fly for her vacation.

As a general rule, patients need to have emergency surgery whenever there is evidence of GI perforation. The surgeon would open up and explore the abdomen. He would clean up the "muck" inside the abdominal cavity, try to find the exact site of the perforation and either patch it up or cut away that segment of the perforated bowel.

However, surgery was deemed unwise for Cynthia for two reasons.

The first was that she had a low white blood cell count, as she had just received her chemotherapy a few days before her flight. This would affect her ability to fight the infection.

The other concern was the fact that she had been on a medication called Avastin.

The use of this drug has been associated with perforation of the GI tract in about 3 per cent of patients. It is generally advised that GI surgery should be avoided for six weeks after the patient has received the medication. Otherwise, there would be an increased risk of poor wound-healing, resulting in further perforations.

After careful deliberation, the consensus was to treat Cynthia more conservatively. She was given strong antibiotics and put on intravenous feeding to allow her bowels to rest.

Thankfully, Cynthia is slowly making good progress and the latest CT scans show that the free gas is gone.

But the road to recovery is going to be a long one. Our priority is to get her well enough to return her to her medical team in San Diego. Her intended vacation on the sunny beaches of Bali will have to wait till she gets well enough to travel again.

The question for patients whose equilibrium of life is upset by complications from treatment is this - what would they have done differently?

Should Cynthia have travelled for the holidays?

With her compromised immune system, should she have taken the chance of being on such a long flight? Or should she have stayed at home and have a quiet New Year?

The scenario is more poignant for cancer patients.

Their time is limited, so each minute is all the more precious. But their health risks are higher, so what they can do is also limited.

The choice is up to the patient.

As a doctor, I always encourage patients to live life to the fullest. But only they can decide for themselves whether this means taking a small risk, or playing it safe.

angpt@pcc.sg

Dr Ang, medical director of Parkway Cancer Centre, has been treating cancer patients for 27 years.

In 1996, he was awarded Singapore's National Science Award for his outstanding contributions to medical research.

This article was first published on January 29, 2015.
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