Eyeworld

EW NEWS & OPINION 32 September 2016 by J.C. Noreika, MD, MBA six to four: fear, anger, happiness, and sadness. In the span of a few days, I experienced them all overlapping like a Venn diagram or Rothko's oils. I felt empathy with the med- ically uninitiated. How might a layperson react to the news of a new lesion in her liver? How long might she have to wait to get the answer that all is well? Or not? How much needless worry might she and her loved ones suffer? How is a physician taught to check and recheck an image before pronounc- ing a lesion new? How does he learn that there are no trivial concerns when it comes to a patient fearing pain, imagining mortality? In the era of big data and quality of care, mistakes still happen. But there is no margin for error when a patient must embrace speculation and emo- tions intrinsic to life's terminus and death's inevitability. In the end, only a first-person narrative of my experience could be good and true. Hemingway understood. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio since 1983. He has been a member of ASCRS for 35 years. Contact information Noreika: JCNMD@aol.com approval would be efficiently ob- tained. I asked for and got a copy of the CD containing the provocative image. I could see that the lesion in the parenchyma of the liver looked regular in outline and consistent throughout. But it was new and that was disturbing. In The Sun Also Rises, Jake Barnes observed, "There is no reason why because it is dark you should look at things differently from when it is light. The hell there isn't!" Waiting for the CT scan, my wak- ing hours were filled with the usual quotidian activities that make one day seem much like another. But the nights were different, worrisome, anxious. One's mortality takes on remorseless gravity at 3 a.m. I could imagine "A NEW LESION IN THE LIVER," capitalized, the font large and bold. I had the CT scan early on the following Friday morning, and I got a call from a radiologist that afternoon. On the scan, the MRI's abnormality was consistent with a cyst. It was one of a few and all were most assuredly benign. Had I ever taken high doses of vitamin E over an extended period? And then he added that he had gone back to the older CT scan; the "new" lesion was there all the time. The first radiolo- gist had looked but failed to see it. All of us are perfectly imperfect. Current research has reduced fundamental human emotions from phobias, but I can sympathize with patients who might be weirded out by the MRI's technologic coffin. Ly- ing flat for an hour proved a daunt- ing, uncomfortable challenge. It took a couple of days and the young specialist called back. It was Monday. The MRI revealed the oph- thalmologist's occupational hazard: cervical degeneration. But the cause of my ribcage pain was a bit more exotic, a herniation of a thoracic vertebral disk. Because the thoracic spine supports the ribs and lacks the flexibility of its cervical and lumbar counterparts, these disks are not supposed to tear. I felt relief; it's good to have a definitive answer. But then the young doctor hesitated. The radiolo- gist's report also mentioned that, at the edge of the field, there appeared to be a lesion in the liver. Compar- ing the MRI's images with an older CT scan, the radiologist judged this shadow new. Further studies were recommended. A new lesion in the liver of a cancer survivor? Never good. There are advantages to being a physician. I knew that every new lesion has a differential diagnosis and not all possibilities proscribed the purchase of green bananas. I also knew how to work the system. A couple of phone calls and I would have a more definitive CT scan of the abdomen in days, not the cus- tomary weeks. The health insurer's Insights A radiologist's oversight forces an ophthalmologist to face down a patient's greatest fear The afternoon was bright and clear. The square was empty. Men sat in the shade under the café's arcade. I ordered a Pernod. It was good. A breeze blew across the hot parking lot and raised a plume of pumice. It was a good and fine afternoon. P arody allegedly is the last refuge of the bankrupt writer. In the summer of 1926, Scribner's published The Sun Also Rises, the novel that made Ernest Hemingway and engendered endless caricature. Its stark, adjective-less prose abrupt- ly relegated Henry James, Edith Wharton, and Marcel Proust to the back shelves of Sylvia Beach's Paris bookstore. But Hemingway obsessed about his first novel, starting and re- starting it several times. Should the tale of Jake Barnes and Lady Brett Ashley be told in the first or third person? Choosing the first person, the naked immediacy of Jake's retell- ing proved revolutionary. Like Hemingway, I considered using an omniscient third person to write the lessons to be related here. All-knowing narrators use many perspectives, but their depiction of emotion can fall flat, false, remote. Only a first-person narration con- veys the vital intensity of mental impression and physical tremor. I had pain, neuropathic pain from below my scapula to my ster- num. It was on the right side, and I knew it was neurologic because it would wax and wane, burn and sting. Certain that it would improve, I settled into a routine of acetamin- ophen and ibuprofen to get through the day. But it kept me up at night. Weeks passed and, remembering the anatomic construct of dermatomes, I made an appointment with a spine specialist. He humored me by taking a history and then ordered the oblig- atory MRI. Claustro is not one of my In life's bingo, B-9 is a winner J.C. Noreika, MD, MBA

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