Incidental

A patient getting a heart workup for chest pain has the incidental finding of a large lung nodule. Her chest pain is due to critical aortic stenosis, causing symptoms of dizziness, fainting, and shortness of breath. With her severity of aortic stenosis, her life expectancy is only a few years. Nevertheless, the cardiac surgeon wants the lung nodule worked up. The patient undergoes a video-assisted thorascopic surgery for a wedge resection, but this is emergently converted to an open lung surgery because her anatomy is challenging. Post-operatively, she develops a severe pneumonia. Her lungs are so severely impaired that she eventualyl needs a tracheostomy. She has multiple drains placed in her chest, requires high doses of blood pressure medicines, and stays in the ICU for weeks. The worst part? The pathology from the lung nodule shows a benign mass. She was never going to die from this lung finding.

This and other similar cases illustrate some of the incredibly bad consequences that can result from one simple medical decision. Every test we do can have incidental findings - findings that are abnormal but unimportant. Scans we order may show normal variations of anatomy, artifacts that end up being nothing, and disease processes that ultimately don't matter. But as physicians, we are biased towards chasing these findings. While most of the time, these extra tests and interventions don't cause significant harm, injury, or suffering, some small percentage of the time, consequences can be devastating. This woman's aortic valve narrowing was life threatening. But because of an incidental finding her physicians wanted to chase, she underwent operations fraught with complications for no benefit. She will never get to her previous level of functioning, and probably will never have her valve replaced. Not only did we shorten her life, but we made the end of life one of intensive care and intensive suffering.

When I receive these patients in the surgical ICU, I come into the story too late to change the course of events. But I try my best to reorient the surgeons and other physicians to doing what's best for her. There is a surgical mentality (in my opinion) that if a patient suffers complications, the surgeon wants to do everything to right it. And I can understand that; the surgeon feels guilty even though complications are a normal part of his work. But he will put a patient through a lot of medical tests, interventions, further surgeries, and potential suffering just to fix his mistake. Sometimes stepping back and looking at the big picture suggests that we should simply stop. Sometimes, we need to recognize that our mistakes cannot be fixed.

I write about incidents like this because I think we can do better. They are terrible situations where medicine has done wrong and a patient has suffered, but if we do not realize what is going on, we will never resolve the problem. Each medical decision and judgment can dramatically change the life of a patient. Sometimes incidental findings are not worth investigating. Sometimes if a patient has complications from therapy, we cannot save their life. In these situations, we ought to consider palliation and attention to suffering rather than persistent attempts at cure.