Healed by TEAMWORK

It took the efforts of several doctors, working in unison, to save a patient from the cancer threatening her life

My patient was bleeding to death as I struggled with a decision – her leg or her life?

An emergency colonoscopy had shown that she had a “spurter”. In layman’s terms, her cancer had eaten into an arterial blood vessel and it was spurting out blood.

The surgeon had tried his best to catch and tie off or burn the “spurter” to no avail.

“I’m sorry but there is nothing else I can do,” he told me.

The patient is a retired senior lawyer from Malaysia. I have looked after her for some time and I knew her illness well. She first saw me when she discovered a large mass on the right side of her pelvis.

This cancer grew next to the vagina, bladder and rectum, and snaked around the nerve bundles and blood vessels of the right leg. Chemotherapy had shrunk the cancer, and her case was discussed at our Tumour Board to deliberate options.

Tumour Boards are a regular feature in our cancer centre. It brings together specialists of different disciplines to discuss interesting or complicated cases. These boards are important for cancer doctors to learn from one another and to understand one another’s capabilities. With teamwork, we can do much more than any single doctor.

The patient was given the option to go for surgery or have radiotherapy. While surgery was likely to be more effective in removing the entire tumour mass, there was a possible loss of function of the right leg, as the nerves controlling the leg may need to be sacrificed during the surgery. Being an avid ballroom dancer, she opted for radiation.

Then came the fateful day when the call from my colleague in Nuclear Imaging arrived: “Hey, I think you better see this patient soon. She just passed out loads of blood and her blood pressure has plunged!”

She was admitted quickly, given intravenous fluids to prop up her blood pressure. I also called for emergency blood transfusion and more to be held in reserve.

By the time I saw her, the blood was already being transfused and she was resting comfortably. “I was fine when I flew in yesterday,” she chirped cheerfully. “I started to pass out blood this morning. It poured and poured until I felt faint. Thank God I’m already in hospital,” she said.

How I wish I shared her confidence! In my discussion with the surgeon, there were no viable surgical options for her. The tumour was likely to have grown and was invading into the rectum.

When we offered her surgery after initial chemotherapy, it was likely to be difficult but possible. But now, after completing the radiotherapy, surgery would be nigh impossible as the entire area would be badly scarred and hardened with fibrosis.

Since the surgeon had already conceded that there was nothing he could do, I was facing the possibility that the patient was going to die from the massive blood loss. By this time, we had already transfused her with six bags of blood. The bleeding persisted.

The drama was made worse by the fact that she came alone and despite all our attempts to contact her family, the phones remained unanswered.

I called up Dr Peter Goh, an interventional radiologist who is another member of our team, and explained our predicament.

“We need to do an emergency angiogram and try to block off the bleeding blood vessel,” I said. We have no other options.

Peter worked a miracle. He carried out the angiogram and was able to identify the “spurter”. He called me to explain that in order to block off the blood flow to this bleeding vessel, he had to also block off the blood supply to the right leg.

We had no choice so I gave the instructions to go ahead. If we had to lose the leg to save a life, so be it – I was prepared to face the music later.

Thankfully, minutes later, Peter called back and gave me a better option. He suggested blocking off the blood vessels and immediately after that, the patient could have an emergency by-pass operation to shunt blood from vessels supplying the left leg over to the right side.

If successful, the right leg would remain viable.

Six weeks have passed since her ordeal. She continues to fly in and out to receive her chemotherapy. Most of the time, I am the only doctor she sees. But I am actually only the tip of the iceberg that saved her life – and her leg.

Dr Ang Peng Tiam