Sometimes We Find a Zebra

It was 2020. We were in lockdown, but as essential workers we still had to go to work as GPs. Telehealth was how we conducted most of our consults. If you needed an examination, we gave you permission to come in.

She was in her 40s. She called complaining of back pain. She always had back pain. She was a busy mum of three. She never had time to rest. But this time the pain felt different. It wasn’t going away; it was constant, gnawing. I had never met her before, but something in her voice felt unusually worried. I felt the urge to call her in.

She eventually attended with two young kids in tow. She didn’t have a choice. I had to overlook the social distancing rules to have them all in the room. It was the only way she could attend. She looked pale and tired. Was she normally this pale? Or anaemic? I took a further history and found out she had been spotting constantly. “Isn’t that just a side effect of the Implanon though?” she thought out loud.

I saw that she was overdue for her cervical screening, and as a dutiful GP registrar I performed a speculum examination.

I couldn’t describe what I saw where her cervix was meant to be. It was a fungating, bleeding mass that distorted the normal anatomy. In my alarm and haste, I quickly took a sample, commented on how there was contact bleeding and things didn’t look normal, and sent her on her way with a blood test and a CT scan of her lower back.

As a bewildered and naive first-year registrar, I discussed what I saw with my GP supervisor. “Should I wait for the results first?” But no, I was told to immediately call the gynaecology registrar on call at the nearest tertiary hospital and discuss the case.

She was seen within the same week. Biopsies came back as metastatic adenocarcinoma of the cervix. The back pain was a bony metastasis. Her haemoglobin was in the 60s. She must have been bleeding constantly. She must have been so tired. But she probably brushed it aside for so long, putting her kids and family first.

It was too late for anything to work. She left behind three kids and a husband in less than a year.

I reflect on this case often. What if I had also brushed off her back pain over the phone? What if she had never come in? What was it that compelled me to call her in? Could we have prevented it all earlier had she not been years overdue for her cervical screening?

I work hard now to not brush off any complaints. To create a space for my patients where there are no questions too silly or symptoms too small to bring up. To listen and investigate appropriately, and to trust my gut and seek a second opinion if something doesn’t feel right. Because sometimes when we hear hooves, we will find a zebra.