[Medical Human Story - Episode 79]: Part IV: The Final Scan, and What We Must Protect Until the End

Beyond the Stuffy Nose: The Dark Shadow Within

Part IV: The Final Scan, and What We Must Protect Until the End

1. The Word "Final" Was Not Easily Spoken

"This scan might be the last one." I couldn't bring myself to say it. Looking at the patient and their caregiver sitting in the consultation room, the word just wouldn't cross my lips. Final. It is a common word in medicine. Final scan. Final treatment. Final outpatient visit. Final imaging. However, to a patient, that word carries an entirely different meaning. Instead, I said, "This scan is crucial in determining our treatment direction." The patient nodded. "I understand." They already knew. They knew this imaging was not just a routine follow-up.

2. The Light of the MRI Room

The patient paused briefly in front of the MRI room. "Doctor." "Yes." "I've lost count of how many times I've had this scan." "I haven't kept an exact count either." He smiled. "At first, just going inside that machine was terrifying." "You're used to it now, right?" "I thought I was... but today, it feels scary again." Instead of answering, I gently patted his shoulder. The scan began. The door closed. And once more, a long time passed.

[Insert Figure 13]

3. Images Do Not Lie

The images that came out of the scan room were silent. I scrolled through them one by one. Post-surgical changes. Scars. Tissues with potential inflammation. And among them, visible abnormal changes. This time, they were clearer. The lesion was growing. The boundary with surrounding tissue was fuzzier than before. I went back to the previous scan. Then back to the current one. And back to the previous one again. In moments like this, a radiologist travels back in time. We check past images, find current changes, and trace back when those changes began. We reread the past to understand the patient’s present.

4. What the CT Revealed

We checked the CT scan alongside it. While MRI shows the extent of soft tissue, CT provides essential information for evaluating bone changes. The nasal cavity and paranasal sinuses are made of complex skeletal structures. The thin bony walls of the ethmoid sinus, the orbital wall, the maxillary sinus, the sphenoid sinus, and the skull base. Even small changes can affect the treatment plan. In this imaging, the medical team re-verified even the structural changes in the bone. "We need to discuss the scope of surgery again," the surgical team said. I nodded. The issue was no longer diagnosis. It was how to treat.

5. The Possibility of Surgery

The multidisciplinary meeting convened once more. "Is local re-operation possible?" "It's possible, but the risks are high." "What about the relationship with the orbit and the skull base?" "We need to accurately confirm the extent of invasion." "What about systemic lesions?" "We need to check for additional metastasis in the current staging evaluation." Each medical specialty spoke in its own language. Yet at the center of the meeting was a single person: the patient.

6. Returning the Right to Choose to the Patient

I met with the patient again and explained the available options. "Based on current imaging, we assess that the lesion is progressing." The patient lowered their head. "Do I need surgery?" "We are reviewing the possibility of surgery. However, we must also consider the extent of the surgery and the potential for functional loss." "Can I get better if I have surgery?" Faced with that question, I paused again. "I cannot guarantee a complete cure." The patient's eyes wavered. But I continued. "Still, it is meaningful to find a way to treat." The caregiver asked, "How dangerous is it?" I explained the possible complications and treatment goals. Surgery. Radiation therapy. Systemic therapy. And palliative care, if necessary. Every choice came with both benefits and burdens.

7. Families Ask Different Questions

Stepping out of the consultation room, the caregiver waiting in the hallway called out to me. "Doctor." "Yes." "Please tell me honestly." "Yes." "How much longer can we be together?" I briefly looked out the window. I wanted to give an exact medical answer. But no doctor can precisely calculate a specific patient's remaining time. I said, "I cannot give you an exact time." Tears welled up in the caregiver's eyes. "Then..." "We must provide the care we can now, while also making sure to protect the time that the patient values most." The caregiver was silent for a long moment, then quietly said, "That's what I needed to hear."

8. The Goal of Treatment Is Not Singular

In cancer treatment, the goal is not always just one—to "get rid of the tumor." Removing the tumor when possible, slowing progression, reducing symptoms, maintaining quality of life, and helping the patient spend the time they want with their family—all of these are part of treatment. Especially in advanced malignant tumors, it is vital that these goals are established together by the patient, family, and medical team.

[Insert Figure 14]

9. The Radiation Therapy Room

The patient visited the hospital once again for radiation therapy. The medical team greeted them outside the treatment room. "Have you been well today?" "Yes." "Any discomfort?" "I'm a little tired." "That can happen. Please let me know if it gets too hard." He sat in the chair. Radiation therapy is invisible. The patient receives treatment even in moments when they feel nothing at all. However, repetitive treatment takes a toll not only on the body but also on the mind. Traveling to the hospital, waiting, receiving treatment, and returning home—this daily routine repeats. For some people, that routine itself is part of the treatment.

10. The Family Dining Table

One weekend, the patient shared a meal with their family. The caregiver said, "Let's not talk about the hospital today." The patient smiled. "Good." They talked about ordinary things. The weather. Television. An old trip. The children. And food. For that moment, neither melanoma, MRI, CT, nor immunotherapy was brought to the table. I didn't see that scene, but the caregiver told me about it later. "That day was really wonderful," I remembered those words for a long time.

11. The Role of the Medical Team

A doctor cannot control every moment of a patient's life. There are times when we cannot stop the progression of a disease. However, the medical team must remain by the patient's side to explain uncertainties, organize options, reduce unnecessary suffering, and find viable treatments. Above all, we must listen to the patient. What do they want? What do they fear? What can they not give up? Without knowing these things, we might choose the right treatment yet fail to provide good medical care.

12. One Morning

7:00 AM. As soon as I arrived at the hospital, I received a message. The patient’s condition had deteriorated rapidly. I hurried to the room. The caregiver was sitting by the bedside. The patient had their eyes closed. "Are you in a lot of pain?" He said in a very faint voice, "A little..." The caregiver took his hand. "I'm right here." The patient opened his eyes and looked at his family. His expression was strangely peaceful.

13. The Final Treatment

The medical team evaluated the patient's condition. We reached the conclusion that active anti-cancer treatment was unlikely to help the patient further and might instead increase their burden. The direction of treatment had to change now. This was not giving up on treatment. It was changing the goal of treatment. Pain control. Relief of dyspnea. Reduction of anxiety. Management of bleeding or secretions. Time with family. Patient dignity. The palliative care team joined us.

14. "Are You Stopping Treatment Now?"

The caregiver asked, "Are you stopping treatment now?" "No," I explained slowly. "We are still treating. However, we are shifting our goal from attacking the tumor to reducing the patient's suffering and helping them live comfortably." The caregiver wept. "That doesn't mean giving up, right?" "No," I said clearly. "It is not giving up." With eyes closed, the patient was listening. A moment later, they said, "Then... please do that."

15. Doctors Can Cry Too

That evening, I stood alone for a moment at the end of the hallway. Tears fell. Some people live having been told that doctors must not cry. But a doctor is not a machine. Encountering countless patients does not make emotions disappear; rather, it teaches us how to handle them. If a doctor accepts a patient's death solely as their own personal failure, they cannot properly care for the next patient. Yet if they feel no emotion at all, medicine cannot be a human act. I tried to find a balance between the two.

16. The Last Night

The patient said to their family, "Thank you." The caregiver replied, "What are you talking about?" "You've been through a lot." "You've been through a lot too." The patient smiled. "I'm so grateful to the people at the hospital." The caregiver looked at me. I lowered my head. "We are even more grateful." The patient looked at me. "Doctor." "Yes." "Please take good care of the next patient too." I couldn't answer right away. A moment later, I said, "Yes. I will certainly do that."

17. That Promise

That was the last promise I made to him. Even in moments when a doctor cannot save a patient's life, we must meet the next patient. That is a cold reality, but at the same time, it is how medicine continues. Just because one patient's story has ended does not mean the doctor's story ends as well. Rather, those memories come alive again the moment we meet the next patient.

18. A Morning That Felt Like Time Had Stopped

The next morning, family members gathered in the hospital room. I quietly opened the door. The patient looked peaceful. The caregiver was holding his hand. No one spoke. The medical team stood quietly as well. Before the numbers on the monitor, the faces of the people caught my eye first. And we knew: the time for treatment had now come to an end.

19. There Is No Correct Answer to Grief

After someone passes away, telling the family to "stay strong" sometimes feels far too easy. There are moments when you don't need to stay strong. It is okay to cry. It is okay not to speak. It is okay to be angry. It is okay to want to ask why this happened. There is no correct answer to grief. The same goes for the medical staff. We each process the loss of a patient in different ways. Some check the records again. Some focus more on the next patient's consultation. Some spend a moment alone. And some remember the patient's face even after returning home.

20. The Final Scan

A few days later, I sat in the imaging room again. The patient's MRI appeared on the screen. I stared at the screen for a long time. At first, I only saw the tumor. But after a moment, other things began to appear on that screen. The face on the day of the first diagnosis. The look while waiting for treatment. The moments talking with family."Please take good care of the next patient too." Looking at the monitor, I quietly said, "I promise." And I closed the scan.

[Insert Figure 15]

21. The Next Patient

A few days later, a new patient walked into the consultation room. "What brings you in today?" The patient said, "My nose has been constantly stuffed." I put down the chart. "Is it one side or both?" "One side." I looked at the patient for a moment, and then slowly began to listen. The illness was beginning anew. But this time, it was someone else's story. I turned on the monitor and waited for the scans once more.

22. A Doctor's Resolve

Since that day, I have come to hold one principle even more dearly: never trivializing a patient's symptoms. Of course, not every nasal congestion is cancer. Not every nosebleed means a malignant tumor. However, if a symptom is persistent and unilateral, its cause needs to be verified. And when a small abnormality is found on imaging, never brushing it off as "nothing." This is one of the most vital responsibilities a radiologist can give a patient.

23. Clinical Lessons on Sinonasal Melanoma

Sinonasal melanoma is not a common condition. However, rarity does not diminish its importance. Because symptoms are non-specific, diagnosis is often delayed, and it is not uncommon for cases to be discovered in a locally advanced state upon presentation. Imaging examinations play a crucial role in determining the location and extent of lesions, evaluating surrounding structure invasion, assessing surgical feasibility, and identifying post-treatment changes or suspected recurrence. In particular, CT and MRI are not competing tests; they provide complementary information. CT excels in evaluating bone structures, while MRI is useful for assessing soft tissues and complex anatomical relationships such as nerves, the orbit, and the skull base.

24. What Patients Need Most

What patients need is not merely complex medical jargon. "What disease is this?" "How severe is it?" "What tests will be done?" "Can it be treated?" "What are the side effects?" "What should I do from now on?" It is essential that the medical team answers these questions in language that is easy to understand. Furthermore, patients must be given time to ask questions. Good medical care does not end with the doctor talking a lot. It is complete when the patient understands and can ask questions.

25. Families Are Part of the Patient Too

Only one person is diagnosed with cancer, but they are not the only one affected by the disease. Spouse. Parents. Children. Siblings. The lives of the entire family change. Therefore, the burdens and emotions of the family must also be considered throughout the treatment process. While the patient receives treatment, caregivers wait in the waiting room. Waiting for test results, waiting for surgery, waiting for consultations, and waiting for the next treatment. That waiting is also a part of medical care.

26. How Far Can Medicine Save Humanity?

I have pondered this question for a long time. Medicine has achieved remarkable advancements. High-resolution MRI. Multi-detector CT. PET/CT. Molecular pathology. Immunotherapy. Precise radiation therapy. Multidisciplinary care. Even so, we have not conquered all cancers. Can we say we have failed because of that? I do not think so. The purpose of medicine is not merely to eliminate death. Delaying death where possible, reducing suffering where possible, preserving time where possible, and helping patients choose their own lives—that, too, is medicine.

27. Signals We Must Not Miss

Symptoms that may arouse suspicion of a sinonasal tumor are non-specific. Representative signs include:

· Unilateral nasal congestion

· Recurrent nosebleeds

· Decreased sense of smell

· Facial pain or pressure sensation

As the disease progresses, visual or neurological symptoms may also occur depending on the invasion of structures around the orbit or skull base. Therefore, if symptoms persist or worsen, an evaluation by an otolaryngologist is necessary.

[Medical adviser]

28. What We Left Behind

The patient has left. Yet what he left behind was not just sorrow. He left questions for the medical team. Could we have found it earlier? Could we have evaluated it more accurately? Were our treatment choices sufficient? Could we have better protected the life the patient wanted? These questions do not easily fade away. And the advancement of medicine begins precisely with such questions.

30. Beyond the Dark Shadow

Sinonasal melanoma can appear as a dark shadow on an MRI screen. However, that shadow does not represent the patient's entire life. Imaging shows the disease. Pathology explains the identity of the tumor. Treatment fights the illness. Yet what completes a patient's life are moments spent with family, trust in the medical team, and the ability to live the way they choose. I try never to forget that.

31. Not an End, but a Record

I reread the patient's final medical record and wrote down the final sentence: "Treatment and care performed with the patient's life and dignity as the top priority." That sentence was merely a line in a medical chart. But to me, it was a long story. In that story lived a person's fear, a family's love, the medical team's deep contemplation, and time spent refusing to give up until the very end.

32. And Morning Comes Again

The next morning, people gathered at the hospital once more. Patients checked in, nurses moved through the wards, and doctors entered consultation rooms. I walked down the hallway holding a cup of coffee and opened the consultation room door. Today, I had to meet a new patient. I sat down in my chair. The door opened. "Come in." A new patient walked in. I smiled and asked, "What brings you in today?" At that moment, I was standing at the starting point once again.

Part IV's Final Sentence

A person's story has ended, but the questions they left behind continue to live on inside the heart of the doctor meeting the next patient. And today, I look at the scans once more— to ensure I do not miss a single small signal on the screen, because behind that small signal lies someone's family and life.

Part III: The Reappearing Black Shadow☜ Previous Chapter

Next Chapter ☞ Epilogue: What We Must Protect Until the End