We've all heard the phrase "It's better to be lucky than good." I typically believe in that adage quite strongly, but sometimes it's just better to be good.
I was consulted today on a 26-year old healthy woman who was having excruciating acute-onset abdominal pain, mainly on the right. It was so severe that she was requiring 20 milligrams of morphine per hour. In case you aren't a pharmacologist, that's approximately the dose that would put an elephant to sleep instantly. But she was still very much awake and still writhing in pain. But her abdominal exam was relatively benign, and her lab work was normal. Oh, did I mention that she's 28 weeks pregnant?
Pregnant patients are always diagnostic dilemmas. It's very difficult to work these patients up, and even more difficult to treat certain things, especially surgically. But because her pain was mainly on the right, the immediate concern was acute appendicitis, something that can be very dangerous to the fetus. But something just didn't sit right with me. Actually, all of it didn't sit right with me. Her history wasn't consistent with appendicitis, her exam wasn't consistent, her lab work wasn't consistent, and she even had a CT scan read by two different radiologists who didn't see appendicitis.
I agreed. I didn't think the CT showed anything abnormal. I thought she had a kidney stone.
A third radiologist disagreed - she thought it was appendicitis. The OB-GYN thought it was appendicitis. I asked a colleague (who happens to be chair of the department) to see her as a second opinion - he thought it was appendicitis. Here now were three physicians with about 100 years of combined experience all telling me that this woman had appendicitis.
I still disagreed. My mere 5 years of post-training experience was screaming "IT ISN'T APPENDICITIS! THEY ARE WRONG!"
Unfortunately my hand was forced. I was forced to operate on her because of the radiology reading. I took her to the operating theatre, made a small incision, carefully pushed her uterus to the side, and lifted up a PERFECTLY NORMAL appendix. She and the fetus both tolerated surgery just fine, and she felt much better the next day after she passed her kidney stone.
After this little episode today I've created my own new adage - "It's better to be good than wrong."