What could possibly be better than being right? You get to look smart, prove someone else wrong, and generally look like a hero. So what could be better than that?
"WHAT?" I hear you scream. I've said before that it's better to be lucky than wrong, and there have been very few times in my career when I have hoped against hope that I'm wrong. These have been the times when I suspect a diagnosis that is life-altering, and not for the better. Come on, I'm not diagnosing winning lottery tickets here, people.
A 30-something year old woman came to the emergency room complaining of abdominal pain which had been ongoing for the past several days. As soon as any young person (or any person, for that matter) complains of abdominal pain, it seems that ER docs immediately think "APPENDICITIS! CALL SURGERY!". True to form, I was called. Fortunately the ER doc had at least done the workup, and I will freely admit it was very concerning. At first glance, she looked ill. And when people look ill, it's a pretty damned good sign that they are ill.
The first thing I did (after glancing at her) was to talk to her, something that many doctors these days just don't do, preferring to rely on lab tests and CT scans, and failing to realise how much invaluable information can be gleaned from a simple conversation. She told me that the pain had started a few days ago in her lower abdomen, and around the same time she started having some yellowish vaginal discharge (red flag). She had also noticed pain during sexual intercourse (BIG RED FLAG). I pressed on her abdomen, and she was clearly in excruciating pain. I then excused myself to look at her CT scan (yes, they're still almost as important as talking to the patient), and she had large abscesses (collections of pus) on both sides of her pelvis.
Well, I've never heard of someone having an appendix on both sides, so my mind immediately went elsewhere - girl parts. In my mind, this woman did NOT have appendicitis; rather, she had tubo-ovarian abscesses on both sides, and she needed urgent surgery by a gynaecologist to drain them and possibly remove her infected tubes and/or ovaries. Rarely, infections (usually chlamydia or gonorrhea) can spread up the female reproductive tract and form horrendous infectious complexes in the ovaries and fallopian tubes.
This was where I desperately hoped I was wrong. If one (or both) ovaries have to removed, it can be devastating for a young woman's fertility. Even if the ovaries and tubes are left in, they can scar to the point where they no longer function. And it gets worse (of course it does!) - she and her husband were trying to get pregnant with their first child, and she had just stopped taking her birth control pills 2 months prior.
PLEASE LET ME BE WRONG! PLEASE LET ME BE WRONG!
The last thing I wanted was to be right. A ruptured appendix with an abscess is fairly easy to take care of, but this diagnosis was potentially life-changing. Unfortunately, according to the ER doctor and the gynaecologist, I was already wrong. Despite all the evidence to the contrary, they were firmly convinced that it was her appendix that was the problem, not her girl parts. Another surgeon, one of my most senior colleagues, was brought in as a second opinion, and he agreed with the gynaecologist.
By this point her blood pressure was starting to drop, her temperature was going up, her heart rate was starting to go up, she was sweating more...she was getting sicker. There wasn't any more time to argue, so I ended up taking her to the operating theatre at 1 AM. And much to my surprise, I found...(please let me be wrong, please let me be wrong)...
...tubo-ovarian abscesses. On both sides. GOD DAMN IT. Her left ovary looked ok, but her left fallopian tube was a mess. Her right tube and ovary were both obliterated by the infection. The gynaecologist ended up taking out her right tube and ovary, but he kept the left tube and ovary in.
The next morning I told her and her husband what we found and what we did, and naturally she was devastated. I reassured her that she still had one fairly normal ovary and a perfectly normal uterus, so at worst she would need to have her eggs extracted, fertilised in vitro, and implanted into her uterus. Her egg, her baby. It was cold comfort at best.
Sure I had been right, but that had been even colder comfort. There's just no way to sugar-coat it. Sorry folks, no happy ending this time.
Stories about general surgery, trauma surgery, dumb patients, dumb doctors, and dumb shit from the dumb world around us.
Sunday, 3 February 2013
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I Agree - hardly a happy ending, but then not quite the terrible ending that it might have been. It might not be much comfort right now but at least she will survive to raise a family if she chooses and has the option of IVF.ReplyDelete
Not too many years ago she would not have had even that outcome and there are plenty of people still who would not have access to IVF even if they had received the emergency attention she needed.
We live in an age of miracles but we don't see them because they are what we now expect. Perhaps one day another doctor in your place would be able to grow her another ovary & pop it in a few weeks later. That would be incredible now but hopefully one day will be just as routine.
You saved her life doc'. That's all you could have done with the tools you have and it's hardly a small feat. Let's hope one day there will be even more fabulous tools available so that something more can be done in that situation.
After reading the entirety of your blog, laughing and crying, I must say....ReplyDelete
You are one of the most empathetic, understanding humans I've come across in my journeys. I am so happy there are people out there like you. Not just doctors, people. So, thank you.
Also, I'm a huge hypochondriac, and my "I'm going to die" moments have lessened significantly since reading your blog.
And I always wear my seatbelt.
I still think it's a fairly happy ending, considering she could've lost both her tubes and ovaries AND she could have died. I don't know if it's because it's almost 2am and I'm tired or because I've been watching Grey's Anatomy (don't judge me, it's entertaining)... But... You know, anything that doesn't end in death or some sort of excruciating disability sounds like a happy ending to me.ReplyDelete
I have tried to post this before- but I was unsuccessful.ReplyDelete
Doc- Not all hope has been lost. When I was 19 years old, I suffered a horrific miscarriage that left me legally dead for a short time and required me to lose one of my fallopian tubes. The doctors told me that there was a good chance that I would have difficulty getting pregnant again and that if I ever did there would be a good chance that my pregnancy would be considered high risk. I am happy to say that when I was 23 I gave birth to my oldest son and at 25 had my second. Nothing is impossible, so don't give up hope. That woman could have died, but instead you found the root of her problem and saved her. She's just going to have to take it one step at a time.
This happens in dogs all the time!!! One f the biggest (besides overpopulation) reasons to sterilise your female dog. Pyometra is a horrible life threatening condition. I have helped remove huge, like 3-4kg uterine horns full of pus from dogs in surgery. Nothing worse than an older, often breeding bitch, coming in with pyrexia, nausea, and a vulva dripping pus. Ugh I hate hate hate it. I had never heard of a human equivalent, I am thinking maybe dogs are more prone to UTIs tracking up into the cervix and onwards, maybe because of anatomy and... Dogs having slightly (debatably) lower hygiene standards???ReplyDelete
Ps loved the trichobezoar story! I have pulled plenty of those out of stomachs and intestines too.