Friday, 17 May 2013

Victory

I recently wrote about a patient with a big problem but no symptoms and how this can be a very difficult diagnostic situation to deal with.  Fortunately, this is a relatively rare occurrence.  Unfortunately, the opposite can also happen, too.  What do you do with patients who have lots of symptoms with no good explanation for them?

Is that even possible?  Well, of course it is, otherwise this would be the shortest post ever.  To be fair, I see lots of people who complain of pain with nothing actually wrong because they just want me to give them narcotics.  And I'm not referring to hypochondria, where people think they have pneumonia just because they sneezed.   I'm talking about people who are actively dying, but we can't figure out why.  What then?

I was called to see a woman in her 50's who had undergone open heart surgery earlier that day to repair a damaged heart valve.  The report that I got was that other than mild thyroid disease, she was a healthy woman, and according to the cardiac surgeon, the surgery was uneventful.  She had been admitted to the intensive care unit just to keep a close eye on her, but about 8 hours later, something happened.  Her blood pressure suddenly plummeted, her heart started racing, and she lost consciousness.  A breathing tube was inserted and she was placed on life support, and several medications were started to keep her blood pressure up in an attempt to maintain oxygen flowing to her heart and brain. 

"IT'S HER HEART!  IT'S HER HEART!!" I hear you screaming.  Of course!  Why didn't the cardiac surgeon and intensive care doctor think of that!  Oh wait, they did.  And tests confirmed her heart was absolutely fine.  Her extensive workup had included a CT scan of her chest and abdomen, and that painted a very different (and very bizarre) picture - her entire colon looked inflamed, almost like it was dying.  And it seemed that it was actively killing her.

Wait, what the hell?  How the hell did that happen?  The cardiac surgeon had operated on her heart, not her abdomen!  He and the intensive care doctor didn't know how it could have happened, so they called me.

YES! I get to save the day!  Doc Bastard to the rescue!  Except for one teeny, tiny, itsy-bitsy problem - 

I didn't have a clue either.

The colon can become inflamed if it loses its blood supply for some reason, including a very low blood pressure.  And her blood pressure was very low, so that could possibly explain it.  Except that her blood pressure hadn't dropped until AFTER she had crashed.  So what had caused her blood pressure to drop in the first place?  I was baffled.  It seemed like a very nasty cycle, but something had definitely gone wrong that had kicked her into a downward spiral, and that something was about to kill her.

As a surgeon, there are certain situations where I don't have time (or a need) to ask why, when I have to leap into action without knowing exactly what's going on.  This was definitely one of those times.  It's a "shoot first, ask questions later" sort of thing.  I spoke briefly to her husband, explaining that her colon looked like it was dying, and that if she didn't have immediate surgery to remove it, she would most assuredly die along with it. 

I got her to the operating theatre about 20 minutes later, made a big incision in her abdomen, opened her up, and saw...

...a perfectly normal abdomen.  Her colon was absolutely fine, as were her small intestine, stomach, liver, spleen, gall bladder, and pancreas.  There wasn't the slightest hint that there was anything remotely wrong with this woman.  I went over everything again, and again I couldn't find a single thing wrong.

DAMN IT!  What the hell do I do now?  I came in here to remove some evil, diseased organ to save this woman!  Come on, throw me a bone here!

Realising there was nothing I could do to save her, I started closing her up, mentally preparing my discussion with her husband about how we did everything we could but weren't able to bring her out of it.  But just as I was silently reviewing my feelings of uselessness, the anaesthesiologist told me that her blood pressure was starting to pick up, and her heart rate was returning to normal.  But...I hadn't done anything!  Had I?

As we were getting her back to the ICU, her vital signs continued to improve, and once we got her there, she immediately started to wake up.  When I came to see her the next day, the breathing tube was out, the medications to keep her blood pressure elevated were off, and she was drinking a ginger ale. 

As much as I love saving lives, I can't claim credit for this one.  At least I don't think I can.  Maybe I released some evil humours or a demon or something.  Who knows.  This case happened some time ago, but to this day no one has been able to give me any reasonable explanation for why she got sick OR why she got better.  But just like I don't need to ask why someone is sick sometimes, here I don't really need to ask why she got better.  Sometimes it's just better to accept a victory and move on. 

5 comments:

  1. Maybe you just had to lay your hands on her. You are magic, like the ER doc from a whole back suspected!

    ReplyDelete
    Replies
    1. Uh oh just noticed that typo. *from a while back

      Delete
  2. Should change your name to Doctor Gregory House

    ReplyDelete
  3. Doc, I know how much you love the pseudonym "it is what it is" ha :-) anyways, my husband has the gift you describe but instead of people its usually just the tv or fridge and air conditioners he operates on. He will literally take them apart fixing nothing put it back together and bam its fixed. It's the gift.

    ReplyDelete
  4. If I had to guess, electricity or neurostransmitter (or both) hickup to the heart but I'm baffled...

    Al

    ReplyDelete

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