Monday, 11 May 2015

Crazy

There’s a very good reason why I don’t treat children, and I can sum it up in one word: parents.  I don’t mind the kids themselves (remember I have two of my own), but the parents can either be so overwhelmingly crazy in trying to protect their children that the craziness metamorphoses into sheer lunacy, or not show even an iota that they care about their child at all.  I’ll admit to understanding the crazy feeling when my own child had croup as a toddler, but I never let myself (or my wife) go completely down the rabbit hole, staying rational while also remaining right by her side every second she was in hospital.

So on the one hand you have crazy overprotective parents who constantly interject, thereby not allowing me to work effectively or efficiently, and on the other you have parents who obviously don’t care one way or the other, which is even more infuriating.

And then you have parents like Yvonne (not her real name©) who have no reservations whatsoever and allow their emotions to completely override any rational part of their brain and are JUST.  FUCKING.  CRAZY.

A laughing emergency physician is a dangerous emergency physician.  When he chuckles as he starts to tell me about a patient, it means it’s either A) something so completely stupid and irrelevant that even he knows he shouldn’t be consulting me, B) something so bizarre that he doesn’t have the foggiest notion how to handle it, or C) a rectal foreign body.  Sadly for me (and for you, I’d imagine), it was not C, but rather B this time when Dr. Mike (not his real name©) called me:

Dr. Mike: Hey Doc, so I have this very nice young lady who clinically has appendicitis, and I’d like to order a CT scan to confirm it, but her mother isn’t consenting to the scan.
Me: Oh, she must be very young then.  But I don’t do kids, Mike.  How old is the patient?
Dr. Mike: 22.
Me: Months?
Dr. Mike: No, years.
Me: ...
Dr. Mike: Are you there?

Apparently Yvonne (the patient’s mother) was afraid of the radiation because her daughter Lilly (not her real name ©) was, and I quote, “so young”.  Mike politely asked me (with a very nervous chuckle) if I would come assess the young lady and talk with her mother.

I audibly groaned, and Mike laughed again.


Fuck you, Mike, I thought.

When I got to her room a few minutes later, Lilly looked mildly uncomfortable, but her mother looked significantly worse, pacing around the room as nervously as a bank robber in a police convention.  On examination, Lilly was definitely tender in the right lower quadrant of her abdomen (right where the appendix is supposed to live).  Her history was consistent with appendicitis and her pelvis was nontender, all things pointing to a single diagnosis.  However, I explained to both Lilly and Yvonne that in a young lady of childbearing age, the right thing to do is a CT scan to confirm the diagnosis.  It could be a Girl Part Problem (like an ovarian cyst or abscess, ovarian torsion, ectopic pregnancy, pelvic inflammatory disease, endometriosis, etc) and confirming appendicitis with a CT scan would reduce the risk of an unnecessary surgery from 20% to less than 5%.

“No,” Yvonne said adamantly, “I don’t want her getting that much radiation.  She’s too young.”

I very calmly explained that the radiation from CT scans is much lower than most people think, and the amount from a single scan would only be a concern if Lilly were an embryo (yes, I actually said that).

Lilly sat there quietly looking at me while her mother shook her head and not-so-politely continued to refuse adamantly.  Resigned to this overarching stupidity, I explained that because her history and examination and blood work were all consistent with appendicitis, and because Lilly was so uncomfortable, the correct next step would be immediate surgery, even though there was still about a 20% chance I was wrong about the diagnosis.  I also explained again about reducing the risk of unnecessary surgery is as easy as a 10-second CT scan. 

"No, absolutely not.  But," Yvonne continued, "I’ve been reading online about treating appendicitis with antibiotics”.  

Oh, shit.

After describing her research at Google University, she then went on to explain how her own appendix had ruptured when she was 7-years old.  I just stared at her, mouth agape, as she recounted how she had needed multiple operations and nearly died because her parents had waited too long before seeking medical care.

"Wait just one goddamned second, you insufferable twit.  You’re actually asking me to make the same mistake your parents made and wait to operate on your daughter until her appendix ruptures and threatens her life?  Are you that mind-numbingly stupid?"  

Ok, there's a chance that I only said that in my mind.  But I wish I had the balls to say it aloud because that’s exactly what was going through my head as I tried to explain patiently and rationally why waiting to operate was the wrong move without using the words “FUCKING MORON”.  Finally, shockingly, she agreed.  Lilly had remained silent the entire time, merely nodding occasionally.

And if that weren't bad enough, that's when the real craziness started: “Have you had enough to eat today?  Are you well hydrated?” Yvonne asked me.

Wh . . . what?  I’ve never been asked that before in my entire medical career.  And before you think this was real concern over my well-being, it clearly was not.  It was just lunacy.

About 30 minutes later Lilly was brought up to the operating theatre, where the anaesthesiologist witnessed Yvonne again asking me if I had had a bite to eat.  “Yes madam," I forced myself to say, "I had a granola bar and a Coke.”

“Ugh, COKE?  Oh dear!  Oh my!  I’m a nutritional microbiologist, you see.  You drank Coke?  Really?  Ugh!”

The anaesthesiologist glanced quickly at me with a look that clearly said, “What the fuck is this lunatic raving about?”  I laughed politely and said nothing, worried that one of the truly revolting thoughts that had been percolating over the previous half hour would come spilling out of my brain through my mouth.

Finally it was time for surgery.  I inserted my laparoscope through a tiny 1cm incision, hoping to find a nice, plump, juicy, inflamed appendix, and the first thing that I saw was . . .

. . . a normal appendix.  There was perhaps a slightly engorged blood vessel on its surface, but not the nice chunky inflamed organ I was expecting.  DAMN IT.  I guaran-damn-tee that this girl's mother is going to accuse me of doing an unnecessary surgery now.  FUCK ME.  I took out the appendix, hoping that there was inflammation inside that I just couldn’t see (this has happened to me in a handful of appendicitis cases).  While I had the scope in there, I examined the ovaries (normal), uterus (normal), colon (normal), small bowel (normal), liver (normal), and gall bladder (fucking normal).

I heaved a great sigh and finished, bracing myself for the conversation to come with Yvonne.  I went out to the waiting room to talk to Yvonne.

Deep breath, Doc.  Deep breath.

I explained what I had found and that I couldn't be sure it had been appendicitis.  I explained the other possible explanations, including food poisoning (which is due to toxins produced by bacteria), a "stomach flu" (which is actually a viral infection, not the flu), mesenteric adenitis, pelvic inflammatory disease (though I had seen no evidence of that intraoperatively), or possibly appendicitis that I just hadn't appreciated.

"So are you saying this was an unnecessary surgery?"

And there it is.  Of course she would ask that.  Deep breath.  No, I told her, even without the CT scan, it was the right thing to do, and this was exactly why I had explained the possibility that it wasn't appendicitis even though her symptoms all fit.  And why the CT scan would have been useful, idiot.  We would just have to wait until Lilly woke up - if she felt better, it was appendicitis.  If not, then we would have to keep looking for other causes and wait for the pathology report, which would still take a few days.  I thought the insanity was over until she asked her followup quesions:

- Could she have room-temperature water when she woke up?  Yes.
Should she stop eating corn after surgery?  Uh, what?  I mean, no.
Could this have been caused by the organic quinoa she ate last week?  Ah, no.
Could this have anything to do with a pain Lily gets in her chest whenever she's sleep-deprived and which goes away after a good night's sleep?  What the ever-loving fuck are you talking about?  I mean no.

Lilly woke up feeling great, and she went home from the recovery room.  Her pathology report came back two days later:

"MILD ACUTE APPENDICITIS"

I don't think I have had that deep a sigh of relief in years.

19 comments:

  1. I don't get why a 22 year-old needed parental consent in the first place. Or was she just agreeing to whatever Mum said?

    ReplyDelete
    Replies
    1. There are some mothers you really don't say no to.

      Delete
    2. I'm wondering about this too. Couldn't you just talk to Lily directly?

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    3. Ok. I have never seen this in practice at all there would be exploratory surgery without CT and X-ray scans.

      Additionally, I have never seen an ER doc get a trauma surgeon without performing the CT scan. Plus you don't need a trauma surgeon for this if confirmed as appendicitis but a general surgeon. Finally, I have never heard of a trauma surgeon going in alone without a gen surgeon on something like this because during surgery this would be a general surgeon and the trauma surgeon would only assist.

      This would never happen in a level 2 or 1 hospital. Never. This sounds just odd.

      Delete
    4. Well thank goodness you aren't a surgeon then. In no textbook anywhere in the world does it say that any X-ray or CT scan is required before any surgery is done for anything.

      And apparently you missed that part in the "About me" where it says "I am a trauma and general surgeon". Besides, trauma surgeons ARE general surgeons.

      Idiot.

      Delete
  2. The correct answer was "the appendix is at pathology, now. if it comes back negative, then, yes, this was an unnecessary surgery which you forced on us by refusing to allow us to do a non invasive surgery on your adult daughter."

    ReplyDelete
    Replies
    1. correction: a non invasive scan on your adult daughter.

      Delete
  3. Yvonne reminds me of the helicopter parents of many of my patients in their early-mid 20's. They still answer for their kids, even when the question is "are you in pain?" They question every decision and know better, while their child lies there playing with their iPad. I agree with advocating for your family but let a grown adult speak for themselves.

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  4. I just can't wrap my head around why anyone would still want to be treated like a child at 20? I moved out at 17 and the taste of freedom was so sweet I never looked back. Don't get me wrong, my parents have always been happy to help out, but this is just... well, you said it best.. Crazy!

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  5. Lilly will probably be back with a bleeding ulcer if she stays with her mother too much longer. I can't even imagine growing up with that kind of overbearing, irrational mother.

    ReplyDelete
  6. Doc after reading this I was wondering if you had treated my fiancée because her mother is exactly like the one that was described. It's painful to watch her answer for an adult but the mother is so crazy that the fight that will be needed to make her grasp logic and let the 22 year old girl answer for herself because understands what is happening just isn't worth the effort anymore.

    ReplyDelete
    Replies
    1. just be aware this will not change after the wedding.

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    2. To echo Ken, and having kids will intensify whatever relationship you have with the in laws for better or worse.

      Delete
  7. ...and then there are those of us who just say "OK, go ahead," when we're in the ER waiting to get a CT scan and a couple of bright-eyed young med students come traipsing into our bay while dragging a portable ultrasound machine, and ask if we mind if they check us out. It was worth it to see them do a doubletake when they saw something unexpected on the screen--based on where they were on my abdomen, I had a pretty good idea of what they were looking at.

    "I have a Mirena IUD."

    "Ohhhhhhhh..."

    (They couldn't figure anything else out, though, and it took the CT scan to whittle down the 4 possibilities -diverticulitis, ovarian cyst, gallstones, or appendicitis; I already had a history of the 1st two--to appendicitis. A few hours later, my appendix was on its way to pathology, and I spent the next 3 days in the hospital on IV antibiotics, just in case.)

    ReplyDelete
  8. I'm one of those children with a crazily, overprotective mother. My stepfather and I developed a plan early on that I would schedule my Dr/dentist/optometrist appointments for while my mother worked, he would drive me, and we/I would only inform her if I was actually put on a prescription. The doctor & MOAs were so sympathetic they even agreed to tell her, "It was the only time we had available" when my mother inevitably called in to complain. For the record, I don't like lying to my mother, but she would kick up and loud and public fuss if I refused to let her into the examination room.

    I'm 27 years old and married; she has only just learned how to use the Internet and still harasses me every time I have a medical issue/appointment.

    ReplyDelete
    Replies
    1. My sympathies. At least you both realize the craziness and are able to work around it… and at least it took her this long to get online. Still… wow.

      Delete
  9. Wow, if I had been the daughter I would of punched the mother to be honest. The shit you put up with...

    ReplyDelete
  10. Okay in moms defense, my son had scoliosis surgery with tons of xrays and 2 CT scans, (all this before and after surgery) when I took my son for the 2nd CT scan the radiologist called the doctor to ask if the CT scan was really necessary because of the "massive amount of radiation he would be exposed to" The doctor then left it up to me. I reluctantly agreed. I went home googled CT scan and pediatrics and it scared me. So I can sympathize. Is there another way to rule out appendicitis without a CT scan?

    ReplyDelete
    Replies
    1. CT scans are not "massive" amounts of radiation. But yes, ultrasound is usually done in the paediatric population to rule out appendicitis.

      Delete

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