Monday 17 October 2016

Correct vs lucky

I can't tell you how many times I've said "Better lucky than good".  Well, I could tell you ("You can tell me, I'm a doctor"), but it would be nothing more than a wild guess.  And while some people may like making wild guesses (I call them "gamblers"), doing that in my line of work can occasionally (read: nearly always) be dangerous and/or reckless.  Fortunately I very rarely have to make wild guesses, since most of the guesswork is eliminated with the assistance of blood work, X-rays, and CT scans.  Oh, and also with the assistance of physical examinations and talking to patients.

Obviously stupidity aside, sometimes all the lab work and studies and tests in the world won't answer a question, and that's when I have to make the very uncomfortable decision of guessing.  At that point it is clearly an educated guess, but it's a guess all the same.

Such was the case with Raul (not his real name™) recently.

Raul was around 70, very healthy for his age, and came to the hospital complaining of abdominal pain.  This is an incredibly common complaint, and there are entire textbooks devoted to delineating the cause and treatment of abdominal pain (no seriously, look it up).  The problem with Raul wasn't necessarily his pain, but where it was located - in the left upper abdomen.  This is a very unusual site for pain, because in all the other parts of the belly we usually at least have some idea about what's going on:
  • Right lower quadrant: appendicitis, right kidney, Girl Part Problems
  • Right upper quadrant: Gall bladder, liver
  • Epigastrium: foregut stuff (stomach, duodenum, esophagus), heart
  • Mid-abdomen: midgut stuff (small bowel)
  • Left lower quadrant: diverticulitis, left kidney, Girl Part Problems
There really isn't much that can cause pain in the left upper abdomen other than the spleen, and that's such a rare problem outside of trauma that we tend to ignore it.  But Raul kept pointing to his left upper abdomen, saying that it felt like a sharp pain, but mainly when he sat up.  He had no other complaints, no fevers, no nausea, and he was moving his bowels normally.  

In case you are wondering why I mentioned that last bit, pooping is very important to general surgeons, almost as important as that big beaty pumpy thing in the chest whose name I forget.  Honestly, I'm halfway convinced that cardiologists have murmurs and extra heart sounds built into their stethoscopes because no one else can seem to hear them.

Anyway, I kept mashing on Raul's left upper abdomen and was rewarded with . . . absolutely nothing.  Not a grunt, not a wince, and no masses that I could feel.  Nothing.  Zip.  His ribs didn't seem to hurt either, nor did his back.  All the while he kept saying his left upper abdomen hurt, though not when I examined it.

Hm.  What the hell.

With a confusing exam in hand, Raul went off to the CT scanner.  As the pictures initially flew by, something strange caught my eye.  I went back over it carefully slide by slide, and there was definitely something wrong with his bowel.  There seemed to be a twist in the mesentery (the blood supply) of the small intestine known as a "whirl sign".  There were also a few loops of intestine in the left upper abdomen (of course) that were very slightly dilated, but they did not appear obstructed.  He had gas and stool throughout his colon, so whatever he was eating and drinking (and all the various fluids his body was making) was making its way through to the end.

Hmmmm.  What the hell.

I went back to talk to Raul and his wife, and I gave them the news.  I wasn't exactly sure what the news was, and I made sure to express that quite clearly to them.  I was not impressed with his exam at all, and while the whirl sign can be indicative of a small bowel volvulus (twist), most of the time it is not.  And since Raul had no nausea and was passing gas from below (yes, farting is also very important to general surgeons), his bowels were not clinically obstructed.  Armed with that very strange information, I explained that we had two options - 1) do something, and 2) do nothing.  I could immediately take Raul to the operating theatre to take a look inside and see if something was twisted, or we could watch him and see what happens.

I was unclear of the cause for his pain, because any gut pathology should refer pain to the  mid-abdomen, not the left upper abdomen.  But something was definitely off here.  I just didn't know what.  I didn't have a clear diagnosis, and I didn't want to guess.  He was having little pain at that point, so he and his wife sagely decided to wait.

I hate waiting.  I HATE WAITING.  I suck at waiting.  God damn it, I did not go into surgery not to operate.  I chose this field so I could FIX stuff, dammit!  Unfortunately sometimes not operating is the right thing to do.


I went to see Raul first thing the next morning, and he was feeling somewhat better.  He had been drinking fluids overnight still with no nausea, and he was still passing gas.  His pain, however, was not gone, though it was mildly improved.  I mashed on his belly again and he still felt no pain whatsoever.  I again presented him his two options: something or nothing.  I didn't feel that he needed an operation, though that was mainly a guess because something in his presentation gnawed at me.  Something about this whole situation Just Wasn't Right, but I still hesitated to guess what that meant.  We opted to wait another day.

The next day, Raul still had no nausea, he was drinking, and his pain had improved a bit more.  At that point I decided to send him home, with the understanding that if whatever he had returned, he would most assuredly need an operation.

I heard nothing from him or his wife the next day.  Success!  Huzzah!  No news is supposed to be good news.  Right?

HA!  No.

The next morning I woke up to an email from his wife saying that he had woken up at 2 AM (WHY THE HELL IS IT ALWAYS 2 AM??) with the same exact left-sided pain.  He still had no nausea, he was still drinking, and he still was pooping.  She also mentioned that their regular doctor had asked why the stupid consulting surgeon, who clearly was an idiot, didn't order a follow-up X-ray to see if the twist had untwisted, and he told them to head back to the hospital immediately.

Damn damn DAMN.  I was the stupid consulting surgeon!  What the hell had I missed?  Am I a terrible doctor?  Am I a shit surgeon?  I hadn't thought he needed an operation, but should I have just bitten the bullet and taken him for a potentially massive surgery?  SHITSHITSHITSHIT

I drove to the hospital trying to figure out A) what I was going to say to them when I saw them, B) when I was going to do his surgery, and C) how I was going to rearrange my schedule since I had patients to see in the morning and a lecture to give to medical students in the afternoon.  By the time I got there, he was already prepping for his repeat CT scan, and I nearly called the operating theatre to schedule him before seeing him.  But now something about him seemed . . . different.  He still looked quite comfortable, he had still been eating normally and passing gas, and his abdominal exam was still completely normal.  But his pain was significantly worse and now localised mainly in his left back.  

Wait, what??  Why in the world was his back hurting now?  What the hell is going on with this guy?  I must have missed the "Intestine bone connected to the back bone" day in medical school.  But it still didn't sound like any kind of bowel issue.  Did he have a kidney stone?  Some kind of weird lumbar hernia that I hadn't seen the first time?  Did he have a short in his internal wiring?  Or was it something else entirely?

I wheeled him over to the CT scanner personally to avoid any kind of delay.  The radiology techs seemed a bit startled to see a surgeon pushing a gurney, but I ignored their strange leers.  And just like last time, I watched the pictures as they flashed on the screen.  I scrolled through his scan picture-by-picture, and unlike last time his bowel looked completely and utterly normal.  The twist that had been there before was gone, and the oral contrast he had just drunk had traversed all the way to his colon.  There was no dilation, no obstruction, no inflammation, nothing.  But then I went back up to his chest and saw something completely unexpected: 


Raul's left lower lung was completely collapsed and filled with infection, he had a pleural effusion, and just to tie it all up with a nice little bow, he had a pulmonary embolus too. 

So I hadn't made a huge blunder after all.  The sigh of relief that I heaved was probably rivaled by the one when Mrs. Bastard said "yes", and I must admit I mentally pumped my fist several times as I walked back to Raul's room.  I also must admit I felt pretty shitty for doing so knowing that Raul was still very sick.,  He just wasn't surgically sick.

"I have good news, and I have bad news," I started with a bit of a smile.  "Which would you like first?"

"Uh, the good news," Raul's wife said.  She had a tendency to talk for him, as I've noticed many wives do.  No offence, ladies.

"Well, the good news is that you don't need surgery.  Your bowel is completely normal.  {dramatic pause}  The bad news is that you have pneumonia."


"Yes, pneumonia.  And a pulmonary embolus."

They were probably more surprised than I was at the diagnoses, but they were also both visibly relieved that surgery was not in their immediate future.  Though some people seem to enjoy undergoing painful and risky procedures, most people don't.  But just as I was about to leave, Raul's wife gave me an even bigger surprise.

"That's actually not the bad news," she said.  "The real bad news is that we won't need to see you anymore."

I'm sure I blubbered and gibbered nonsensically as she asked if I was absolutely sure that I didn't want to be Raul's and her GP.  I am fairly certain I blushed, and I haven't blushed in years.  Decades, even.

Raul stayed in hospital for a few days getting antibiotics, and he felt like a new man (not really) when he went home again.  But before they left they both made sure to ask one more time if I would be willing to be their GP.  I wanted to say that no one in his right mind would want to be a GP, but that would be an insult to GPs everywhere.  Instead I just politely smiled and declined.

But seriously, why would anyone want to go into internal medicine?

I could probably answer, but it would just be a guess.


  1. Wouldn't Raul have had shortness of breath and low 02 levels with a collapsed lung?

    1. My mother is a serial pneumonia victim and has actually had a partially collapsed lung (top) and didn't know it. She never has shortness of breath during these episodes, she just gets so worn out that she can barely function. So I think it may be possible to have very bad pneumonia with a partially collapsed lung and not realize that's the problem, especially when it hasn't been an ongoing issue. With my mother we're almost at the point that if she coughs once or twice we want her in to have her lungs checked.

    2. My infant son had a subglottic cyst on his throat that was blocking 99% of his airway. His O2 sats were still in the upper 90s.

  2. Likely a pulmonary infarction after an embolus, possibly became infected.

    1. PE probably showed up on the CT scan secondary to other risk factors.

  3. I've noticed in recent years that doctors, and various local health agency public information campaigns, including the CDC here in the USA, have started to recommend pneumonia vaccines for *all* older adults now (starting at age 60 or 65), not just those in the "very frail/very elderly/high risk" category, as was done in the past.

    It makes sense, when we consider the fact that as life expectancy in the technologically-advanced countries increases, there are more and more older adults like Raul, who are in "generally good health," so tend to remain more active amongst the general population. Many people postpone retirement, either due to economic needs, or because they just want to continue to be involved with their work. Others who retire take on second careers in volunteerism, or finally realize their ambitions of travel. Many are well and active enough to enjoy regular activities with grandchildren and even great-grandchildren. So, even though our immune systems tend to become a bit less efficient with age, more older adults are "out there" interacting with the rest of the world, and all the germs that live in it too :)

    My own mom was hospitalized a few years ago, when we pretty much hauled her off to the ER in protest because she just "didn't have any energy." Turned out that her *major* issues were a need for adjustment in her diabetes management (she needed to switch from a mild oral medication to once-a-day insulin) and a minor cardiac arrythmia had escalated a bit to the point where her cardiologist recommended a pacemaker for better regulation. But we were *all* surprised to find out that she had a mild case of pneumonia too. She'd had no coughing, fever, pain, or other symptoms that we would have *expected,* and she thought she'd completely recovered from a mild cold she'd had a month or so previously. Fortunately, it wasn't serious, so all went well. But of course she got her pneumonia shot at her very *next* physical!

    1. Walking pneumonia. It's the only type of pneumonia that walks from person to person. The symptoms are "mild" enough to allow you to do daily activities and do not require hospitalization.

  4. better still to be lucky AND good. unlike the patient's GP, who, in this case, was neither.

    but on the subject of lucky and good. this just happened.

    the surfer was lucky in that there was a trauma nurse on scene. he was good in the fact that HE was the trauma nurse and was still able to direct HIS OWN emergency care, until they got him to the paramedics.

  5. This is similar to making a brain death diagnosis. You're either correct or you can prepare to dish out millions for supportive care.

    1. nowadays a brain death diagnosis can be corect and the taxpayers STILL have to dish out millions for undeath support.

    2. They're hoping for another differential diagnosis and other god given rights in the Bible.

    3. When the Bible mentions eternal life it isn't referring to the earthly realm.

    4. If I was the surgeon operating on a patient and he died on me, and his spirit was hovering above his own body looking down on it, I would take out a $100 bill, flash it at the spirit and then stuff it in the hand of the dead body. This would coax the spirit to return to his body. If that didn't work, I'd put the body's hand on the breast of a nurse. That ought to do it. In any case, I'd take the $100 bill back before he woke up.

  6. I'm a little late to the comment party of this one. Sorry about that. I had pain in the upper left quadrant. It started when I was around 18. It took them until I was in my 40's and it got infected to figure out it was my gallbladder. I had atypical pain. Slightly to the left of my breastbone, right below the ribs. Episodes of excruciating pain and then nothing for up to several years at a time.


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