by Lisa Sanders
If the potassium was high because of his kidney failure, what had caused his kidneys to fail? Dr. Peter Sands, the intern on call in the ICU, gnawed at this question as he reviewed the chart and results of all the tests that had been done. It wasn’t a drug error. The patient’s medication box showed the correct number of pills. And it hadn’t been a heart attack; a blood test proved that. Sands looked for the results of the urinalysis to see if there was any clue there but he couldn’t find it. Somehow no one had sent any urine to the lab. Were his kidneys too damaged to produce urine? That would be critical to know.
Sands asked the nurse to get some urine from the patient. She returned empty-handed. The patient couldn’t urinate; he told her he hadn’t been able to since the night before. The nurse hadn’t been able to insert a Foley catheter, a rubber tube that is passed through the urethra into the bladder to collect urine. Was something blocking the urethra? A urology resident finally managed to get a catheter into the bladder and immediately urine gushed out of the tube—nearly half a gallon of it. A full bladder comfortably holds a little over a cup of urine. Charlie’s bladder had held just under eight. The urology resident looked at the intern: “I guess now we know why his kidneys weren’t working.”
The urethra was blocked—by the prostate gland. The prostate surrounds the urethra, and when it enlarges, as it often does with age, it can impinge on the narrow outlet, obstructing and ultimately blocking it so that no urine can pass. As the trapped liquid filled the bladder, stretching it far beyond its normal capacity, the pressure shut down the patient’s kidneys. Just hours after the obstruction was relieved, Charlie’s potassium began to drop as the kidneys went back to work. Four hours later, his heart rate was up over sixty. By the next morning, the abdominal pain, probably caused by his hugely distended bladder, had eased. When he left the hospital three days later, his potassium and heart rate were normal and his kidneys nearly so. He would have to keep the tube in his bladder until the obstructed tube could be opened.
In the hours before his diagnosis, Charlie was seen by at least two nurses and three doctors. He had complained of abdominal pain. How is it possible that none of these doctors or nurses noticed that his bladder, normally the size of a hockey puck, was the size of a football? Charlie’s a slender man, over six feet tall and weighing only 140 pounds. His belly is normally flat. I didn’t see him that day, but I’m guessing it was distended and tender. No one noticed, I suspect, because no one looked.
No one examined Charlie Jackson—until it was almost too late.
The Delirious Doctor
As a practicing physician, I understand the temptation to skip the physical exam. A sick patient comes in and you are so focused on the thing that you are certain might kill him that you don’t think of looking at anything else. There’s a kind of anxiety, a controlled adrenaline-fed panic, when facing a patient who could die before your eyes. You pore over the labs and the studies. You get the consult. You send him to the ICU. But you don’t examine him. That’s not what doctors do anymore, in part because they no longer know how.
So thoroughly has this lesson been absorbed that doctors—those in training and out—often don’t even notice when the loss of this creaky old antique makes a classic diagnosis impossible. I frequently attend medical conferences with the hope of finding cases for my newspaper column. I ran across a perfect example of this at a recent conference of the Society of General Internal Medicine, a gathering of academic physicians.
Judy Reemsma, a third-year resident, stood by her poster in the rabbit warren of partitions that make up the display halls where residents and medical students display research and case reports. She spoke with confidence about the case presented in her poster. She should—in this case she was both the doctor who made the diagnosis and the patient.
During her second year of medical school Reemsma became ill and was taken to the emergency room by her fiancé, David DiSilva. Assigned to the case was Dr. Jack McFarland, an emergency medicine resident and close friend of Judy’s.
McFarland, tall and slender with a slight stoop to his shoulders, greeted his friend from the doorway one spring evening in 2004. “What are you guys doing here?” he asked. It was strange to see her there. And shocking for her to be out of the usual scrubs and white coat, dressed in the flimsy johnny coat that marks you as the patient.
As McFarland traded quick pleasantries with David, he tried to assess Judy’s condition. She looks okay, he thought. Her heart was racing; the tracings on the heart monitor sped by at 150 beats per minute. Her blood pressure was high and though she did appear anxious, she didn’t look particularly sick.
And then she began to speak. A wild river of words poured from her mouth. Random phrases, meaningless sentences, rapid incoherent paragraphs. There were snatches of sense scattered throughout the discourse but they were nearly drowned in the rushed torrent of speech. McFarland was stunned. He looked at the young man, who nodded. This was why they’d come.
Judy had been fine all day, David told him. He had the day off from work and they’d been together most of the afternoon. She had classes in the morning. Came home and studied. They’d gone to the gym and then made dinner together. Afterward, she’d gone upstairs to study. Maybe an hour later she’d complained of stomach pains. And the computer screen looked blurry, she told him. She decided to go back to the bedroom and lie down.
Another hour later he’d heard her fall—he rushed upstairs and found her on the floor crying uncontrollably. When she spoke, her words made no sense and it was clear to him that she was confused. That’s when he started to get scared. Coming here she’d been so unsteady on her feet that he’d practically had to carry her to the car.
The patient was twenty-seven, athletic, and had no significant medical problems. She was taking an antidepressant, Paxil, and had been given another, Elavil, to help her sleep. But, David added, Judy didn’t like the way the Elavil made her feel so she didn’t take it anymore. She didn’t smoke, drank only occasionally, never used illicit drugs. As McFarland and Judy’s fiancé went through her history, the patient moved restlessly on the gurney. At times she would try to answer the questions, but her speech was jumbled—a word salad carrying little useful information. She seemed unaware that she wasn’t making any sense.
“I need to examine you; is that okay?” McFarland asked the patient tentatively. She nodded her consent. The lights in the room had been turned off and when the doctor turned on the light, Judy cried out and covered her eyes. “Oh yeah, the light’s been bothering her since we got here. That’s why we turned it off,” her fiancé told him. McFarland reluctantly dimmed the lights. She had no fever. Her mouth was dry and her skin was quite warm though not sweaty. The rest of her exam was normal. He tried to perform a thorough neurological exam but the patient was too confused to cooperate. An EKG showed no abnormalities beyond the rapid heart rate.
McFarland thought carefully about his friend, now his patient. For almost anyone with a change in mental status, illicit drugs had to be at the top of the list of possible causes, as unlikely as that seemed in this case. In addition, she had been prescribed a medicine—Elavil—that could cause many of these symptoms when taken in large doses. She had a history of depression, and her fiancé had been out of town frequently over the past several months. Was she suicidal? Could she have taken an overdose? That could cause the rapid heart rate and confusion. He knew that a high dose of Elavil causes blood pressure to rise initially, but that the real danger came later when it can drop precipitously. Her pressure was high, dangerously so. Maybe she was in the early stages of the reaction. On the other hand, it was hard for McFarland to believe that his friend had been that depressed. She’d seemed fine when he saw her last.
Perhaps she didn’t have simple depression—maybe she was bipolar and her antidepressant had moved her from depression to mania. That could cause the pressured speech, but would it cause the very high blood pressure? And he knew her; wouldn’t he know if she was bipolar?
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Or could she have too much thyroid hormone? The thyroid is the flesh-and-blood version of a carburetor—working to regulate how hard the body’s machinery works. Too little of this hormone and the body slows down. Too much and it speeds up. That could cause the tachycardia and the hypertension and sometimes pressured speech and confusion.
He questioned the patient’s fiancé. Had she ever shown signs of mania? She had a history of insomnia, and sleeplessness was one sign of both mania and thyroid overload—was she up all night? No, until this evening she’d been fine, he insisted. She had been depressed, but that had all but disappeared after starting the Paxil—and that was months ago. Her sleeping was no worse than usual.
David paused. There was one other thing: after dinner he’d felt a little funny too. Not as sick as Judy, but his heart had been racing and he’d felt a little nauseated—though he felt fine now. They’d eaten some lettuce from their garden that night. Could their symptoms have something to do with that? Hearing this, the resident immediately thought of a patient he’d seen not long ago who had eaten pesticide-tainted vegetables from his garden. That patient had nearly died. But he’d been much sicker than this young woman. Moreover, his symptoms were the opposite of hers; his heart rate had been slow, his blood pressure nearly undetectable. He’d lapsed into a coma not long after arriving in the emergency room—they’d had to intubate that patient because his lungs had filled with water. Overall, a very different clinical picture.
Still uncertain, the doctor ordered some routine blood tests to look for the presence of an infection or an imbalance in her blood chemistry. He checked the thyroid gland. He also ordered a urine test to look for illegal drugs and Elavil, the medication she had been prescribed for sleep.
As the doctor waited for the results of the tests he’d ordered, the patient became more and more agitated. She kept getting out of bed and walking into the chaotic hub of the emergency room. Once she put on gloves and picked up the chart of another patient as if she were at work. Several times the nurses had to guide her back to her own bed. Lying on her gurney, she seemed to talk to people who weren’t there, pointing to and batting at creatures no one else could see. At times she quieted down, mumbling words that her fiancé couldn’t understand.
The results of the tests dribbled in but provided no additional clues. The thyroid hormone was okay. The drug screen was completely negative. There was no trace of Elavil. What was going on?
By dawn the patient’s blood pressure had come down into the normal range, but her heart rate remained high. She was less confused. But she was still far from normal. Was this part of some underlying illness? She had an MRI of her brain to look for evidence of a stroke, a CT of her chest to look for tiny clots. Both scans were normal. After four days the patient had completely recovered and she was discharged, her diagnosis still unknown.
At home, Judy was troubled by her brief episode of madness. The unanswered questions were frustrating.
That afternoon she wandered out to the garden to do some weeding, and her attention was immediately drawn to an uninvited guest growing in her lettuce patch. Among the green and purple leaves she and her fiancé had planted were several strikingly beautiful white flowers, blossoms that hadn’t been there before and that she was certain she’d never sown. Could the early tendrils of this plant have been mistaken for lettuce and ended up in her salad? She pulled the three plants up by their roots, put them in a Baggie, then drove to a nearby nursery.
As she pulled the plants from the bag to show the owner, the woman exclaimed, “Don’t touch those plants! They’re highly toxic. That’s jimson-weed.” Also known as the devil’s trumpet and sometimes as loco weed, this plant has been known to cause a temporary kind of madness in man and beast for centuries, the woman explained. The symptoms caused by the active ingredient found in this plant are so well known that there is a mnemonic widely taught in medical school to identify its symptoms: mad as a hatter, blind as a bat, dry as a bone, red as a beet, hot as a hare.
As it turned out, the patient had had all the classic symptoms: the plant’s toxin makes you blind as a bat because it makes the pupils dilate. (This chemical is still used by ophthalmologists for that very purpose.) And she was quite flushed, according to her fiancé. McFarland missed both symptoms in the emergency room because he had turned down the lights to alleviate his friend’s discomfort. Her mouth and skin were noted to be dry and of course the madness was clear, but this wasn’t enough to make a diagnosis. By the time the other doctors in the hospital saw her, most of these characteristic symptoms had resolved.
I asked Dr. McFarland why he thought he had missed such a classic presentation of this well-described syndrome. “I’ve thought about that. A lot, actually. I think my friendship with the patient made it difficult for me to really put on my doctor’s hat. I never was quite able to see her as a patient.” The doctor-patient relationship requires a certain distance that the resident wasn’t able to impose on his friend. “You want to sort of keep your eyes averted, intellectually, when you’re taking care of someone you know. You need to dig and yet it’s uncomfortable.”
But there’s something else going on here too. McFarland didn’t insist on being able to turn on the light to examine his patient completely. Would he have been that blasé if the patient had refused to allow him to take her blood or urine for tests or balked at the idea of a CT scan? Why didn’t he insist on having the light up so that he could perform the exam properly? Could it be that he didn’t believe that the physical exam would provide any useful information that would allow him to make a diagnosis? Ultimately, of course, that loss of faith becomes a self-fulfilling prophecy. If you don’t expect to see something, how hard are you likely to look?
And because he didn’t insist on seeing her in the light, he didn’t notice that she was flushed or that her eyes were oddly dilated in the bright light of the room. Opting to leave her in the dark, he unintentionally left himself there as well. He missed two essential clues that might have allowed him to solve the mystery of her illness.
The Science of the Senses
It’s been over fifteen years since Salvatore Mangione published his groundbreaking studies on the loss of physical exam skills among physicians. The studies have prompted active and passionate debate but little action, and even as these skills wither in the subsequent generations of doctors, we still have no idea what effect this change may have had on our ability to take care of our patients. Can technology replace these skills? Or will the loss of the exam damage our ability to make a timely diagnosis? With few studies done, we have no better idea of that now than we did in 1993. But anecdotal information suggests that there is a great deal being lost.
Doctors are not known for their rapid embrace of the new. Medicine has held on to the paper chart long after virtually every other industry and profession has made room for electronic efficiency. Physicians are so reluctant to change the way they practice medicine that it takes on average seventeen years for techniques well established by research—such as giving an aspirin to a patient having a heart attack—to be adopted by even half of those in practice. In other words, it usually requires an entire generation of doctors to turn over for a single new practice to become routine, part of medical “tradition.”
Medical training itself has not effectively changed since the end of the nineteenth century, when Sir William Osler developed the hospital-based residency system as a method for standardizing and institutionalizing medical apprenticeship. Changes that have been imposed on doctors—for example, the eighty-hour workweek—have been derided and abhorred by them from coast to coast.
And yet physicians and even patients have seemed willing, even eager, to abandon the physical exam, painstakingly developed over the past two centuries, and allow its erosion to advance unchecked. Undoubtedly medicine’s characteristic conservatism has contributed to this loss. The almost pathological unwillingness to change the way new doctors are trained in the face of a rapidly transforming e
nvironment has helped bring about one of the most radical changes to how medicine is practiced in its history.
Nonetheless, over these years there has also been a growing sense that the physical exam can make an important contribution to our ability to understand the patient and his disease. With this acceptance has come a new set of once unaskable questions: Which parts of the physical exam are valuable and worth saving? Which parts could and should be disposed of? And once we get a better handle on which are worth saving, how can we incorporate this into the education of our new doctors?
In the next few chapters I will examine each of the several parts of the physical exam, looking at the way each works to provide clues to the mystery of the diagnosis. We’ll look at each part in the order we are taught to perform them: first by observation, then by touching, then by listening. Each method of evaluating the patient directly through our senses provides immediate and essential information. Each has its own limitations.
Once the exam is broken into its component parts, can we then identify which parts are important and useful and should be kept and what turns out not to be so valuable after all? If it is possible, if we can separate out those parts of the physical exam that are useful and discard the parts that are not, we will be left with a physical exam that is leaner but keener. If not, and the physical exam is lost, we will end up with a health care system that is slower, less effective, and more expensive—a high-tech, low-touch system that fails patients along with the doctors who care for them.