Every Patient Tells a Story
Page 15
The score is useful for those at the extremes—patients with a score of 4 or less and those with a score of 7 or more. But what do you do with those in the middle? Those who have signs and symptoms that suggest appendicitis but whose scores don’t put them in the definite category? That’s when technology comes in handy. CT scans can correctly distinguish between those who need surgery and those who don’t almost 100 percent of the time. Using both the Alvarado score and CT scans in cases when the diagnosis is unclear has been shown to be very effective and reduces the rate of negative appendectomies to nearly 1 percent.
If the CT scan is so good at showing who needs to go to surgery, why not use it all the time? Why not take all patients with possible appendicitis pain straight to the CT scanner? In fact, that is what has happened. CT scans are routinely used to evaluate virtually all patients with abdominal pain. But a recent study suggests that this may not be the best strategy. Herbert Chen and others at the University of Wisconsin looked at the records of 411 patients diagnosed with appendicitis. Two thirds had a CT scan before going to the OR. In the other third, the decision to take the patient to surgery was made based on the history, physical exam, and laboratory findings. What they found was that those who had the CT scan had a much higher rate of complications than those who went straight to the operating room. And the rate of perforations was twice as high in those who had the test. Why? The authors speculate that it was the slower time to the OR. The third that didn’t have the CT scan went to the OR within the first five hours of their arrival in the ER, while those who got the CT scan had to wait almost twice as long for surgery.
Despite the research, this is still a remarkably hard sell. In my community hospital Dr. Jeff Sedlack is in charge of teaching general surgery residents. For years he lamented the fact that his trainees took virtually all patients with abdominal pain straight to the CT scanner, skipping the exam completely. He got tired of complaining, so eventually he decided to try something new. He set up a competition. Surgical residents would get one point for every patient with a suspected appendicitis that they examined and calculated an Alvarado score for. Patients who had a CT scan before being seen by the resident were disqualified. The trainee with the most points would win a small prize.
The residents took the competition seriously. One second-year resident got a bonus when he was able to persuade the ER doctor that the patient had a clear diagnosis of appendicitis without the expensive test. Instead of taking the patient to the CT scanner, the surgeons took him to the OR, where a pus-filled appendix was quickly removed. The competition was a tremendous success. The rate of CT scans went down, complications went down, and as an additional benefit, says Sedlack, the residents’ exam skills improved dramatically. The next year the competition was brought back—by popular demand.
The presence of abdominal pain and tenderness can be extremely useful in making a diagnosis. Sometimes the inverse is also true: seeing a person in pain when that pain cannot be elicited by touching can also be informative.
The Dog That Didn’t Bark
It was July 1, my first month admitting patients as a resident. As an intern I had a resident at my side supervising my every move. Now I was the night float resident—taking admissions after the on-call team had reached their quota of daily admissions. My presence allowed them at least the possibility of sleep. It was exhilarating and a little scary being on my own this way. I knew there was always someone with more experience around—should I need them. Still, I was nervous.
I got my first call from the ER at around two a.m. A woman had been brought in from a nursing home by ambulance. Over the clatter of a busy ER the doctor spoke in the coarse, cryptic patois of medicine.
“We got a sick, demented eighty-seven-year-old female, name of Carlotta Davis. Sent from an ECF [extended care facility, or nursing home] with acute change in mental status. She’s got a history of hypertension, CAD [heart disease], and a three-vessel CABG [heart bypass surgery] twenty years ago. She was out of it when they came to tuck her in, so they sent her over. Nothing on exam except a borderline low BP [blood pressure]. Labs showed a white count of sixteen [that’s high] and a dirty [infected] urine. We sent her up on IV Cipro [an antibiotic] and a liter of saline [for the low blood pressure]. We’re getting slammed down here so I gotta go.” And the line was quiet again.
Here’s rule one you learn as a house officer—never just accept the emergency room’s diagnosis. It’s their job to determine if a patient is sick enough to be hospitalized. They like to give a patient a diagnosis because the paperwork asks for one and they often have a good idea of the problem. But they don’t have the time or the resources to determine the diagnosis for any but the most obvious cases. Rule two: if the ER says someone is sick, go see them right away. They know what sick is.
“Mrs. Davis,” I said softly as I entered the darkened room. I heard a long, deep moan. I turned up the light to reveal a tiny woman engulfed by pillows and blankets, moving restlessly in the bed. I crossed the room to the bedside and introduced myself. The patient lay with her eyes squeezed shut, shifting from side to side as if looking for a comfortable position. Her legs whispered to me as they slid back and forth continuously across the rough white sheets.
“Carlotta?” I tried again. No answer. I touched the thin skin of her wrists. She was warm and her pulse rapid but barely palpable. Her blood pressure was low—same as it had been in the ER.
“Can you open your eyes, Mrs. Davis?” Again she didn’t answer. If anything, she squeezed her lids even tighter, as if opening them would make the unbearable even more so. Just the moan and the near constant motion on the bed. Was it pain that was causing this movement, or delirium? Could be either. I listened to her heart, then slid my stethoscope beneath her bony back to listen to her lungs. I pulled back the covers and hospital gown to reveal an unexpectedly rounded stomach. Why wasn’t her stomach as thin and as flat as the rest of her tiny slender frame? I rested my stethoscope on the mound lightly. Silence. I forced myself to listen for a full minute. Normally the gut is always making noise. Not this gut.
The emergency room doctors found that she had a urinary tract infection and were concerned it had spread to her blood. They’d already started her on intravenous antibiotics. It was a common cause for hospitalization among the elderly and frail. And sometimes a severe illness can cause the gastrointestinal tract to shut down temporarily. Was that what was going on or was there something else? I carefully examined her abdomen. I felt no masses—no tenderness, either. She never flinched, never reacted to even the deepest touch. She was clearly in pain, but what I was doing didn’t seem to affect it.
I pressed my fingers firmly down over her bladder. She had an infection here—was this the source of her pain? No reaction. I squeezed and thumped her flanks where the kidneys were hidden. Was the infection there too? No change in her restless movement. I finished my exam, carefully looking for any other potential sources of discomfort. No bedsores; no swollen, painful joints; no redness anywhere. Nothing that would account for the terrible restlessness and the haunting moans that escaped her lips every few minutes.
I had cared for many patients with urosepsis but none of them had looked like this. I ordered a small dose of morphine. We’re taught not to treat pain until we know where it’s coming from but I wanted to see if it gave her relief—if her distress was from some unfound source of pain. The morphine stopped the restless movement, but the moaning continued. I still didn’t know whether it was pain or delirium.
According to the aides at the nursing home, the patient had complained of abdominal pain earlier that day. She may have had an infection in her urine but she didn’t seem to have any pain in her bladder or kidney. What else could it be? In this age group cancer was likely. Did she have a colon cancer that was obstructing her bowels? Her stomach was soft, easy to examine, and I hadn’t felt any of the firm linear masses that suggest stool trapped in the colon. A gallstone could cause fever and an elevated white blood cell
count, but I would expect that to cause pain when I palpated her right side. There was none. Same with appendicitis, kidney stones, pancreatitis, a perforated viscus—all caused tremendous pain but those pains were usually localizable. I couldn’t think of anything that could cause a pain this intense that couldn’t be made worse with pressing.
And her blood pressure was still too low. I ordered another liter of normal saline. In the very ill, inadequate fluid in the bloodstream due to not eating or drinking or to excessive sweating can cause blood pressure to drop. Replacing that fluid will often restore a normal blood pressure. If her blood pressure didn’t come up with this fluid, she’d have to go to the intensive care unit to get medicines to restore it.
I sought out Dr. Cynthia Brown, the third-year resident on call in the ICU. Cynthia was a lively, down-to-earth redhead who had been a physical therapist before going to medical school. Older than most of the residents, and like me, a southerner, she and I had bonded almost instantly. I found her at the nurses’ station drinking hot tea and reviewing charts. She hadn’t been to bed yet but looked remarkably awake and cheerful. She greeted me enthusiastically. I briefly laid out the case, running through my differential and my misgivings.
“There’s something more going on but I can’t figure out what. And I’m not even sure where to start. Do I send her down for a CT scan? And what of? If I don’t get her blood pressure up, she’s coming to you anyway.”
Cynthia thought for a moment.
“She has heart disease?” she asked.
She did.
“And her blood pressure is low?”
It was.
“Would you say that you thought she had pain that was out of proportion to what you found on physical exam?” she asked.
Absolutely.
“Those are the classic symptoms of ischemic colitis.”
Like so many terms in medicine, the words themselves tell you much of what you need to know about this disease: ischemia—from the Greek isch, restricted—and hema, meaning blood. Restricted blood flow to the colon. It’s a disease most commonly seen in the elderly, often under conditions of a significant infection. I knew about this entity, of course. It’s in my Harrison’s—the textbook I used to learn about diseases. But the “pain out of proportion to the exam” isn’t in Harrison’s. Or in any of the other textbooks I’d reviewed. It’s part of the oral tradition in medicine, picked up—like so much else—the hard way, by not knowing. Still, I should have at least included it in my list of possibilities. She was a perfect setup for it. My face burned as I realized that, of course, ischemic colitis was the most likely diagnosis. And I had missed it.
“Just remember, the reason you took this miserable, low-paying job was because of the education.” Cynthia smiled as she repeated back to me the words I’d said to her once as an intern. As I hurried back to the patient’s room I boiled with frustration. How was I ever going to master all this? I read the textbooks, the little books of clinical pearls, the countless journal articles, and yet with a classic presentation of a classic little old lady disease I’d missed the boat. Internal medicine seemed suddenly, once again, completely overwhelming. It is vast; it is constantly changing; it is unmasterable. A resident I’d known during my intern year had recently shared with me her decision to leave internal medicine and go into dermatology. Why? I’d asked. She said, “Because I want to be right more often.”
With the diagnosis of ischemic colitis in mind, it was easy to reconstruct what must have happened. The patient had an infection, which caused her blood pressure to drop. She had hardened and narrowed arteries—that was why she had the heart bypass surgery years ago. Low blood pressure and bad arteries together can cause some parts of the body to be starved of new blood and oxygen. The pain she felt was the tissue dying for lack of oxygen. It’s a terrible disease and often requires surgery. Mortality is high—in part because only those with multiple illnesses and poor overall health tend to develop this disease.
The room was quiet when I returned. The morphine finally allowed the patient to sleep or at least to stop moaning. And her blood pressure had crept up with the additional fluid. An X-ray confirmed the diagnosis of ischemic colitis. I called the patient’s primary doctor and, at his request, the surgeons.
Additional admissions sent me scrambling down to the emergency room. I returned a couple of hours later to see how the patient was doing and what the attending physician had done. She’d been evaluated by the surgical resident, who wanted to take her to the OR. New labs suggested that there was dead tissue that needed to be removed.
Her family did not agree to the operation. She had already made her wishes known to them—no extraordinary measures, no surgery. They would control her pain, the family instructed, and see what happened. If she survived, so be it; if not, at least let her slip away peacefully. Her daughter would be in as soon as she could get there. I went in to see the patient before I left that morning. The room was quiet but now filled with light from what looked to be a glorious summer day beyond the window. She lay unmoving on the bed; her eyes remained closed but the muscles of her face were finally relaxed. The delicate pale skin of her face draped gracefully over her cheekbones, like a sleeping beauty never found by her prince.
Although there was nothing I could do for her, I dropped by to see Carlotta the next night, and the night after that. She never woke up when I called her name or touched her thin shoulder. The room slowly filled up with cards, colorful drawings, and flowers. “We love you Grammy,” neatly outlined in black and roughly crayoned in primary colors, was taped to the wall across from her bed so that it would be the first thing she saw when and if she opened her eyes. Toys stored on the deep window ledge suggested at least one grandchild or great-grandchild was a regular.
When I came by the fourth night the room was empty. The cards and drawing were gone; the bed, crisply made, waited for its next occupant. Standing in that doorway, I said my own goodbyes to this woman. This is how every doctor learns, often by standing at the bedside of the patients she didn’t save. And this is how doctors pay their own private respects. I have diagnosed this disease and others similar to it, and every time I make the right call, I see Carlotta’s face once more.
Hand to Hand, Mind to Mind
Part of the romance, the appeal of the physical exam—at least for me—comes from the way it’s taught. I learned from the individual physicians who instructed me. They, in turn, had learned it from the physicians who taught them, creating a line of transmission that extends backward, like genealogy, to the originator. Emphasizing the personal nature of this transmission, the examination maneuvers or techniques often carry the name of the doctor or sometimes nurse who created them. Spurling’s sign, named for an early-twentieth-century American neurosurgeon, describes the maneuver Roy Glenwood Spurling developed to see if a pain in the arm or hand originated in the cervical spine. In this maneuver the head is tilted toward the side with the pain and then the physician presses straight down, compressing the soft discs between the bony vertebrae. If this reproduces the pain, reported Spurling in a paper published in 1944, the pain can be attributed to a pinched nerve in the neck, a useful tool in the days before MRI and still routinely taught as a way to evaluate arm pain.
Tinel’s sign was named after a French neurologist, Jules Tinel. He developed the test while caring for World War I soldiers with injuries due to gunshot wounds. Frequently, once the wounds were healed, sensation and strength would still be limited due to damaged nerves to the region. Tinel would tap on the nerve just before it entered the injured extremity. If the patient felt tingling in the damaged area, said Tinel, the nerve was recovering and the soldier could expect to get back some sensation and use. These days, it’s commonly taught as a method for diagnosing carpal tunnel syndrome, an overuse injury of the median nerve that causes numbness or tingling in the thumb, first finger, or second finger. If a tap on the wrist reproduces these symptoms, the patient is said to have carpal tunnel syndrome.
Tinel’s sign is just as worthless in diagnosing carpal tunnel syndrome. People who have carpal tunnel syndrome may have tingling when the nerve is tapped, but so will people with other problems. And many people with carpal tunnel syndrome won’t feel the diagnostic tingling when tapped. So it can’t reliably identify either those who have it or rule out those who don’t.
The individual components of the physical examination were developed when physicians had few other means of diagnosing problems. Any sign or symptom that was found useful at the time was welcomed into the fold. Unlike modern (and expensive) high-tech tests or medications, there was no requirement for any of these exam techniques to be evaluated. And often, when these techniques were developed, there was no way to tell if the tests were right or not except by surgery or autopsy. As technology improved, so did our ability to test our tests. But we’re only beginning to do that. In the meantime, doctors keep teaching them.
A colleague, Dr. Tom Duffy, told me about a test I’d never heard of, and about a patient for whom it made an important difference. Michael Crosby was a young man—healthy and active with no medical problems at all. Michael remembered clearly the moment he became aware that he was ill. It was his second day of teaching. A new job, a new school. He was giving the class a quiz and as the students worked he paced between their desks. Their heads were down, pens in hand, eyes moving from the words on the board to their own papers as they worked their way through the first test of the year.