There’s a certain patient population that surgeons see too much of: a particular personality type among lonely middle-aged females, who tend to develop excruciating (to them, at least) abdominal pain, and turn up in clinics and ER rooms with distressing frequency. All too often, what they’re really looking for is a percocet script to last them through a difficult week. Unfortunately, it takes some expensive scans/consults/scopes to rule out other problems. (There’s more to this scenario, but I don’t want to give too many details; there’s a reason for my cynicism.)
I spent the last year figuring out that these patients do exist, and that some people with abdominal pain are never going to get better until someone (either a determined intern, an attending tired of hearing about them, or an efficient case manager) puts their foot down and shows them the door.
Now I have to relearn the fact that just because a patient fits a certain profile, she is not necessarily without real problems.
Two patients, actually. The first seemed a classic instance of nothing to treat. She’d been calling the office for a few weeks, complaining of vague abdominal pain, with alternating diarrhea and constipation (this kind of alternating symptomatology often turns out to be simply “irritable bowel syndrome,” which to my mind is GI-speak for “I have no idea”). Finally she came in to the ER; the pain was worse, she simply couldn’t stay at home. A CT scan showed nothing at all, not even anything to theorize about. She spent a few days in the hospital; we shook our heads every time we discussed her on rounds, and couldn’t think of anything particular to do. Eventually she felt better and went home.
But the calls to the office continued, and a week later she came back in. The pain had started at 3pm – precisely – and had never let up since. The CT scan was still impressively benign. But this time she looked so miserable that we had to rethink our conclusions. Plus, being able to pinpoint the exact moment the pain started is usually a bad sign. She was taken to the OR, and found to have a small fascial defect, with a loop of ischemic bowel inside it. Apparently the defect was so small that it was invisible on CT. The loop had probably been intermittently trapped in there for the last month, and this time it was squeezed tight enough to be ischemic, and swollen enough not to slide out on its own. The next day she was a different woman: walking laps in the hallway, smiling, anxious to get back home – and refusing any narcotics at all.
A week later, we got one of our favorite consults. The only time worse than five minutes before evening signout is ten minutes before morning sign-in. Do we have time to see the patient before the chief arrives? Is it better to do a quick job on the consult, maybe miss something in haste, or appear uninformed at sign-in, and then go take more time afterwards?
The patient was a retired gentleman who had been admitted by medicine with complaints nonspecific enough that the ER didn’t even consider a surgery consult. Overnight, he’d complained of increasing abdominal pain. A CT was at length obtained. The radiologist discussed various “unusual findings,” but couldn’t pin down anything specific. Most people who saw him were unimpressed, since he’d been admitted with a smorgasbord of nonsurgical issues (headache, leg swelling, palpitations, etc). But when we finally got to go through the CT carefully, we recognized the most classic case of an internal hernia I’ve ever seen. (These are usually difficult to visualize on CT, and radiologists often don’t call them; it takes a surgeon who’s been dealing with the population prone to developing them for years to have any reliable interpretation of them.) He rapidly earned a trip to the OR as well.
Take-home lesson: just because the last ten patients I’ve seen with this medical history and these complaints had absolutely nothing wrong with them, does not mean that this patient has nothing wrong with him. Each patient deserves a completely fresh slate, and a ground-up approach.