Sometimes they live

A patient walked out on me the other day.

It doesn't happen every day, but it happens often enough.  I usually never find out why.  Sometimes it's to go pick up children or meet another time-sensitive obligation.  Sometimes it's to go smoke a cigarette or get a dose of drugs.  I think sometimes they get scared and feel as though running from the department can help them escape their diagnosis.  Whatever the reason, I learned early on that I have to be able to let those people go.  The other side of the patient autonomy coin is this: they're responsible for getting the care they need and it's not my job to force or coerce them.

Except when it is.
-------

"My stomach really hurts."

I sighed internally. Another belly pain. Any ER doc can tell you abdominal pain is one of the vaguest, most potentially frustrating complaints that we see.  It could be anything.  Dissecting aorta?  Gas pain?  Sure, I don't know, maybe.  Sometimes it turns out to be a horrible emergency. Sometimes I send dissatisfied patients home without a diagnosis because all of my work up was negative. There's often no way to tell in advance.   This lady didn't look too bad just sitting back in bed, although that can be a trick in a patient who is naturally stoic.  Vital signs looked normal.  I listened to her story.

"I've never had pain like this, doctor.  It's been there for days, just comes and goes, but today it's not going away and it's been there the whole afternoon.  It hurts so bad, right here."  She gently pushed on the right lower side of her abdomen.

I nodded, now mildly concerned.  Pain that gets worse or is the worst pain a person's ever felt can be a worrying thing.  It can also be crap (figurative or literal).  She was gesturing to the part of the abdomen that contains the appendix, which is not good, but at the same time she was sitting up and pressing on her own abdomen, which is generally a good sign.  On the badness/ not badness scale, she was still squarely in the middle. 

I did a quick exam.  The right side of her belly was a little bit tender when I pressed on her. "Do you still have an appendix?"

She squinted.  "I think so?" (You would be surprised how often people are not sure which organs they still have.)

After another internal sigh, I grabbed her chart and turned to go. "Well, let's check some lab work and a urine sample.  I think I'd also like to get some imaging of your abdomen."

She shook her head. "I don't want any imaging.  Can we just do the blood work and see what that looks like first?"

Eh?  Whatever, fine.  We're not that busy and she doesn't look sick.

A short while later, the patient was saying that her pain was worse despite two doses of IV pain medicine, and all of her bloodwork looked normal except for a slightly elevated white blood cell count.  A slight elevation can be a sign of infection, inflammation, or just pain - so again, a completely nonspecific finding. I stopped back in to talk to her.  Did she look a little pale?  "If you're doing worse, we really need to get a CT scan of your abdomen, especially since you're hurting in the right area for this to be your appendix."

She grimaced. "That will take a long time, though.  Do we really need it?"

I frowned right back at her, unimpressed.  "You tell me. Isn't this the worst pain of your life?  If so, don't you think it's worth waiting around a while longer to try to find out what's hurting you so bad?"  We went back and forth a couple rounds, but she acquiesced eventually.

Then she disappeared 10 minutes after the scan was done.  No warning, no announcement. She just left.  Honestly, I had other patients to take care of.  I shrugged and moved on.

20 minutes later I got a call from the radiologist.  You never want a call from your radiologist.  It means they've seen something serious enough that it needs to be passed on in real time; they cannot wait for you to just read their report.  "Hey, did you get a look at that CT scan?  Your patient has an intussusception.  Pull up the delay sequence and look at image 47."

Say what?!  In a young adult?

I pulled up the images in a hurry, and there it was, a couple of tightly nested loops of bowel sitting in the right lower quadrant of her abdomen.  The last part of the small intestine had telescoped into the beginning of the colon and gotten stuck there.  There were clear signs of edema in the fat around the bowel, indicating that the blood flow had been cut off for long enough that the bowel was starting to die.  In these cases, the segment of stuck intestine must be either un-telescoped or removed.

Intussusception in an adult is a surgical emergency, and my patient was no longer in the department to have her emergency surgery. 

The radiologist and I pondered what to do for a few minutes. After all, she had left without being discharged.  Would she actually return?  Would it be a waste of my time to contact her?  But what person in good conscience could fail to let someone know that they have a serious, urgent diagnosis?

Of course I called her.  She didn't explain why she left, but she also didn't resist my command to get back here right now because you are very sick.  She was in surgery by lunchtime.

The next night the radiologist called me again. He'd checked on the patient and wanted to give me an update.

"You know they had to surgically remove that intussusception, right?  It was so swollen they couldn't reduce it. I'm glad you called her."  He paused for a moment.  "You know, you saved her life by calling her to come back in."  I was taken aback and tried to demur, but he was having none of it. "No, Zoe, if you hadn't called her she probably would have come in way later, septic, and not done well.  I mean it, you saved her life." 

I brushed it off at the time, but a few days later his words came back to me.  Did I save her life?  In the most obvious sense, of course I didn't. The radiologist that diagnosed her did that.  The surgeon that took out her intussusception did that.  But... I did get the ball rolling by insisting on the CT.  And while it was a no-brainer, the phone call I made to bring her back for definitive medical care was undeniably important. Without it, she may have stayed at home until she was extremely sick indeed. 

I think I'm willing to give myself a small sliver of the credit in this case. Sometimes I get more and sometimes I get less, or none at all. But it's nice to see something I've done make a direct difference.  Sometimes I get to help save someone's life.  Even if it's just with a phone call.