The Intestinal Obstruction That Wasn’t

84 year old male – known to have chronic constipation, and on warfarin for atrial fibrillation – referred in by his GP for ‘inability to open bowels for 2 weeks’ – yes you read that right folks, T-W-O W-E-E-K-S! – ‘increasing abdominal distension and abdominal pain, along with decreased appetite and a possible mass in the pelvis/abdomen going above the umbilical area’.
The nurse triaging him came to me, asking for some pain relief for the patient ‘and an enema because that’s what he usually has for his constipation’ – I decided to go see the patient myself. I stepped into the cubicle and the gentleman seemed to be in some discomfort, but he kept saying that he was in an uncomfortable position/posture rather than anything else causing him discomfort. I introduced myself and asked him what had brought him to ED – he replied by telling me he had not opened his bowels for 2 weeks now, and though was still passing wind and had passed some today, he was drinking very little and felt nauseous and omitted a few times in the past 3 days. I asked him if he had been passing urine normally, and he reported that yes he was peeing fine, but that he was drinking so less due to the nausea that only small amounts were trickling when he needed to go. I took that statement at face value and moved on. He was lying in a trolley, awake but lethargic and completely oriented. His observations were all within normal limits except for a systolic BP of 89, and his GP notes reported a background of chronically low blood pressure. I examine him, of particular note is his visibly very distended tummy – which assort but distended, feels like gaseous distention from the percussion notes, and with tinkling infrequent bowel sounds – and is quite sore particularly in the lower half of the abdomen, and I can also palpate a mass in the lower part of the abdomen – the patient reports that’s been going on for atleast 3-5 days, possibly when the vomitting began as well. This seemed very much to me to be a classic case of intestinal obstruction – and the management plan is – do baseline bloods (already very kindly done by the triage nurse), get venous access (also done), start some fluids, abdominal X-rays, nasogastric tube and surgical referral, and also catheterise patient, to monitor intake and output.
I speak to my registrar who agrees with said plan of action and while I request the X-rays and take the patient down for it, the lab apparently calls back and my registrar takes the call – the patient’s urea is 44, and the creatinine is 469, last creatinine 3 weeks ago was 141 – so he is going into renal failure, if not there already. While I seemingly faff around with the surgical consult, my registrar gets an ultrasound machine, and I assume it is to rule out a AAA, so I walk into the cubicle with him. And he explains to me a great pearl of wisdom that clearly comes with experience but is such a simple thing that I am left berating myself for not thinking about it earlier. He told me that if someone comes in with such significant renal function decline so acutely, always think of and rule out an obstructive cause for this presentation before moving on to other more sinister things. He was doing an ultrasound to look for hydronephrosis or hydroureter, which is basically the dilated urine collection channels in the kidney downwards and the reason they are dilated is due to an obstruction further down the channel. And that is exactly what he found. The left kidney was moderately enlarged but the right kidney was massive and its ureter was like a fire hydrant pipe rather than the small thin tube – and the mass in the lower part of the abdomen, going from pelvis and extending up from the umbilical area? His urinary bladder!!! I was in shock – as my registrar then gave me the second pearl of wisdom: never believe anything you are told, do not take it for granted until you have objective evidence. The patient felt he was peeing less and less because he wasn’t drinking enough. Yet he was peeing less because the channels beyond his bladder were so narrowed and obstructed that they did not allow emptying of the bladder and it just kept filling up till it was a massive huge thing floating in his belly. I at once made arrangement to catheterise the patient, whereby 2000 ml (that’s 2 litres!!!) of dark brownish urine poured forth out of him.

He had been in urinary retention for the better part of 3-4 days, possibly due to an enlarged prostate that had just gotten worse, and his constipation (though being chronic) was either a factor of his massive bladder pressing on his rectum/colon and not allowing the contents to move ahead; or (a bit like the chicken and egg thing, of which came first?) he was constipated, which gave him some abdominal pain (expected) and that pain had the added effect of causing urinary retention – anyways, after passing the catheter and draining all that urine the patient felt quite comfortable, and the surgeons took him away to do their wonderful things.

Sometimes it is the smallest things that make you the saddest

Ever notice how you can go on being an automaton, robotically engaging in work stuff, moving from one patient to the other, each one a statistic on your ever growing list of patients to see or having had seen – no interaction long enough to actually create a connection other than that of patient/doctor and you professionally enter and exit the cubicle and move on to the next job, next patient, or indeed next shift. And yet sometimes it does happen that something hits the mark, and there is a chink in the armour, the professionalism slips (not outwardly, but it surprises you that you feel something other than empathy towards the patient in front of you – you really look at the patient, not as just a patient but an actual human being with feelings, and thoughts start milling around your head – or your heart? – and you think of the patient’s feelings, their desires and weaknesses, the consequences of their actions – and you realise with a jolt that you are not an automaton, that you are, indeed, human.

I am usually a happy presence at work (if I may say so myself) but I was having a particularly ‘smiling-from-ear-to-ear’ day a few days back. A recent couple of professional achievements, along with being well rested from a full night’s sleep meant I was walking around with a bit more bounce in my step. I was working a late shift, but from the broad smile on my face you would have thought I was about to go home on a 2 week holiday! (I was not, but yes, I am a bit weird – I actually have fun at work!) – I was assigned to see paeds patients in ED, all the minors, majors, ENP ones etc – and I was going about my day when the consultant asked me to come out of Paeds for a bit and see the next adult patient, who was already at 3 hours (that much time had elapsed since she had come in to the hospital) – the brief note from triage nurse said that this was a young female between 25-35 years of age, who had come in with a self harm injury or injuries – she was categorised as a ‘yellow’ which meant there was no imminent threat to her life but she did warrant a thorough assessment.

Treatment/management of such cases is usually 2-pronged: one, manage the obvious injury or insult and treat the current presentation, and two (and more importantly) try to deal with and manage the longterm/shortterm psychological aspects of the presentation (not an ED thing but there are certainly specialist who are better equipped to deal with this and who very kindly assess and evaluate patients from that perspective after they have been treated from a physical ailment point of view. So anyway – I went in to see the patient – it had been mentioned in the notes that she was accompanied by her support worker – but the woman who stood up when I announced the name in the waiting area was alone. And she stood up at once and followed me into the cubicle to be assessed, along the way I introduced myself, and thanked her for her patience in waiting. She was extremely polite, and even offered me a smile, but she kept looking anywhere but at me directly. I asked her what had brought her to the ED that evening and she matter of factly stated that she was here because she had self-harmed. Again. She did not seem to be in any sort of pain, so I assumed (wrongly) that she had a superficial sort of wound that wouldn’t really require too much medical attention. I smiled at her and said something along the lines of ‘well, let’s see what we are dealing with here, and I will try to help you any way I can.” She exposed her left arm unto her shoulder, and I took off her temporary dressings from her upper arm (above her elbow) – while I was doing so, I kept making small talk, and registered the many, many scars from previous self harm attempts there before me were 4 very large, very long, and VERY gaping full thickness lacerations to her upper arm. In places where normally the skin/muscle sags a bit, it was really using the lacerated margins to gape quite widely. The patient had something like an hour left before they breached? NO WAY was I going to be able to administer local anaesthetic AND suture all 4 of these wounds in under an hour. Alone.

This patient completely threw me off my game. I have closed wounds in numerous ways, and in all sorts of weird and wonderful places – I have once years ago even raced my mentor consultant orthopaedic surgeon in bilateral knee replacements to see who closed up their respective knee first! – But this time was different. This patient was different. And the reason will become apparent up ahead.

I called my consultant because he may have been under the impression this was a quick ‘tape-wound-shut-refer-to-psych-move-on’ kind of situation – he stepped into the cubicle and hemmed and hawwed. I was silent throughout. This felt like an operating table scenario with a patient’s body cavity open up in front of me – The smell was exactly the same. Flesh. Blood. Sadness.

Right then, the consultant asked me to stitch the wounds up – I gave the wounds a good thorough clean with some saline and the patient did not flinch. She did however, apologise quite sincerely for wasting my time. I will not go into the details of why she thought she needed to do this today – absolutely no judgements to be passed here on that account. But I did assure her she was well within her rights to be there. I said I would go calculate the amount of local anaesthetic require and get it and get it all ready – and her polite demeanor stiffened up. She absolutely refused any local anesthetic. She said, and I quote: ‘ I am not here to waste any of your valuable resources. Please use them for someone who really deserves it – and anyway, I am not in pain and the stitching can’t hurt me more than I have done myself – also (and I was surprised that she knew this) the amount of local anaesthetic required would be a bit too much and wouldn’t be safe for me – and it would wear off by the time it was done being administered!” She was right on all counts – but I requested my consultant to give me an opinion, since she had me absolutely flummoxed. He agreed, no need for the anaesthesia – and that I would achieve better results with a skin stapler rather than suturing the wounds. I had never used skin staplers outside of an OR before, and never on a patient who was conscious and sitting up and talking to me and FEELING THE STAPLES GOING IN! I took a few deep breaths. Got the stuff ready. Took a few more deep breaths. And a few more. And dove in. I put in upwards of 45 or so staples (yes metallic pins sharp enough to stab through the superficial tissues of skin etc and pull them close to optimise wound healing) – did I mention the wounds were exceptionally gaping? Each staple gun comes with 30 or so staples – and I had to use a second one about halfway as well. Wow. My mind was already blown after the first 2-3 staples. But I went on putting more in. I did my best – and to her credit she did not flinch. There was silence. And that smell. And sometimes she would talk to me.

She kept thanking me, and apologising to me, and kept pushing her other hand through her hair as if berating herself mentally. She told me she had a masters degree in something (I forget what – my ears still start ringing everytime I think back to that cubicle) and we chatted about how I wanted to pursue another degree, maybe a masters of some sort and hadn’t quite decided what. She guided me about which staple to remove because it had been bent at an awkward angle due to how gaping the wound was initially, and so when I had ‘scaffolded’ it with staples next to it either side, I removed the offending staple and put another one in. Like I said, she didn’t flinch. At all. She kept that small polite smile in place, was very respectful and I learnt something new about myself that day. That this had gotten to me beyond what I can express here or anywhere. I had seen dead and dying people almost on a daily basis. People in pain, people vomiting with pain, people trying to process bad news or loss or a shock. I have been the villain in so many stories in peoples lives – the bringer or the news that someone they loved had passed away, or what the reports had shown or why we feel that further aggressive measures would be futile – But I had not been affected by those things as much as this calm young woman had affected me. What about her affected me? Nothing about her situation. It was sad, no doubt. But what really affected me was what I realised about myself: I judge people, I am cynical about them, about their diagnoses, about their mental health problems – I never fully appreciated that when someone comes in to hospital following an overdose or some deliberate attempt at self harm, I focus solely on the physical aspect of the case, and let someone else deal with the mental/psychological/psychiatric aspect of it. But this time, I was metaphorically chained to the situation I usually avoid and judge as a spectator – and I could not escape how normal this young woman appeared. She was well read, had a grace and calm in her manner that belied a good upbringing – yet she was obviously in this mental pain and it got so severe sometimes that like this day, the thought of cutting herself and so brutally was her only way to cope with it, and possibly caused her less pain that she was already in. And to be able to get sutures or staples without any anaesthesia on board – how remarkably strong a pain threshold would you have to bear that? Or that you were so used to it that this was all just commonplace occurrence to her. And this wasn’t even the worst part. The worst part was that this was neither the first time, nor (we both knew) the last time that she went down this route. I could help her physically, suture/staple everything – but did I actually do anything at all to really, truly help her?

So like I said – we are usually automatons, going about our daily drudgery – and then one day a patient really opens our eyes and makes us sit back – and question …absolutely everything we know and believe in and understand. Or don’t understand.

(Edit: The rest of the shift went by in a blur or a haze, I don’t know if it was all too fast or all too slow for me. I am I think back to my usual self now – albeit with one difference. I am maybe not so quick to judge – and maybe not so quick to dismiss mental anguish based upon my perception of the physical consequences of that mental anguish. I admit to not knowing enough – and hope I can change my practise in a way makes all of this worthwhile.)

Blogger Recognition Award

I know this post is fairly late in the day – but better late than never, right? Now this isn’t a formal or official award, but it is a mark of recognition bestowed by our peers, recognising our writing/blog work as something that is worth the time and effort that’s been put into it, and for whatever reason was deemed worthy of a more detailed look rather than a cursory glance over the shoulder. I am ever so grateful to the surprisingly humble Kershelle Mike @ The Angry Marketer Blog for deeming the MDB worthy of that second look – so honoured and surprised (read flabbergasted!) at the nomination!

Now the way this works is that:

Step 1: you give an account of how your blog came into being – and;

Step 2: any advice you want to dole out to new and upcoming and ‘thinking-about-it’ bloggers – and mine is this: be yourself, don’t force yourself, don’t try too hard – discover your strength and play to them, be unique and then be regular, don’t worry about how many people are reading your stuff – if you feel you have the right idea then this will take commitment and time invested! Do think about this long and hard, don’t just jump into it – look at other blogs, look up others’ ideas and see how they implemented their ideas – and find out what works for you, and then, finally;

Step 3: you nominate 15 (or upto 15) other blogs/bloggers that you feel deserve to be recognized. It isn’t an official platform, but it sure is nice to be recognised, don’t you think? So without further ado (and in no particular order) my nominations for the Blogger Recognition Award are:

  • My class fellow, friend and colleague, Dr. Haseeb Ashraf’s blog Medical Solutions: The Medic Helpline (link here)  – which aims at creating awareness about various medical conditions, easing definitions for laypersons/non medical personnel and any guidance/medical queries you may have as a doctor or other medical professional, or even indeed any member of the general public
  • Another friend and superstar colleague Anita Mitra – and all round amazing person – she is an encyclopedia on all things ‘women’s health’ – including some topics oft considered taboo – her blog as The Gynae Geek is maybe even more impressive than the legend herself!
  • One of my juniors in medical school is doing something that I am secretly (OK maybe not so secretly!) proud of and who I think has the capacity to touch so many lives for the better – and not just by means of her medical degree! – she does this by reviewing (after reading) the most amazing books as The Doctor Reads – she writes succinct and amazingly relevant reviews that connect you to the books in a way no review or book recommendation has ever done before – atleast not to my knowledge. Absolutely love her style, and the sense of humour just takes it up another notch. She does not have an official blog, but check out her work here, and here – she takes Instagramming to a whole new level!
  • FifisLounge – An amazing cook, who tries and tests recipes herself all the time, and then recommends the successes to anyone looking for yummy morsels and tasty treats – having tried this chef’s cooking firsthand, I can vouch for this blog with confidence! Check out this blog here, and try out the great tastes!
  • A newcomer to the blogging scene – nevertheless ‘Life as Sid Knows it…’ is someone to follow – day to day musings, and personal experiences and an interesting take on the daily routine things that we take for granted – this blog is also a part of my list.

    Unfortunately I don’t have an extensive list of 15 blogs to recommend – but at least the ones I have recommended I honestly believe are worthy of your attention, whether you are a follower of the MDB or just randomly looking for inspiration. Do check them all out!

The world is indeed your oyster – always work to improve!

Always set goals for yourself, it is never too late to improve yourself, or hone a skill. Add to your already accumulated skill set, or improve pre-existing ones. There is always room for improvement. Always another star you can aim for.

If you find yourself saturated (or the environment around you saturated, and you can’t get a foothold) move to greener pastures – if you are the best at something in one place, chances are there will be something new to learn in a different place, even if you do the same thing.

Get another degree (something which I am trying to do), study a new culture, learn a new language (something I am currently working on!) get a new hobby (like photography? cooking? Blogging!) Move to another town, another city, another country – see how another part of the world does it’s business. Read a new book – finish it and pick up another one, go through a personal list, then go through someone else’s list – make new friends, meet new people. Make a mistake. Learn from it, move on. Do not be afraid to make a mistake. Share your knowledge (yes, you have it!) Pick someone up from where they have fallen. Help them if you can. Surprise yourself with how good it feels, and how easy it is to make someone happy (or just less sad).

Be the best you can be, and then strive for even better than that.

Always improve. Always be open to change. Always be open to suggestion to make yourself better. Always be humble enough to know that there is always room for that little bit of change, however hard you try to fight it – you will end up being a new ‘you’, very likely for the better. You are your own best investment. Do right by yourself.

Rant (I have a feeling this is going to be a series!)

OK – here is something I have been meaning to get off my chest for a while now. Always remain true to your oath. Never forget, you are here – as part of a team – to help people at their most vulnerable. Do NOT become arrogant, or cocky. Do not think you know more, or enough even. It is always going to be a learning curve. You will always find something new, a different perspective, a different set of circumstances, a different allergy spectrum, a different way to treat and a different response. Always be open to suggestion, and NEVER assume the tone of ‘Me, Myself and I” – You are part of a team. Say it after me. T-E-A-M. TEAM. You can not and will not be able to see, treat, investigate, counsel, manage and completely sort out ANY patient thoroughly on your own. You will need to be part of a team, whether it is the nurses, the junior (or senior) doctors around you – in your specialty or in another specialty who you call upon to ask for advice, or whether its the janitor or the lovely lady who makes the tea and sandwiches for the patients. You can not do without any of them. We are all cogs in an intricate system, and should you feel the urge to think you are the most important cog or the biggest or the brightest – just remember, even the smallest nut can cause a whole plane to come down.

*OK. Deep breaths. You got this. Keep it together*

Where is this coming from? This is coming from an increasing number of experiences I have had interacting with colleagues from different specialties, whereby as soon as they answer the bleep or pick up the phone for a potential referral or even an opinion, you can almost hear the wheels turning in their heads in trying to pick out any reason to refuse the referral or bounce it on to someone else. But wait – I did not bring this patient from my home. I have assessed and tried to sort him out – and based on my assessment with the tools I have, I am obliged (in the interest of patient care and safety) to refer to your expertise in the matter. Not your expertise in how to NOT accept a patient into your services, but the actual expertise of your specialty, which you have signed a contract for and willingly and knowingly have signed up to provide!

Case in point: 80-something year old female, with some medical history which I now forget, admitted with non specific symptoms of progressively worsening mobility issues over the past few weeks, acutely deteriorating over the past week to become completely bed bound and unable to get out of bed – associated with a very poor oral intake of food as well as water. Husband called the paramedics that day because she was literally unable to lift up her head to have a drink of water. There were no other symptoms – no pain anywhere according to the patient, no recent fevers, no vomiting and normal bowels. Paramedics found her to be very tachypneic (higher than normal respiratory rate – hers was about 55) but the rest of her observations were all within normal parameters. She arrived into ED where I was the first one on scene along with the resus nurse. We quickly connected her to a monitor, and established an IV line, taking some baseline blood tests including a very quick blood gas, which gives us a very quick assessment of anything acutely going on. We found her lactate levels to be 11 (yes, ELEVEN – classified as sky-high in my dictionary!). I thought on examination her abdomen was slightly protuberant (?distended?) but not tender – thought she did appear slightly uncomfortable when I examined her. She was conscious, but drowsy – yet was able to answer all my questions. I got my registrar to come in and review her (sky-high lactate!) even though I basically knew my plan of action. He felt that the patient’s tummy was actually distended, with diffuse tenderness instead of discomfort. He advised I urgently get x-rays of the abdomen and an erect chest film, to rule out bowel obstruction/perforated bowel loops. As I was requesting said scans, the consultant was sat beside me on the next computer, she overheard the words ‘high lactate’ and ‘abdominal pain’ and immediately wanted me to drop everything, call the surgeons and get a ct scan of the abdomen to rule out bowel ischema. I requested the CT scan first, spoke to the radiology consultant, who (surprise surprise!) wanted the patient to first be seen by the surgical team and then be considered for the scan. I then bleeped the surgical team, this was a registrar, and our very pleasant conversation went thus:
Hello there, sorry to bother you – I am one of the ED SHOs, I would like to refer a patient to you please.
*give him the patient’s details*
after being interrupted 4 times during the whole history etc he asked me 3 things: Have you requested a CT scan? (yes) Have you discussed it with the medical team? (no, why would I do that? abdominal pain/tender abdomen with a high lactate, medics won’t touch her with a barge pole) and have you at least rung up ITU? (No, once again, why would I – patient is unwell I agree, but she is stable aside from a high resp rate, she may progress to needing ITU care but currently would really benefit from an opinion/referral to surgeons, and should you see fit to inform ITU you can let them know as part of a pre-op thing) No this patient does not sound surgical (excuse me? what part of abdominal-pain-high-lactate did you not understand? I hate using the ‘because my consultant wants you to see the patient’ card – and I rarely, if ever, use it. But I had to this time. He was not happy, but he came down to review the patient)

And still did not think they had a significant surgical problem. So my consultant had a word with him, and he still insisted the patient needed to go to medics. To which he was reminded that we have referred tot he specialty we think is appropriate for patient care in this patient’s current condition, so if he felt that the patient required to come in under a different specialty, he would have to convince that specialty himself. There was a bit of an argument – and he conceded. He saw the patient in detail, and informed us he had referred to the medical specialty who had accepted the patient, and that he had booked a contrast scan for the patient to rule out bowel ischemia – but unless something horrible showed up on CT, this patient was not to come under surgery. It seemed like the case was sorted, I made sure the patient had adequate analgesia on board, antibiotics and fluids ongoing and then went for my break.
I came back after half an hour, and picked up the next card – but my consultant reminded me that the medical team still hadn’t come down to see the patient, could I give them a call and find out what the situation was. THE MEDICAL REGISTRAR WAS NOT AWARE OF THE PATIENT! I could have almost cried. I had worked with her, though, so she very kindly listened to the story, but understandably (well, maybe not) asked that I get that CT done before she gets moved from ED on to the medical ward. I felt like banging my head against the wall. My shift was about to end in 45 minutes, but we got a CT scan requested, vetted by the radiology consultant who finally agreed because the surgeons had touched the patient and given me their blessing (so to speak) – and the last thing I did before my shift ended was confirm that the patient had had the scan, she had come back from it, I said good bye to her and told her and her husband that the results were still awaited, but since my shift was ending, it was over to the surgical team then.

Questions –
-Was the event survivable from the beginning when she first came in? Unlikely, based on how acidotic she was, and her lactate and kidney functions were through the roof.
-Could I have done anything more? There is always something that can be done to improve outcome – but I was hitting roadblocks left right and centre. In the event of each one, I escalated to the appropriate seniors, but all that did was save my back. It did nothing for the patient, and that is something that I had (and am still having) a hard time accepting.
-Was this case mis-managed? Not at all. The patient was treated adequately as and when we were finding things, thoroughly investigated, and seen/reviewed by 2 different specialties aside from ED – ITU and surgeons. She was at the ceiling of care when she passed away. The reason I am ranting here is that sometimes, or more often than not, it is a multistep process to achieving optimum care for each patient, and at every step of the way there are potential hurdles, things that are the rate-limiting factors that if the pieces do not fall into place in a timely manner, everything gets delayed. And the reason I am ranting is also – please be humble. If someone asks for your opinion or an assessment of a patient based on a skill set you have, then you should be honoured, and also honour the ethics behind the title. It is a huge responsibility, and you need to make sure that every step of the way, every day, you are discharging that obligation with humility and respect. Your patients, unaware of your moral standards and ethical beliefs, rely on you bringing your A-game. They are usually already fighting a battle, and they need you to fight for them, because they won’t be aware of the minutiae of the battle. That is where your responsibility comes in. And your A-game. Bring it. Or don’t come at all.

(Edit: I came in to work the next day, and due to force of habit I check up on the online patient database of admitted patients what had come of the case. The patient’s CT Abdomen/pelvis with contrast had been reported: “Intra-abdominal air, likely due to perforation in the sigmoid colon, secondary to probable diverticular disease. ”

My patient had passed away about 45 minutes after my shift ended.)