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.)

When you hear hoofbeats, think horses, not zebras. Mostly true.

But if zebras are more common in the geographical area where you are at the time, then do, please think about zebras. But I digress.

57 year old female presented to the ED with chest pain, sudden onset, associated with shortness of breath, referred to us in acute medicine (yes a lot of my talks have been acute medicine related, those are the wounds that are freshest!) to rule-out-slash-treat-for a PE (pulmonary embolism, or a clot on the lungs). So I went through the motions, history, physical exam, investigations etc. Her past history was significant for dual malignancies (breast AND colorectal, both treated with surgery and chemo/XRT as needed quite a few years back). This history is what had freaked A&E out and had sent her in our direction (we OK, she was high risk for it, but I digress again).

Her D-dimers were not elevated, which basically is a test to rule in or rule out a PE (it being positive could be for a number of reasons, including a PE, but it being negative in her case basically ruled out the possibility of a clot). Her observations (or vitals, as we called it in the good old days) were all within normal limits, so her oxygen levels and her heart rate and her blood pressure and her cooking abilities were all top notch. Well the last one wasn’t (I mean it may have been top notch but it wasn’t a vital observation. Wow, I should get a degree in digression). Her pain had since then subsided, and all the rest of her blood tests including those for infection etc like a white cell count, and a CRP (both markers for infection, something that would cause her chest pain if the infection were focussed in her chest) were also within normal limits. And to top it all, her troponins were not raised either (serially done, these are enzymes which leak out into the blood to signify myocardial damage – myocardial = heart muscle), so it essentially looked like she was ready to go home.

For every symptom or complaint that a patient has, doctors and nurses and other allied healthcare professionals are trained to go through a checklist, usually a mental one (or physical, if you like to tick off or cross things off a physical paper list) of things that can cause the afore-mentioned symptom/complaint. Another checklist that they have is of a list of investigations or manoeuvres or steps that need to be taken in order to rule in or rule out certain diagnoses. This will basically decide whether or not a patient is safe to be sent home with just reassurance, or the condition warrants further investigation but non urgently and can still be safely sent home now, to be called in for outpatient investigations and assessment at a later point, or can not be sent home at all, and would benefit most from urgent or in-hospital investigations/assessments/services. As part of the checklist of ‘chest pain’, there are innumerable causes, and as part of the workup of significant chest pain (significant being a vague term, but significant enough to warrant a trip to the doctors’ or ED or to seek medical advice) a chest X-ray is very important. I had requested the chest X-ray for this patient (or ED had done so, and I took credit for requesting it, sue me) and the consultant who did the post-take with me on this patient agreed that she could indeed go home, once the chest X-ray had been done, and unless there was something absolutely horrific on it, he saw no reason for the patient to stay in. And you can well imagine, I am not writing this post just for the heck of it (well, partly, but I do have a point) and it was related to this chest X-ray, and this is where horses and zebras and hoofbeats make a cameo. But not for the reasons you probably think.

The patient came back from her chest X-ray, I looked it up, and I saw (as you may have probably guessed by now) a huge stinking mass in her right mid and upper zone of the lung. OK my radiology colleagues (and possibly most of my other colleagues) would kill me for not saying this right; I will rephrase: There was an well-defined opacity in the right lung encompassing the right mid and upper zones, extending from the hilum medially to the chest wall laterally.It could be a pneumonia but hey, with everything under the sun being normal for her and keeping in mind her strong prior history, my mind jumped to the possibility of it being a malignancy. More like…probability of it being a malignancy. I took a deep breath to calm myself, before I could step behind the curtain to break the bad news to this grandmother of 2. I was about to do so, when the consultant rounded the corner and asked me about the x-ray. Thankfully, I took him round to have a look at the X-rays before I broke the news to this patient, because this is where the twist came (and here you thought the twist had already come and gone, and that the mass on the chest X-ray in an otherwise completely normal looking patient was the twist. No it wasn’t as you are thinking, or as I thought. And boy, am I glad I was wrong!)

The consultant took one look at the x-ray (this is after I had told him that I had found something horrible on the X-ray, it could be a pneumonia but very likely a mass that needs to be biopsied etc…) and then placed his open palm very delicately to the middle of his forehead and very matter-of-factly said the magical words: “Have you asked the patient if she has had a breast implant?” My jaw dropping to the floor and my deer-caught-in-the-embarassed-headlights look told him I hadn’t. I went and asked the pleasant question (seriously, the things we want to know about!), and sure enough, she had had a mastectomy 7 years back for her breast cancer, followed by an implant. The totally non-threatening implant that I saw on the X-ray and mistook for a life-threatening infection and/or a life-threatening malignancy. The patient smiled. I smiled. The consultant laughed (cackled more like, rubbing his hands together with glee. OK I may have imagined that last part, because he was thoroughly professional, and actually taught me something I had not thought of. Chest X-rays or just any X-rays in general, just make sure you think of anything on or under the patient’s body causing that shadow, before you jump to the worst possible conclusion, for the patient, but like in this case more so for you. Very common ones are metallic sequins looking like metastatic nodules on lung; bra-hooks being mistaken for evidence of cardiac surgery; and when yours truly had the case of the misunderstood breast implant. Sheesh!

PS: I realize all the examples I have provided were related to female patients. Please don’t call me a chauvinist or start a feminists’ war on the blog. I apologise but it is midnight, and I can not think of any helpful examples from the male population. Maybe men (and their x-rays) are just …easier to read *runs and hides*