Life and medicine has taught me a valuable lesson about the importance of perspective. Two people can look at the exact same situation, with the exact same variables, exact same confounding factors, in real time and yet see completely different situations. It’s both amazing and frightening.
In medicine this usually works to our advantage. The collective thinking power of many people with different levels of knowledge and experience means, looking at 1 patient with 6 sets of eyes, 6 brains and a combined total of 36 years of undergraduate studying, 18 years of basic supervised training and then the excess of years of experience. The first time I realized this, I looked up in a room of colleagues and I couldn’t help but smile beneath my N95 mask. I smiled because I knew that the complicated case in front of us had 6 brains and 83.5 years worth of knowledge and experience, all working together in unison to solve the complicated puzzle of pathology. It had no chance And answers were inevitable. I giggled in wonder.
It got me thinking about a situation I had encountered many years back and the importance of perspective. It was a relatively ordinary call in casualties, until it wasn’t. The triage system was working flawlessly and all the “red” emergency cases had been attended to. The medical team had flown in swiftly and claimed their congestive heart failures, pneumonia’s and hypertensive emergencies without asking for panels upon panels of blood work.
The surgeons took their testicular torsions, appendicitis’s and diabetic feet with no fuss. This left us twiddling our thumbs for about 7 good minutes until we saw him. He didn’t look a day over 30 with a defined physique that spoke of years in the gym and possibly park runs and marathons, something I knew very little about.
His abdomen didn’t get the Gyming memo and had distended to twice the size of a full term pregnancy. We approached him with caution, ready for a resus situation. After all i had been fooled many times before by “stable patients” eating chips then having a stroke in front of my face. I was weary with fear. I cracked my knuckles in anticipation of chest compressions. I looked at my senior and saw the same look of confuzzlement on his face that I felt.
The gentleman introduced himself first. We breathed a little easier. A talking human is a nice thing at 3AM in the morning. He asked us how we were and made some small talk. We waited for him to address the elephant in the room (his abdomen which looked to me like it was actively distending). Frankly, I was worried. but what worried me slightly more than the abdomen was the fact that he wasn’t worried at all. He was chirpy, happy and unbothered. I blurted out questions about his abdomen and he looked slightly perturbed.
I felt guilty, then confused. Why were we tip toeing around the very reason he came here? My senior dabbled in chit chat for a while seeing as we had no other pending cases. I stared at the abdomen awkwardly. I heard them talk about golf, the weather, the rand and even Koeksisters. When my senior got to the history part, I chimed in. I knew it wasn’t painful because if it was, we wouldn’t be talking about koeksisters.
The distention began 2 weeks prior and was associated with no symptomatology at all. No pain, no fever, no vomiting, no diarrhea, no jaundice, no shortness of breathe, no seizures, no headache, no dizziness, no indigestion. I couldn’t accept this and I dug deep into my mind looking for more clues to ask about. No urinary symptoms, no constipation, no palpitations, no chronic medication, no past medical history, no past surgical history, no relevant family history, no loss of weight or appetite, no Recreational drugs, no smoking, alcohol twice a month, no sentinel events, no worms in the stool, no blood in the stool. How could an abdomen just begin distending completely unprovoked? I felt the annoyance of inconclusivity brewing.
The only reason he came to casualty At. 3am was because he felt like the mass was increasing in size over the last few hours. I knew what I had to do, I rushed to the right side of the bed and asked if i could examine this ball of confusion. I was bursting at the seams. I needed to know what was in that abdomen! The moment of truth, I placed my hand over the abdomen, I started on the right and proceeded horizontally, making sure I touched each anatomical quadrant. I couldn’t afford to miss anything. Superficial palpation then deep palpation, I could almost hear a med school examiner in my ear. I shuffled on the spot. I pressed down deeply and looked at his face, he caught a chip from his bottom lip and munched away.
I felt for the liver, the spleen, the kidneys, any masses and the bladder. Absolutely normal. The abdomen was soft as a marshmallow. The answers the abdomen could not give me, would be revealed by the rectum. I explained that I needed to venture south. I double gloved and waited. I proceeded and became disappointed very quickly.
Normal stool, no masses, no blood, prostate was smooth. I reported my findings to my senior and he began his own fruitless examination which ended quickly. We both were dumbfounded. My senior ordered blood work and I got it done swiftly- we needed answers! I ran to the lab.
“Morning, this is urgent please ”. I bolted back and waited. We consulted the medics and the surgeons for good measure. Our differential looked sad and uninformed. The medics arrived and examined the gentleman. They checked each system so thoroughly, we knew they were digging for any positive findings. Their list of differentials mimiced ours and included everything under the yellow sun. The medics were also frustrated by the lack of clinical findings and waited patiently for the surgeons. At this point, a diagnosis of exclusion would have put us all at ease.
The surgeons arrived and were obviously visibly excited by a distended abdomen but were quickly disappointed. Their green theatre garb swayed in the wind they created by their rushed steps. I saw the surgical reg lay a hand on the abdomen and his face fell. “This is not a surgical abdomen” he announced very quietly.
A huge abdomen Stared at us and the gentleman eating Simba chips, stared back. The only thing worse than a crowded casualty is one patient keeping you on your toes for hours with no end in sight. We decided to observe him in casualty and get imaging done at 8AM. The koeksister talk commenced and I disappeared to get his blood results. His blood work was normal, his organs were functioning well with no derangement. His hemoglobin was slightly low at 11, but nothing to shout about. The perplexment continued.
Time seemed to drag on and 6am finally approached us. I’ve learned quite quickly that sh*t usually goes down at midnight, 3AM or 6AM. Midnight, when hope has faded and the thick of the night is upon you. 3AM, when the ancestral spirits punish you for no good reason and 6AM, cruelly close to the end of your call.
6AM, our adrenals simmer down from the night, we become slightly calmer and fatigue sets in, 2 hours to go before the day team arrives, the sun has come up and the end is in sight. We scurry around making sure blood results have been seen and acted upon, we don’t want trouble, we just want to leave in peace. But we of course, we didnt.
The sudden drop in blood pressure was so obvious as the gentleman stopped speaking. Sweat dripped from his forehead as he struggled to breathe. The 6AM drama had commenced and he was in florid shock. His pulses were non-existent. 2 large bore of lines were in, fluid being manually squeezed into his veins. The abdomen was growing in front of our eyes. We called the surgical registrar to reasses the patient. We couldn’t wait for 8AM, he needed surgery now. Something extremely sinister was in that abdomen.
The surgical registrar agreed and wheeled him to theatre himself. We finished up our handover and rushed upstairs to theatre on our way out. What did they possibly find in that abdomen?
We speed read the surgeons notes and glanced at each other. A perforated piece of bowel that had sealed itself then bled through again. 3 LITRES OF BLOOD. How on earth did this happen!? It could not have been a blunt abdominal trauma because we didn’t get that history. How could there be 3 liters of blood with no pain and no irritation to the peritoneum? We stood there waiting for the anaethetist to extubate the gentleman so we could ask him.
People often think doctors have a lot of answers but honestly, we rely so much on patients for answers. The anaethetist looked at us as though we had post call delirium(which we probably did) and shoo’d us away. We left with so many unanswered questions and possibilities flew around in my mind. I returned to ICU the next day and thankfully found the gentleman awake, eating and talking. I had to Ask- what happened?
And that’s when he told me that looking back, he had a fall from a ladder while fixing his satellite to his roof a month back. He thought nothing of the fall because it wasn’t a long distance fall and he was completely fine thereafter. He had no pain, no abdominal dissension or any problems whatsoever. In fact, he had completely forgotten about it and it took 3 litres of blood in his peritoneal cavity to jog his memory.
Blunt abdominal trauma in such an atypical presentation definitely left us all..
Shocked (pun intended).