Meanwhile, Back on the River

(Warning: This post contains graphic, unpleasant descriptions and explicit anatomical references, all of which do lead to an important conclusion.)

Men can also sail Denial River, sometimes with dramatically tragic outcomes.

I remember this 45-50 year-old businessman from way back to my student days at the Medical College of Wisconsin. On call at the VA Hospital during my 3rd year general surgery rotation, I picked the patient up after his initial triage in the ED. The chief complaint line on the ED chart simply stated "Smells Bad."

His employer had forced him to seek medical attention. "Man, you stink, and you have been stinking for too long. I can't have you around our customers when you stink. So either go to the hospital and find out what's wrong, or you're fired."

In spite of having showered that day, he absolutely reeked, like an obnoxious combination of feces and rotting flesh. We wondered how he could even stand to be around himself, let alone foist his malodorous presence onto others. He'd been that way for weeks if not months, yet had somehow managed to deny to himself and his family that anything was wrong...until threatened with financial ruin.

The symptoms of his underlying disease began about six months previously, with a change in his bowel habits and persistent abdominal bloating. He had sometimes noticed blood in his stools, but figured he must just have hemorrhoids. Finally he had only liquid stools, nothing solid, and a chronic sensation of incomplete evacuation. And, yes he had lost weight, but couldn't say how much. Plus he admitted to progressive fatigue. And he didn't sit much, because it hurt his buttocks to do so.

When examined, he was running a fever and looked ill. His abdomen was mildly distended, diffusely tender and tight, with rare high pitched, rushing bowel sounds. The cause of his vile odor resided in his perineum and peri-rectal area, where a raging infection had invaded the soft tissue spaces around his rectum and genitalia, enlarging his scrotum to the size of a softball. 

The cause? Some time previously, a fungating invasive cancer had  perforated his rectal wall and allowed the bacteria-laden fecal stream to gain access to the highly vulnerable soft tissues on the other side of that wall. For months these voracious microbes, who do not require oxygen to live, had feasted at will on his flesh, creating new pus-laden cavities where only virtual spaces normally exist. Had he not been forced to seek medical attention, these insensate microscopic space invaders would eventually consume the life of their most accomodating host.

The treatment turned out to be more gross than the disease. The surgical team labored for hours, with oil of wintergreen stuffed up their noses to fight off the stifling stench, methodically filleting wide open all the involved tissue to get rid of the bacteria, then packing the exposed flesh (testes included) with gauze to encourage healthy remaining tissue to overgrow that which had been destroyed by the microbial invaders. The cancerous tumor, meanwhile, had to be left alone for the nonce. It would continue to grow in place because we had to control the infection first before the surgeons dared to resect the tumor.

I rotated from that surgical service while this unfortunate man was still in the hospital, but I believe he survived this tragic event. His open wounds were gradually healing, and the surgeons talked of taking him back to the OR to get rid of the cancerous mass. That would take extensive resection and an even longer recovery, and would leave him with a permanent colostomy. But he would live.

A prominent colo-rectal surgeon once stated that the most efficient, effective, and cheapest diagnostic tool for early detection of rectal cancer is a digital rectal examination...an admittedly uncomfortable and sometimes embarrassing procedure for the patient. In truth, most rectal cancers can be felt by the examining finger way before they can take down a grown man like this one. 

Considering alternatives like the one above, overcoming denial and accepting that simple procedure seems well worth the brief moment of embarrassment and discomfort.

Sometimes You Need That Egyptian River

"This is Rescue 7,"said the paramedic's tremulous voice over the radio as his vehicle's siren wailed in the background.

"We are en route Code 3 to your facility with a 15 year-old female, gunshot wound lower abdomen. Pulse 120, BP 90 over 60, respirations 26. We have started two large bore IVs of Normal Saline and have 100% oxygen running by mask. ETA your location is five minutes."

Now this be badness.

It happened early in my civilian practice, before the hospital where I worked established itself as a Level I Trauma Center. An abdominal GSW mandates surgery. As the nurses set up the trauma room, I phoned the on-call general surgeon and gave him the news that he needed to leave his office full of patients and come immediately to take this young lady to the OR. He would arrive in 30 minutes. In the meantime I was on my own.

I gave the nurses a litany of STAT orders to be done as soon as our patient hit the door: "Complete blood count, chemistries, urinalysis, type and crossmatch for six - make that eight - units of blood. Foley catheter..."

The doors burst open as the paramedic team rolled through with our patient. She was a pretty caucasian female with long blond tresses. I quickly surmised that her usual complexion was probably less pallid than her currently white skin color. She'd clearly lost a significant amount of blood, which I could not see because it was inside her abdomen. So no telling how much. Undressing her quickly, we found a single entrance wound about two inches below her navel. We rolled her on her side to examine her back. No exit wound. And no telling where the missile had traveled once it entered her body. Rolling her back to supine, I noticed powder burns around the bullet hole.

I turned to the medics. "How did she get shot?"

"Appears to have been self-inflicted," they responded. A neighbor heard the shot and called 911. We found her in her bedroom. She had her father's handgun."

As I turned back to the patient, the nurses completed inserting a urinary catheter into her bladder. The drainage was red with blood. "Keep those IVs going wide open," I ordered. "And get me a central line setup. Any word on our surgeon yet?"

"On his way," replied a nurse.

I quickly started a central IV line in order to give her more fluids. Her vital signs had begun to stabilize, so at least we were matching her blood loss and keeping her intravascular volume steady. She would make it to the OR where our surgeon could definitively stop the bleeding and repair whatever organs were injured.

Another look at the girl's entry wound had me feeling her lower abdomen. Sure enough, a mass the size of a softball was palpable. (There was no such thing as ED ultrasound in those days.)

"The OR is ready and the surgeon is prepping," said the nurse.

"Good," I replied. "Tell them to call an obstetrician as well."

This pregnant teenager survived her internal injuries. The fetus whom she shot herself to kill did not fare as well.

Not Only the Egyptian River - Part Two

Some time after the 18-year old single female delivered the baby she didn't know she carried in her womb, I saw a 39-year-old married woman who presented to the emergency department with - yep - acute onset crampy lower abdominal pain of several hours duration.

Other than her age, marital status, and somewhat less obesity, this lady's case evolved very similarly to the one I described in my last post. History was unremarkable except for irregular menses. Physical exam at first revealed nothing, then the unmistakable contractile mass in the abdomen, with palpable fetal head in the pelvis. No clinical badness here. This lady was in active labor with a full term baby, yet vigorously denied that she could be pregnant.

"My husband had a vasectomy," she told me with absolute sincerity. "We can't afford another child. I'm not pregnant."

My mind quickly sorted through the various reasons why the mere fact of her mate's vasectomy did not rule out what the physical exam unequivocally indicated. I reassured her that she was indeed 1) pregnant, and 2) in active labor. Then we did the math. She recalled the date of her husband's vasectomy with fair certainty. Assuming that she was now truly at term and in her 40th week of gestation, she had conceived roughly two weeks BEFORE her husband underwent the baby prevention procedure. At the very least, that should mitigate any paternity doubts that might afflict her mate.

I found her husband in the waiting room and invited him to join his wife briefly before we whisked her up to labor and delivery. "Yes," I confirmed, "she's in labor." The gentleman appeared briefly stunned but took the news in relative stride. He opened his mouth as if to ask a question, then paused, and then remained silent.

As he entered the room, his wife looked at him plaintively. "Sorry," she said. He held her hand. "What are we going to do?" she moaned.

"We're going to have this baby," he replied warmly, "together." Then he tightly but gently squeezed her hand.

I smiled as they were whisked out of the emergency department to L & D.

They say that good pitching beats good hitting on any given day in baseball. In life, truth holds that same edge over denial.

NOT ONLY THE EGYPTIAN RIVER - Part One

"Eighteen year-old female c/o abdominal pain," read the Chief Complaint section on the emergency department treatment record that I picked up in the midst of a busy evening shift. The venue was John C. Lincoln Hospital in Phoenix, early in my civilian days of emergency medicine practice. I was not residency trained. None of us were, because EM residencies barely existed in those days. We gleaned our knowledge base mostly from the trusting patients who sought our care. I worked about 192 hours a month, single coverage. I saw a many women with abdominal pain, but never anyone like this lady, from whom I learned several valuable lessons.

Approaching the bedside I observed a young, very obese woman in obvious distress, holding both hands over her lower abdomen. In between her paroxysms of pain, I asked the usual questions intended to quickly identify any potentially life-threatening source of her abdominal pain. When first evaluating a patient, regardless of presentation, the emergency physician must immediately look for badness, especially treatable badness, and intervene appropriately if warranted.

Abdominal pain infrequently harbingers "badness" in the true emergency sense. Patients usually define "badness" differently, as in "I really hurt" or "I'm really scared." Because they came to the ED they expect us to do something about it NOW. They want relief. We want a diagnosis. This difference in perspective sometimes generates early conflict in the ED physician-patient relationship. Said conflict often leads to a different sort of "badness," and often makes the subsequent evaluation more difficult for both the physician and the patient.

In many cases of abdominal pain, we can initially rule out true badness by the history alone. My interview of this lady tweaked my badness sense, but did not raise the titer to alarming levels just yet:

Pain is crampy in nature, started four hours ago rather suddenly, gradually increased in intensity, no fever or chills, no nausea, vomiting, or diarrhea, no urinary symptoms, last menstrual period started this morning, and she's always been irregular.

Needing more information I went directly to a focused physical exam. I felt her massive doughy abdomen and did not elicit any areas of rigidity or point tenderness, so maybe no badness there after all. But then the exam findings suddenly changed. A large contractile mass rose up to meet my examining hands. Quickly palpating the mass, I noted it extended most of the way up her abdomen. As the contractile mass relaxed, I thought I felt a small arm or leg move under my fingers. I quickly reasoned the need for a more accurate history.

"Are these cramps regular," I asked. "Yes," she replied, "they come about every five minutes."

"And tell me again, when was you last period, and how heavy was it?" I asked.

"Just this morning, not heavy."

Finally the right question: "When was the prior period?"

"I don't remember," she said. "A few months ago maybe."

She denied she could be pregnant, but I pretty well knew better by that point. A quick speculum and manual vaginal exam confirmed that this woman was indeed in mid-labor well on her way to delivering a full term infant. A couple of hours later, with the help of our reluctant on-call obstetrician, she delivered a healthy baby. Proverbially, mom and baby both did well, at least by our ER definition of lacking badness.

Over the years I've sometimes thought about this lady, although not so much about the emergency department drama. This case taught me most of all about the role of denial in the human psyche. Somewhere deep in her mind this young unmarried woman must have known or at least suspected she was pregnant. But so terrible to her were the psychological consequences, that her mind simply yet elaborately blocked that fact from conscious thought – even once the inevitable process of childbirth began.

This learning case was ultimately not about emergency medicine, or obstetrics. The most valuable lesson learned here came from the realm of mental health: Denial is a powerful yet subtle human defense mechanism that can ultimately wreak great havoc in one's life, greater even than whatever the psyche fears from the inciting event.

This was the first such case in my early emergency practice. I would not be the last...