Wednesday, November 20, 2013

Arts 1 Science 0

There are just some diagnoses in medicine that science cannot make. All that is left is the clinician's human acumen and skills. This is a life saving story of just such an experience....

The tap on the door was unexpected. So was the condition of the patient without an appointment as she half collapsed through the door supported by her partner.

I was sitting chatting to a friend, a general surgeon of the highest caliber, congratulating him on his acceptance into a top international cardiothoracic residency. Oh, he was good. He was the best.... but only at modern style medicine. I had studied the arts of medicine under various masters with infeasible who had taught me the keys to those arts and how to learn them.

I already knew what was wrong with her. I had seen it is her fevered face and in the way that she painfully moved. It was a reasonably common surgical problem, everyday stuff for him.

He was on his home ground. He had more experience. All I had was a year of surgery a decade earlier before pursuing a career in family medicine. He really should have won hands down.

So I challenged him, his science against my arts.

He took a brief history. Her vague lower abdominal pain with right loin pain and fever started two weeks ago and progressively got worse. During this time, she had seen five specialists from both gynaecology and surgery. Each had ordered blood tests and scans but none of them could offer a diagnosis. None of them could even decide if it was an intestinal, gynaecological or kidney infection. Each had just given her more antibiotics blindly. Her pain had just got worse. Now she was vomiting all over the place. Her general condition had deteriorated dangerously.

His examination was no help. Vague diffuse lower abdominal tenderness and tenderness over the right kidney. He could not make the diagnosis. He was unsure what system was infected. He would repeat the bloods and scans.

By now her blood results would have been frightening. She was entering septic shock and multisystems failure. But the blood tests would only show that she had severe bacterial infection, not its source. The scans would still pick up nothing specific.

It is all so easy when you already know the diagnosis and the history and diagnosis are only to prove that first impression. I teased out the history as a textbook example of a slowly exacerbating lower abdominal pain and low grade fever with minor loss of appetite and nausea. A sudden increase in pain and fever came with the onset of back pain which slowly spread upwards.

He had had his forehead slapping moment by now. The patient had appendicitis, the other sort of appendicitis, and all the doctors had missed. It was the rarer form of appendicitis, the one that haunts surgeons. In 10% of cases, the appendix does not come forwards as it does in 90% of cases to give that area of well defined tenderness on the front of the abdomen but flops back behind the large bowel. It does not cause specific tenderness, even in the back because it is hidden behind the muscles and pelvis.

Without treatment, her appendix had formed an abscess which had ruptured and filled the anatomical gutter behind the large bowel on the right with pus. And that is exactly what the textbooks say happens.

We sent her to the surgeon on duty with the history told my way and the diagnosis. She immediately had the surgery she needed two weeks earlier but spent a few days in high dependency. She recovered fully, except for the extra abdominal scarring from an extended incision, drains and the bill. Regardless of the fact that her life had been saved in the end, she was not a satisfied customer. She had to be talked out of a pointless attempt to sue before some predatory lawyer took over. She could not understand that the medicolegal system is not about getting the right diagnosis. It is about being average. It is about ordering scientific tests and proof. All the doctors who had missed the diagnosis had dotted every medicolegal I and crossed all the Ts.

After my vehemently ranting about the ridiculous legal system culturally dumbing down medical practices to dangerous levels, we finally agreed that the law was an ass, which I suppose makes it an ass's ass.

It really was a textbook case. The only problem is that a many other infections can cause superficially similar symptoms and the differences in their history are only in the finest details. You need to already have the highest suspicion of this diagnosis to clarify those details.

And examination just does not help. Blood teasts do not tell you where the infection is. Nor do x-rays or ultrasound scans. Bowel gas gets in the way of the abscess and once it is ruptured, the thick viscous pus has a similar density to normal and blends in with it. CT and MRI have a similar problem making it easy to miss.

This is one bitch of a diagnosis. It is notorious. It is feared. When surgeons operate on a patient for appendicitis and find no appendicitis, it is through fear of this diagnosis that can only really be diagnosed with the most intuitive art. They have a 100% hit rate with normal appendicitis.

I have a 100% hit rate with the difficult form of appendicitis: zero false positives and zero false negatives. It is not just experience otherwise my more experienced colleague would have got the diagnosis, not me. It was not the vague phrase of experience, 'I have seen it before'. The other cases I had seen were early and unruptured. I had only heard this scenario described. I had never seen a case like this.

No, I was taught the art of objectively assessing what a body is feeling from facial expressions, tone of voice and the way that it moves under non-exam conditions when the patient does not think anybody is looking. Hell! The standard medical examination hardly asks the patient to move at all.

Perhaps I was not taught this art of astute observation. I experienced it. Somebody showed me that it was possible. Somebody showed me its power. They opened my mind and spurred me on to learn such levels of clinical acumen through experience. They showed me that the extra dedication that it would take would pay off. It has saved patient's lives.

This person was not a doctor. She was not even a nurse. She was an untrained nursing auxillary but she had worked on the same ward for nearly two decades.

At first I thought it was a joke on a young doctor to teach me a little respect for the nursing staff of all levels. I was told she could diagnose a patient just from one look at their face as they were wheeled past her. I was warned never to disagree with her diagnosis. If ever I did not know a diagnosis, I should ask her.

It stopped being a joke when I witnessed the hospital's senior surgeon ask for her opinion when he was undecided between two diagnoses and he took the patient to surgery on her word. She was right of course, as ever.

The only exaggeration had perhaps been her ability to diagnoses the patient with a single glance. She also greeted them. More than that, she was always the one transfering the patient from the trolley to the bed, watching their every move like a hawk.

Despite the fact that it was not in my job description, that is what I did. I mucked in with the most mundane tasks of the nurses and paid acute attention to the patients' every gesture and move when they thought they were not being observed. I did not analyse or categorise. I cannot give words or descriptions to what I learned. I took complete four sense impressions, including with my nose (not taste, thank you very much). And I correlated these sensations with the textbook descriptions of the pathology going on behind their diagnosis. I imagined and felt how different diagnoses felt.

And that is how I learned to diagnose patients at a glance. It is why my surgical friend, qualified and experienced as he was, could not compete with my clinical acumen. He had stuck to his job description and the hierarchy of the ward and so had the nurses he had worked with. Despite all their experience and that they are the only ones who really see patients move naturally, they were not allowed to use their invaluable perceptions and suggest diagnoses. More than anything, he had never had the five minute mentor that I had been gifted with to show him just what is possible with careful observation under non-exam conditions.

I thank this great mentor from the depths of my heart. Many of my patients owe her their gratitude. Some of them owe her their life.

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