Sunday, September 25, 2005

Pain Out Of Proportion

Part of the prolonged process of becoming a physician is learning to separate the wheat from the chaff --- getting down to the meat of what is wrong with patient, and putting aside other information that is distracting, or at least of lesser importance. This is a skill that is not instinctual, never formally taught, and is always in the process of being refined by the practicing physician. In many respects, it is what general surgeons must pretty much always do when faced with the patient in the ED.

Sometimes, we get clues that lead us in one direction or another --- certain typical complaints from the patient, worrisome lab or X-ray findings, etc. There are also specific phrases when spoken by the ED physician tend to make us pay a lot more attention --- like "free air under the diaphragm," "hypotensive patient with abdominal pain," and "get down here now!" One of these phrases that makes the hair on the back of my neck stand up when delivered by an experienced (old like me) ED doc is "pain out of proportion to exam." Quite literally, it means that the patient complains bitterly of abdominal pain, usually a gnawing and difficult to control pain, with a fairly benign abdominal exam.

WARNING! WARNING! DANGER WILL ROBINSON!

Pain out of proportion to the exam (POOP) can be a sign that a piece of bowel is on its way to dying, or may already be dead. It often means a trip to my favorite place, the cold room with bright lights, warm blankets, and your friendly neighborhood anesthesiologist.

So, when Dr. Smith (pardon the Lost in Space reference) called the other night and used the magical catchphrase, I was out of bed and in the ED at 2AM. He was very concerned about the lady in exam room 16, and thought she needed to be explored. I found there a very sweet little lady in her 70s, with a lot of good reasons for having ischemic bowel --- she was a long time smoker and resultant vasculopath, and she had undergone three or four abdominal operations. This means that she could have compromised bowel on the basis of [1] an adhesive small bowel obstruction or [2] mesenteric ischemia due to her vascular disease.

She was in a fair amount of discomfort, but had received only a small amount of narcotics at that point -- somewhat unusual for a patient with dead bowel, but not at all uncommon in the elderly. Her abdominal exam was pretty benign; although she did complain of diffuse lower abdominal pain, her abdomen was soft. Labs were unremarkable. Plain X-rays and abdominal CT also unremarkable. In fact, the only two things that were remarkable about this lady were her tears and her frequent repetition of the same question --- "Has my daughter gotten here yet?"

There are unfortunately not a whole lot of additional tests that help us decide which patients with POOP need to go directly to the OR, and which ones can be safely observed. This is where the experience of the refining process I wrote about above can come in real handy -- but it is by no means infallible. So, I left the exam room, telling her I would go review the CT with the radiologist; in all honesty, with cases where things are a bit murky, I need a few moments alone with my thoughts to help me make a good decision. Besides, the only thing the CT revealed was an abdominal aorta that contained enough calcium that it looked like a misplaced femur.

I returned and reexamined the patient, who if anything was more agitated and uncomfortable, perhaps crying even more --- with fear? pain? worry? Her daughter arrived, and she simultaneously lit up and sobbed a bit harder. I have been presented with this scene before, and am not such a cold-hearted SOB that I didn't leave the room to give them a few minutes together.

As they say where I grew up, "sumpin' ain't right here," but I wasn't convinced she needed urgent exploration. I had decided to admit her for observation and serial abdominal exams and was writing my notes & orders when her daughter approached me. "My mother has had a rough time lately. You see, my father died unexpectedly a few weeks ago, and Mom .... well, she's just .... just not doing well with all of this."


I probably spent way too much of my youth watching old TV shows and movies, but at that moment I felt like the two-bit safecracker in a black and white cop show who heard the final "click" while breaking into the big score. I also felt pretty stupid.

So, with a little help from time and an antidepressant, this nice but distraught lady was able to stay away from the OR. Her pain was out of proportion to her exam, but definitely not out of proportion to her exigency.