The Heartsink Patient

As I sat in my consulting room waiting for the nurse to fetch notes from Dr Braver’s room, I heard a light tap on my door but no one entered when I said, “Come in.” I walked to the door and as I opened, the auxiliary nurse had been struggling to open the door with one hand whilst the other hand supported the huge sets of notes to her chest. I helped her with the door as I wondered why, after a long period when I virtually did nothing, I now had to see so many patients within the remaining period and the clinic would be ending shortly.

“Dr Braver has had to leave. I think it might be his wife that phoned him as he seemed to be in a hurry when he left. You know what he’s like when Mrs Braver phones. Sounded like he was taking her to the hair dresser.”

“So, he wants me to see all of these this morning? Tough.”

“Yes. He said you should make sure you see all the patients and phone him with every case that you saw.” The auxiliary nurse said, as she carefully placed the notes on the floor close to my desk.

“This must be a joke!” I exclaimed, “Never mind. Hopefully he would return to the clinic.”

“I doubt very much.” She said, as she prepared to call the first of the patients into my consulting room.

My heart sank as the auxiliary nurse ushered in the patient. I had seen her before and I felt like telling her to rebook on another day to see the boss himself. She was a patient that never smiled. She looked thinner than she did the last time that I saw her and the look on her face today was that of the devil just woken. But that wasn’t the reason why my heart sank. The first time I saw her was on the ward when she was admitted for investigation of her abdominal pain. Dr Braver had recommended an exploratory laparotomy to her. But she declined. That did not surprise me after reading her case history. The first operation that she had was laparoscopic appendicectomy, the removal of the appendix through the keyhole method. Prior to having the operation, she had been complaining of pain in the lower part of her tummy. Dr Braver told her that she had a grumbling appendix and that her pain would settle after he had removed the appendix. She suffered an injury to her large bowel which resulted in having a colostomy. On her insistence, Dr Braver took her back to theatre to rejoin the bowels after three weeks. The joined bowels broke down and Dr Braver yet again took her back to theatre to have the colostomy restored. The restored stoma broke down and she had to undergo further surgery. After four weeks Dr Braver had planned to close her colostomy but she developed a deep vein thrombosis. Now her legs were permanently swollen. She was still complaining of abdominal pain. She was as thin as bone and smoked like a chimney.

“Oh he is not here today!” she said, as she settled down in the chair in front of me.

“Im sorry, Dr Braver has had to go to attend to an emergency,” I said, seeing the disappointment on her face. Normally, patient like her would be seen by the consultant as they usually were too complex for the junior doctor and were not satisfied.

“How come no one had told me?” She shouted. And after coughing several times, her chest still rattling, she said, “And I have sat down there for two hours waiting to see the consultant!”

“I am sorry.” I said, with empathy.

I didn’t know what else to say. She was right. Someone should have told her she was not going to see Dr Braver. At least, it would have been up to her to decide if she would like to see me. It made me wonder how many patients waiting out there were hoping to see the consultant.

“Not your fault, I guess,” she said, as she stared uncomfortably into my eyes.

“So how can I help you today?” I asked, unsure of her reason for her attendance. According to Dr Braver’s last letter to her GP, he had discharged her from his clinic. But she was now back and I could not find her new referral letter. It was probably in Dr Braver’s folder. He usually kept such letters in a special folder.

“You can’t help me. Look at the mess he had made on my tummy.” She got up and lifted her shirt to show me several scars on her abdomen.

“I see.” I said.

But I didn’t think that was the reason she had come back to see him. I waited expectantly to hear what more she was going to say.

“My pain has got worse. It’s tummy pain day in day out. I can’t eat. Look at me. I am now a walking skeleton.” She said, tears streaming out of her deep orbits.

“You said you can’t eat. What happens when you try to eat?” I asked.

“I have a good appetite but I daren’t put anything in my mouth.” She replied.

“Why?” I asked and screwed my eye.

“You are asking me, why? Have you not been listening. Or are you too telling me I am mad?” She shouted.

“Who said you were mad?” I asked softly.

“Him. The God himself. Luckily he is not here today. I would have shown him that I am truly a mad woman.”

“That sounds serious.” I cleared my throat and paused to regain my composure. “What about if I  asked you to tell me more about how eating affects your stomach pain?”

She coughed again and almost choked as she replied, “When the food gets to my stomach I start with severe pain and this can go on for several hours. I am sweaty and feeling faint. The pain is so severe. It’s murder. I just can’t face food any more. Sometimes I thought it was better to die than live like this, because this is no life.”

After further questioning, I suspected that this woman had Mesenteric angina caused by some narrowing in the arteries of the bowels. This condition is common in long term heavy cigarette smokers. Patients with this condition have severe pain in their abdomen after eating. This is because, after eating, there is not enough blood flow to the bowels due to the narrowing of the arteries. I told her to lie down on the examination couch. And when I placed the bell of my stethoscope on the top part of her abdomen, I heard a loud bruit. I became more convinced of my diagnosis, but still needed to confirm it.
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I wasn’t sure if that was the problem with this woman. But I thought it would be prudent to rule it out. Nevertheless, I was careful not to raise her hope, knowing that Dr Braver could disagree with me, particularly, since that would make him feel less knowledgeable should that be the diagnosis. And of course, he could override my decision.

“So, what are you going to do?” She asked, now almost pleading.

“I am just thinking. I’m not sure. I just wondered if we should rule out a condition that can sometimes cause this kind of pain. But that would mean having to undergo further tests.”

“I don’t care what tests you do as long as you find out what the problem is. Nothing can be worse than the pain I have been having.” Her face became less narrow, showing a glimpse of hope.

“Okay then. I just need to nip to the X-ray department to chat with the radiologist.” I said.

The woman needed to have a special scan to diagnose the problem. I had to do this before Dr Braver got to know. I knew I was taking a risk. If the scan turned out to be negative it would be real trouble. But if the diagnosis was confirmed it would be a relief for everyone although he would still criticise me for taking the liberty to organise an MRI scan without first discussing with him.

In the twinkle of an eye I had arrived in the X-ray department. I was glad that Dr Grayson was the duty radiologist. Unlike his colleagues, he was approachable and knew a great deal of clinical medicine. Having initially trained as a surgeon before becoming a radiologist, he was always very helpful when surgeons needed radiological input. Dr Grayson agreed with my suspicion. Fortunately, there was a cancellation and he was willing to perform the procedure that afternoon if the patient was prepared.

I raced back to the OPD, relieved that I was able to organise an MRI Angiogram within a few minutes, something that would normally take several weeks to arrange.

“You will be having your scan this afternoon madam.” I said, with a beam of smile.

“Oh thank you, doctor. Thank you. You are God sent.” She jumped up. Suddenly, her strength returned from nowhere. And for the first time after many months, she smiled as she hoped to see a way out of her predicament.

“I am not promising. And I’m not even sure if we will find anything. But I believe it’s worth a try.”

“As I said, I will try anything.” She said.

“Now, you better go and get yourself ready before Dr Grayson changes his mind.”

“Thank you again, Doctor.” She said, as she shut the door behind her.

Just before I called the next patient, there was a tap on the door. I thought the woman had come back to decline the MRI scan.

“What have you done to that woman?” Sister Bamforth asked, as she pushed through the door.

“Which woman?” I puzzled.

“The patient that you’ve sent to the X-ray department. She was singing your praises as the nurse took her to the department.”

“Oh God. I hope I have not raised her hope too highly.”

“I don’t think it mattered to her. And I don’t think anyone can stop her either.” She said.

“Oh well, I wish her good luck.” I said, trying to stop the discussion going further. I really didn’t have time for further gossips.

“You know the problem you have now got, doctor?”

“What?” I asked.

“The patients are now changing their mind. Many of them were trying to rebook their appointment. But they are now waiting to see you. That means, a long clinic.” She replied.

“I’m sure we’ll be fine.” I tried to draw the discussion to an end.

“Sure.” She said, as she swiftly walked out of the room.

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