“Everyone thinks I’m a hypochondriac. It makes me sick.”

Felix Unger, classic character from “The Odd Couple”

     I was very excited to finally be a part of the surgery resident team, starting my very first afternoon rounds on my surgery patients.  We had a list of twenty-one patients, most of them on the eighth floor surgery ward, with a few scattered on floors seven and four.  We had gathered all our charts onto a cart that we dragged around with us.  Outside each room, the medical student gave a brief presentation on the patient, then we went into the room and quickly looked over the patient.  We discussed what the next steps for the patient would be and answered questions.  We checked surgical wounds.  The student would stay behind to replace dressings on wounds and then catch up.  Poor Sam did not know much about his patients, so Stuart supplemented and corrected his presentations.  Jessie did tend to chat with the patients quite a bit, slowing things down.  Stuart would subtly move the team out of the room and keep things going.  There was a mix of post op colon resections, a stomach resection, two appendectomies, gallbladders that had just been done or were waiting to be done tomorrow, diverticulitis, bowel obstructions, and a few mastectomy patients.  

     We finished rounds down on the fourth floor just as Jessie’s beeper went off.  She looked at it and murmured something about being late to the ICU.

     We followed along with her as she rushed down the stairwell, running through the list of patients to make sure we had all the details of what needed to be done prior to going home.  Stuart divided up some small tasks among the students, and we sat down to go over the patients in a little more detail.  We had barely started when his beeper went off.

“Damn, it’s the ER,” he exclaimed.  He called them back to see what they had for us.  He was the intern on call for the night, so he would see any patients coming in to the ER that needed a surgical evaluation.   At a teaching hospital, patients who come to the ER are first seen by an ER physician, who determines who else they need to see, if anyone.  The good ER physicians can take care of the routine stuff, figure out what is going on with patients, and only call surgeons if the patient really needs a surgeon.  However, some just want to shuffle the patients off onto someone else so they don’t have to worry about making a diagnosis.  So everyone with abdominal pain, nausea or vomiting gets a surgical consult, everyone with chest pain gets a cardiology consult, everyone who acts weird gets a psych consult.  The surgery intern generally sees the patient, reports to a senior resident, who also sees the patient, then they report to an attending, who is responsible for the patient.

“First, we have to make a crucial decision,” Stuart said, looking at his watch.  “Dinner?  Or ER?  We could eat dinner now, but then we have to rush through it to get to the ER, and the patient gets all pissed because they have to wait.  If we go to the ER first, we risk getting slammed with three more patients, then we miss dinner, because the cafeteria closes at seven-thirty.  But we can always find food in the ICU nurses’ lounge.  Let’s go to the ER, we can whip this out in fifteen minutes.”

     I trailed behind Stuart down to the ER.  He had been called to see a thirty-two year old lady with abdominal pain. 

“So the ER doc says she has rebound and guarding.  The chances of her actually having rebound and guarding are slim to none.  They are right about one out of twenty calls,” Stuart explained as we went down the back stairwell.  Rebound and guarding are very specific signs on physical exam.  Rebound is increased pain upon sudden release of pressure from the abdomen – it hurts more when you let go, compared to when you push in.  Guarding is tensing the abdominal muscles almost subconsciously to protect underlying inflamed tissue. These are signs of a serious intraabdominal problem like an appendicitis or a perforated ulcer.

     Abdominal pain is a very common reason for people to come to the ER.  Most cases of abdominal pain are due to things like viral gastroenteritis, constipation, food poisoning, irritable bowel or other things that do not benefit from surgical intervention or even need surgical evaluation.  The ER doctors try to sort these out from the patients who have appendicitis or gallbladder disease, diverticulitis, pancreatitis, bowel obstructions, or perforations or other conditions that do need to be seen by a surgeon.  Surgery residents are busy, and don’t like to have to run to the ER to evaluate people that don’t really need a surgeon.

“Well, aren’t they fairly good at triaging these patients?  Do we end up seeing a lot of non-surgical patients?” I asked. 

 “Oh, little naïve one.  To think, once I was so innocent and green,” he answered, wistfully staring off into the distance for dramatic effect.  “The goal of the ER doctor is to get someone else to take care of the patient as quickly as possible.  They know the things to say to get us down here to see patients.  They are always claiming someone has an acute abdomen, rebound and guarding, peritoneal signs, blah, blah, blah…You get down here, and they have nothing.  You can press on their belly ‘til you feel spine and they don’t even flinch.  Wait ‘til you meet up with Dr. Crumley.  Remember that name.  Sear it into your brain and learn to dread it.  With him, everyone, and I mean everyone, has a rupturing aortic aneurysm.  They may be a perfectly healthy sixteen-year old with left arm pain and stable blood pressure, but he’s always sure they’ve got a rupturing anuerysm.   ‘Can you get down here right away, he looks like he could go south at any minute, this isn’t one to sit on’ he’ll say.  Then you end up sending the patient home because they have the stomach flu or something equally unimpressive.  One or two of the ER docs are good, but overall, they just want to get the patients out of the ER and make someone else take responsibility for them.”

     We walked into the nursing station and found the chart.  A large, rather brusk nurse plopped down beside Stuart and tapped the chart.

“She’s a real winner.  You’re gonna love her,” she said sarcastically.

“Hey, Sheila-woman.  How are you?  Did you bring in anymore mushrooms?” he asked excitedly, turning towards me.  “She grows all sorts of fungi- the edible kind, not the mind-altering kind-that are better than anything you can buy in a grocery store around here.”  He turned back to Sheila.  “I need to make this chicken marsala thing, it’s fantastic.”

“That’s what you said last time I brought them for you, and you never showed up with any chicken-anything.  What did you do with all those mushrooms, try to smoke them?”

“Oh, I made the chicken thing, and it was delicious!  I just didn’t invite you,” he informed her.  She rolled her eyes.

“So what’s wrong with this chick?” he asked the nurse.

“Well, you’re the doctor, that’s what you’re supposed to figure out.  I’m not going to prejudice the good doctor’s opinion before you even see her,” she responded as she walked off.

“Okay, but you already have – we are sufficiently prejudiced already,” he yelled after her.

  We flipped through the chart, and Stuart let out a groan.

“Oh, God have mercy on us.  She’s got the triad.”

     He held the chart out for me to see, pointing to her surgical history.  She had undergone an appendectomy at age eighteen, a cholecystectomy at twenty-four, several laparoscopies, and a hysterectomy at age twenty-eight.

“What’s the triad?” I asked sheepishly, wondering if I was missing something obvious.

“Appendectomy, cholecystectomy, and hysterectomy before age thirty-five.  This is diagnostic of one thing.  One thing.”  He stared at me, waiting for an answer.

     I strained my memory, trying to recall some syndrome that would result in needing your appendix, gallbladder, and uterus out at a young age.  Some kind of polyposis?  No, all those syndromes always involved colon.  Cervical cancer?  Mucinous cystadenoma involving all three of those organs?  I was grasping at straws, not coming up with anything except a puzzled gaze.

“It has become painful for me to watch you stress your brain to its capacity, so I’m just going to tell you the answer.  It means they are crazy.  Insane.  Surgical addicts.  Hypochondriacs who have spent a lifetime, starting at an early age, complaining of vague abdominal pain.  No one can ever find anything wrong, so they shop around until they find some doctor to take out all the stuff in their abdomen that can be removed without actually killing them.  Usually in this order:  appendix, gallbladder, uterus.  I bet she has a bunch of ER visits listed.”

     He brought up her record on the computer.  She had at least thirty ER visits over the last year, and multiple admissions.  We scanned through her previous radiologic studies.  Over the last six months, she had many CT scans, two small bowel follow through series, plain x-rays by the dozen, some pelvic ultrasounds, and even a mesenteric arteriogram.  All the tests that we checked were reported as normal.

     She had undergone an abdominal and pelvic CT scan with oral and IV contrast today that was normal.  No dilated bowel, no fluid, no inflammatory changes anywhere.  Everything looked perfect.  Her blood work all looked good – normal white blood cell count, normal liver function tests. 

“Okay, Sawmiller, let’s go.”

We knocked on the wall to let the patient know we were coming in, and pulled the curtain back on room twelve, peeking in.

“Ms. Warren?  It’s Dr. Wells and Dr. Sawmiller, from the surgery department.  They’ve asked us to come take a look at you,” Stuart introduced us.

She was lying on her side in a fetal position, with the blanket up over her head, moaning.

“Can I get more pain meds?  It’s really bad again,” she said.

“Well, it looks like you just got some morphine a few minutes ago…” Stuart started.

“Morphine doesn’t work on me, and I am allergic to Demerol and Toradol and Tramadol.  Ibuprofen does not work and makes me sick.  Dilaudid will work, but you have to give me a high dose, at least ftwo or three milligrams IV, otherwise it just runs through my system without any effect,” she interrupted him. 

“Okay….well tell me when this pain all started.”

“I have adhesions from my last surgeries, and I just need to have them out.  I can’t stand this pain anymore.”

“Okay, let’s focus on the question that I actually asked.  What can you tell me about when the pain started?” Stuart continued, trying to get some useful information out of her.

“I always get pain a couple months after my last surgery, because the adhesions just build up.  My stomach hurts all the time, all over, and I can’t take it anymore.  I haven’t been able to eat or drink for over a week, everything comes back up.  It hurts all over, and it’s just getting worse.  They said we could do surgery today.”

“Who said you are having surgery today?  We don’t have any surgery planned.  We never would do surgery without even seeing you or figuring out what’s wrong,” Stuart answered.

     Her eyes filled with tears, and she angrily explained that the ER doctor had said we would operate on her today.

“Well, the last time I checked, the ER doctor was not a surgeon, so he would never make that decision.  He doesn’t have the training, experience, or board certification to decide whether or not you need surgery.  He does not have staff privileges to do an exploratory laparotomy.  You surely misunderstood him.”

     Again, tears flowed down her face as she tried to explain about her adhesions, and that she couldn’t stand the pain anymore, and she was here for an operation, because that was the only way she would ever get better.

“We need to clear up a few things.  First of all, we generally don’t operate on people without a good reason.  We can’t get rid of your pain unless we know what’s causing it.  Pain cannot be surgically removed.  It’s not a solid thing that can be visualized and cut out of your tissues.  Sometimes, we can help relieve abdominal pain by removing something that is inflamed, infected, perforated, twisted, or otherwise messed up and causing your pain.  But we have to find the reason for the pain and fix that, otherwise, surgery only increases your pain,” Stuart responded, as if he had given out this same explanation a million times.

     She was getting more hostile as he spoke.  “I have adhesions that need taken out, I can’t go on with this pain.”

“That brings me to the second point.  Adhesions don’t cause pain.  They cause obstruction, if they trap bowel, but then we would see dilated bowel, and you would be throwing up.  If adhesions caused pain, nearly everyone who ever had surgery would end up with chronic pain.  Almost everyone we operate on gets adhesions, and almost no one gets chronic pain after surgery.”

”Well, I know my body, and there is something really wrong!” she burst out.  “They kept telling me nothing was wrong the last time, and finally a surgeon went in there, and he said it was lucky he got in there when he did, because if we had waited, I probably would have died that night.”

“Let us at least take a look at you, and look at your x-rays, and go from there,” Stuart responded impatiently.

     Stuart gently placed his stethoscope on her abdomen, and she flinched in pain, pushing his hands away.  He had me listen as well.  She had nice, active, normal bowel sounds.  Her abdomen did not look distended and was soft.  She groaned with pain with even the lightest touch to her skin.  Stuart started asking her questions about nausea, about her bowel movements, about any urinary symptoms or vaginal discharge.  When we kept her distracted with questions, we could put significant pressure on her abdomen and not elicit much of a response.  We asked where the worst pain was, and she again started grimacing and moaning with any light touch anywhere on her abdomen.

     We said we would go review her labs and x-rays and return.  She again made some very specific requests for high doses of intravenous dilaudid, and strongly reaffirmed her need for urgent surgery.

     “So, she has nothing.  A perfectly soft abdomen with normal bowel sounds,” Stuart sighed.  He looked over her bloodwork again.  All normal.

     “For someone who has been vomiting for a week and unable to eat or drink, her labs sure look good.  She has no sign, not even the slightest little inkling of even mild dehydration,” he stated.

     Stuart then went on to explain some basic truths to me.  He went over what he called “The Big Adhesion Myth”.  After abdominal surgery most people form adhesions, membranous sheets of scar tissue, between loops of intestine, omentum, and the abdominal wall.  If they get thick enough to entrap intestine, they can cause blockages of the intestine.  This results in nausea and vomiting, then as the bowel becomes very distended, eventually causes pain.  But you don’t get pain without the obstruction.  Many, many people have second or third or fourth operations for various reasons, and numerous dense adhesions are found, but these patients never had any pain.  Adhesions don’t cause abdominal pain. There is a population of patients with chronic abdominal pain, and no one can find a good reason for the pain.  Eventually someone, usually a primary care doctor or a gynecologist or a nurse practitioner, tells the patient they probably have adhesions, they should go see a general surgeon.  And if they look around enough, they will find a surgeon who will operate on them.  And shortly after surgery, the pain comes right back.  So then they figure they have formed more adhesions, so maybe they need another operation, and a cycle of numerous, largely unnecessary operations begins.  Some people have multiple laparoscopies or open surgeries for lysis of adhesions for pain, but the pain always comes back.  The adhesions were never the cause of the problem. 

“Why, when they have already had three or four operations that did NOT fix their abdominal pain, why do they think another operation will?” Stuart asked. “I just don’t get it.”

     Then we talked about the patient who is allergic to many pain medications, and has specific doses of specific pain medications that they want to receive.  They make these requests because that is “the only thing that ever works for me.”  As if they are somehow physiologically different than the rest of us.  Anyone who is “allergic” to all non-opiod pain medicine and knows exactly the dose of IV Dilaudid that they want is a drug seeking sociopath.  No one should know that much about IV pain medicine dosing unless they are in health care, or they are a drug-seeking sociopath.  Some people do develop tolerance after long term use, and adjustments have to be made, Stuart would admit.

“It’s really a bad sign if you have already tried every pain medication known to man enough times to think that you are allergic to fifteen of them and then know the exact dose you want.  Normal people don’t know that stuff, and they don’t obsess over it the way she does.”  

     He looked over her long list of recent radiology studies.  “Okay, she has had eight abdominal CT scans in the last six months, all of them normal.  Huge, huge warning sign that she is crazy.  And her story about how she would have died that very night if the surgeon didn’t operate – bullshit.  She thinks we are so stupid that we will ignore all the objective evidence that she has nothing wrong with her and rush off to surgery, because the last guy did.  If he was so great, why isn’t she seeing him again?”

     He handed me a History and Physical (H&P) form and told me to start writing.  Jessie was on as the senior resident.  We would call her, give her a detailed presentation on this patient, and see what she wanted to do.  

     Stuart started to pick up the phone.  “We must be a wall against this admission.  She cannot get through.  She will torture you every day if she gets admitted to us.  And she does not need a surgeon.  We are not the ones best suited to help her.  She needs an internist or a psychiatrist, or a chronic pain specialist.  Part of your job as an intern is to protect your service from these bogus admissions who have no general surgical issue whatsoever.  We can offer her nothing helpful.”  He was psyching himself up for the conversation with Jessie, because he knew she would want to admit this lady.  She admitted everyone.

“Hello, Jessie,” he started.  “I have a lady down here in the ER, but I don’t think she is anything for us.”  He went on to give her all the details, including her extensive history of ER visits and normal studies.  He quietly listened to her response.

“Okay, Jessie, I would rather gouge out my left eye with an eleven blade than admit this crazy lady to our service.  She has nothing wrong with her.  She will never, ever, ever want to go home, and every day she will demand an operation, and she has no reason for an operation.  Her exam is totally normal, her CT is totally normal, her labs are all fine.  She is a crazy girl looking for someone to cut her open.  She will ball and cry everyday when we tell her she doesn’t need an operation.  We will have to spend hours trying to calm her down and emotionally comfort her.  She will suck up the entire narcotic supply of the hospital.  She will be a demanding pain in the ass, and everyone involved will be miserable until she gets so pissed off that she signs out AMA (against medical advice).  She will drain the soul, the very spirit, out of our team, and crush any medical student’s desire to even consider going into general surgery as a career.  They will tell all their friends, and no one will apply for general surgery residencies.  In five or six years there will be a serious shortage of general surgeons.  People will start to die by the thousands from hernias and gallstones, because there will be no general surgeons around to take care of them.  All because we admitted this lady to our service.”

Stuart sat, listening to her response.

“Okay, but what are the chances of someone really having an appendicitis, cholecystitis, and a uterus bad enough to need removed by the time she’s twenty-eight?  We found the path report for the uterus.  Normal.  No fibroids, no endometriosis.  Normal.  She convinced some poor sucker to take out her perfectly normal uterus.  She still has ovaries, we should make gyn see her,” he argued, unsuccessfully.

     Jessie responded, and Stuart held the phone away from his ear so he didn’t have to listen.

“I’m going to repeat this one more time, because you couldn’t have possibly heard me correctly.  Any reasonable senior resident who heard me correctly would be telling me to dump her as fast as we can and to run, screaming, as far away from this patient as we can possibly go,” he continued.  He spoke with a mockingly exaggerated slowness as he repeated, “Her CT scan today is normal.  Her bloodwork is normal.”

Stuart listened to her response and hung up.

“Alright, we’re admitting her.  Jessie is coming down to see her.  The only consolation in all of this is that in two days, I will be thirty miles away at the University doing my cardiothoracic rotation, and she will be your problem.”