On the Other Side of the Stethoscope

It began with an ache in my right lower abdomen. There was a sharp edge to it, at times. Not severe, just not normal. It came and went, lasting a few minutes before gradually ebbing away. Being a physician, and thereby a hypochondriac, I immediately considered the worst possible scenario—acute appendicitis. Not the worst because of its potential to kill me, but because of the inconvenience such a diagnosis would be at that particular time.

This was a Friday, about noon. My wife was scheduled to leave town to attend the wedding of her step-nephew, (details not that important), the next morning. The wedding was to be in Santa Rosa, a place about 450 miles from our house and a place where no one involved in the wedding lives. A ‘destination’ event in a peculiar destination requiring a plane flight and numerous Uber and Lyft rides to get to the various venues. All in the pouring rain.

The idea of spending 3 days and a significant amount of money to go to a wedding out of town for everyone involved and in no place I had any interest in being had caused a certain friction between the wife and myself. We eventually decided I should not go, but that she should. At the time we came to this conclusion we had no idea it would be raining, but as the date approached and the storm descended on northern California it washed away any residual misgivings I had about my refusal to attend.

I had better things to do. Things involving work, maybe a dinner with a couple of the guys, time to play the guitar, watch sports and be a slob, all by myself. And the dog, of course. The dog has no problem with any of the above activities, as long as we do them together.

So when the pain started and my mind conjured appendicitis another storm began to brew. Appendicitis requires surgery. The sooner the better. If diagnosed early it can be treated on an out-patient basis with laparoscopy, a couple hours in the recovery room, and discharge home, to the care of a family member. My only local family member was getting on a plane the following morning, and though plans could be changed it was unclear at the time what would be more awkward—asking her to change plans we’d already wrangled about for a couple of months or toughing it out on my own.

On the other hand, if the diagnosis is missed or delayed due to an atypical presentation, as often occurs in people my age, the appendix can rupture. This requires an actual incision, with mucking around in the area of the ascending colon to find the damned thing, remove it, and clean up the septic mess it made when it burst. This usually includes leaving a drain in place and carries the risk of systemic infection, a protracted hospital stay, and sometimes, yes, death. A ruptured appendix would solve the problem of no local family member, assuming she’d be back from the wedding before I was ready for discharge, but involved a number of other inconveniences I’d rather avoid.

By mid afternoon the pain had changed. It was no longer localized to my right lower abdomen but was hopping around from my right flank to my right upper abdomen, with an occasional twinge in the original spot. This, I thought, was most likely due to a kidney stone. Technically a ureteral stone. These things form in the kidney, much like a pearl in an oyster, where they remain, silent, until they one day pop into the ureter and begin their descent toward the bladder.

The ureter is a narrow tube and it doesn’t take much to obstruct it. A stone of a mere 2mm in diameter can do the job, and when it does the pain is epic. There is usually nausea and vomiting involved. It can last for hours or weeks. But it’s not appendicitis and it does not require immediate surgical intervention. Lots of ibuprofen and water are the mainstays of management, and hospitalization is not required unless you are puking your guts out and can’t keep the water and ibuprofen down. Nausea was not a significant issue for me. I was good, relatively speaking.

Throughout the night the pain came and went, meandering from one part of my right side to the other, making sleep impossible. I spent a few hours upstairs on the sofa, reading, then about an hour in bed, sleeping, until the dog woke me up at 7 AM demanding her morning walk. OK. Fine. Let’s go.

At about 9:15 the Uber car arrived, I wished the wife a safe voyage, and settled in. For what I was not certain, but I had the next three days off and if I could somehow pass the stone quickly I could still salvage some of my alone time. I diverted myself with baseball games and whatever other TV sporting events I could find, assiduously avoiding anything newsy or political, not wanting to add any unnecessary angst to the situation. I was tired, but I’m not a good napper and thought it best to stay awake until at least early evening, thereby maximizing my chances of getting some actual sleep despite the fluctuating discomfort.

By 8 PM the ball game was over, literally and figuratively, and I shut the lights. Before falling asleep I made note of the fact the pain in my flank was gone and only some vague residual aching remained in my right lower abdomen. Good, I thought, the stone is passing and by morning all will be back to normal.

Three hours later I was once again awake and experiencing intense pain in my right lower abdomen. This overlies the area in which the ureter enters the bladder via a somewhat diabolical course involving a kink right at the junction, causing many ureteral stones get stuck for a while prior to entering the bladder. Pain which might have been primarily in the flank could now be in the right lower abdomen or groin. One last bit of misery before the ordeal is over.

But, this is also the area of the appendix. Distinguishing one pain from the other is difficult and generally requires a CAT scan. Poking on the belly and lab tests can be somewhat helpful, but not definitive. The vast majority of kidney stones are made of calcium and show up as bright white objects on a CAT scan. Plus the kidneys and ureters can be visualized, and if swollen would further establish the diagnosis. Conversely, absence of these findings and the presence of a distended appendix with inflammatory changes adjacent to it would point to appendicitis as the cause of the distress.

As the pain intensified I realized I had a choice to make. Namely, which sort of asshole did I want to be? Did I want to be the guy who shows up in the emergency room at midnight on Saturday with a kidney stone he’s had for a day and a half? (Whiny asshole). Or did I want to be the one who toughs out an incorrect diagnosis, ruptures his appendix, and shows up in the ER on a paramedic gurney? (Dumb asshole). Being an old-school ER doctor the choice was more difficult that it might seem.

I decided it would be better to be whiny than dumb. But I needed a ride and with the wife in Santa Rosa, unaware of all the pathos going on at home, I would need to call a friend. This is actually a good way to see who your real friends are, and also a good way to alienate them. I didn’t have much choice and picked up the phone. He answered after the first ring, and 20 minutes later we were on our way to the hospital.

In years past I would have gone to the hospital about 8 miles away at which I had been the ER medical director. I would have been given the full red carpet treatment. In and out as quickly as possible and among friends the entire time. But that hospital no longer exists and the place I work at now is almost an hour’s drive. That, I realized, would be pushing things a bit too far.

We got to the ER a few minutes before midnight. My pain had dutifully kept its intensity and when asked by the triage nurse I was able to honestly rate it at a 6 or so. Anything less, I realized, would have caused some eyebrows to raise and aspersions to be cast. “No, I don’t need any pain medicine right now. I’ll let you know if things change,” I replied when asked. Stoicism is a virtue in my business.

A brief history was taken, vital signs and weight recorded, (as was a mental note to get back into the gym as soon as all this was over), and I was then sent back to the waiting area. ER waiting rooms are interesting, as I previously noted in Surviving the Emergency Room, and this one was no exception. Midnight on Saturday is prime time for ER people watching.

As my friend and I watched and chatted I noticed that my pain was beginning to subside. This is a common phenomenon in emergency medicine. I had long suspected that it was due in large part to the alleviation of anxiety a patient experiences by being in a safe place. The problem still exists but there is less reason to worry. This theory works well for lay people. It is less satisfying in my case. I’m in the ER, it’s inconvenient for myself, my friend, and the staff, and if anything I feel a bit more anxious. Nevertheless, my pain was going away.

About an hour later I was admitted to the ER proper. Pain now a 2 or so. More vital signs and a visit from the Physician Assistant who learns I’m an ER doctor, agrees to order the tests I suggest, then leaves, never to be seen again. Blood is drawn and an IV line is placed. A request for a urine sample is made, and when I say I gave one in the waiting room the nurse has to admit they can’t find it and can I please try again.

Eventually the actual doctor comes in. Introductions are made, the ER secret handshake is given. I tell him my story, we agree it’s probably a kidney stone, (my exam at this point is unremarkable), and I’m told a CAT scan will be ordered. Thanks, Doc.

When working a night shift time passes slowly if the patient stream dries to a trickle. As a patient, I learn, time practically stands still. There was a TV up in a corner opposite my gurney playing some sort of closed loop video of various things. I got to watch the World Trade Center being hit by planes about five times. An unusual bit of broadcasting considering the situation.

My friend tried, unsuccessfully, to get some sleep by positioning two chairs in a way that allowed him to more or less stretch out. At least he didn’t fall and hurt himself, though he was in the right place had that happened. Hours passed. No news. I didn’t want to be a pest but my friend was not as obliging. He tracked down the doctor and was told all was proceeding well, the urine test showed some red blood cells, consistent with a kidney stone, the other labs were pending, and the CAT scan should be only a short while away. Upon hearing the news about the blood in the urine I felt immediately vindicated. It was concrete evidence that something was going on to justify all the fuss.

Finally, a little after 4 AM, the x-ray tech came to take me for the scan. By then I was feeling fine. Of course. The scan itself took only a few minutes, and the tech, knowing I was a doctor, let me look at the images. I saw some interesting things, but nothing that looked like a kidney or ureteral stone. Hmm.

Back in my exam room we waited for the official radiology report. Forty-five minutes later we got it. No stones, no dilated ureter, no appendicitis, and all the lab tests normal, save for the bit of blood in the urine. I was disappointed. There had been significant drama leading up to this moment and the payoff was, well, meager. The likely diagnosis was a passed stone with no residual stones lurking about. The back pain had dissipated at about 8 PM, the CAT scan was at 4 AM, enough time for the ureters to resume their pre-stone size. Still…

On the drive home my friend casually mentioned that if it weren’t for the blood in the urine he’d be inclined to think I’d been overstating things. He might think that anyway.

Reviewing the reports later that day I noticed that one of my lumbar discs was in pretty bad shape. Three days later, while bending over to put something under the sink, it ruptured. I chose to tough it out.


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