Necessary Testing

“Ma-a-ark,” I heard the distinctive warbly voice upon answering the phone. It was my mother-in-law, Peggy, better known as Mom Mom. When she called my name like that it always reminded me of a beloved hen that my brother had as a pet when we were children. “My stomach still hurts. I’m not feeling any better?” We had been going back and forth for several days on the phone. She was complaining of ‘knot’ in her stomach that ‘hurt like a boil.’ She had mentioned the problem to her family doctor at a recent visit to deal with another problem. Mom Mom reported that her doctor, a young woman fresh out of residency training, simply told her that she probably had the stomach virus that was circulating through the community. It was not the reason for her initial visit to the doctor, so I understood why her doctor gave it little notice. When I had questioned her, I had to admit that the history seemed benign. But when the problem didn’t resolve she went back to the doctor two more times, each time hearing the same explanation. Now she was turning to me. She lived two hours away. What was I to do? I finally did something that I’m loathe to do to a colleague, I sent a little old lady with vague abdominal pain of two weeks…to the ER…on Christmas Eve. “I’ll meet you at the hospital,” I told her.

“Should I wait for you to get here?” She was the ever obedient patient.

“No. Let them go ahead and get started with the workup, ” I sighed. I actually thought it might take two hours for her to get into the ED.

The snow was 21 inches deep and glistened like diamonds in the sun. It was supposed to be a Christmas to remember. My wife and I loaded all the presents for our out-of-town relatives in the car and headed for the hospital.

Rebecca’s mom and dad are 80 and 83 years old, respectively. Both are in reasonably good health. Pop Pop recently noticed that he couldn’t walk to the nearby shopping center without getting short of breath and having to stop. A cath showed moderate multi-vessel disease, but with a few stents he was as good as new. Mom Mom was a little more complicated. A delicate Christian woman who was loathe to complain about anything or anybody had, a few years back, finally owned up to the fact that her back and leg had been painful for years. An MRI revealed a spondylolysis that was crushing several nerve roots and corrective surgery was undertaken. But the result was an unpredictable pattern of RSD-like pain in her leg that made her life alternate between simply miserable and hell. Despite this, she refused to say more than “It’s really uncomfortable today,” when asked. And being hypersensitive to narcotic pain meds, she resigned herself to simply live with the situation.

“Let’s start from the beginning again,” I told her on the cell phone as we both drove to the hospital. “It’s been going on how long.”

“Two weeks, maybe. Maybe longer.”

“No nausea, vomiting or diarrhea during that time right? Isn’t that what you told me,” I repeated the previous history.

“Well, my stools have always been a little runny,” she said in an embarrassed lowered voice.

“And no fever, right? Just pain?”

“I felt a little hot last week, ‘Didn’t I Charles?’” she again sought his confirmation.

I finally pieced together that her pain had accelerated after I had insisted that she supplement her diet with Ensure. I had heard that she had quit eating and was losing weight. It was beginning to sound like gall bladder disease. “Was it tender in your abdomen when the doctor examined you?”

“No, she never examined me.”

I thought she didn’t understand me. “Was there any pain when the doctor pushed on your stomach?” I rephrased.

“No, the doctor never pushed on my stomach. She just talked to me. And when I told her my stomach hurt, I don’t think she was listening. Doctors don’t really listen to you after 70. Anyway, she was very busy she said.” It was all said in her warbly unemotional voice as if to say that’s just how life is.

I didn’t know what to say.

When we arrived at the hospital, the waiting room was, as I had expected, packed. There was a line of patients waiting to be checked in. A sign directed visitors to another hole in the glass around the corner. But when we went there and waited we were directed back to the patient line. After a half hour wait in line, we were given tiny slips of paper to put on our clothing identifying us as visitors and buzzed back to see Mom Mom.

As we entered the room with our arms full of gifts we expected to see Mom Mom’s usual warm smile. Instead she lay almost motionless on the bed. Her face was pale and expressionless, either asleep or absorbed in trying to block out the pain. When I called her name, she barely smiled. No one had seen her yet, having just arrived in the room herself. Feeling no need to have her repeat her history yet again for me I simply asked if she minded if I examined her abdomen. My hands lightly palpated her abdomen without response until I reached her right upper quadrant. There I found the most obvious gall bladder I’d ever examined. It was exquisitely tender, firm, and the size of a kielbasa.

I was frustrated with Mom Mom and furious with her family doctor. How could Mom Mom let this go on so long? How could her doctor miss this? It was hard to believe that her family doctor never touched her. Sure, my mother-in-law was a stoic, but that was even more reason to take her complaints seriously. Then I recalled her comment about doctors not listening to elderly people. Have elderly people been written off by the medical establishment?

To my great pride, the ER staff was competent, friendly and efficient. Despite it being a teaching hospital, Mom Mom was not treated like a guinea pig for the students. Everyone did crowd around her ultrasound to see the text book case of cholecystitis with its thickening of the walls and loads of gall stones. I guided an intern’s hands ever so gently over Mom Mom’s abdomen in a gall bladder exam that the intern will not likely forget. We still had to contend with the obligatory contrast CT and raft of pre-op lab and X-rays. But we finally got her to the OR where an experienced surgeon took care of the problem.

When he met us in the post-op waiting area, I thanked him deeply for his kindness and skill.  And I assured him that, while no one was litigious in the family, Mom Mom’s family doctor needed to know that her failure to examine her patient, if that’s what truly happened, was inexcusable and could have resulted in catastrophe.

On the way home from the hospital to celebrate Christmas with the remainder of the family I listened to yet another debate of health care reform. The supporter of reform was extolling the virtues of having a family doctor, a medical home, who will have financial incentives to limit the number of unnecessary medical tests, referrals, and emergency room visits. In this way, he explained, we can save up to $500 billion in Medicare expenditures. I knew that what he said was true, in theory. But it is putting that into practice, by doctors who are already stressed to the max, that will be difficult. 

CDR Mark Plaster, MC, USN