Wednesday, March 23, 2016

A Tale of Two Stomachs


 “Drag your thoughts away from your troubles...by the ears, by the heels, or any other way you can manage it.”  ― Mark Twain


A/N: As usual, these patient scenarios are composites of my experiences. No one person is represented. As the movie disclaimers read: ‘Any similarity to any person living or dead is merely coincidental.’ The essence of the dilemma remains the same.

“Ohhh… doctor! My stomach!” the young woman cried clearly distressed as she moaned and rolled disturbingly close to the edge of the exam bed on which her generous body habitus nearly flowed off.  “My stomach is paining.” She clutched her abdomen to emphasise her point.

“Where is it paining you?” I asked as I tried to write a coherent history in her medical book at my desk, making observations as we spoke. I checked her vital signs; all were rock solid and normal. (She wasn’t dying at least.)

“All my stomach!” she groaned and winced as another wave of abdominal cramps overwhelmed her. “Owww…”

“Do you have any fevers?”

“No.”

“Any diarrhoea?”

“No.”

“Vomiting?”

“Any belches, pain when you pee, vaginal discharge?”

Essentially, in the end, she wasn’t having any problems except excruciating abdominal cramps. I stood up and went over to the examination table where she looked over at me with tear-brimmed eyes. “Please doctor, the pain is too much.”

I checked her eyes. Not pale. Good. She wasn’t having internal bleeding. A thorough palpation and auscultation of her ample belly did not reveal anything life threatening.

“But, doctor, the pain is too much.”

“We’ll give you some medicine for the pain and check for any infections,” I reassured her. “Your stomach pain will cool soon. Be patient just a little longer.”

She nodded.

In the interim while waiting for her malaria smear (standard on almost anyone in Africa) and typhoid test, she received a dose of IV Spasfon (an anti-spasmodic) medication to calm her cramping. When that wasn’t enough, we gave her a second injection of Novalgin IM, basically an injection form of a drug in the category of NSAID (same category as ibuprofen). My nurses took her over to the hospital where she gradually calmed down on one of our unoccupied patient beds.

This wasn’t the first time that Ms H had come to the hospital with the problem of acute abdominal pains. The first time she’d come, one nurse took me covertly aside. “Doctor, Ms H has been having this kind of pain in her stomach for a long time. Her mind ‘de over worry’.”

“So what usually happens?” I queried, curious to hear what my predecessor had done in the past. Had the former physician done a work up on her to find any signs of celiac disease or an inherited autoimmune inflammatory bowel disease or gallbladder stones, pancreatitis, diverticulitis, kidney stones, pelvic infections, dysmenorrhoea, endometriosis, giardia, amoebas, etc. After all, the list of diseases that might cause abdominal pain in a young woman is infinite.

“She usually just checked a few labs and gave her tablets for pain,” my nurse explained with a shrug.

“So she never figured out what was causing her stomach pain?” I hoped perhaps she might have come up with a diagnosis.

“No,  she just gets better after a few days.”

“Ok. I think I am getting you,” I frowned. I was still a little confused but marginally reassured that Ms H has survived similar attacks in the past without any apparent long-term detrimental effects. I moved forward with my treatment plan.

There are a limited number of tests one can do in a mission hospital, especially on a woman with limited financial resources. Certainly she couldn’t afford to see a specialist in the big city of Douala. She didn’t seem to be in such serious condition as to necessitate a CT scan of her stomach. And the value of an X ray  to diagnose her problem was questionable enough to tip the balance in favour of cost outweighing benefit.

In the end I checked the malaria and stool analysis. We did a rapid blood test for typhoid.

“It looks like you have a little infection in your stool,” I sat down next to her at her bedside in the hospital where she was resting much more comfortably. After a few hours of spasmodic abdominal pain, she could smile. The nurses had found her clean hospital sheets and she was resting comfortably.

“I can’t say exactly what infection might be going on, but there are some white blood cells in your stool that could mean you have an infection.”

She nodded.

“We’ll give you some ORS (oral rehydration salts) with zinc and ciprofloxacin along with some more anti spasmodic medication and paracetamol to help with the pain. You’ll be ok in a few days.”

I smiled at her. Part of medicine is letting the body heal itself. In this case, I wasn’t sure the antibiotic was essential but given the inflammatory white blood cells in her stool, it might help.  The odds of an infectious form of diarrhoea is high in Africa where sanitation is less than ideal sometimes. The good news was that her symptoms were improving.

She would get better – of that I was certain. Time was my biggest alley. Her labs and my physical exam assured me she wasn’t dying. With a little magical ‘tincture of time’ she would soon be back to normal.

Ms H gave me a tired smile. “Thank you so much, doctor.”

“You’re welcome. Just be patient, you’ll be fine.”

As Ms H gathered up her things and headed home from the clinic the following morning, she saw me and rushed over. “Doctor, thank you!” She hugged me and then as a parting gesture, she placed her hand on my shoulder and gazed into my eyes, “God will bless you,” she earnestly bestowed this tender and honoured gift upon me and the ministry.

A warm glow filled me.  I had contributed very little and yet her gratitude was immense.

******

And so, it was with a sinking feeling that some time later I saw Ms H sitting disconsolate in the waiting area of our clinic.

“It’s paining again, doctor,” she cried. “I’m sure something else is wrong inside my stomach. Can’t you do an echo (ultrasound) and look?”

“But an echo won’t show everything that could be wrong?” I explained.

“There might be something though. My stomach keeps paining. Can’t we make sure everything is ok?”

Perhaps it was the curly eyelashes and liquid brown of her pleading eyes, or perhaps I was feeling a bit more generous than usual that day, I’m not sure, but, in the end, I caved to her pleas. “You’ll have to wait until I finish seeing the other patients, then we’ll do a little echo, ok?” I bargained with her.

“No problem. I’ll wait,” she eagerly promised.

She spent the next six hours waiting in our hospital compound, chatting with my nurses and other patients, while I continued my day-to-day consultations. At last there was a break in the flow, “Come on back, Ms H, we’ll check your stomach.”

“Everything looks ok,” I cheerfully proclaimed as she watched anxiously at the moving grainy black and white pictures on the ultrasound machine.

“Then why do I keep having this pain?” she sat up and dressed.

“Well, there are many reasons for the pain that don’t show up on the ultrasound.” I helped her down from the exam table. “The inflammation can take time to clear up completely in your stomach and the pain to cool completely? You’ll be ok. We’ve made sure there is nothing else that we need to treat.”

“Ok, doctor. Thank you so much for checking. God bless you. You are so kind.”

“Just remember, try to relax your mind and not worry. You’ll get better soon.” With much reassurance from me, reinforced by our nurses, she eventually went home.

Over the following week, the local community visited Ms H and comforted her with a plethora of ‘ashias’ and distracting company. She unburdened her troubles through countless conversations with her friends. Although she lacked family support, neighbours and church members stepped in as her surrogate family and talked her through her panic over the future.

A few weeks later, I ran into Ms H at the market. “How are you?”

“I’m fine, doctor,” she smiled. “It wasn’t easy. I really suffered.” She shook her head at the memory. “But, now I’m fine.”

“Praise the Lord.”

“Oh yes!” she agreed with enthusiasm. “Without Him I couldn’t have survived. God is good.”

“Amen.”
 *********
Ms H would go on to have other attacks of her mysterious stomach pains. The attacks had a habit of occurring during times when there were increased stressors in her life – worries over finances,  schooling, or children. Each time she came to visit us, she received compassionate care. She found a hospital where nurses prayed with her and gave her prompt attention. Although I doubt we will ever find an organic reason for her pains, we do a standard examination of her with a physical and basic labs to ensure nothing out of the ordinary is suddenly attacking her body each time.

Friends often pray with her and come and sit with her at home when she has these pains that typically last a few days. Eventually they always go away – probably more due to her own body’s inherit healing rather than any medications we administer. She’s always grateful and later comes with fruit or vegetables to share with hospital staff. My predecessor was correct in her diagnosis of her abdominal pains: ‘over-worry’. 
 *********************

Stomach 2 (Ms T)

Ms T was a 20 something year old female who came in with her stepmother. She gave me a fleeting soft smile that could immediately put the most anxious at ease. Clear blue eyes shown out from under a mass of unruly red hair. Outside of being having a high BMI, she appeared healthy. That is, until one opened her medical chart!

Pages and pages of doctor visits, blood tests, procedures, tests, and even surgery. She was barely 20. How could someone so young already have such a medical saga?

I sat down across from Ms T.

“What can I do for you today?” I began our interview.

“It’s my stomach,” she answered flatly.

“Oh?” I left my sentence open for her to elaborate.

“Pain.”

“Ok?” I tried to give her free rein to continue her narrative.

She sat silent in the chair in the exam room. I wasn’t sure what to do. I looked over the list of various problems in her medical chart and felt mildly overwhelmed. What was wrong with this young lady with such a complicated medical history? Perhaps I was not the right doctor for her. Why wasn’t she seeing her specialists?

“Why don’t you give me a little recap about your stomach pain since this is the first time we’ve met?” I encouraged.

“Well, I’ve been having pain in my stomach and it’s still there.”

“OK. How long have you been having this stomach pain?” I decided to be a little more directive in my queries.

“Years.”

“More than five years or ten years? Can you be a little more specific?”

“Since I was in school,” she shrugged without emotion. “No one can seem to figure out what’s wrong.”

“Oh? So you’ve had a lot of tests already? Have they found out anything?” I attempted to ascertain what her own understanding of her medical condition was.

“Well, first they said it was stomach ulcers but the medicine didn’t do anything.”

I nodded, listening. “And what else?” I prompted after she fell silent.

“Well, then they said it was Celiac and put me on a gluten free diet but that didn’t really help.”

“OK,” I still wanted her to continue her narrative.

“Then they said I had asthma.”

That explained the inhaler prescriptions in her chart.

“But they didn’t do anything either.”

“I see you’ve also been diagnosed with depression too,” I prodded.

“Oh yeah, they keep telling me I’m depressed but the drugs they give me don’t do anything,” she answered. From her lack of interest in her health, I did wonder if this might have been more accurate than she gave it credit.

As we went through the litany of various diagnoses that she’d been labelled with such as depression, anxiety, cholecystitis, pancreatitis, acid reflux, peptic ulcers, gastritis, gluten sensitivity, asthma, angina, irritable bowel, chronic pelvic pain, etc. I could sense an aura of fatalistic opposition. Ms T expressed a confusing puddle of passive victimization. She had a mysterious ailment of her stomach that doctors couldn’t figure out. When she mentioned the complementary and alternative providers that she’d been to see, I began to wonder what I was going to contribute. In my few minutes allotted to our interview, what would I discover that so many before me had failed to address? She gave the impression of having lost all faith in the medical community. I wondered what she hoped to gain by her office visit today.

“It looks like you’ve had a pretty thorough work up for you problem,” I commented. “Colonoscopy…”

“Yeah, that was no fun,” she muttered.

“Endoscopy (tube down the throat). Rheumatology work up (lots of blood tests). Electrocardiogram. (lots of wires) CT scans (lots of IV sticks and scary machines)… Quite a lot of tests.” I turned to her. “And you had your gallbladder out too?”

She nodded to the affirmative. “It didn’t help though.”

I looked at Ms T. Really, there was nothing left for me to investigate. Every conceivable test had been done. Already she’d been exposed to enough risks associated with invasive procedures, anaesthesia, and surgery, and radiation. Her chart was riddled with a long list of problems from psychological to biological but way too many for one patient just barely out of high school. Every time a medical professional opened her chart, he or she would be inundated with a mountain of extraneous labs, procedures, and specialist reports without really understanding the true issues or the person underneath the burden of medical reports.

“Why don’t you describe for me, in your own words, all about your stomach pain? How it began? What it feels like? What makes it better or worse? How you’ve treated it in the past? That kind of thing,” I rewound her story and decided to let her start the slate clean. I prayed for wisdom.

She blinked and stared at me for a few moments. Finally she shrugged and in her characteristic monotone that I’d started to get used to told me the details I needed for my history. It was not as complicated as I was afraid of at first. In fact, her history was rather similar to another young female patient – a Ms H.

As I reassured myself that I was not missing anything life threatening with a thorough physical exam, I inquired into her own understanding of her illness. “Is there anything you’re particularly afraid you might have? Something you are concerned that could be wrong? You’ve had a very comprehensive work up for all the dangerous things that could be wrong,” I reassured. “But perhaps there’s something that you’ve read about or heard on TV that you’re concerned about?”

Ms T sat up and thought for a few moments. She shook her head no and shrugged. “Not really.” she leaned back in her chair as if challenging me to come up with a new diagnosis for her to defy. Another label for her symptoms, another pill for her to proclaim useless, another reason to distrust the medical professional community.

“Ok.” I sat and gave her some time to think. I didn’t have a new label for her. She’d been labelled with everything already. I was at a loss of what else to do for her. I typed out the history she’d given me in the computer while she sat with her arms crossed, watching me tap away on the computer keys.

Mid keystroke, she decided to speak up. “Doctor, do you think this could be due to panic attacks?”

“It’s possible,” I answered hesitantly. “Why do you ask?”

“Well, I always get them when I’m stressed out, like when I have a deadline at work to meet.”

“Why don’t we have you keep a diary of when your stomach pains occur and see if we can correlate them to certain stressors?” She agreed to our plan.

At the end, she left with a promise to reinvestigate what stressors might be triggering her pain along with a refill of a mild anti spasmodic to use at times when her pains were particularly interfering with her ability to work.
***********************

So now I sit back and reflect on the contrasts between these two young women with stomach pains. Similar situations in regards to life transitions and stress but different countries and different cultures. Both boiled down to stress-induced stomach cramps or ‘over-worry’.

Ms H had multiple doctor visits, stool tests, and one ultrasound. She recovered with a tincture of time and community support after each attack. She was an honoured member of society and went about her business between attacks. She knew most of our staff at the hospital and was always welcomed when she needed treatment. She made her own decisions and was content with the treatment given.

Ms T, in a similar fashion, had multiple doctor visits and stool tests. She also had multiple specialist consults, invasive diagnostic procedures, radiation-filled imaging, blood draws, and dietary restrictions. She is dependant on the charity of friends and family for housing. She distrusts the medical community and yet remains apathetic regarding decisions about her health. The real person, that disarming blue-eyed lady with a kind soul, is lost under a mountainous medical record. She is unhappy with her medical care and hopes that one day she’ll find the magic doctor or test that will diagnose her pain and alleviate it forever.

Is there a moral to this comparison? You choose. I simply make the observations.