lan’s abdominal pain had begun less than two hours previously. After 10-15 minutes it had become bad enough to phone 111, which had sent him to the out-of-hours centre.
“We wondered if it was the fizzy drinks,” his wife said. “He had two cans, one straight after the other.”
It’s a human trait to try to make sense of unusual events in terms of the everyday and familiar. Alan was restless, periodically shifting in the chair. And though he was trying to concentrate on talking to me, he appeared preoccupied. Some doctors describe a lurch in the gut; others talk of the hairs on their neck rising. For me it’s a rush of alertness, as though everything else is suddenly irrelevant. There’s no way of teaching this as it’s something acquired only through experience: the sixth sense that the patient in front of you is in trouble. Carbonated pop definitely wasn’t responsible.
All Alan’s observations were plumb normal. He got on the couch without movement exacerbating his pain, and abdominal examination revealed only mild tenderness in the left upper quadrant – nothing to write home about. A past screening scan effectively ruled out a ruptured swelling (aneurysm) in the main artery, the aorta. A urine test was clear, making a kidney stone unlikely. He was on various medications to prevent a heart attack following stents for angina several years before. The aspirin could have provoked a stomach ulcer that had now perforated. But I would have expected a history of indigestion and more examination findings. Plus he was on another drug to protect against just such a side effect.
I was still trying to make sense of it when Alan grabbed a bowl and vomited. The pieces abruptly slotted together: he looked exactly like a patient in the midst of a heart attack, where a blockage in an artery starves the cardiac muscle of oxygen – so-called ischaemia. Everything fitted. Everything, that is, except that his pain was abdominal. But heart attacks can, on rare occasions, present with tummy rather than chest pain. Set against that, though, was the mild tenderness in his abdomen – not something I’d expect if his heart was the problem.
He needed urgent investigation, but that only deepened my dilemma: who to ask for help? If he was having a heart attack then he needed to be under the medical team, pronto. But if something catastrophic were going on in his abdomen, it was immediate surgical care he required. Admit him under the wrong team and precious time would be wasted.
The out-of-hours centre is located just across from A&E. They generally refuse referrals from us – they’re overwhelmed with their own workload, and expect us to admit to specialties direct. I could see Alan’s case becoming a turf war in which more time could be lost.
I walked round to A&E and found the consultant in charge. The simple phrase, “I really need your help” got her attention, and after a brief rundown of Alan’s presentation she grasped my dilemma. Casting protocol aside, she booked him straight in from the scant details on my hastily scrawled scrap of paper, while simultaneously sorting a High Care bed for him.
I went back round at the end of my shift. A&E had excluded a heart attack with ECGs and bloods. An urgent CT scan had shown that the problem was indeed ischaemia, though the blocked artery in Alan’s case was supplying part of his intestine rather than his heart. The surgeons took him on, resecting the dying segment of bowel well within the narrow window before it caused potentially fatal peritonitis. Alan was home ten days later, full of praise for the speed with which he’d been treated.
Intestinal ischaemia is rare, and characteristically produces few physical signs until far gone. I hadn’t been able to diagnose it, but I’d recognised the ischaemic pattern to his presentation. And even though I still can’t define exactly what triggered it, that sixth sense compelled me to carve him the quickest, if unconventional, path through the system.
This article appears in the 14 Aug 2019 issue of the New Statesman, The age of conspiracy