In ER his ordeal got worse.
“We can’t give you anything for pain until the surgical resident examines your abdomen,” said a young trainee in a short white coat who had to be the most junior student on the ER food chain. Christ, peach fuzz covered his cheeks.
“I’m Earl Garnet, Chief of Emergency Medicine at St. Paul’s Hospital in Buffalo. Get me your staff person, or give me Demerol, damm it! And for your future edification, a surgical abdomen doesn’t present as cramps.”
The boy looked unimpressed. “Does this hurt?” he asked, palpating deep into his lower right side, then abruptly lifting off.
Nurses started IVs.
A clerk wrote down his mother’s maiden name.
Someone took custody of his wallet; someone else drained a dozen tubes of blood from his arm.
“You haven’t got a fever, and your pressure’s fine,” a nurse reassured him.
The surgical resident came, prodded his stomach a few times, then went off to consult with his staffman.
Still no one gave him Demerol.
“Not before the surgeon himself sees you.” It became a reoccurring chorus.
“And where’s the surgeon?”
“In the OR.”
Where else?
He flagged another passing nurse, easily catching her attention as they’d parked him in the middle of a busy main corridor. Sporting tousled brown hair and covered in freckles, she could have been the kid sister of the lowly resident who checked him in, until she turned and he saw the triple silver rings piercing her eyebrow. He thought of J.C. in his own department, and felt oddly reassured. “I want to speak with the doctor in charge,” he demanded for the second time since his arrival.
“He’s managing victims from a bus accident,” she called without breaking stride.
“Then phone Melanie Collins.”
This got her to pause. “The Chief of Internal Medicine? I don’t think so.”
The fiery vengeance in his stomach shot to a new level, and he let out a loud groan, curling into a ball again. “Call her, please!” he managed to gasp between clenched teeth a few seconds later, his skin once more soaked with perspiration. “I’m a friend. Say that I need her help now!”
Whether his appearance, his use of “please,” or his claim of being a personal acquaintance to an important doctor convinced her, he couldn’t tell. She nevertheless walked to the nearest phone and made a call. She spoke a few words into the receiver, then stopped, a dumbfounded expression slowly spreading across her face like a connect-the-dot drawing.
“Dr. Collins will be right in,” she told him with newfound respect.
“Thank you,” he said, and forced a grin that must have made him resemble the grim reaper.
Twenty minutes later Melanie arrived at his bedside flanked by peach-fuzz and the ring-wraith. An additional bevy of students, interns, and residents formed a semicircle around them.
“Earl, I’m so sorry,” she said, patting his shoulder.
“Me too. I didn’t mean to haul you in here-”
“Don’t think anything of it.” She gave a thousand-watt smile and turned to her following. “Now, gang, let’s give our distinguished guest a show of how to do it right. What’s the presentation here?”
“Abdominal pain, crampy, generalized, and acute onset,” peach-fuzz called out.
“Any vomiting or diarrhea?”
“No, ma’am.”
“Vitals?”
“No fever, normal BP, but pulse is 120.”
“Yours would be fast too, if you had the kind of pain that I know it would take to bring this man into ER. Any abdominal findings on exam?”
“Abdomen’s soft, no rebound, no masses, no bruit, but increased bowel sounds.”
“Urine?”
“Normal.”
“Rectal?”
“Negative.”
“You checked for occult blood?”
“None.”
“So what’s your thinking?”
“Well, first off I’d consider this to be pain from a hollow organ rather than a solid structure, given its colicky nature-”
“I don’t want to reread the entire text on abdominal pain, so let’s bypass the general stuff and pinpoint the most likely possibilities. Yes it’s colicky, and originates from something hollow. But the lack of nausea and there being no focal, right-upper-quadrant tenderness means we don’t even have to think gallbladder, and with a normal urine, it isn’t renal. Any history of hypertension, Earl?”
He shook his head no, wishing she hadn’t chosen him to grandstand on. But he was imminently grateful to her for coming in and getting things going, and if he had to endure a few minutes of being a teaching specimen, so be it. Besides, it wasn’t entirely a waste. The latest rage in teaching hospitals was for the teachers to take a turn on the other side of the white coat. He’d let the residents know he’d had his, thank you very much, when he got back to Buffalo.
“So, his lack of risk factors, along with the absence of a pulsatile mass, means an aortic aneurysm is unlikely,” she continued. “The patient being male, what’s left that’s hollow?”
“GI!” responded a bearded man at the back.
“Sold!” Earl said, figuring it was time to wrap up the bidding on his diagnosis.
But Melanie hadn’t finished putting on her show. “Right. And since there’s no vomiting, we can assume the problem doesn’t lie in the upper gastrointestinal tract, which leaves us with?”
“Lower,” her audience said in unison.
Get on with it, Earl nearly told her, his innards clamping down on themselves again.
“Now I know this thought process sounds oversimplistic, but it’s what should have zipped through your heads in the first few seconds you saw this patient, and everyone’s focus ought to have been on the lower GI for a nonsurgical problem from the get-go. Okay, what’s the differential? But this time start with the most probable. Don’t bother me with stuff about tumors, obstruction, ischemia, or chronic things like inflammatory bowel disease. And for God’s sake don’t begin with rare genetic disorders like porphyria. I hate having to look up those damn metabolic pathways.”
A collective chuckle came from the group.
“Enteritis, colitis, or both,” one of the young men said.
“Very good. The probable cause?”
“Viral or bacterial contamination from food,” he replied.
“Which bacteria?”
“Campylobacter jejuni, salmonella, shigella.”
“Treatment?”
“Hydration, electrolyte management, particularly potassium replacement, Cipro, and painkillers!” He spoke with the certainty of someone on a roll.
Yes! Earl wanted to yell out. You can replace peach-fuzz as my doctor.
“Not so fast,” Melanie said. “Is there any danger in giving ciprofloxacin at this point?”
Oh, Melanie, he wanted to shout, surely old Earl Garnet didn’t have to be treated by the book. Come on, give the Cipro. As physician to physician. Cut corners.
The bearded resident seemed at a loss for words.
“Any reason to wait for stool culture results before treating?” Melanie prompted.
The man stroked his chin as if contemplating a chess move, then shrugged.
Melanie searched the crowd for any other takers. There were none. “Okay, here’s the teaching nugget of this case. The severity of Dr. Garnet’s pain plus an apparent delay in the onset of the inevitable diarrhea makes me think this might be an organism other than the more common ones you listed. With them, the diarrhea usually follows closely on the heels of the pain. But with some of the enterohemorrhagic E. coli, where toxins are the culprit, they need time to work, and there can be the sort of delay we see here. In other words, the agent infecting Dr. Garnet may be none other than E. coli 0157:H7, which can not only cause a hemorrhagic colitis, but in 10 percent of cases, introduce toxins which attack the kidneys to produce a hemolytic uremic syndrome. The latest evidence suggests antibiotics may actually increase the risk of complications, so we hold the Cipro.”