It's hard to say what we often refer to as gut instinct really is. Is it some type of paranormal sixth sense, or perhaps it's just a subconscious collection of past experiences that we apply to the situation at hand? Whatever it is, one would hardly find it in the medical literature and one can hardly consider it to be evidence based medicine.
A very nice and ever so slightly demented woman in her early 90s was admitted this weekend with some fairly nonspecific abdominal pain, nausea, loss of appetite, and dehydration. She had a somewhat similar episode three months ago, but didn't feel the two were related. What did concern her, however, was that she was dying. In fact when I admitted I asked her her thoughts on what the diagnosis was and she said, "I think I'm dying."
We did some simple blood tests and x-rays and noted she had some mild
pancreatitis and a couple of gallstones which could have been at play. The IV fluids were tuning her up and she was clearly clinically improving. There just was something unsatisfying still though. My gut instinct told me there needed to be more done. She was certain she was dying and I still really didn't have a lock on what process was going on here.
The residents I was working with thought I was crazy to go to the time and expense to order a CT on the abdomen of a patient clinically improving as she was. Fortunately in this situation I'm the attending and they are not. Unfortunately for the patient she appears to have a
cholangiocarcinoma --a difficult to treat cancer of the biliary system and often involving the liver and pancreas.
We have some difficult conversations ahead today, but now at least we know what is wrong. I'm glad I trusted the
patient's gut instinct about her gut.
The Country Doctor
A very nice and ever so slightly demented woman in her early 90s was admitted this weekend with some fairly nonspecific abdominal pain, nausea, loss of appetite, and dehydration. She had a somewhat similar episode three months ago, but didn't feel the two were related. What did concern her, however, was that she was dying. In fact when I admitted I asked her her thoughts on what the diagnosis was and she said, "I think I'm dying."
We did some simple blood tests and x-rays and noted she had some mild pancreatitis and a couple of gallstones which could have been at play. The IV fluids were tuning her up and she was clearly clinically improving. There just was something unsatisfying still though. My gut instinct told me there needed to be more done. She was certain she was dying and I still really didn't have a lock on what process was going on here.
The residents I was working with thought I was crazy to go to the time and expense to order a CT on the abdomen of a patient clinically improving as she was. Fortunately in this situation I'm the attending and they are not. Unfortunately for the patient she appears to have a cholangiocarcinoma --a difficult to treat cancer of the biliary system and often involving the liver and pancreas.
We have some difficult conversations ahead today, but now at least we know what is wrong. I'm glad I trusted the patient's gut instinct about her gut.
The Country Doctor