Things Aren’t Always What They Seem…

Long time no talk to…

Work has been pretty interesting of late – we’ve been getting our usual amount of more than usual business, but we’ve been getting a lot of stuff that is less than normal variations of normal conditions.  I also encountered a “zebra” – an unusual condition – this week.

We’ve had a big run of appendicitis for some reason lately, and all but one or two cases did not show up with a sign saying “HOT APPENDIX”.  What I mean by that is that they didn’t show up with textbook symptoms of this problem.  Something I learned a long time ago is that very few things ever show up “text book” – usually they’re subtle variations…and sometimes not so subtle.  This is where the art of medicine comes into practice.

Don’t get me wrong, there is a lot of science involved in medicine; however, it is an art form as well.  Experience, intuition, what and how questions are asked, physical examination skills, and audio-visual observation all come into play at this time.  Take appendicitis as an example – there are “typical” signs and symptoms that are in the textbooks.  However, your patient may or may not have all or even just some of these, and assumes that all people have typical anatomy.  The other problem is all diseases are continuums – people often present at different times within the disease process, so you may have to “sit” on someone to see how things progress…this is why we always tell people to come back if things aren’t improving or they’re changing.    A wise doc once told me “One of three things will happen – they’ll get better, get worse or stay the same.  If they get better, great.  If they stay the same, get concerned and look harder…if they get worse, worry and look even harder.”  Sometimes that happens in the ER.

Another doc also told me that “It’s always the last doctor to see someone that is right”, being that when someone shows up after seeing a few people over time with vague things and now show up with defined disease, they turn out to be the hero as it were.  Of course, the other people “misdiagnosed” the patient – which often isn’t fair, since people tend to show up for care much earlier in their diseases these days than they used to (dare I say Gen Wuss?), so might be sent home without a diagnosis, other than belly pain not yet diagnosed.  When they come in with disease that’s finally declared itself as we say, we deal with it and can carry on.  It’s always easy to diagnose things in retrospect…so something else I’ve learned is not to be he “Monday Morning Quarterback” and second guess things retrospectively, unless of course they’ve obviously dropped the ball.

On totally different note, I encountered a “zebra”, a term in North American/European medicine meaning an unusual condition.  We’re always told that “If you hear hoof beats outside your window, look for a horse, not a zebra”.  This means that, even though you have to entertain certain differential diagnoses and some you cannot miss, that common things happen commonly – so if you have a problem that shares symptoms with X,Y and Z, and Z is incredibly rare, it’s more likely to be X or Y.  In my case, this was so incredibly rare that nobody, including my attending and our radiologists even thought about it and were treating this patient like they had something considerably less innocuous than they actually had.   The disease process was something I’d seen once in a case report online a few months ago, but didn’t even cross my mind.

This case comes back to the art of medicine – something that is based on experience and intuition, so if you haven’t seen it, even though you may have read about it many moons ago, your intuition isn’t fed enough to make your neck hair stand up…in this case, I was treating this person based on my experience of what I’d seen frequently in the past.  This condition, though, was much more benign that what I was concerned about…and they’re improving quite quickly now that we’ve figured out what’s wrong.

As the saying goes, things aren’t always what they seem…so I pay attention to my gut a lot more these days.