A Kidney Stone

        In my last post on this subject, we were talking about how country docs think about acute illness.  To make my point, I’m gonna tell you about my kidney stone.  Believe me, there ain’t much that is more acute than than a rock.

        Here in N.C., we not only live in the Bible Belt, but also the kidney stone belt.  No one knows why we have so many stones around here.  Come to think of it, it is the bluegrass belt too.  I hope it ain’t related.  At this age I’d be hard pressed to give it up.  (Bluegrass, not kidney stones.)  The urologists here swear SunCola, a popular local soft drink, is the culprit, but no double-blind study has ever demonstrated a causal relationship. (doctor talk for we have no idea what the heck causes ’em.)  At least for me, it ain’t from corn liquor, though some of the musicians have been known to treat a stone with this remedy.

        We might not know much about what causes ’em, (in some cases, we do) but we sure know when one hits us, or at least we think we do.  The story of how I thought about my kidney stone is illustrative of the doctor thought process.

        One early Wednesday morning three winters ago, I awoke about 4:00 am with a strange feeling in my right side and around towards my back.  “What the heck is that?”  I thought.  I hadn’t played golf in a week, and any workout schedule I would contemplate was far too light to cause any bodily injury.  I went downstairs to start the coffee.

        About halfway down the stairs, my status took a dramatic turn.  Wham!  “Who hit me in the back with a sledge hammer?!”  I clutched the railing, limped into the kitchen, and paced the floor in circles. 

        I remembered a patient who was in so much pain he grabbed my rolling stool, and used it as a walker of sorts.  He weaved through the office saying, “Gotta help me Tommy, gotta help me.” It was all the history I could gather.  Myrd and I chased after him all the way into the break room, where we injected him with an analgesic, and then gave him a Co-Cola once we had him calmed down.

        My patient was hurting so bad he couldn’t sit still. (what docs call akathisia) The diagnosis:  kidney stone. 

        Hm.   I was the same way- just a pacing.  A stone seemed likely.  (You will find I file illnesses in my brain under patients first, then books second- both are important but the patients come first for a country doc.)

        When the first wave subsided, I had a moment to think.  Now, just how sure are you this is a kidney stone, pal?  What if it was something else?  Hm, what else could it be?  Another wave hit, then nausea and, as my patients say, vomiking. (sorry to be so graphic.)  There was no hematuria (blood in the urine.)  I got the question right on the last boards about the percentage of stones that didn’t show any blood, but I was hurting too bad to recall the number.  I thought about my appendix, but it had come on too quick, and I didn’t seem too have any fever.  Unlikely. 

        I recalled the old saw that a kidney stone is as bad as having a baby.  When my Marfar got up, I was gonna have to thank her again for those children.

        I began to sort through the differential diagnosis, (the possibilities) to decide whether or not to wake her and get some help.  I wondered if I could have a triple A.   (not baseball or the automobile outfit, but an abdominal aortic aneursym.)  I checked my pulse.  Not too rapid, about 90.  I checked the pulses in my feet.  (In an aneurysm, there ain’t as much blood getting there.)  It was four in the dang morning, and I had never checked my own pedal pulses before- I had no baseline and could only hope my judgement was accurate.  Then I poked around on my belly- didn’t feel a pulsatile mass- couldn’t remember the exact sensitivity for that maneuver- probably it was worse when checking one’s own self.  I remember the State Board had sent a bulletin out warning us not to treat ourselves- where were they when I needed them? 

        Lordy, here came another wave of pain and nausea, then it passed again.  Hm.  I didn’t feel too light headed.  I decided to stand up all of a sudden, and there was no dizziness.  Docs call it orthostasis.  This is when the blood pressure drops sharply when you stand up.  I wasn’t too dizzy, so I figured it was unlikely I was losing much blood.  (Ie not likely to be a ruptured aneursym.)  I needed to check my blood pressure- where did I leave that dadburn stethoscope?  I think I made a house call at the Ponders a couple days ago- I didn’t want to wake ’em- it was 4:45 am for heaven’s sake.

        Kidney stone.  What a beast.  How was I gonna work today?  Work. Then it hit me- it was Wednesday and I was off.  Even better,  it was the day of my scheduled urology check-up.  (I always get it done in the winter so it won’t interfere with music or golf as much.)

        I contemplated calling my urologist, but didn’t want to bother him, and he’d have to send me over to the emergency room.  They’d be a crowd there with colds and such as that, and I figured I’d be more comfortable at home.  I checked my watch.  Only a four hour wait now.  That was about the ER standard, and that was if there were no car wrecks.  I decided to tough it out. 

        Well when I got to my appointment, I blurted out all that history, and Doc Gosnell said, “Bibey, you’ve got a stone,”  just as calm as that.  He’d seen about eight million of ’em, and I think I had the look.

        I tell you all that to tell you this.  So far, I’ve never diagnosed a kidney stone, and then had my patient die of an aneursym.  It could happen tomorrow.  If it does, I’ll sit in the corner and cry like a baby, and it will take a long time to get over it, but so far, so good.  So, even when it seems obvious, still let your doc go through a checklist in his/her head.  If nothing else, it will reassure them. 

        Of course, this can be carried to an extreme.  If your doc insists on reading the kidney stone chapter in Harrison’s Text of Medicine before treating you, I’d find someone else, ’cause those rascals hurt.  The whole process should happen in such rapid sequence you don’t realize it is going on, sort of like the way Tiger Woods makes hitting a golf ball look easy.  (I ain’t that good a doc- wish I was.)  But even though the process moves along at warp speed, it should go on. 

        All this took place three years ago, and I still recall my thought process like it was yesterday.  It is the same routine I’ve run through my head thousands of times.  I have practiced it so much I’m no more likely to forget it than the chorus to “Little Cabin Home On the Hill.”

        I believe we should treat out patients like we would want our family treated, and I reckon this is as good example as any of how we do that.  For acute belly pain, that is how this doc thinks.  One thing Dr. Groopman said jumped off the page at me.  Maybe it is ’cause everyone likes to read something where smart people agree with what they think.  It was this statement.  “What is the worst thing it could be?”  It is a question I try to ask myself on every encounter too, and a good one for a patient to pose.  When you see your doc with an acute illness it’s not a bad question to ask, just in case they are having an off day and need their memory jogged. 

        After all, this doc/patient thing is a co-operative venture.  The doc might be too proud to tell you it helped ’em, but forgive ’em for that.  We’re supposed to be like Tiger Woods and play pro golf a lifetime and never hit a ball out of bounds.  If Tiger does, people just shrug their shoulders, say he’s human, and send another million bucks.  (I’ve got nothing against Tiger- he’s a great player.) 

        If we hit one out of bounds, the penalty is a bit more severe, and more so for the poor patient than the doc, onerous as the threat of litigation might be.  We are human, and gonna mess up, so like Dr. Groopman says, any way you can help me I’m gonna appreciate.  Every so often the patient saves the day with one last question.  Again, if you only get one, “What’s the worst thing it could be?” ain’t a bad closer.  

        I hope this was of some benefit to your life perspective, and I did not bore you out of your skull.  Most of all, I hope it helps you understand how country docs think, ’cause it could come in handy some day. 

        If you look back at the comments from the last post, the Parson is right- docs are just like mechanics or folks from other disciplines who are in the problem solving business. The stakes can be pretty high, though, so help me out any way you can.

        In the next session, I’ll tell you how this stone thing played out, unless all you guys gong me and want me to go back to bluegrass right away.   

Dr. B   

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16 Comments on “A Kidney Stone”

  1. Ted Lehmann Says:

    Sounds a lot like when I paced the floor certain I was dieing of a heart attack after each meal eaten too fast until a doc figured out I had gallstones. Meanwhile, I can picture you in your kitchen palpating yourself and avoiding the inevitable call to a doc, just like every other medical professional does every time s/he’s sick. I don’t like it much when my editor tells me what to change in my texts, either. Trouble is, I’ve lived with her for more than 43 years and she’s earned the right to diagnose. – Ted

  2. drtombibey Says:

    Gallstones should have been on my differential that night. In my defense, the pain was too low, and I was hurting pretty bad, so I guess I’ll forgive myself for not making 100 on my test. I would have been embarrased if Doc had referred himself to the wrong doc, though.
    Gallstones and heart attacks- many stories there. If you go with the Groopman hypothesis, and I do, then you did exactly right. Think of what might kill you first, then work your way down the list. Dr. B

  3. bobleckridge Says:

    I got called out one night to a man who said he had toothache. Well, in the middle of the night, being called for toothache…….there’s an awful temptation to say “I’m not a dentist. Call the dentist” and go back to sleep. But I was trained same way as you, Dr B., and I thought “better go see if it really is a toothache”. Well when I got there he looked in a bad way. Pale, sweating, and breathless, and when I asked him about his toothache he said it was in his jaw and spread all the way down his neck and down his left arm.
    Yep, you guessed it. He was having a heart attack. I got him into the local hospital right there and then.
    I was very glad I hadn’t said “I’m not a dentist”! (and I bet he was too!)

  4. drtombibey Says:

    Good man, Dr. Bob. Just the kind of stuff Dr. Groopman talks about. Makes your year (and the patient’s) huh?

    Dr. B

  5. Parson Bob Says:

    “When Docs Hurt” might be a good title for your insights, so many thanks. ( For telling the story, not for hurting!) But one question, doc: when we start at the top of the tree like that (“what’s the worst thing this could be?”) how do we eliminate all the more serious possibilities? Here, how could we eliminate the presence of an AAA?

    I understand how you, a trained & experienced MD, can dis that possibility, but me…I’d be off to the ER! I’ve always told myself, “When you hear hoofbeats, think horses, not zebras”, but when the pain hits me it’s 100% zebras!

    A couple of years ago I had one of those 4:00 am episodes: dizziness and disorientation, clammy, BP probably off the charts, and a history of carotid stenosis. “It’s the Big One”, methinks, and woke Ann to call EMS, who promptly got me to the ER and the good docs there made a diagnosis of vertigo. I felt pretty darn foolish, but the next time I bet I’ll do the same thing again! Zebras all he way!

  6. drtombibey Says:

    Oh I would definitely do the same thing again Parson. For every time I think I’m about to make a brilliant diagnosis, most of the time I’m just paranoid. But in the Groopman thought process, we have to think disaster to ever pick it up when it comes around.
    And, I don’t think it is the patient’s responsibilty to make the diagnosis. At the same time, nudging the doc with the question of “what is the worst thing it could be?” isn’t a bad idea, especially if you have some deep down sense of impending doom.
    In the final analysis, your job counts for more than mine. Ain’t none of us getting outta here alive, and that eternity business is quite a long spell of time. I’ve always told my Pastor friends my job is to keep folks here long enough to understand what you guys have to say is what counts for the long haul.

    -Dr. B

  7. mrschili Says:

    I am very much enjoying these conversations, Doc. I don’t really have anything of value to add to them, but that doesn’t mean I’m not learning a lot as I go. Thanks!

  8. drtombibey Says:

    I appreciate you being a part of the conversation. When I read your post on grammar, I was afraid you might fire me! I’m enjoying your weblog. It helps me make up for the fact I played too much music in high school. My mom never took to the Internet, but she would be proud you are a part of my rehabilitation.

    -Dr. B

  9. pandemonic Says:

    Sounds horrible! I hope to never have to feel your pain!

  10. drtombibey Says:

    I hope you don’t either, but they say it ain’t as bad as birthing them babies. At least you ladies have something beautiful to show for it. All I got for my suffering was a rock! Dr. B

  11. uroblade Says:

    The issue with “Suncola” has to do with the absence of “free” H20 in this and other beverages with a high sugar content. People in these parts tend to indulge their sweet tooth with their choice of beverages, leaving them mildly dehydrated and vulnerable to urinary crystal generation. The same criticism applies to our dedication to dietary salt.
    Excellent discussion of the difficulties encountered by a physician trying to pass a “people pearl”.

  12. drtombibey Says:

    Y’all that’s a specialist weighing in- I recognize the lingo. Appreciate it Uroblade. I better go drink some water. Dr. B

  13. Paul Says:

    Flat out… NC has so many kidney stones because of the “house wine of the south” – Iced Tea.

  14. drtombibey Says:

    Lawd, Lawd, my habits have done been discovered. Dr. B


  15. I use to have kidney stone attacks but no

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    I make a tea out of watermelon seeds. Get the

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