And the Winner Is….
First of all the patient was the winner. Like I said, I got a pound cake from her at Christmas so she is still O.K. (I’m doing all right too- still getting pound cakes.)
So, what did the x-ray show? As crude as banjobilly was in his comment, he was on to a clue there. What the x-ray showed, as billy had figured, was a CAMERA! That thing was supposed to have come through a few days prior, and the fact it had not should have been my clue. Not only did the x-ray show a camera, but there were air fluid levels. To a doc this means small bowel obstruction. Now, there is an old saying in medicine, never let the sun set on a small bowel obstruction. It isn’t always true, but I think it is fair enough to say a Family Doc should never let the sun set on a SBO without the blessings of a surgeon, so I knew a consult was in order before my patient left radiology. Rocking Robert Linney came down and looked the situation over.
“I’m willing to go get it Bibey, but I expect Sandhills would rather do the case since they are in the middle of it.”
“Yeah, and I figure they might want their camera back, too.”
“If they won’t take her, give me a holler, but I feel sure they will.”
I got ahold of the intern and decided to have a bit of fun. “Hey this is Dr. Tommy over in Harnett County. How are y’all today?”
“Good Dr. Bibey.” Everyone down there knew me, not only was I a graduate but Neuse River was the go-to band for faculty pig-pickings. (The Docs didn’t know much bluegrass, but could count on me to round up all the best without fail.) “Whatcha got?”
“I need to brag on Sandhills. You know that new fangled camera you’ve got down in G.I.?”
“Yes sir, sure. I was on that rotation last month.”
“Well tell ’em good ole Dr. Bibey said I sure am happy y’all got all that high tech down there, cause its sure enough made the diagnosis for my patient. I need to send her on. She has a bowel obstruction, so she needs to go to the OR down there tonight, and not just me but Rocking Robert Linney thinks so too.” Robert was well respected in the Eastern N.C. surgical community, and I knew his opinion would trump me, and more important, the intern.
“Really, how’s that?”
“Son, I’m gonna make you a star today. You tell ’em you talked to Dr. Bibey, and he was just a going in circles, but you extracted such a good history you know where to make an incision that guarantees the diagnosis, and you can do it without looking at the x-rays.”
“How I am going to do that?” I had him confused.
“Don’t you worry about that. When she gets there, you’ll understand. Just tell him ’em Dr. Bibey knows and trusts his patients, and we’ve got ’em a diagnosis. She’ll be NPO, and ready to go.”
“I don’t get it.”
“NTW, and lay money on it.”
“O.K., Bibey, will do. Send her on.” I knew my patients, and he knew me. He decided to have faith.
I went back to my patient to break the news. “Ms. Andrews, I think we are finally gonna resolve this thing. Your camera is stuck, and I think whatever has it hung up is our problem.”
“What do you think it is, Tommy?”
“Well, I don’t know for sure, but I feel like we have to find out. I’ve talked it over with Sandhills and they agree. I’m sorry, but I think you need to go to surgery tonight.”
“Do you think I’ll be alright?” She seemed more relieved than worried.
“Yes ma’am, I do. One more thing. You mind if I do a little art work on you? I think it’ll help speed things up at the Medical Center.”
“Sure, Tommy. Anything you think that’ll help is O.K.”
Well, I pulled out an erasable magic marker and drew an elaborate map right on her abdomen. It was a beauty, complete with an arrow pointing to the spot which corresponded to the location of the camera on the x-ray. Much like an anatomical treasure map, it was quite elaborate, and reminded me of the circuitous route I outlined in my high school English paper on the “Ryme of the Ancient Mariner.” A prominent arrow pointed to a large ‘X” denoting the point of interest. —> X- Albatross shot here.
In this case, the arrow pointed to the “X” and said, “Think carcinoid.” I signed off with “Bibey was here.”
I kissed her on the forehead, and then tweaked her big toe. “Good luck, kiddo. You’re gonna be fine. Come visit when you get back home.” I read a long time ago about a patient who thought she was dying, but took heart ’cause a doc tweaked her big toe. She figured no Doc would tweak her toe if she was doomed, and it encouraged her. I’ve never admitted why I adopted the habit till today, but I always sensed some relief when I did so. Besides, I reckon no Doc would draw a treasure map on your belly if they thought you weren’t gonna come home. I think she got it, ’cause when they loaded her up in the ambulance she waved bye and promised me a pound cake.
Ms. Andrews went to surgery the same night, and as several of you guessed, had a carcinoid tumor just shy of her appendix. They resected the tumor, and took her appendix out while they were there. And, not just in this story, but in real life, the woman has sure enough lived happily ever after.
The intern, by the way, followed instructions and won all his bets.
Now for free tetanus shot contest. Well, Ted and Irene were right. Ted is a Professor, and like me, he tends to read a lot. We have learned over the years not to let all that education get in the way of the simple truths of bluegrass music and its’ people. He was afraid to ignore banjobilly’s homespun wisdom.
It’s sort of like the old saw about reading music. A fellow asked a bluegrass man if he could read music, and he replied, “Well, a little, but not enough to hurt my playing.”
Irene, as it turned out, had taken anatomy in college, so she was not relying solely on intuition. She figured the camera was stuck, and came very close to the right location. Ms. Susan also got it, though she came to her conclusion from a different angle- woman’s intuition re: the daughter in Tennessee. mrschili, having studied Bibey’s peculiar writing style, figured it out from a literary point of view, and Dr. Bob knew all along but didn’t tell ’cause of HIPAA . For that matter Ms. Pande was correct also; the thing was right near the appendix and it indeed had to come out pronto. The fact the pathology did not end up as appendicitis is immaterial, ’cause Pande understood surgery was indicated that night. Remember- she said, “Her appendix needs to come out, and don’t wait a day.”
Correctamongo. Serendipity and the Good Lord have saved me before when I was not as close as she was pre-op, so I have to give her credit for a correct answer also. When you think about it, the surgeons did not know for sure either prior to going in. Sometimes knowing what you have do is more pressing than knowing why. The situation had changed from chronic to acute. I am thankful we didn’t stay in chronic illness mindset mode, and changed gears.
banjobilly, crude as he is, made the right call. One fellow wrote in and said, “I think banjobilly is right. That woman has a camera problem.” I asked billy what clued him in, and he said it was the one summer he worked as a plumber’s assistant, and had to fish all sorts of things out of septic tanks and toilets. Like he said, “unless that woman has done s#&^ her a camera, she’s got a blockage somewheres.”
I’ve always liked banjobilly. One should never discount folks ’cause of social status. billy has virtually no book learning, yet he’s smarter than he looks, but the boy needs to work on that cussing of his. I don’t want anyone to toss him out of bluegrass music.
So, even though everyone thought about the problem their own way, in the end all my regular readers were right. I guess they’ve been studying Bibey speak so long they are developing doctor intuition.
Now all I gotta do is figure out how to explain all those free tetanus shots to Corporate. I hope they ain’t gonna be mad.
I know you wonder why I chose carcinoid. Well, I have found through the years once you have gathered all your data, run all your tests, analyzed the thing from every scientific angle you can think of, and still have the diagnosis dangling in the wind, flip a coin and go with intuition. The daughter from Tennessee thought carcinoid, so it was good by me. And, I didn’t learn that from books, but from my wife, my daughter, and those office ladies. They are the best. To the patients’ daughters’ everlasting credit, she never said “I told you so” or complained I only made the diagnosis months after her. She was just glad her mom was O.K.
Gonna toggle back to music for a while, but I’m not done with chronic illness yet.
If it don’t rain in the morning, I’m gonna tee it up with the choose-up boys. Remind me to tell you about a golf tournament a buddy mine is trying to qualify for. I’m not going to say much till I see if he gets in, but I’ll let you know.
Dr. BAdvice- Five Cents