Secret Messages

The other day a woman presented to the hospital with vague abdominal pain. It had been nagging at her for about a month, and she just felt that something was wrong and wanted to get checked out. The emergency room scanned her over, and decided that there was something to her pain, and so she was admitted. The admitting medical team concurred, and consulted the gastroenterology group. Everyone was in agreement – her story, her looks…it all pointed to her gallbladder.

The only thing was that ultrasound – which is usually the best test for the gallbladder – was completely normal. But her blood-work indicated some sort of pathology- perhaps the gallstones had already been expelled from the gallbladder and were now stuck downstream? An MRI was ordered to confirm, but it, too, was normal. Her labs continued to worsen, and her pain persisted, so a nuclear medicine test was ordered. These are very good at picking up an occult cholecystitis, or attack of the gallbladder – sadly, it was negative.

I say sadly because patients like to know what’s wrong with them. Even when we hunt for a diagnosis and it comes back something scary, there is a certain relief in at least knowing what the problem is. There is a degree of comfort to at least giving your enemy a face, even if it is an ugly one. Most patients who have abdominal pain get a CT scan at some point during their hospital stay – in all honesty, it is often the first thing ordered. But in this woman’s case, the testing was more discretionary, and rightfully so. But now, with all roads turning up empty, worsening labs, and continued pain, a CT was justified.

When a CT scan is performed, it collects hundreds of images in just a few seconds to compile the pictures we see. Oral contrast is ingested to illuminate the bowel, and intravenous contrast is injected to illuminate the blood vessels and the highly vascular organs. When we ordered this particular CT, we asked the radiology tech to time the imaging to optimize our views of the liver and pancreas – the supposed region of interest – in the hopes that it might pick up any pathology. And it’s a good thing we did. The venous phase of the study showed the portal system was largely occluded. The liver actually has two systems of blood supply. It has an arterial supply (via the hepatic artery) which is analogous to every other organ in the body. But it also has what is known as the portal system. This is the network of veins which drain the bowels and bring their contents to the liver for processing. This is actually the major source of the liver’s blood. The clot within the portal system was so extensive that it had managed to kill the central portion of the right half of her liver. She wasn’t sick from a simple gallstone – she was sick because a major blood clot was killing off her liver.

She needs to have her blood thinned right away. And she’ll need that for about six months or until the clots dissolves. And we need to find out why this happened. There are really only two possibilities – either she has a disorder of her blood that causes her to make clots, or she has an occult malignancy, like lymphoma, that is causing her blood to behave this way. Either way, her life has been severely altered. It’s humbling to arrive at conclusions that are so far from where we start. Life’s messages are often hidden – we just need to keep searching to find them.

Pathways

A couple of weeks ago in church we heard the familiar tale of one of the most famous journeys ever undertaken. A long time ago, in a land far away from here, three wise men traveled a great distance to worship a child. The details of their trip are not recorded, but I can imagine that it was long, exhausting, and…indirect. I somehow doubt that their trip went too smoothly, and I am quite certain that it took them to a place – literally and figuratively – that they did not expect. For how could it not? It brought them to such a foreign land, with a radically different culture, where they experienced divine incarnation. Now how’s that for a road trip?

It’s interesting to think of our lives in this way - as a wondering journey, with some vague and abstract guide, leading us on to some foreign place. And what will we find? And how will it change us? Will we be so lucky as to encounter the divine along the way?

The great comfort of any journey is knowing that others have gone on before. Things are somehow less scary when we think we’re not alone, or at the least that the emotions and fears we’re experiencing are not totally unique. It’s comforting – don’t you think? – to pause and realize that others have done this before. A class in school, or a move, or a surgical residency…others have taken this path before. And made it. And the journey at the end of life – the pathway into death – I guess that’s the journey none of us really want to take. But as my friend’s father said at his wife’s funeral: how great the comfort is, knowing that our Lord has traveled there before.

I think about death often. I guess it’s because of the work I do, and that death is so prevalent around me. I think of my patients journeys into death, and what a wondering and twisted road it must have been – all the more twisted because somehow I became a part of it. I ended up being a part of their story, albeit at the end.

Today I told someone she was going to die. She is seventy-two, has five children, and yet I doubt that even one month ago she imagined she’d be sitting in that tiny hospital room she was sharing with someone else, with the curtain half-drawn and the TV next door still on, listening to some young guy like me tell her how mortal her condition is. Some journey. But then, in my mind…the knowledge and comfort that so many others – including our Lord! – have traveled this road before keeps me from breaking down. I pray that it brings us all peace, and that the journey – with all it’s indirection – leads us to encounter the divine.

Gut Check

The other day we were consulted to see a patient in whom they had discovered a pancreatic mass. This type of consult carries with it a mix of emotions. It usually means pancreatic cancer – a deadly diagnosis that often claims the life of its victim quite rapidly. Conversely, pancreatic surgery is some of the most challenging and rewarding operating there is. In a perfect world, we cure these individuals in fantastic manner. This patient was not the healthiest I’d ever seen. Pancreatic cancer normally strikes elderly, sickly folks, and this gentleman was no exception. He had smoked enough for two lifetimes, and it took its toll on his lungs and arteries. To even consider operating on a guy like this meant a meticulous pre-operative work-up. A work-up so involved, in fact, that we wanted to transfer him to a larger hospital because they had a greater ability to run more thorough tests. He was hesitant. He liked the hospital he was in – he felt comfortable, and it was close to his home so his wife could visit easily. She’d never be able to see me down town, he said in complete earnestness, even though it was hardly a fifteen-minute ride by car, bus, or train. It might as well have been half way across the country, to hear them talk. We argued gently. This was cancer, after all, and the bad kind – the kind that kills, and painfully, too. We weren’t even at the point to offer surgery. We just want to run some tests, and talk to some specialists….we just want to see if we can even do the surgery. Can’t we do it here? No; not well. We need you in a larger facility. He looked me in the eyes. I just have a bad feeling, he said quietly, his oxygen tubing snugly in his nose. Doctor…have you even had a feeling that something just wasn’t going to work out? Of course. Of course I do. Al the time. It’s my job to worry about the worst-case scenario, and to put my patients in the best possible position to survive should something catastrophic happen. Ok, he conceded, you’re right, I’ll go. But I just don’t think I’m going to make it. He went quietly. He thanked us and smiled. Two days later he was dead. I don’t know what happened, and nobody does. A heart attack, or a pulmonary embolus? He was in the hospital getting his myriad of tests and he just coded and died. Just like that. I guess he was right, this wasn’t going to work out for him. He knew something none of us did. He should have ignored us and just gone home. He should have – we all should have – listened to his gut.