Diagnostic tools you can't afford to ignore

Despite all the equipment at doctors' disposal, the best indicator of a patient's condition isn't high-tech at all.

By Denise M. Visco, MD
Ophthalmologist/York, PA

I make my living looking into people's eyes. But no matter how hectic things get, I just can't look at someone's eyes without trying to see who he is and what he really needs.

Recently, I found myself looking for clues in the eyes of a surgery patient who came in one week post-op. His vision was giving him trouble. He also looked green and pale, and seemed a little short of breath. I asked him how he felt, and he said, "Just a little dizzy. I get that way sometimes."

I dilated his eye, revealing a hemorrhagic swollen optic nerve. This would have been typical for a central vein occlusion, or possibly an ischemic neuropathy—a common condition for people his age, and one that would require minimal further workup. But I just couldn't get past the fact that this guy looked like crap. I knew I had to look at "him," to figure out what he needed.

I knew this because of Effie, a sweet lady in her 80s. I met her when I was an intern doing an FP rotation. The night float signed her out, noting a "right inguinal mass." During morning rounds, we discussed the differential diagnosis. The chief resident said confidently that we wanted a CT. I soon found out this was her favorite test.

Effie had never been in a hospital, as a patient or a visitor. She had no regular doctor, no spouse, no siblings, and no children. She had a cat, which a neighbor was caring for in her absence. She rarely went out, except to buy groceries. Effie told wonderful stories about when she was a little girl.

As I looked into Effie's eyes, I could see she was terrified. She told me she was afraid she would die, because when her parents went into the hospital years ago, they didn't come out alive.

After lifting something heavy, Effie had felt excruciating "groin pain" that left her no choice but to call an ambulance. My exam revealed an obvious inguinal hernia. I wanted a surgery consult to reduce and possibly repair the hernia, but I wasn't sure how Effie would take this news.

I gently explained that she needed an operation. Her eyes told me she knew the end was near, and nothing would convince her otherwise. The chief resident still wanted a CT before the surgery consult, even though the diagnosis was so clear. She said it would be a good "teaching tool."

I couldn't understand why we should needlessly put this frightened woman into a scanner. Poor Effie might as well be beamed up to a starship. Thus began my feud with the chief resident. I lost, of course, and this didn't bode well for me politically. But I had to protect Effie. I couldn't betray those eyes.

So I went to her room and told her I was going to try to reduce her hernia. If I was successful, she wouldn't need the CT. I could see the pain in her eyes as I proceeded, then the anger in the chief resident's eyes when I told her there was no longer any mass to scan.

Joe, the surgeon who consulted, was sensitive to Effie's naivete about the medical system and offered to fix the hernia under local anesthesia. He quietly told me that reducing the hernia was the proper thing to do, and we had a good chuckle about the now aborted scan. Effie's other option was to take her chances and not get the hernia fixed. My gut told me to let her run home, but I followed my intellect and told Effie to get the hernia fixed. She trusted me.

She should have run away.

After some preliminary testing of Effie's cardiac function, we scheduled the hernia repair. I arrived the morning after and found Effie in the ICU, intubated and obtunded. Evidently, she began flipping T waves as soon as Joe injected some local into the right inguinal area. He never even made an incision. Effie went asystolic and was resuscitated.

Subsequent echocardiography discovered a ventricular aneurysm with clot. Effie was then anticoagulated and proceeded to have a major hemorrhage into her abdominal cavity requiring further life support measures, a central line, and blood transfusion.

My God! Could anything else have gone wrong?

As Effie recovered in the ICU, I felt consumed by guilt. I hadn't fulfilled my duty to her. How could I be so arrogant and headstrong about the CT, yet so cavalier about surgery?

Effie spent a week in the ICU before being transferred back to me on the floor. She was severely depressed and wouldn't eat. Our conversations were no longer happy and lively. She wouldn't even get out of bed to void. She began wasting away.

At morning rounds, the decision to start hyperalimentation was being made. Almost crying, I argued that this was not what Effie wanted or needed. She needed to go home to her cat, buy groceries, and tell stories about when she was a little girl.

The attending (why are they always so wise?) turned to me, and to my astonishment, told me to send her home. Staring back at him, I started second-guessing myself. Effie was still receiving a lot of care; how would she manage, once we stopped doing things for her? The attending smiled and said, "What are we doing for her? We certainly didn't fix her hernia." Then I understood what he meant.

I went to Effie's room later that morning with a red scarf I'd bought in the gift shop. I told her it was a present to celebrate her discharge. She'd be going home in two days.

The life came back into those eyes, and a smile spread across her face. Effie chowed down at breakfast, lunch, and dinner. She called her neighbor to check on her cat. She began walking up and down the hallway to rebuild her strength so she could walk to the grocery store. When she left the hospital, she kissed me, grinning from ear to ear, wearing her new red scarf.

As I regarded the ill man with the hemorrhagic optic nerve, I remembered Effie's eyes, and how important it is to be the patient's advocate.

Looking beyond the pathology in the man's left eye, I saw the helplessness in his gaze. Although his words said it was nothing, his eyes told me he was afraid and wanted someone to take care of him. His wife also looked concerned. They trusted me.

I fully examined the eye that hadn't required surgery. Sure enough, that optic nerve was swollen and hemorrhagic, too. His blood pressure was sky high, even though he had no history of that problem. I called his primary physician with the probable diagnosis of malignant hypertension, and said that an emergent CT and neurology consult would be needed to fully work up his papilledema. I made arrangements for an internist to meet the patient at the hospital and had an ambulance transport him.

When he left my office, I saw gratitude in his eyes. He affectionately grabbed my arm as the stretcher went by, and I gave him a squeeze back, glad I'd been able to give him what he needed.

And once again, I thought of Effie's eyes.

 

Denise Visco. Diagnostic tools you can't afford to ignore. Medical Economics 2001;18:70.