David H. Newman - Hippocrates Shadow: Secrets from the House of Medicine

At the risk of trite clich, first and foremost I thank my mother. She is my brilliant editor and my tireless cheerleader, and she is the reason that this book exists. She is good and she is right.

Binky Urban saw a sculpture inside this block of marble. Binky is the talent among the talent, and her vision is the gift that marks her. I will forever be profoundly grateful to have been an unlikely beneficiary. Thank you, Binky.

Nan Graham, Nan Graham, Nan Graham. Nan and Susan Moldow also have the gift and graciously accepted this stone. Thank you to Jim Morgan, whose patience is impressive and whose skill as an editor and writer are apparent here. To Samantha Martin: I will not be able to properly convey my gratitude. Samantha is brilliant, perceptive, and probing, and these pages (all of them) reflect her work. Meetings and diet cola in the library with Samantha were where my writers eyesight began to find focus. And in case I didnt say it before: Nan Graham, Nan Graham, Nan Graham.

My sister, Andrea Newman, is a deeply gifted writer. Anything that I have, anything that I am, anything that I have done, is a reflection of her and her talent and her help. This book is no different. My father believes in me, and his generosity of spirit and dedication to advocacy are not just guiding principles within this book, they are a reason for it.

Leslie Marnett has been my strength and my secret editor. She is Beauty, and she is the reality and the gift that keeps these pages grounded and true. Beautys time, love, and strength are all here, and she reminds me every day to walk rather than simply to talk. Love is a many-splendored thing. For truth, Beauty.

Lucas Miller, a brilliant writer and lifelong friend to whom I owe more than I know how to say, sculpted this book and gave me the gift of his concentration, criticism, and conversation. Reading the cave drawings of friends (and others) is the burden that all serious writers are, quite unfairly, asked to bear. Luke gracefully accepted this burden. This is unsurprising, for Luke and Jen are two of the most socially graceful humans I have ever known. They and Dick and Joan are all an inspiration for this book.

Many doctors have played a role, too many to list. Abby Wolfson, my friend, my travel companion, and my EM mentor, was yet another secret editor. Abby, more than anyone, suffered my resistance with tolerance and time, as he always has. And as it always has, it improved me. It also improved the book. Cliff Callaway, a genius-level researcher and a profoundly good human, is as dedicated to the truth as anyone I have ever met. I am lucky to have worked with him. I would like to believe that his passionate search for truth is emulated in this book. Other excellent doctors who have, knowingly and unknowingly, played an important role in this book include Dan Wiener, Ian Greenwald, Vince Verdile, and Henry Pohl. And of course, the enduring goodness of the men and women, doctors and all, of the 344th.

D r. Newman, phone call, 6800.

Emergency department, Dr. Newman, I answered, thinking the call was likely to be a doctors office sending me another patient on a busy Monday.

T, honey? She used my childhood nickname, as she always does.

Mom?

Yes, sweetie. She forced the breath between her lips. Honey, somethings wrong. I need some help.

What do you mean, Mom? A knot started in my stomach. My mother is stoic and selfless, and doesnt ask for help (she doesnt want to impose). That she was asking for help and bothering me at work were both ominous signs.

It hurts in my stomach, baby. It started a few minutes ago, all of a sudden. I dont know what to do.

Are you at work, Mom?

Yeah.

Im calling an ambulance for you. Youre going to come here now.

No, sweetie, thank you, but thats too much drama for the office.

I shook my head. She apparently believed that she could settle gently to the floor like a leaf, passing quietly into the next world, and that this would be preferable to causing a scene.

Give Heather the phone, Mother.

I spoke to her assistant at the next desk, who was, as I wouldve guessed, obliviousnot because of inattentiveness but because my mother doesnt complain. Heather escorted her into a cab and brought her to the emergency department. When she arrived, she was doubled over and visibly short of breath. A colleague I trust and respect evaluated her.

My colleague performed a rapid history and physical examination. She had blood drawn for tests, chest and abdominal X-rays, an electrocardiogram, oxygen administered through her nose, a heart monitor, and two intravenous lines placed in her armsall within the first few minutes. Tests for liver disease, pancreatitis, gallstones, internal bleeding, ulcers, gastritis, and kidney stones were normal. Blood tests and X-rays for her heart and lungs were normal, and she showed no signs of serious infection. She underwent a computed tomography (CAT) scan of her abdomen to evaluate her intestines, her appendix, her aorta, and the rest of her abdominal organs, and we did a bedside ultrasound to see her liver and the blood vessels in her abdomen. All of these were normal. And slowly she began to feel better, with no particular treatment.

After three hours of observation and a battery of test results, the colleague I had handpicked to see my mother shrugged sheepishly, apologized, and said, I dont know, I just dont know. Im just gonna call it abdominal pain.

Undifferentiated abdominal pain was my mothers diagnosis. It is a trash-bucket term that means we dont know what caused the problem. It also means we have found no reason to believe its dangerous (arguably good news), and its likely, though not guaranteed, to go away without any particular treatment. In other words, we dont know what caused it, we dont know what to do about it, we dont know if itll come back, and we dont know where to go from here. Undifferentiated abdominal pain could more accurately be called a nondiagnosis.

Whats perhaps most remarkable about my mothers experience is how utterly unremarkable it is. Mom got better. As inexplicably as her pain appeared, so too did it disappear. Over the next few days she went for an official ultrasound of her liver and gallbladder, and two follow-up appointments with her physician. The nondiagnosis did not change. Roughly 40 percent of visits to the emergency department for abdominal pain are ultimately categorized as undifferentiated abdominal pain; no definitive diagnosis is made and no successful diagnostic or therapeutic procedure is performed. Whats surprising, however, is how rarely doctors say the words undifferentiated abdominal pain to the patients who experience the problem. Much more often a provisional, specific diagnosis is givenmaybe peptic ulcer disease, or ovarian cyst, or colitis, but when a physician makes one of these diagnoses, its often based on what we call clinical criteria. In other words, we take an educated guess, but we dont know.

An extremely common example of a provisional diagnosis is gastritis, or inflammation of the lining of the stomach. Gastritis is usually associated with nausea, vomiting, and pain, and can be precisely and accurately diagnosed only by looking at the inside of the stomach through a camera. This requires an invasive test called endoscopy, and we rarely do it in the emergency department (except in extreme, life-threatening situations). Therefore, while gastritis is a common provisional diagnosis in emergency departments and medical offices, the only method to definitively diagnose it is rarely performed in emergency departments or medical offices. And disturbingly, studies have shown that when physicians think the problem is gastritis, they are frequently wrong.