In this ongoing series, Dr. Thomas N. Told, Regional Director of Clinical Education for RVU-SU, shares his thoughts and experiences as a family medicine physician of more than 35 years.
When I started my studies at the now-Kirksville College of Osteopathic Medicine, the anatomy lab was a converted gymnasium; in its earlier days, Kirksville hosted basketball games with colleges and universities from the Midwest, including Notre Dame. The gymnasium-turned anatomy laboratory was a cold, cavernous space illuminated by a few old skylights and light fixtures that were too weak to provide enough light for dissection. A small surgical theater, which dated back to the formative years of our profession, could be found on the East side of the hall. It was a circular room with an operating table located in the middle and spectator seats above the table. I could envision old osteopathic pathologists and anatomists performing autopsies and dissections while interested students observed from the gallery above.
Medical students were encouraged to attend autopsies and I tried to go to as many as I could that first year, even continuing to attend in my second year of training. I could not have imagined at the time what a positive force that would be in shaping my education, and the knowledge and skills I gained there would help me to serve as the coroner of Moffat County, Colorado years later.
One night during my second year, I observed the postmortem examination of a particularly tragic case that further hardened my resolve to learn as much as I could about all of the signs and symptoms of acute abdominal pain. This case galvanized my goal to never misdiagnose common and easily correctable conditions that, when left unrecognized, could turn fatal.
However, this was a tall order. While my goal was well intentioned, it was also very naïve for I later learned that even the most skilled and experienced surgeon could miss up to 15% of cases with acute appendicitis. Nevertheless, this case spurred me to greatly enhance my knowledge and skillset, inspiring me to become an early adopter of computerized tomography (CT) scans and ultrasound for the purpose of early detection of intra-abdominal pathology.
When I arrived in the gallery one evening, I expected to see an older adult on the table. Instead, I was shocked to see an 18-month old infant occupying a small portion of the massive stainless-steel table. Our pathology instructor, upon seeing that she had students in the gallery, began to give the history of the case out loud as she worked.
The infant, she said, had been well up until the week before when they had stopped eating and began vomiting continuously. The parents took their infant to a local physician several times over the course of that week where they were first diagnosed with colic and then constipation. However, the examiner made no mention of any acute abdominal signs other than some abdominal distention, which was treated with an enema three days before the infant rapidly deteriorated. Sadly, after the infant was brought to the hospital in an unresponsive and moribund state, the baby passed away. The patient’s young age and the lack of clear signs of a cause of death had triggered the need for the autopsy. That night, I learned that infants do not often display the usual signs of an acute abdomen like adults do. Sometimes, acute signs come later in the course of the disease, and this may have been a possible reason for the failure to identify an accurate diagnosis in this case.
The case was also especially shocking and memorable for me because my wife and I had recently become parents to our first child, and, as I watched the autopsy take place, I could almost see my young son lying on that table. As a sophomore, I had also acquired an acute case of “Sophomore Syndrome,” where my family members suddenly exhibited all of the signs and symptoms of the diseases that we are currently studying at the time. Whatever the reason was, this experience had a lasting effect on my professional life: I would never want to lose any of my family members or patients to such a common and easily treatable condition.
Our pathology instructor opened the tiny chest with the standard Y-shaped incision, clipping the tiny ribs with a large set of bone shears and removing the front of the tiny thorax. We viewed the contents of the chest: a normal and tiny heart and beautiful pink lungs, the latter which had not been damaged by tobacco or other forms of pollution. Wielding the scalpel in her right hand, our instructor skillfully extended the incision into the abdomen, immediately exposing the thickened and strikingly edematous and inflamed organs now bathed in a feted brownish fluid. Prominent on the right side in the mid portion of the abdominal cavity was a mass containing the remnants of what had been the stricken appendix, along with the fragile tissue and fluids that formed the friable abscess cavity. This infant had become a victim of an acute appendicitis, a totally curable condition if diagnosed and corrected in time. Instead, the infant had passed away from an agonizing condition characterized at the end by massive peritonitis and resultant septic shock.
“How had things gone so horribly wrong and allowed such a tragic thing to happen, and how could anyone have prevented it?” Those questions occupied my thoughts long past that night and up into my clinical years. I tried to reconcile this tragedy in my mind. I read extensively on the subject, including a new text out in our library: Cope’s Early Diagnosis of the Acute Abdomen, which is now in its 22nd edition. I would also casually bring up the subject on rotations by asking every surgeon and generalist physician I worked with: “What is your sure way of diagnosing acute appendicitis?” To my amazement, there was much variation in what each physician felt was the cardinal sign for finally deciding to take a patient to surgery. With that many diverging opinions, it was easy to understand why the diagnosis of an acute appendicitis remained so elusive, especially in a time when the good imaging modalities that we enjoy today were nonexistent.
During my internship as a young medical corps officer at Brooke Army Medical Center, I continued to hone my diagnostic skills on the hundreds of soldiers and their dependents who passed through our Emergency Room (ER) and outpatient clinics every day. Each time we had a case of suspected acute appendicitis, the protocol dictated we call the Operating Room (OR) for a resident or attending physician to confirm the diagnosis before taking the patient to surgery.
One day, I called the OR to obtain a consult on a young soldier who had all the signs of an appendicitis, including the positive lab finding. I felt that my diagnosis was rock solid and anxiously awaited the Chief Resident to come and confirm my diagnosis. I was then surprised when the OR nurse told me to send the patient to surgery without a consult. I inquired as to why the Chief Resident was not doing an evaluation of the patient first, to which the nurse replied that the Chief of Surgery had instructed them as such: “If Captain Told says he has a patient with an appendicitis, that’s probably the case and there’s no need to delay the process by getting a confirmatory consult.” For a young physician in the military, there was no greater compliment than that of having gained the respect of an elite group of experienced surgeons at one of the Army’s largest and more prestigious surgery services. In that moment, the experience from years before at Kirksville was worth all of the thought, preparation, and study I had dedicated myself to, and it greatly bolstered my confidence.
I left Brooke Army Medical Center that following summer to begin practice in Craig, Colorado, and received my Colorado License on July 10th 1974 at 1:30 in the afternoon. I remember the time well because only fifteen minutes later, my first patient, who we’ll call Bob, walked into Craig Medical Clinic with, of all things, signs and symptoms of an acute appendicitis. He was a 55-year-old oil field worker who for the past 12 hours had been experiencing generalized abdominal pain and a distinct loss of appetite, but with no vomiting. His exam showed mild tenderness in the lower right side of his abdomen, but only mild displays of Blumberg (rebound tenderness) or Markle (jar or heel drop tenderness) signs.
To help fortify my presumptive diagnosis, I tried to elicit a positive Rovsing’s sign by pushing down on the left side of his lower abdomen, then quickly releasing pressure to see if any pain would occur on the right lower part of the abdomen, but this proved inconclusive. I had always been fascinated by the Rovsing’s sign for it was a strong confirmatory sign that was not often present. Bob, my patient, was stoic throughout the procedure, which made the evaluation a bit challenging. Urinalysis was totally clear and his white count was mildly elevated; he also had a mild fever of 100 degrees. While I was quite sure it was an early appendicitis, I was not sure that my partners would agree.
Armed with the confidence I had gained in the military, I marched down the hall to my new partner, Raymond G. Witham, MD, who was the town’s most revered surgeon, and I asked him if we could set up the OR for an emergency appendectomy. Dr. Witham looked at me with startled disbelief. I could read his thoughts by his facial expression alone. “This is his very first patient and he wants to take him to surgery? What kind of a nut did we hire?”
At the time when I applied for my position, I had not been aware that my prospective employment had generated much discussion about hiring an osteopathic physician. I would later learn that several previous osteopathic physicians in Craig and surrounding towns had been forced to leave due to questionable practices. The feeling at the time was not to hire anymore DO’s, but, the physicians at the Craig clinic had just lost a partner and could not keep up with the increased workload, so hiring an osteopathic physician seemed like the best option despite those concerns. After all, they reasoned, I was military-trained in one of the Army’s largest medical centers, which also had a world-renowned burn center, and they figured I would be okay because of these credentials. However, now with my request right out of the gate to take my first patient to surgery, I was sure my new partners earlier doubts had begun to creep back in.
Dr. Witham examined my patient, and who at that time was displaying only a mild rebound tenderness on his examination, I argued that he was stoic and it was early in the course disease. I pointed out that we needed to consider other factors like a loss of appetite, a mild fever, and an elevated white blood cell count as equally compelling signs. Dr. Witham responded that while those symptoms may be important, my patient had not vomited. Every patient he had operated on with an acute appendicitis had vomited at some point in the early course of the disease, so he didn’t think it was an acute appendicitis.
I stood firm in my insistence that the patient needed surgery for I had seen patients that had only displayed mild nausea with mild pain and no more. To break the stalemate, we called in our other partner – he was just as skeptical of my diagnosis as Dr. Witham and diagnosed Bob with an acute hematoma of the rectus muscles of the abdomen. I had never heard of such a thing, but he countered that in his experience it was common among oil workers who routinely lifted extremely heavy objects. Though I was out voted, I insisted that, to be safe, we should watch the patient for a day or two in the hospital, and they both reluctantly agreed.
Bob was admitted to the hospital and placed on intravenous fluids and a liquid diet, which he tolerated very well, but the abdominal pain remained at the same level after repeated examinations, as did the white blood cell count. By the second day, Bob was becoming more distended and the pain was gradually increasing in intensity along with the rebound of Blumberg’s sign. He did not, however, show Rovsing’s sign, which would have sealed the diagnosis for everyone. Instead, my examination further revealed quiet bowel sounds and some percussion tenderness. Fearing a concealed ruptured appendix, I ordered an abdominal X-ray. The radiologist observed some gas and fluid levels in the lower right abdomen indicative of a bowel that was shutting down in the area of the cecum. No one could doubt any longer that this was something other than an acute abdominal process, so we took the patient to surgery.
To my relief, we found a large and gangrenous appendix with an organizing abscess cavity all around it, which was not long from rupturing. Our timing, though delayed, did not harm the patient in the long term. We removed the appendix and widely drained the organizing abscess cavity. Bob left the hospital four days later and, over the weeks that followed, his postoperative recovery went smoothly. No one said a word after his discharge, and that was just fine with me. I was glad I had persisted and stuck by my decision to keep him in the hospital. We now had his problem corrected, and as I had learned years before, the consequences from an undiagnosed ruptured appendix could be devastating.
Several months later, I had another patient walk into our office with the signs and symptoms of an acute appendicitis. I vowed there was no way this patient was going to endure an ordeal like the one Bob had gone through, by waiting until the appendix had begun the process of rupture. I made this diagnosis air tight, and luckily, this patient had also vomited, which was the cardinal sign that Dr. Witham relied on to take people to surgery. I walked over to Dr. Witham’s office and said, “Ray, I have a fellow with what I am quite sure is an acute appendicitis. Do you want to take a look at him?” Dr. Witham paused before answering, then looked up with a big smile and said, “No need Tom, just tell me when you want to do it.”