The Big One

???

Lately I can’t even finish a thought. That is because everyone who walks in the door has splenomegaly or a giant pelvic mass or a blood pressure of 194/105 or a hematocrit of 20%.

Sometimes I try to redirect them into familiar territory.

“Yes I know you have a giant spleen, but do you also have diabetes?”

“Your blood pressure is quite high. When was your last pap?”

But, really, those things don’t matter when you’re staring the Big Question Mark in the face.

My job is full of little question marks. “Should I check labs now or in 3 months?” “What’s the best antidepressant for this patient?” “Does this patient need a follow-up DEXA scan?”

But time stands still when I have to ask “What the hell is happening here?”

And it’s not such a great week when the Big Question Mark happens 5 times.

Put aside for a moment the technical difficulties in actually obtaining diagnostic tests in such very sick patients without insurance or any money for food. It’s hard enough to even know where to begin the work-up.

Monday started with a patient with itchy hands and feet, worse at night. No rash. Oh, and she’s also 37 weeks pregnant. I ordered some bile acids and LFT’s, and started her on ursodiol for presumed cholestasis. Then I called the Dragon, who happens to be an expert in the field. I interrupted him during tai chi. Yes, he is 85. And Chinese.

“So if this turns up positive, should I induce? She’s a VBAC.”

Then on to the next several patients. Soon I met a man with a rash all over his body for 8 years with a large, firm spleen. To be honest, I’ve never felt anything like it before. I’ve tried and failed in Africa, and confirmed its absence in kids with mono. This one was hard to miss. I percussed it too. I texted a photo of the rash to Dr. DDX. Then I got out my Washington Manual and read the section on splenomegaly. HIV. TB, mycobacterium avium. EBV. Portal hypertension. Tumor. Hemolysis. Awesome.

Then I put in 2 IUD’s.

Tuesday a lovely lady came to see me after a several year absence in which she developed worsening pelvic pain. She is 49. She has a gigantic pelvic mass.

Forgot to mention the 47 y/o cocktail waitress who presented with restless legs and turned out to have a hemoglobin of 5.7. I ended up sending her to the ER to get transfused so we can potentially get her a colonoscopy.

None of these people have insurance.

I soon found myself between patients texting my dad about splenomegaly, emailing Dr. DDX, and browsing through 3 derm atlases and a stack of charts, with 5 AAFP articles open on my desktop.

It was a bad week. I read a lot and didn’t come up with many answers. I was just busy enough not to dwell on the ridiculous inadequacy of our medical care delivery system. Not too busy to feel completely inadequate, myself, though.

But the good news is there’s time. All except for the pregnant lady, who’s been in and out of labor and delivery three times this week at my behest.  Everyone else has time. Time for me to think, and study. Time for studies to be done. Time to work on funding.

Everything seems urgent, because these are major medical unknowns. But the truth is these people have been living with these problems for a lot longer than I have. All of them for months, at least. And if all I can offer them is questions, at least I’m asking them. At least they’re here. It’s not my fault they couldn’t see a medical provider sooner. It’s not my fault they don’t have any money. It’s not really theirs either. It is what it is.

I can’t fix very much about this system. And I'm not going to know all the answers tonight. So probably I should go home before it’s time to come back again.

I added 5 stickers to my S.L.