I was covering the emergency room the morning that Sarah (not her real name) presented with excruciating abdominal pain. Married, in her late 40s and otherwise healthy, she had come to our clinic a few weeks earlier with a benign blood vessel tumor in her liver. Because of the risk of spontaneous rupture, her surgeon, the most senior member of our department, suggested she have the grapefruit-sized tumor, a hemangioma, removed electively and as soon as possible. They settled on a date, but as Sarah left the clinic, he offered one cautionary piece of advice. "If you develop pain in your belly, come in right away. It may be a sign that the tumor has ruptured."
In the emergency room that morning, we all assumed the tumor was at least leaking if not already in the early stages of rupture. Sarah lay on the narrow emergency room gurney, her face pale and covered with a patina of cold sweat. In the few minutes that it took for her surgeon to arrive in the E.R., the operating room personnel had prepared a room and warned the blood bank that she might need an emergency transfusion.
The surgeon asked Sarah several questions: how her pain started, where it was, and how she might describe it. He put his hand against her belly, gently palpating the area of her liver, around her belly button and near her pelvis. His hand rested for a moment in the bow of her pelvis, and he lowered his head and closed his eyes. Slowly he began moving his hand in small circles, as if feeling for something below.
"I don't think her diagnosis is hemangioma," he said as he emerged from Sarah's room. "I think she's got dead bowel."
That diagnosis, usually seen in the elderly or in those with rare clotting disorders, had never crossed my mind that morning. It, too, would require an emergency operation, but there would be no life-threatening hemorrhage and an entirely different set of issues to consider post-operatively. Caring for Sarah with dead bowel would not be the same as caring for Sarah with a ruptured hemangioma.
Later that morning in the operating room, Sarah's surgeon would peel free a perfectly intact hemangioma from her liver. But deeper down in her belly, he would find what only he had felt in the emergency room, the cause of her excruciating pain — a two-inch segment of dead intestine, telescoped so tightly on itself that it had kinked off its own blood supply.
That Sarah's surgeon could make such a specific and accurate diagnosis still mystifies me, and her story has become one of several diagnostic mysteries I find myself recounting over and over again. Like doctors everywhere, I relish anecdotes like hers because they are evidence of extraordinary medical sleuthing and intuition.
But, as Dr. Lisa Sanders shows in her thought-provoking new book, "Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis" (Broadway Books, 2009), my fascination, our fascination, with diagnoses may have more to do with the importance of having a diagnosis than with the robustness of the process itself.
Few individuals have considered the diagnostic process as extensively as Dr. Sanders. For the last seven years in The New York Times Magazine, she has offered readers a new diagnostic dilemma every month, a peek into the way doctors think about disease.
Her new book is filled with similar fascinating patient stories — the young woman who turns "highlighter yellow," the medical student who suddenly becomes inarticulate, and the muscular man who suddenly can no longer hold a coffee cup or walk straight. But unlike her column, where each story is the focus of discussion, the patients who appear in the book are springboards for a discussion of how methods of diagnosis, or lack thereof, ultimately drive patient care. With a diagnosis, the doctor-patient relationship has direction, a purpose, a common goal. Without it, both the patient and physician are unmoored, cast in a sea of overwhelming and often paralyzing possibilities.
With an understated but unwaveringly clear narrative voice, Dr. Sanders takes readers on an examination of the tools of diagnosis, touching upon the obvious and the not-so-obvious — the physical exam, the effect of physician biases, and even the reliability of computers and Dr. Google.
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