Monday, December 7, 2009

Grim Google

I walked into one of our big trauma rooms to see a medical patient who had been placed there because of overflow.

After introducing myself to the patient and his very pregnant companion, I asked him what brought him to our ER.

His chief complaint was as big as the room.

"Doctor, I'm dying of colon cancer."

His exact words. And as he spoke, his words were accompanied by his companion's eye-rolling.

I think now is a good time to describe the patient. He was 25. Yes, 25. He looked very nervous but otherwise normal appearing, short brown hair, 6'0", 220 lbs. Pure muscle. I think he ate a side of beef for lunch every day.

"Why do you think that?" I asked, suspicious I might already know. "Do you have a family history of colon cancer?"

"Well, no. I don't think anyone in my family ever had it--until now. But," he hesitated, choking back his emotions, "every time I go to the bathroom, you know, from behind, I see blood in the toilet and on the tissue."

"Bright red?" I asked. "Yeah," he replied.

What twisted human nature compels each of us to look in the toilet when we are done using it? I am reminded, though, of reading that if you put just one ml of blood in a toilet bowl, most people would overestimate how much blood they were actually seeing. I doubt this patient was an exception.

His concern for his health was very real. And although he was not your average demographics for a colon cancer patient, he still warranted a thorough physical exam and blood work.

"So, every time you have a bowel movement, you see blood?"

"Yes, sir, for the last two days."

"Any pain?" I asked.

"Not, really," he replied, "just a little itching and discomfort."

"Have you ever been constipated?"

"Well, yeah, I have," he answered.

"And obviously, you work out a lot. Do you do a lot of sit-ups? Crunches? Core workout?"

"Yeah, how did you know?" Don't give me too much credit--like I said, the patient was pure muscle. A four-pack wasn't a far stretch of the imagination. However, the abdominal strain and pressure from those exercises could be a contributing factor to his problem.

My next question surprised him. "Do you have internet access?"

"What?" he asked, glancing at his companion.

"Well, did you 'Google' your symptoms?" I asked with sincerity.

His female companion jumped in and answered for him. "Yeah, he did. Yesterday. And since then that's all I've heard about--'I'm dying,' 'I'm not gonna see my kid be born,' 'Why me?'."

On a roll, she took a deep breath and continued. "I have to be honest. I'm 37 weeks pregnant and I have to listen to him whine? I don't think so--it should be the other way around, right? Just tell him he's okay, Doctor, and we'll get out of here."

She finished speaking, looked at the patient, and gave him another dismissive eye-roll.

I loved it. I was going to ask her to give me an eye-rolling lesson when we were done. Twenty times a day, easy, I could be using that talent. And who knows, maybe for extra credit, she could teach me to bob my head, hold up my defiant index finger, and drawl out, all with a little attitude, "Mmmm hmmmm". High-pitched, of course.

After finishing the patient's history, we moved on to his exam. I reviewed the patient's vital signs with him--all good. I performed a very thorough physical exam--all good. This included a pain-free abdominal exam. I reviewed the patient's blood work results as ordered from triage--all good. Again, this included a normal CBC (no signs of anemia). I saved the best for last.

"I'm going to need to do a rectal exam to see exactly what's going on."

This was the moment when I knew this patient seriously did think he was dying. He had no objections to a rectal exam. There are very few reasons that a 25 y.o. male wouldn't object to a medical rectal exam. Very few. So his willingness for this exam spoke volumes of how ill he thought he was.

I performed the exam. And, I'm happy to report, it was in his favor--no blood, no pain (a touch of discomfort, at most), and no unusual findings.

Well, except for one. He had two small, inflamed hemorrhoids that were the most likely source of his bleeding.

Ugh! More near-death hemorrhoids! God's joke on the human race, they are.

I explained in detail to this patient what hemorrhoids are. I explained that we treat them with sitz baths, suppositories ("you mean I gotta put one up my ass?"), creams, and stool softeners. If his symptoms continued, I explained, his family doctor may change treatment, order a colonoscopy or CT scan, or have him see a colo-rectal specialist.

"An ass doctor?" he asked. "They really exist?" Oh yes, Virginia, there is a Santa Clause. And to you, buddy, yes--ass doctors do exist. They're the ones wearing heavy cologne along with plastic face shields and cover-up procedure gowns.

During this conversation, out of the corner of my eye, I saw this patient's girlfriend trying to hold back her smile and failing miserably. And yes, she was rolling her eyes at him. Again.

I liked her. And I liked this patient. In all seriousness, his worries could have been any of ours.

Finally, after my best reassurances that he was not dying of colon cancer, the patient finally relaxed and joked a little about "his new little buddies down there." I actually think he was going to name them.

I pulled out a blank sheet of paper and wrote on it. H.E.M.O.R.R.H.O.I.D.S.

I handed it to him.

"What's this?" he asked, taking the note and reading it aloud.

"Your next Google search," I answered, smiling.

His companion laughed out loud and rolled her eyes. Again. Only this time, they were directed at me.

After the recent news report of how people are bypassing their doctors and relying on search engines to make self-diagnoses of their symptoms, I decided to flip that coin. Thanks for reading, as always. Next post will be Wednesday, December 9.


DreamingTree said...

Sorry, doc...women have eye-rolling down to an art form. Some men can pull it off, but very few. ;-)

Nick Dawson said...

We are working so quickly to index everything and put information at ever finger tip. This entertaining and poignant post is a worthwhile reminder that without the right education on processing all that information we can (along with google's help) be our own worst enemies.

It also seems like there is a flip side of that coin. Is there a role for google in becoming a more educated patient? Can we use technology to take the strain off primary care docs? Or are we still missing that key part of an educated triage?

Greg Friese, MS, NRP said...

I am grateful that his anxiety did not lead to chest pain which would have caused him to call for an ambulance.

Unknown said...
This comment has been removed by the author.
Unknown said...

Very enjoyable essay.

But next time please recommend Medline rather than Google, which can just compound the problem.

Or SearchMedica, where there's no junk "information" to be found. (Full disclosure: I'm content manager.)

Anne Marie Cunningham said...

So what could have made this story better? A patient with a new synptom of rectal bleeding sought medical attention because of what he read on the internet. Surely that is a WIN!
Yes, he was low risk of a bowel carcinoma but he still needed to be seen by a doctor. Would things have been any better if he had used a better search to access this information? Probably not. As soon as one sees that cancer is a possibility it tends to stay in one's mind until you are told that it is not cancer.
In the UK, despite the universal coverage of the NHS people who live in poorer areas and are diagnosed with bowel cancer die more quickly that those who live in well-off areas. We don't know why but one reason might be that they present later. They don't know that passing blood is something that you SHOULD bother your doctor with.
We need more informed patients. I'm a GP in the UK and I have blogged about this here:

Thank you for the story.

The Hopeful Elephant said...

Chalk another one up to Dr. Google. Sigh.

Attic Aunt said...

Dr. Google has her place. Imagine a case of celiac disease that would have been evident to a goat and the semi-rural gastro docs wrote the raging anemia off to 3 teeny med ulcers. The gerd that developed at the same time made me puke when brushing my teeth. Had DH at the same time, odd but impossible. They had no clue.

Yeah, I diagnosed myself on Google, and Mayo later confirmed it, and bless my doc there for giving me credit in finding it.

What helped? LPN training 30 years before (got my lic. never practiced)and enough common sense to know my body was really messed up.

Attic Aunt said...

Sorry for the minor rant.

Wanted to say, as a long time patient, I love your blog. You seem to understand people well and I bet you're a great doc, complete with compassion and kindness.

Rositta said...

I'm not sure this guy needed to be in a trauma centre. I think a doctors office would have been more appropriate. That's the kind of people who clog up the ER's dont you think?
Google is a good place to get information not to diagnose oneself. It has helped me to know what's ahead for a very ill family member. It also gives me the right questions to ask my physician if I need to...ciao

SeaSpray said...

Compassion, humor .. I enjoyed the post. I felt like I was in the exam room. ..although glad I really wasn't. :)

I was 22 and one morning before work ..saw that I was bleeding in my stool. Scared the heck out of me, but still went to work.

But was increasingly anxious and asked if I could come in to see the doc asap. I left work before lunch. I was hardly there a minute when the doc asked if I had beets for dinner.

Yes I did.

Mystery solved and I was GREATLY relieved and one HAPPY girl because I your patient ..thought the worst.

How embarrASSing though! :)

Re: googling med info ..I have and do..but have to be careful because sometimes I scare myself erroneously thinking something may apply to me that doesn't. I prefer to talk with the docs.

Cal said...

Thank you for another entertaining and well written post; I am enjoying these. I am always very embarrassed when I go to the doctor for one reason or another, and it ends up being nothing to worry about. I always feel like I have wasted their time, while rationally I know they are probably happy that I was not seriously ill, just like in this hemorrhoids versus colon cancer example of yours. A few years ago I went to see my PCP for a small complain that ended up being rather serious. Even though the news were tough, part of me was relieved that at least I didn't waste their time. I am not sure where this streak of mine originates from, but it can sometimes be counterproductive.

make mine trauma said...

Nice! When I read "bright red blood" I felt like I imagine a med student must feel when they know the answer to a question .....or like Arnold Horshack on Welcome Back Kotter....."Ooh, ooh, Mr Kotter!"
Wait, did I just date myself!?

SeaSpray said...

Ooh, ooh, I LOVED Welcome Back Kotter! :)

just sayin :)

Jen said...

I LOVE your entries. please continue writing!

NYCRN said...

rectal bleeding is such a common complaint in triage these days,
unfortunately we can't turf these cases to urgent care.

911RN said...

Along the same vein as effective eye rolling is "The Look." Have never seen it on or from myself but I am told by husband, boys and coworkers it is one of the best. Another artform that comes naturally from those of the feminine persuasion, especially mothers. Sorry, doc. We take are perks as they are given to entertain our XY counterparts.

I, like Make Mine Trauma had diagnosis figured out long before end of story but did not make it any less enjoyable. AND MMT- Oh, Oh...I am from the same generation. Loved your comment.

First time posting, have been reading awhile- love stories!

Ambrosia Bierce (2014 AD) said...

I was once in the ER, in & out of consciousness, but stuck next to someone who was arguing with the doc about the diagnosis. The doc kept saying that a bleeding H can really look scary but here's nothing else wrong. The patient wouldn't buy it. I was grateful to lose consciousness again.