© Springer International Publishing Switzerland 2015David A. Schulsinger (ed.)Kidney Stone Disease10.1007/978-3-319-12105-5_1
1. Room #2: The Test I Could Not Study For!
Department of Urology, Stony Brook Medicine, Stony Brook, NY, USA
David A. Schulsinger
My pain was in the upper right hand quadrant and it was quite significant. The insight I gained from my days of preparation for clinical medicine, a second year medical school class, and my clinical training as a general surgery resident, allowed me to consider the differential diagnosis for this pain. The thought of the pain being caused by a renal stone was not out of the question; it was in the differential for the cause of this throbbing discomfort I sustained. In that the sharp and stabbing sensation appeared shortly after eating, other possibilities were to be considered, including cholecystitis (inflammation of the gallbladder from a stone), a gastric or duodenal ulcer, or even appendicitis. The pain exacerbated after eating food supported this potential diagnosis. In my differential diagnosis, was it abdominal discomfort from a pulled muscle following a long run as I had been training for my 13th New York City Marathon? At the time, I was also one week away from an important examination, so the possibility that I was having some gastritis was a possible explanation. I chose to stop eating food that day hoping the gallbladder pain, my initial diagnosis, would resolve or at least improve. Unfortunately, the pain intensity only got worse. My family and I journeyed out to a Bar Mitzvah that day, as I did not want to spoil the festivities, but the increasing level of agony prevented me from staying beyond the welcome reception.
Hours later, a visit from the local fire department after my wife could not get a hold of me, escalated the level of concern. As most physicians, being our own worst patient, I was able to convince the firemen visiting me in my bedroom that I was just fine and they did not need to continue watching Saturday college football with me any longer.
“A happy wife is a happy life” had taken on a whole new level of concern. As if the fire department visit was not enough, she pulled out all the stops. “It’s not just for me, it’s for our children.” I realized that it was not only just a good decision for me to go to the ER to verify that I was well, but also that it would be healthy for future of our marriage! To amplify the situation, these events were occurring 1 week before my Urology recertification examination. This is an exam Urologists take every 10 years to recertify that their knowledge and practice of Urology is updated to current standards.
Three feet from where I stood, down the hall, was ER Room #2. This was the nebulous room in the ER that seemed to always have the door closed. Over the course of my tenure at this hospital, I have never known who was on the other side, what their diagnosis was or what they were being treated for. Now the site of this closed door represented a whole other world of personal possibilities and threats. Once or twice, I had a patient of mine there who was being treated for a kidney stone. Now I was the patient in this room, being worked up for my inexplicable abdominal pain!
Dr. G entered the room. He was a well-respected ER physician who was not only a colleague of mine, but his mom was also a patient who I had treated. Our initial conversation was physician to physician. I was discussing my symptoms as if I was the physician describing my patient. Only this time, I was both the physician and the patient! With my wife and dad present, he discussed the working diagnosis and the battery of tests that would be completed. With the location of my discomfort and with the onset of pain following food, I was being worked up for cholelithiasis and pancreatitis. I was going to have an ultrasound to evaluate the gallbladder and pancreas and additional blood tests to evaluate bilirubin, pancreatic enzymes, etc. It was now, 7 pm. The night was young!
Several hours later, I received the report that all tests were negative. I was pleased to get this news. While I was feeling somewhat better since I arrived to the ER, the pain was not completely resolved, but the negative test results suppressed my mental distress even more. As a patient, I was delighted to hear the good news. As a physician, I was cautious to interpret these results that the patient was still having pain and that we still needed to find the source. While certain disease states were ruled out, the true diagnosed needed to be ruled in. As a Urologist, I thought, could it be a kidney stone or even a renal mass, despite the fact there was no blood in my urine?
It was now 2 am. I was pleased that all the tests to this point were negative. I was feeling physically and psychologically a bit better. Dr. G entered the room with a poker face that was challenging to read. I lay on the ER stretcher sandwiched between my emotionally drained wife and my concerned dad. He told me that all of my numbers looked good and that all the tests were negative. “Before you go home”, he stated, “let’s get a CT scan of your abdomen.” “I am sure it will be negative”, he affirmed, “but let’s verify this concern.” We spoke to your Internist, Dr. L, who suggested as a colleague and fellow physician that we go over the top to rule out even the most remote possibilities. “You have already spent most of the night here, what’s another two hours?”, he said. This seemed like a reasonable option. My physician cap went back on. I quickly questioned myself whether I needed this CT scan, realizing that this may not have been my medical recommendation. I recalled a recent journal article that suggested the lifetime risk of cancer following a single CT scan was 1:2,000. “Did I need this risk?”, I thought. My patient cap went back on. Unless I was going to sign out against medical advice (AMA), I was going to have this test.
Throughout my life, I was always overly prepared for my examinations. I had developed a knack for excelling beyond high school pop quizzes; college prelims, midterms and finals; taking the Kaplan course for the MCAT’s, urology in-service exams, and board examinations; these all conditioned me to become a tenured successful test taker. I now faced the “pop quiz” of my life, the exam that I could not study for!
For certain, this was the test I could not study for! Preparation for this test included the awful contrast that I always heard about from my patients, but now I had first hand knowledge and confirmation of how it feels to be outside of the white coat. I drank the oral contrast required for this test. Surprisingly, the flatulence that ensued gave me complete resolution of my abdominal pain. It was as if the solution that was intended in making the diagnosis was also the one that provided therapeutic relief. As a physician, I did not lose site of the big picture. The test still needed to be done.
It was now 4 am. I was completely fatigued and ready to go home. It was the type of full day that I usually encountered after being on-call with multiple urologic emergencies, admissions and surgeries. A new ER physician came into the room to report the results. I did not know him directly. He acknowledged me by Dr. Schulsinger, so the thought immediately passed that he knew me or at the very least, he was aware that I was a fellow colleague. His first words spoken were, “do you want me to give these results to you alone or in front of your family?” Wow, what a heavy and loaded question. This response posed some possible answers with that single question. At the very least, I knew they found something. The new question, was, “What was it?”
It was important for my family to be there. They were my support system, my second ear and of course, my family. The news was not favorable. I had a 12 cm retroperitoneal mass. It was the size of a uterus at 12 week of pregnancy! I was told that this lesion was either a lymphoma, sarcoma or GIST (gastrointestinal stromal tumor) tumor. The list in the differential diagnosis was not good. I then wished that it was a kidney stone because unlike the diagnoses they posed, a kidney stone was not life threatening. I knew that this was only the beginning of additional tests and eventually, surgery.