I’ll just put it right out there. I am a Physician Assistant (PA) and have been practicing for eight years. The bulk of my specialty has been in surgery and anesthesia. I am also a mom, wife, and daughter who also finds herself sometimes on the other side of the patient bed, or rather in the patient bed.
My most recent experience that landed me in the patient bed began with abdominal pain. The pain woke me in the middle of the night. It was two am. The pain was in my upper abdomen, but so high it was like a cross between heartburn and stomach discomfort.
My groggy two am brain kicked very slowly into PA mode. A weird gastritis? (Generic term for stomach bug). Those viruses can be so unpredictable; still, no one I knew had been sick. That doesn’t exactly rule out the stomach bug possibility though.
Heartburn? Not exactly classic for it, but stranger things have happened. I didn’t have any fevers, nausea, vomiting, back pain, diarrhea… I considered all of these things good signs. The absence of all of those symptoms was reassuring and excluded lots of possibilities from the diagnostic differential. So, feeling reassured I decided to take some Tums, and Zantac hoping that would ease any discomfort that might be related to heartburn.
The pain was manageable enough that I was able to drift back to sleep. I actually slept quite well until about 6 in the morning. When I woke the pain was still there, had become somewhat more intense and seemed to have taken on another characteristic. There were episodic waves of increased cramping pain that would wax and wane.
Clearly, the Zantac and Tums were not doing the trick. Ok, I thought, not just heartburn. My immediate priority was to ease the pain. I took some Ibuprofen and Tylenol. Knowing it would take roughly forty-five minutes to start feeling any relief, I bided my time.
PA mode struck again. Did I have an ulcer? Worse yet, did I have a perforated ulcer? Maybe it perforated and I was bleeding? Oh boy. If that is it, were there any dark stools to suggest the blood was being digested and passing through my system? Nope. Was I feeling dizzy or lightheaded suggesting that my blood pressure and blood count was low from losing blood? Nope. All good signs.
Another theory. Maybe I had stones in my gallbladder and it was infected? No fevers, great sign. No tenderness when I pushed specifically on the right upper quadrant of my abdomen. Whew. Then what in the heck was it??
Time will tell I told myself. Relax, I told myself. Don’t let your medical knowledge let your mind get carried away. Give the medications time to work.
So I did.
Except that times passed and they are totally not working. Except that my husband is about to go to work and I am finding it increasingly difficult to take care of the kids and feel this uncomfortable. I start pacing, sure sign things are getting worse. I pace when in pain.
“Do I need to stay home?” My husband asked.
“No, no. I should be fine” I replied.
Over the next half hour my pain really escalated. Thank god my husband had not yet left for work. I relented.
“Ok, I need you to stay home. I’m really sorry”.
The whole thing was baffling to me at this point. On the other hand, my PA mind had shut down. I moved into problem-solving mode of what kind of help to seek or not seek.
I stayed conservative. Made a call to my primary care office. They planned to get me into the office that afternoon. It was about nine am at that point. Done. I had made a plan. Time to wait.
About an hour later the pain was getting too intense to wait until the afternoon. I call the primary care office again. They put me through to the urgent care clinic and the appointment is bumped up to eleven am-ish- I can’t remember exactly. We’re making progress.
Half an hour later, with my husband watching the two kids and eleven am feeling like an eternity away, I call my mom and tell her I think I have to go to the emergency department. The pain has become unbearable and I now have some nausea to go along with it, but no vomiting.
Let me fill you in that one big fear for a healthcare provider is going to the emergency department when you don’t have to. I am not sure why exactly. I think because we’re embarrassed that we might be overestimating our symptoms when we should know better.
It’s even a more silly fear because the times I have taken care of a healthcare worker I never felt any judgment of whether or not they did or didn’t come or why they are there. Just like anyone else I am there to help make them feel better and solve the puzzle. I also never feel that way about running to the clinic or ED with one of my kids, family members, or friends but heaven forbid I go when it was something that could have been taken care of at home.
Anyway, off I go in a private vehicle to the ED in broad daylight. They complete the check-in process, the vital signs, and they triage me. I am curious about my vitals but they all look good. I wait, they get me into a room and none other than a PA comes in to evaluate me. It is not someone I know.
I can’t decide if I should tell them I am a PA. I can’t seem to think of a way to say it without sounding “know it all” so I opt not to. I answer all of the questions. He does an exam. I’m starting to feel embarrassed because I have literally no pain when he presses anywhere on my belly.
“Nope, not there. Nope, not there either. Still nope. Nope and Nope”
Great I think, that was super helpful—not!
They start an IV, they give fluid, they take blood. They give me pain medicine and anti-nausea medicine. I let them do their thing. I don’t interfere or offer ideas. I’m in too much pain, and too tired from being in pain and feeling too sick to participate. I just want to be the patient. I try to remember my pleases and thank yous, knowing it’s always nice to receive those when I am working.
The do an ultrasound to check my gallbladder. I am not surprised since that was on my list. The PA returns and reports the gallbladder looks fine. The blood work shows an elevation in my white blood cell count. If this is elevated it can be a sign of infection, but everything else looks good. He is stumped.
I come clean and tell him I am also a PA. He looks a little surprised and asks why I didn’t tell him and wonders what I think is going on. I simply said: “I don’t know.” My PA brain had totally shut down. I felt bad I hadn’t spoken up. I wasn’t trying to be sneaky and spring it on him, I just hadn’t wanted him to feel like I was critiquing his work up. This whole scenario adds a whole other layer of complexity when being a PA and a patient simultaneously.
Interestingly, now sixteen hours later, my pain while easing from the medication seemed to be now somewhat in the right lower area of my abdomen. The idea of appendicitis started to creep into my mind.
They decided to order a CT scan.
Results: acute appendicitis!
It had been a totally atypical presentation.
The classic presentation is pain that starts around the umbilicus (or bellybutton) and then migrates to the right lower quadrant of the abdomen. On exam, the patient is tender upon palpation of the right lower quadrant. There is often a fever. There is often nausea and vomiting. There is often anorexia (loss of appetite).
When my ED visit first began I had essentially only vague upper abdominal pain that was not tender on the exam, and nausea.
The severity of pain and increased WBC were the clues to look a little deeper, hence the CT Scan, which held the answer.
One medical provider classic phrase when we’re presented with an interesting case is: “patients don’t always read the textbook”. Meaning as much as we’d like for their illnesses and injuries to present as they do in the textbooks, often they just don’t. In some ways, I was classic for not being classic.
