Missing the Obvious

The first time I met Ms. B, I found a turkey sandwich hidden under her right breast.

“I left it there for safekeeping,” she explained, chuckling. Ms. B had to sweet-talk an eager nursing student into getting it from the cafeteria. “Shhhh,” she gestured with her index finger up to her lips.

Ms. B had just come out of the ICU, having been admitted for heart failure, blood clots in her lungs, and uncontrolled diabetes. Weighing almost 450 pounds, she needed help to turn over in bed, so she rarely moved. It wasn’t until her transfer to a cardiac unit that her new nurse noticed something she didn’t recognize between Ms. B’s thighs. An in-hospital OB/GYN consult was promptly ordered, and there I was.

Doing a pelvic exam for Ms. B required 4 to 6 people – one or two people to hold each leg, one intern to hold back the abdominal soft tissue, and one gynecologist to do the exam. As I suspected, what I found between her thighs was her uterus outside of her body. The prolapsed organ, moist and abraded, looked generally healthy. My intern and I washed it and gently placed it back in anatomical position.

Over the next few days, I got to know Ms. B better. Every time she budged or coughed, the intra-abdominal pressure ejected the fist-sized uterus, and I would be called to maneuver it back into place. While we waited for the necessary staff, Ms. B told me her life story. She had been a social worker and a church choir leader. She organized the neighborhood kids to visit the elderly in the summers to make sure they had working fans.

I started to wonder how this capable pillar of the community ended up in such bad shape. Five medical teams attended to Ms. B every day, taking turns to evaluate their specialty body part. She received imaging tests from head to toe. Her heart was continuously monitored. A nurse checked her blood sugar every few hours and administered the appropriate amount of insulin. Her upper arms and thighs were dotted with bruises from the blood thinner she needed twice a day. Ms. B’s uterus was actually the least of her problems.

Ms. B endured this extreme level of testing and intervening without complaint for weeks. Something didn’t make sense in the picture of this patient though. She wasn’t a naive person who neglected herself. She kept a neat notebook of her medical history, medications, doctors, hospitalizations, and treatments. Her chart showed that she was a reliable patient who didn’t miss appointments. How did she end up hiding a sandwich under her breast?

I re-reviewed her chart and noticed that her presenting chief complaint a week before I saw her was: “My chest feels heavy.” She didn’t say chest pain, but chest heaviness. That seemed odd to me.

“Ms. B, is your chest still heavy?” I asked one day, deliberately repeating her adjective.

She stared hard at me, and didn’t answer.

I asked more directly, “Why did you come to the hospital?”

Ms. B told me that day, that she had woken up the morning prior to her admission and wanted to end her life. A couple of months before, she had lost her job. She had horrible nightmares of children crying for help but she couldn’t get to them. She couldn’t sleep, couldn’t get out of bed, couldn’t bother to shower, and couldn’t stop thinking that her mom was looking down from above, disappointed in her. The same malaise had happened to her a few years before, after her mom’s death. This time, she just lacked the willpower to pull herself together. She was too ashamed to tell anyone.

The parade of doctors who marched in and out of Ms. B’s room several times a day had missed the obvious. In medical school, it is drilled into our heads that the number one priority is to address the chief complaint. All the specialists had gotten so caught up in fine-tuning Ms. B’s cornucopia of physical ailments that we failed to see the elephant in the room: the profound wreckage of major depression.

I was devastated. It’s easy to rationalize that I was merely a consultant. I was assigned a very narrow set of questions to answer: what is this between her legs, and can you fix it? Technically, it was Ms. B’s primary care team’s responsibility, not mine, to put all the puzzle pieces together. But technicalities, in moments like these, are of little importance.

We all tried our best. We were invested in Ms. B and spared no time or resource in her care. However, it is still infuriating to me that even with the best of intentions, so many doctors can still fail to pinpoint the chief diagnosis. The initial impact of confronting her overwhelming obesity derailed us from the basics of taking a comprehensive patient history. Entangled in imaging tests, blood draws, injections and procedures, we forgot about the one area that fancy technology couldn’t touch – mental health. And it wasn’t for lack of clues on the patient’s part. We treated Ms. B in fragments and fell short of restoring her whole person.

Ms. B’s mental health healing process could not have been completed in an acute care hospital. As is often the case, people go to the hospital with vague physical complaints when they reach the end of their ropes. I offered to set up a consult with a social worker or a psychiatrist, but Ms. B refused. She assured me that she would ask for help if she really needed it next time. I hoped for her sake that it would be that clear cut.