They hit the emergency room like dust devils kicking up prairie straw: a patient upright, gasping on a stretcher, flanked by two hustling paramedics.
Doctor, he looked awful. Sprawled on the basketball court. Fighting for breath, the first medic panted.
The second jumped in, And, man, was that other guy huge-- 220, at least. Flew up for a basket and slammed his knee into Mr. Welch’s chest. Pow. He socked his left palm.
Two nurses closed in to take vital signs. Mr. Welch did indeed look awful: mouth gaping, chest heaving, body wet with a slick, clammy sweat. My instant diagnosis was tension pneumothorax. A severe blow to the chest, or thorax, may collapse a lung and sometimes tear it. Air can rush through the punctured lung, fill the chest cavity, and quickly cut off blood returning to the heart.
Mr. Welch, can you talk?
A desperate headshake. No.
I grabbed my stethoscope and bent down to listen to Mr. Welch’s chest. If one side felt tight as a drum and I couldn’t detect breathing sounds, I needed to pop a needle between his ribs and release the air immediately. Fortunately, although Mr. Welch was too stunned to speak, his breathing seemed normal. But he needed an X-ray of his lungs, and he needed it right away.
Five minutes later we had our answer. His lungs were normal, but his left tenth rib--one of those near the bottom of the rib cage--was fractured. I showed the X-ray to the paramedics.
Tenth rib fracture. His problem is pain more than anything.
The medics eyed the film. The first one whistled. Boy, he sure looked bad.
Rib fractures can be excruciating, I explained. Taking a deep breath can feel like a jab with a red-hot poker.
We’ll watch him carefully, I reassured them.
Oh, we know, replied the second medic. But that other guy was big.
I showed Mr. Welch his X-ray.
Rib fracture. Your lungs are fine. You were lucky.
Whether from rest or reassurance, Mr. Welch was starting to look better. His forehead still glistened with beads of cold sweat, but his breathing was coming easier. Heck of a basketball game.
Will I be okay? he asked. I’ve got to catch a plane back to Boston tonight.
We just need to check out the rest of you, then you’re a free man.
Debbie, our senior medical student, had been watching the proceedings. She was eager for hands-on experience; in nine months she would graduate from medical school and metamorphose into an intern, a real doctor.
Why don’t you pick him up? I asked. We’ll talk about chest trauma.
Sure, she replied.
I showed her the X-ray film.
Tenth rib fracture. What lives under the left tenth rib?
Should I order any more X-rays? she asked. Lab work?
The best test is your eyes and ears and hands, I answered. Clinical judgment relies on the results of the patient’s history and physical exam. Those results point the way to tests--not vice versa.
Dazzled by high-tech teaching hospitals, medical students can easily get the idea that diagnosis is only an exercise in test interpretation. But as I heard myself explaining this I thought, What a sententious old fogy I must sound like.
Debbie took it in stride.
Okay, Mr. Welch, I’m taking you over there to check you out, she said, grabbing hold of his stretcher.
A half hour later she returned. The head and neck exam--
Wait, I interrupted. Pretend I haven’t met him yet.
Sorry. Okay, this is a 52-year-old white businessman who while playing basketball sustained a severe blow to the left lateral lower rib cage. . . .
She skipped to the abdominal exam.
Left upper quadrant benign.
She nodded crisply. Positive.
Anatomic cartographers divide the abdomen into four quadrants, using a vertical line and a horizontal line that intersect at the belly button. The upper quadrants house the liver, on the right, and the spleen, on the left. Problems in these organs can be tricky to detect because the rib cage shields them, making them somewhat inaccessible to an examiner’s hand.
The liver performs a crucial role in metabolism; the spleen’s function is far less obvious. Shaped like a loose fist and tucked under the left side of the diaphragm, the spleen is probably the most ignored and misunderstood of organs. Before medical school, all I knew was that you could literally rupture or figuratively vent it. Until quite recently, medical science was in the same boat.
In the second century A.D., Galen declared its function was to convert the indigestible portion of food into black bile. Fifteen centuries later, when the balance of the four humours--blood, phlegm, yellow bile, and black bile--was the accepted explanation for differences in human temperament, the spleen was felt to be the seat of courage, passion, and ill-humor.
With the rise of modern surgery, this misunderstood organ took on a new role as nature’s make-work project for surgeons. Car accidents and other blunt traumas were more likely to injure the mushy spleen than any other abdominal organ. Since it seemed to perform no discernible function, the easiest remedy was to remove it.
As the number of car collisions climbed over the years, so did the number of splenectomized people. And then the problems began. The patients without spleens began to succumb to overwhelming bacterial infections of the blood, or sepsis. Why? It took the rise of immunology to provide some answers. The immune system is built like a castle with three rings of fortification. If bacteria break through the outer wall--the immune cells in the skin, throat, or gut lining--they encounter guardian immune cells stationed within the second set of ramparts, the lymph nodes. Only victory there will gain them access to the inner sanctum--the bloodstream. And one of the guardians of the inner sanctum, like the Vatican Swiss guards, is the spleen.
Fed by an artery from the aorta, the spleen is a honeycomb of tiny blood vessels through which blood slowly percolates before entering the liver. Packed around these vessels are countless nests of B cells, the immune soldiers that manufacture antibodies. B cells also harbor the memory of past invaders, so they can respond more quickly to the invaders should they reappear. The slow blood flow through the spleen allows policemen such as T cells to take a long, hard look at any suspicious characters floating by. If an invader is detected, they alert a B cell that can form the right antibody to attach to a particular bad guy. Once roused, that B cell quickly divides into millions of copies of itself--each churning out antibodies to collar the intruder.
The spleen also filters out blood-borne debris. Immune cells called macrophages (literally, big eaters) line its blood channels; they swallow worn-out red blood cells and platelets, degrading the hemoglobin they contain into a reusable form. In diseases such as mononucleosis, the spleen goes into overdrive, trapping so many abnormal white blood cells that it can swell to ten times its normal size. In some cases, a bout with mono can cause the spleen to swell so much that it ruptures.
You can live without a spleen because of the immune system’s first two lines of defense, but it’s not advisable. In a pinch, the spleen provides an emergency source of red blood cells by contracting and pushing out more blood. And its role in immune function is so important that humans without spleens, especially if they are young and haven’t formed antibodies to many pathogens, face a much higher risk of life-threatening sepsis.
As for Mr. Welch, Debbie hadn’t found any sign of problems in his spleen. Now my job was to double-check her exam. We went back to his bed.
How’re we doing? I asked brightly.
Much better, doctor, Mr. Welch answered.
Mind if I take another look?
A normal spleen can’t be felt, but if it’s ruptured or bleeding, the left upper quadrant should be tender. Mr. Welch’s was soft as pudding. No sign of distress.
He’s fine, I confidently announced to Debbie. Let’s give him something for the pain. He has a plane to catch.
Mr. Welch had to go to the bathroom. Debbie escorted him, but he moved under his own steam.
Yes, he was fine.
At the moment, though, I was overhauling my own internal barometer.
The week before, a 12-year-old had come in complaining of vomiting and two days of vague belly pain. Since there was no fever and the exam seemed classic for a nonspecific viral infection, I hadn’t ordered labs or observed him overnight. The next morning I called to check on him. His mother said he was improving. I patted myself on the back for my efficient clinical judgment. Ten hours later he was back, and worse. I immediately suspected a ruptured appendix, which, to my chagrin, was confirmed at surgery. The mother berated me for not having ordered labs. I listened. How was I to explain that blood tests are notoriously unhelpful in detecting many abdominal conditions, including appendicitis?
When doctors are faced with uncertainty, the true key to abdominal diagnosis lies in repeated clinical examinations, using each new exam to reinterpret the patient’s history and to keep a sharp eye out for subtle new signs. My 12-year-old patient had been atypical, yes, but I wondered over and over: What delicate web of clues had I brushed off?
Happily, he had fully recovered. But I was still reeling.
Even so, overreacting and ordering shotgun blasts of tests wasn’t the solution.
And besides, Mr. Welch was fine.
I sent Debbie off to examine a new patient and wrote out Mr. Welch’s prescriptions. The nurses checked his vital signs, making sure to test his blood pressure one last time, first while he was sitting, then while he was standing. When a patient stands up, blood pools in the legs. If an internal hemorrhage is causing blood loss, the circulatory system can’t compensate for the shift, and the loss will be reflected in a change in pulse and blood pressure when the patient stands. The pulse jumps and the blood pressure drops. Mr. Welch’s stayed rock-stable.
Then, just as I was handing him the prescriptions, I noticed the beads of sweat. There on his forehead, like tiny half-pearls, they glistened. There is a medical name for this sweat--diaphoresis. And it can be a sign of stress in the circulatory system.
How do you feel? I asked.
Great. Though every now and then I get a warm feeling across my chest.
But your belly feels fine?
I grabbed back the prescriptions. Not so fast, I said half jokingly. How about we watch you for a while? Just to be sure.
Maybe because he remembered how awful he had felt, or maybe just because he was a pleasant, reasonable fellow, Mr. Welch agreed.
An hour later Debbie and I looked in on Mr. Welch. The beads of sweat were still there.
Diaphoresis, I pointed. Possible sign of what?
Blood loss, she answered. Or pain.
Mr. Welch’s pulse and blood pressure remained unchanged. We sent for a blood count anyway.
I feel fine, Mr. Welch assured us.
An hour later Debbie checked on him again.
Findings? I prompted.
Diaphoresis, she answered, then carefully, so as not to presume, asked, Can ruptured spleens take a while to declare themselves?
Yes, they can, I answered. Maybe 15 percent of cases. Which I hadn’t remembered until she asked me. Med students: we teach them what we need to learn.
The blood count came back a bit low. But then Mr. Welch told us he’d once had anemia.
Lots of maybes. But those little beads of sweat kept nagging me. And Debbie saw them, too.
Okay, I asked her, what is clinical judgment?
Hands, eyes, ears. Connected by a brain, she deadpanned.
Our hands show us a benign belly, but our eyes see diaphoresis. The X-ray shows a tenth rib fracture--right over the spleen. Our ears hear a patient saying he’s fine, but the medics said he looked awful. Labs and vital signs are reassuring but not definitively so.
Very good, I said. So how can we clinically rule out ruptured spleen in this case?
Debbie thought a moment. I don’t know, she finally conceded.
Correct, I replied. We can’t. We’ve reached the point where hands, eyes, and ears--even connected by a brain--aren’t enough.
She frowned. So that was a trick question?
Yup, I said, smiling, and you helped me answer it.
So now we do an abdominal ct scan?
There was another consideration: I was about to turn over, or sign out, Mr. Welch to the care of the night attending physician. Sign- out is emergency medicine’s danger zone, especially when a doctor who is uncertain signs off to a doctor who doesn’t know the patient. The time for observation was over: diagnose or discharge. And those little pearls of sweat said No discharge.
I shook hands with Mr. Welch. Good luck to you. Hope you’ll make your plane.
There’ll be others, doctor. And thanks for everything. When I left he was cheerfully downing a preparation that would allow the ct scan to capture an image of his innards. He still looked fine. I wondered if I hadn’t reset my barometer to worrywart.
Next morning my colleague gave me the news.
Good pickup with that ct scan, he said. Ruptured spleen.
Debbie, who was standing nearby, broke into a beautiful smile.
Close one, I whistled. I’d actually written his discharge papers.
Debbie and I hustled up to the surgery intensive care unit.
Mr. Welch looked exactly as we had left him: friendly and upbeat.
The surgeons say if my blood count goes any lower, they might have to go in. But they said it’s not that badly ruptured and that it’s better to keep your spleen, even what’s left of it.
So did you learn a lot?
Startled, I didn’t know what to say. But then I realized Mr. Welch’s question was directed at Debbie.
Oh, yes, she answered graciously.
For the two of us.