New word: globus hystericus

globus (Latin)
: spherical object, globe

hystericus (Greek)
: from hustera, meaning ‘uterus’

globus hystericus
: difficulty swallowing; a sensation of a lump in the throat
: a symptom of conversion disorder

The word hystericus is related to the words hysteria and hysterectomy – the latter being the surgical removal of the uterus.  Apparently, hysteria was believed to be an exclusively female problem of uterine origin until the 17th century.

According to Wikipedia:

The term hysteria was coined by Hippocrates, who thought that suffocation and madness arose in women whose uteri had become too light and dry from lack of sexual intercourse and, as a result, wandered upward, compressing the heart, lungs, and diaphragm. The belief was that hysterical symptoms would emanate from the part of the body in which the wandering uterus lodged itself.

The same general definition… came into use in the middle and late 19th century…. Typical treatment was massage of the patient’s genitalia by the physician and later vibrators or water sprays to cause orgasm.

Hmm…

Today we use the phrase globus hystericus to refer to the sensation in general of a lump in the throat due to any cause: psychological or mechanical. It may be due to spasm of the constrictor muscle of the pharynx (throat). A patient may feel it post-operatively after being intubated, or before surgery due to anxiety. It’s hardly a feeling unique to women.

The word hysteria has fallen out of fashion in psychology. Psychiatrists more often speak of ‘conversion disorders’ which are psychological disorders characterized by physical symptoms of psychological origin.

But the underlying sexism is still in fashion.

After all, when was the last time you heard a man described as hysterical?

On worries

A charming 91 year-old women presented to the Emergency Room the other day with two weeks of constipation and a grossly distended abdomen. After obtaining her medical history and performing a basic examination, the junior emergency doctor explained to her the necessity of a rectal examination to feel for masses or fecal impaction. He apologized for the need for the exam and offered her the option of having me, a female medical student, perform the exam. With almost cinematic emphasis, she looked at him, then looked at me, then replied:

I think she better do it.

So I did. I had done two before on male patients about a year ago and a few on the male teaching dummy before that. Still, the junior doctor had to move me to the right side of the bed because I had forgotten about best positioning, and had to fetch me some lubricant because I had forgotten about the need for it. I thought I remembered the basics of the exam itself though. It ain’t rocket science.

I inserted my gloved index finger as far as it would go, and with circular sweeps tried to feel for fecal impaction. The rectum was dilated and empty and I found it difficult to reach the walls, but I was confident that there was no obstructing mass in the area my finger could reach. Afterwards, the doctor insisted on examining my finger himself for any traces of blood.

After reviewing the woman’s abdominal X-ray we concluded that she had a small bowel obstruction and called the surgeon. Part of the conversation between the emergency doctor and surgeon went something like this:

Surgeon: Did you a do PR?

A ‘PR’ is a per rectal examination.

ER Doc: Yes, I did. Uh, that is, my medical student did the PR, but I was present.

Surgeon: You were present. Has the medical student even done one before?

ER Doc: Oh, yes! She’s done quite a few of them before! And I saw her insert her finger and examined the finger when she removed it.

Surgeon: Uh huh. Yeah well, you should do it again. A PR exam by a medical student is not a PR exam. I’ll be down soon.

To his credit, the ER doctor had faith in my exam skills and didn’t repeat it. But after I heard that conversation, doubt crept in.

When the surgeon finally came down he disagreed with our diagnosis of small bowel obstruction based on X-ray. It was large bowel, which means an obstructing mass was more likely. And he asked me not once, but twice (if not three times):

Surgeon: And the rectum was empty? You felt nothing in the rectum?

humanb: Yes, it was empty as far as my finger would reach.

Surgeon: Well your finger is probably longer than mine. Alright.

So the surgeon sent her for a CAT scan of the abdomen to get a better picture of the problem and had her admitted to the main hospital. Soon afterwards I left for the day, but I carried that patient with me…

In my mind’s eye I kept going over and over that rectal exam… on the long drive home… as I changed out of my work clothes… as I checked my email and stared at the evening news… as I prepared dinner… Did I go as far as I possibly could or was I too gentle at the expense of being effective? Did I sweep the walls for lesions? Could I have missed a mass?

I called my husband at work as he prepared to leave for home. “How was your day?” I asked. My husband, a corporate lawyer, told me something about a client in North America that had him concerned.

“How was your’s?” he asked. I told him about the rectal exam, of course. I was feeling very unsure about it by this stage. His reply:

Wow, your worries aren’t my worries.

Funny. But not true.

Our worries are the same. We all worry about a few discrete things in life: our health, our loved ones, money, and fu**ing up – be it at work, in relationships, or in social situations.  I suppose some of us also have existential worries. I do, anyway.

My husband worried about his responsibilities with respect to his client. The pensions of thousands of people were at stake. I worried about my responsibilities with respect to my patient. A woman’s life was at stake. Did he cover all the bases in the contract? Did he miss something? Did I sweep every surface? Did I miss something?

The problem with the Emergency Department is that you never know what happened to patients after they’re admitted to the main hospital. You move on to the next patient in ED. So the next day, though she was gone, I looked up the results of her CAT scan: she had a mass in her lower colon. It was too far up to have been felt, but the CAT scan report said there was feces and flatus in her rectum. Maybe that was too far up too. Maybe not.

I’ll never know.

An arrogant assumption

This past week in med school I learned about anesthetics in the operating theatre. One of our patients on Friday was a sweet-faced 28 year-old Lebanese-Australian boy. I say ‘boy’ because he was small, thin, and soft-spoken, with an air of innocence about him. (Also, I’m older than he is.) The boy had torn the lateral and medial menisci of his knee playing soccer, and was preparing for his second surgery to repair the damage.

As I stood with him in the anesthetic bay outside the operating theatre, I was struck by the extent of his anxiety. The moment he saw the anesthetist he pulled out a photocopy of his previous anesthetic report from behind his back on the hospital bed. He started asking questions about the anesthesia he would get and fretting that he would be given something different. He went on to explain his injury and the details of his past surgery and to express great concern about what would happen to him this time.

As I prepared to insert an intravenous line into his arm, he became more anxious and asked me if I was giving him a drug. I assured him that I was only establishing access to his vein. As I inserted the needle, his sweet face distorted and he began moaning his discomfort. Once I finished, he picked up his running commentary on his situation, looking more and more agitated as time went by.

I’m ashamed to say that I left the anesthetic bay after I inserted his IV line, because his anxiety was beginning to bother me. Had he been an older patient, or a younger one, or a patient who hadn’t already had a successful surgery, or a patient having open surgery, or a patient having a more life threatening surgery, I would have understood and been more sensitive to his anxiety. But this fellow wasn’t actually a boy. He was a grown man – a fit and healthy young man having arthroscopic knee surgery, a very common procedure. Moreover the needle I inserted – granted with less skill than an anesthetist – was only a tiny one. Rather than being compassionate towards his discomfort, I thought about the fact that I voluntarily and routinely donate plasma. This requires having a much bigger needle stuck into my arm for 30 minutes while blood is drained from me and spun into its components in a machine, before my red blood cells are somewhat painfully pushed back into my vein. Instead of thinking about this patient, I was congratulating myself on being ‘tougher’.

‘What a whinger!’ I was thinking. ‘What a baby.’ If that wasn’t bad enough, my lack of compassion transformed into a blanket judgment against modern men in general, as weak and melodramatic when it comes to pain and sickness. Nurses frequently joke that men are the biggest fainters, and more intolerant of pain. Whether this is true or not, I don’t know, but I was certainly singing that tune on Friday.

So when I returned to the anesthetic bay, I hid my annoyance with his anxiety behind a smile and remarked gently:

This is a very common procedure, you’ve had it once already without problems, and the doctor is very experienced in performing it. Why are you so nervous?

I was expecting him to reply that he hates pain, or that he’s afraid that something (highly unlikely) will go wrong, or that he doesn’t want to be put to sleep. Instead he replied,

I’ll die without soccer.

[Silence.]

Huh.

I thought about that statement after he was put to sleep, and concluded that this guy probably wasn’t a worry-wort or a scaredy-cat by nature after all. And he was probably pretty tough. He had two seriously torn menisci and one surgery already from playing a pretty aggressive sport. His sensitivity to that needle was probably exaggerated by his anxiety about the surgery. And his anxiety about the surgery had nothing to do with cowardice, and everything to do with his desperation to get back on the soccer field.

I’ll die without soccer.

This wasn’t fear of pain or death overwhelming this boy. This was love – love of a game, of a way of life, and of a life-defining activity. This was fear of losing the Self.

But even if he had been a scaredy-cat, or a whinger, or a big-baby, I should have been kinder. I was perfectly kind on the outside, mind you, but my heart wasn’t in it. It should have been.  Had he been a woman, it would have been. Had he been a child, or elderly or critically ill, it would have been. Had he been anyone else but a young-to-middle-aged man, it would have been. I hope.

One of the greatest challenges and achievements in medicine is to become less judgmental. If you form a negative judgment about a patient before you’ve even treated him, how can you ever be certain you’ve treated him well?

This gives a whole new meaning to the guiding principle of medicine:

First, do no harm.

The new currency

For the next week in med school I rotate through anaesthetics. Today was my introduction to the field, and I spent the day shadowing a senior anaesthetist and his trainee. I’ll call the anaesthetic trainee ‘Dr. S’.

The senior anaesthetist was fantastic. He was eager to teach, happy to answer my stupid questions, open to my doing procedures, and patient with my sluggish comprehension. Dr. S was another matter. He refused to let me try procedures, and despite my watching him with interest and curiosity, explained absolutely nothing of what he was doing. He gave only annoyed monosyllabic responses to most of my questions, and when I asked him about a particular drug “x”, he looked at me like I was an idiot and said:

“Drug x is drug x. What do you mean ‘What is it?’ Go read a pharmacology book.”

I’ll do that.

On the drive home I was trying to understand Dr S’s attitude. He could have been in a lousy mood today. Or he could have been sick of teaching med students the same things repeatedly. Or he could have had med students come through before who had behaved badly in the operating theatre, or who had showed him too little respect. But if I’m respectful, behaving well, and expressing an interest throughout the week, and his behavior doesn’t change, these explanations won’t do.

I’ve got another explanation in mind. This guy strikes me as one of those people who treat knowledge like money. They’re loathe to share it if they worked personally to gain it. If you don’t have it and seek it from them, they resist you. Resent you. They want you to work just as hard for it as they did. To get it from them is to mooch.

This view is perfectly acceptable in certain circumstances. Reasonable in others. Even right in some. But not this one.

I don’t fault medical students for this view (and we’re all prone to it). Students don’t have an ethical obligation to help their fellow classmates, although it’s the moral thing to do. But I do fault a doctor for this attitude.

Students learn as much from books as from doctors, and it is precisely the responsibility of doctors to impart their knowledge to those who follow them. It’s how we ensure the continuity of standards in medical practice. This Dr. S. continues to learn every day from his more experienced colleagues, yet he couldn’t be bothered to spread the wealth.

When my classmates and I are doctors, I’ll expect our attitudes and behavior to change, if not our instincts. After all, we’ll become members of a team dedicated to a mission greater than our own interests. The more senior doctor recognizes this, although I suppose there’s also a certain comfort and security in senior leadership positions that inspires generosity. But unlike Dr. S., I suspect the senior doctor was also a man who found the practice of treating knowledge like money to hoard, more than a little ridiculous, and ultimately helpful to no one.

Where hope meets cynicism

I took this picture in a back alley in Ann Arbor. Michigan has the highest unemployment rate of any state since the recession.

These days there seems to be an alley in every American soul, where hope meets cynicism. It’s the cynic that’s foreign to our nature though: we Americans have always been hopeful.

But alas, the cynic has captured the moment. And that man selling hope is alien to us.

Better things can happen, if we let them.