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A Case of Abdominal Pain

I wrote Healing The Power in You;  Tapping into Courage, Hope, and Resilience  because this information has changed my life, and in fact has saved my life.  I share these cases with you because I hope it can help you too or help someone you love.  

I share with you excerpts from the second chapter; the story of a Marine presenting to an Emergency room with abdominal pain and vomiting.   On the next blog, I will include an expert from a professional young man who is a serious marathon runner who came to my office because of persistent tendonitis.   

A Case of Abdominal Pain 

We look for medicine to be an orderly field of knowledge and procedure. But it is not. . . . There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. – Atul Gawande, MD 

In the mid 1980s, before I began studying alternative methods, I worked as an emergency physician in the Boston area. In the ER, there was only one physician in charge at a time. When my shift started at 3:00 p.m., I assumed responsibility for the patients, taking over from the physician who was leaving. Likewise, when my shift ended, I would sign over any remaining cases to the doc- tor succeeding me. 

When I arrived at work, the doctor finishing his shift informed me that he was signing over one patient who had not yet been evaluated because he was considered a private patient, expecting a consult with a general surgeon. The young marine, however, had serious symptoms, including abdominal pain and vomiting, last- ing over two days, without diarrhea. is raised the suspicion of a “surgical abdomen” (a condition requiring emergency surgery). 

Because the surgeon had been tied up in a gallbladder operation for over two hours, the ER staff conducted blood tests and an x-ray of the abdomen, to rule out the immediate concern of an intestinal obstruction. After hearing this report, I asked the nurse to take me to the young man before checking on other ER patients. In this, I acted according to my intuition and contrary to customary procedures. 

Marines are famous for their fitness and strength, but the young man I saw sat upright on the gurney, clearly distressed, incapacitated, and apprehensive. His eyes showed fatigue, as if he hadn’t slept for several days. I introduced myself and greeted him by his first name. “Jacob, can you tell me how your problems began?” 

Jacob sounded sad and weary: “Two days ago I woke up with a tummy ache and vomited. I saw the doctor at the base, and he told me to rest for two days. I felt better, but then today I had more pain and threw up my breakfast. I still have the pain, and I’m nauseated.” I asked about other symptoms, but he denied being feverish or having other intestinal problems. He emphasized feeling weak. 

I began with the ABCs—airway, breathing, and circulation—of evaluation. Noticing that Jacob breathed rapidly, I listened to his lungs and heart, hearing evidence of fluid at the base of his lungs (rales) and an S3 gallop in his chest, both of which are signs of a tired heart. Before proceed- ing further, I asked the nurses to do an electrocardiogram (EKG) and test for oxygen in his blood. Within two minutes, it became clear Jacob had suffered a major, acute heart attack. e EKG also indicated electrical blockage of the heart and abnormal heartbeats. 

We moved him to a critical care bed where his heart and blood pressure could be monitored. Checking his abdomen, I found it was normal. Nurses inserted an IV, and a chest x-ray was taken at the bedside. I started him on oxygen, nitroglycerin, and a strong diuretic (Lasix) to address his heart failure. He received aspirin and blood-thinning medication to dissolve blood clots that might be responsible for his heart attack. Jacob was also given a medication to normalize the dangerous irregularity of his heartbeat and decrease the risk of sudden death. 

For the abdominal pain, which actually was due to his heart attack, I administered intravenous morphine, a very effective pain reliever that also lessens anxiety. This step was not just palliative care—pain and tension can constrict the supply of blood to the heart, a significant risk in this case. I reassured Jacob his abdomen was fine and that the treatments we provided would make him feel better as rapidly as possible. 

I spent twenty to thirty minutes stabilizing Jacob, until the pain subsided entirely and his breathing slowed. I later learned this heart attack had been quite severe, damaging about half the muscle of Jacob’s heart. 

Discussion 

Jacob’s preliminary test results were normal. Moreover, he was considered a private patient, scheduled to be evaluated by a surgeon. At that time in the 1980s, courtesy to the surgeon dictated that I should not evaluate or treat his private patient. So why did I decide to examine Jacob, particularly considering my colleague had not been concerned? 

An adage in medicine advises: When you hear hoof beats, don’t look for zebras. Look for horses. It means one should look for a simple explanation, not for rare and unusual diagnoses to explain common problems. In this case, the hoof beats correlated to the abdominal pain and vomiting. Had they been the hoof beats of a horse, the problem would have been abdominal, such as gastroenteritis or appendicitis. Instead, I encountered a zebra, and the hoof beats indicated heart attack and possibly death. So I would extend the adage to say: If you see stripes, check for zebras. Knowing when to do so is an aspect of the art of medicine. 

In addition, there is the element of my “gut feeling” that per- haps this young man not only experienced acute pain but also faced great risk. e gut feeling is the result of a combination of training, experience, and intuition. I used my knowledge as well as my “instinct” to make this critical decision. 

In my opinion, intuition stems from the ability to apply the lessons of past experiences. It pertains to having a vague feeling or knowing that comes from the subconscious. When that knowing becomes conscious, then it is a skill. e art of medicine is being able to tap into the intuitive information and make it conscious. Because I paid attention to my patients, listening and observing closely, I learned both consciously and subconsciously to be aware of red ags, of things that look suspicious. 

Today, as a mind-body physician, were I to have a case similar to Jacob’s, I would use many of the same interventions, but I also would employ some of the integrative modalities I practice, to help decrease the inflammatory response by summoning Jacob’s innate powers of healing. Natural healing processes exist within the body and mind of each person, though sometimes contemporary medicine and interventions interfere with them. 

Finally, I would put such a patient on an anti-inflammatory diet (see Appendix A). I believe this could be the difference between life and death. You will learn more about this critical component of health as you read on. 

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