The kids were asleep, and I could hear a muted, distant moaning coming from our bedroom. It reminded me of labor pains, but there were three things making labor unlikely: my wife’s IUD, the absence of a gravid abdomen and the kind of unintentional celibacy that occurs between working parents raising two toddlers. I tried to ignore the moaning. In part, because it was a Sunday night, and the sound was disrupting the golden hour (the 60 minutes between the kid’s bedtime and my own), and because I could immediately recognize this was something potentially very bad. If I didn’t acknowledge it, perhaps, it wouldn’t become real. It soon became obvious that this was something I was going to have to attend to. I walked into our bedroom and found my wife supine on the bed, knees to chest, rocking back and forth, wincing in an unsightly grimace. Bad indeed.
I began to take the history. My wife presented this information in a non-linear fashion, complete with contradictions and vague or tangential responses to my pointed questions. Why should this be any different than work? My wife and I are both stubborn and often in some state of emotional burnout. Tonight is no exception. An uncomfortable, terse exchange takes place, but I obtain the salient points. Satisfied with the history, I cleverly distract her with other conversation as I press on her abdomen. It was benign. I suspected a pelvic cause. I texted some colleagues. One suggested a kidney stone. My wife insisted it was gas pains. I had started texting to see who might come over to stay with our children while we go to the ER but my wife was refusing a trip to the hospital. Her pain eventually calmed down with Gas-X and time. She was able to fall asleep, and by morning it was gone. Another humbling experience. I was wrong. The patient was right all along. Gas pains.
Forty-eight hours later, during that same golden hour, I heard the moaning again. This time it was clearly more severe. I had witnessed my wife giving birth to our two boys without any anesthesia and had become desensitized to seeing her in fantastic pain. But this was somehow worse. This time I didn’t suggest the ER but rather insisted on it. The drive was a familiar one, the same route we took to the hospital when she was in labor. Stately homes on pristinely manicured lots, a tree-lined winding path down the shore of Lake Michigan. My wife at my side, screaming in agony. I had previously spent eight years working in an ER myself. As I drove, I thought about how to make the visit as painless and efficient as possible. I thought about what it could be and kept landing on a pelvic cause. I told my wife it was probably ovarian torsion.
Ovarian torsion occurs when an ovary twists on itself causing the blood supply to become kinked off. It is a rare event, occurring in roughly 10 per 100,000 women of reproductive age like my wife. It is a true gynecological emergency, so everyone learns about it in school. But common things happen commonly and because torsion is rare some won’t think of it right away. I had seen hundreds of women with pelvic pain and ordered hundreds of pelvic ultrasounds. I’d seen a handful of ectopic pregnancies, but I’d never once diagnosed an ovarian torsion.
Torsion was not on the top of the ER doctor’s list. I contend this was due in large part to clinical inertia. My wife was started down the kidney stone pathway from the moment we walked in the door, and there was to be no deviation from that algorithm. After three rounds of pain medication, my wife was still in pain. Close to an hour elapsed. The ER physician finally poked her head in — seemingly solely out of curiosity. Who was the creature in room 8 that was responsible for these persistent screams? The physician poked her head in quite literally. The talking head that appeared in the doorway began to inform my wife and me that she would return in another minute or so. When she actually laid eyes on my wife for the first time, something compelled her to enter the room.
A young, tall, pretty woman who had a calm demeanor and never introduced herself, she asked a few questions and told us she had ordered a CT scan to look for a kidney stone. There was to be no pelvic exam or physical exam of any kind. At this point, I was starting to succumb to the inertia. The ER nurses and physician all thought kidney stone. My colleague has suggested kidney stone days before. The pain did resolve on Sunday only to return two days later. Intermittent and colicky — perhaps they were right. At the very least, the CT scan could rule out horrible things like blood or free air in the abdomen.
I waited patiently but knew how long a non-contrast CT scan should take, and this was taking too long. It was after 3 a.m., and I had to go relieve our sitter. I walked out to where the doctor was seated and asked what the CT showed. I told her that I was a PA. She mentioned there was no evidence of a kidney stone. We looked at the images together, and there was a large adnexal (pelvic) fluid collection. The radiologist suggested a pelvic ultrasound which eventually confirmed an ovarian torsion.
A pelvic cause — I was right all along! Most unfortunate for my wife but for me some consolation in being vindicated. How did I know? I’d like to believe it’s my astute clinical acumen. My intimate knowledge of the patient and the fact that I actually performed a physical exam probably helped. But I was also in possession of a unique cognitive bias. I had personally experienced a testicular torsion as an adolescent. My torsion had presented in an atypical manner, and the diagnosis was delayed by several hours. Because of my own experience I possess a false sense of probability. I think everything could be a torsion.
My wife and I met on eHarmony. Data was entered, and we were matched based on some algorithm that uses the data to predict compatibility. Could it be that the computer is matching individuals in other ways we don’t yet understand?
Ronald Zacker is a physician assistant.
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