By Manoj Jain for The Washington Post
Two weeks after my wife has a hysterectomy, she begins experiencing fevers that rise and spike each evening: 99.2, then 100.7, then 101.5. I am an infectious-disease doctor and a consultant for Medicare. And I am puzzled and a bit frightened.
“What do we do?” asks my wife — also a physician. She is lying on the sofa, covered with a blanket, color drained from her face, a drop of sweat rolling down her neck. It is Friday night. “Do we call the surgeon, go to the emergency room or wait until Monday?” Shouldn’t I know what to do?
We would have waited except for the fact that my wife’s case was complicated. A few hours after her surgery, she had massive internal bleeding, requiring the transfusion of two bags of blood and a CT scan that showed a large hematoma, a swelling formed from the bleeding, where the uterus had been removed. “One of the blood vessels must have started leaking just after surgery,” the surgeon had speculated. Luckily the vessel clotted off on its own and my wife came home a few days after the surgery.
“But fevers now means that the hematoma may have become infected,” I say, having seen many such cases in my practice. “We need to go to the ER.”
“Other than the fever I am feeling fine,” my wife insists. We speak in medical parlance, watched by a silent audience of our teenage children and elderly parents, who had come to Memphis to help. I win the argument. At the emergency room, a CT scan shows a “resolving hematoma.” But “we cannot rule out abscess,” the radiologist says in the cavernous X-ray reading room as I stand over his shoulder, waiting to hear his opinion.
My wife’s surgeon, sorry about the complication, arrives a bit before midnight, having been called by the ER staff. As my wife lies on a gurney, the three of us discuss the options.
Ordinarily, the standard approach would be for an interventional radiologist to stick a needle in my wife’s belly the next morning in case an infection had developed and a pocket of pus needed to be drained. Orchestrating all that would be difficult on a weekend, the surgeon admits.
But, my wife insists after the Tylenol helps her fever wane, “you are not putting a needle in me — unless I am on my deathbed. Just wait and see.”
Wait-and-see is a luxury today for doctors and patients, especially patients who are admitted to the hospital. Typically on the day of admission to a hospital, a discharge date is projected, based on the patient’s diagnosis. As a consultant, I help hospitals reduce lengths of stay: Each day of inpatient stay costs the average hospital $2,157.
In my wife’s case, reducing the length of stay is a powerful incentive to put a needle in, make a diagnosis and send her home with intravenous antibiotics. This also gives us more information, removing the cloud of uncertainty that makes patients and doctors anxious.
Yet a needle in the belly sometimes leads to complications. You can perforate the bowel or introduce an infection. Waiting and watching a patient who is not becoming worse may often be the best option, although the wait can be agonizing.
My wife has been admitted, and I sleep on the couch next to her bed. I review each drip the nurse hangs on the IV pole. In the morning, I anxiously assess each lab result even before the doctor or the nurses see them. In our 25 years of marriage, this is the first time she has been hospitalized other than to deliver our three children.
Over the weekend, I consult with my colleagues and with doctors in the family, speaking to them privately in person or on my cellphone, trying not to alarm my wife. In all, 14 doctors of specialties including radiology, infectious disease, gynecology and hematology weigh in. Yet no consensus is reached.
As Sunday night approaches, my wife is still having lingering fevers. “Do we wait and watch for another day, or do we do the drainage Monday morning?” I ask the surgeon. Fevers have many causes. The surgeon and I know this well. What if it’s an abscess with a resistant staph infection? What if it’s a septic vein thrombus, rare but dangerous because a blood clot in the pelvic vein can travel to the lungs? (During my training, I unsuccessfully tried to revive a young woman with a blood clot in the lung which traveled up from a pelvic vein.)
The surgeon gingerly asks, “Are you willing to try a day of low-dose blood thinners?” Giving such a drug to a patient who has already bled two pints of blood is frightening, because additional bleeding would require an emergency operation to clamp the bleeding vessel.
Not knowing if we have chosen the right path of care, which is often the case in medicine, and fearful that a mistake might spiral into irreversible complications, we opt for the blood thinner.
In the morning, my wife’s red blood count holds steady, signaling no further bleeding. The fever does not rise above 100 degrees, a relieving change from the previous days. My wife wants to eat; she sits on a chair by the window; she asks the children if they have done their homework. We add a few more days to her hospital stay and then we go home without having a needle placed in her belly.
Was it the blood thinner or just time that healed her? We will never know.
The human body has its own healing timeline, one that often collides with our urgency and our high expectations of the health-care system and its government and insurance regulations. We have developed the notion that if we do not get antibiotics for every ear infection, an MRI for every back pain or surgery for every knee pain, we will never recover. As we add new technology and treatment options, we forget to ingrain these systems with time for our bodies’ innate power of healing to work.
Doing nothing rather than doing something takes enormous patience. But doing less is often the wisest course.
Back at home, in the living room with our children and parents, my wife and I reflect on our decision-making process. We had been very concerned, of course, but it could have been much worse. What if the stakes had been even higher?
My wife asks, “How do other people handle this?”
I shake my head. “I have no idea.”
Navigating the uncertainties of our health-care system and an unpredictable illness, even for two experienced health professionals, is not easy. Jain is a physician and writer. This article was lifted from The Washington Post.
