Pregnant with hematemesis

The attending physician handed me a slim chart.  “This is the one from the emergency department—pregnant, with hematemesis. What next?” He challenged me. “EGD?”* I responded. On several recent occasions I had assisted him with that very procedure, watching closely as he passed the endoscope deep into the stomach with a few flicks of the wrist. Bleeding was found or reflux noted—straightforward problems with simple solutions. “Go see what the story is,” he said. The whole procedure was already finished in our minds.

The patient glanced up as I entered the room. Her tight shirt revealed a 25-week pregnant belly. She began hurriedly, without preamble. “I was in a car accident a week ago,” she said. “We ended up in a ditch when I swerved to avoid a deer. The car flipped completely over. My kids were in the back seat.” She looked up at me, expecting a reply. A small child with soft eyelashes slept silently in a bassinet by my feet. “How awful,” I managed.

“I had this pain right after the accident. Right here,” she said, pressing the middle of her chest with both hands, thin elbows outstretched. “It hasn’t gone away. I’ve been to two emergency rooms in the last week, and they won’t do anything. This morning, I gagged up the blood clot. I can’t live with this pain,” she choked out, hands still pressing the center of her chest. “I just broke up with my abusive husband. I got hooked on pain pills after he threw me down the stairs. I just started methadone treatment last week. I’m trying to get clean.” The tears had run to her chin, making stark, black eyeliner tracks.

“We’ll find out what the problem is,” I said with the certainty of someone who could fix things with the flick of a wrist.

Not that easy

Later that day, in pre-op, black tears again streaked her face. “They can’t even stick me the right way,” she said, gesturing at her outstretched arm. “You don’t know what you are doing. I’m not staying here if you people won’t even listen to me. I’m in pain!” she cried accusingly to the room at large.

The anesthesiologist turned as we left the room, the patient already getting off the gurney. “She started to back out when I told her that she wouldn’t get any Dilaudid. She already had her methadone this morning.” Was this all about narcotics? I thought to myself as her pregnant form moved purposefully down the hall toward the exit.

“What happened with that crying girl?” one of the nurses asked me.

“Canceled.” I said quietly as I waited in the lounge. I felt empty. This patient had a problem not so simply solved, and likely not in my power to fix. I thought also of the movement of the heart, as it beats against the wall of the stomach, viewed through a small snake-like camera as it is deftly passed with a few flicks of the wrist.


Bulletin of the American College of Surgeons
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