To Save a Life

On Saturday I was volunteering at a student-run free clinic. As an M3, I had an M1 and and M2 under me. They first gather a history and do a preliminary physical exam on each patient before I talk and examine them.

After briefly presenting to me, the M1 and M2 took me to see our first patient. He was a middle-aged guy who had been having nausea for the past 2 months. After talking to the patient for a bit about his history of hepatitis C, I move on to the physical exam. Per my routine, I begin by listening to his heart and lungs. Then I move to his face, eyes, and neck before asking him to lie down for an abdominal exam. I look for every sign of hepatitis and liver disease - jaundice, scleral icterus, spider angioma, etc - none of which he had, which reassured me.

Then I felt something odd. While palpating for his abdominal aorta, I found the edge of it pulse to the right of his bellybutton. I move to the left of his bellybutton and felt the same pulse of his aorta there as well. I move back to the right to double-check. I call out to the M1 and M2 to feel the edges of his abdominal aorta on either side. They confirm that they could feel the pulse on both sides. Eyeing the distance, I ballparked the diameter of his abdominal aorta to be about 4cm. He had an abdominal aortic aneurysm (aka AAA or "triple A").

This was an amazing catch! It's not every day that med students pick up on something so serious, and an AAA is a very serious matter. I ask the patient if he knew what an AAA is, and he said that his father and grandfather both died of AAA's around his age. Coupled with the fact that the patient smoked about 1/2 pack of cigarettes a day, this solidified the diagnosis in my mind. Immediate imaging was warranted to accurately determine the size of his AAA - not knowing its exact size, it might as well be a ticking time bomb inside his abdomen set to rupture at any point inside.

I reassure him that, because he was asymptomatic, he had some time and that we will figure this out. I further counsel him to reduce (and preferably/ideally stop) smoking, as smoking is a huge risk factor for AAA's. Also, smoking cessation can stop an AAA from growing any larger in some cases.

I walk out with the M1 and M2 to find a physician to assess the patient. While they do that, I move on to another pair of M1 and M2 students to see their patient. Later when I touch base again, I was glad to hear that the physician agreed with my assessment and plan. Although a CT scan is the most accurate way to determine the size of an AAA, the clinic didn't have access to "free" CT scans, and so we ordered an MRI for the patient. Really, it's kind of a waste of resources overall because in this case a CT scan is much better and cheaper than an MRI. But, we have to work within the limited resources of the clinic.

Talking to several M3's later, they were impressed that I had caught the AAA. They kept saying how I had, quite literally, saved this man's life. As much as I'd like to believe that, it didn't quite feel like I did. True, I had caught a potentially fatal condition early enough for interventions that would indeed save his life. But the imaging test we had to get for him was expensive and less than optimal, and we had to send him to a nearby hospital to get it done. For all I know, he may never go to the hospital to get the MRI. And even if he did get it, who will follow-up with him? Who will track the size of his AAA? Who will do the surgery when it reaches the dangerous size of 5.5cm? Would he survive long enough to make it to an emergency department if it were to rupture?

There were too many loose ends. This is the limitation of healthcare in the US - this patient is uninsured and we volunteer at a free clinic where continuity of care is fragmented. I may have the knowledge and ability to save this man's life, but he needs regular access to healthcare in order for that to happen. The academic and political discussions about healthcare are no longer abstract. Here is a patient with a life-threatening condition. It need not be so. But he doesn't have access to regular healthcare. Our hands our tied, our resources limited. And so, it remains life-threatening.

I hope he went to get the MRI. I hope it was far less than 5.5cm. I hope he stops smoking. I hope he is able to obtain health insurance. Right now hope is all I have to save a life. But it need not be so.