The Other Chief

Journal of Family Practice, March, 2001 by Jon O. Neher

I walk into the emergency department of Dungeness Hospital* in the early hours of the morning, bent over like an old man. I grip the railing on the wall as I shuffle toward the triage desk. "What can we help you with?" asks the woman behind the glass.

"I don't feel well," I tell her. "There's something wrong in my stomach."

The triage nurse looks at my face. Her eyebrows shoot up and do not come down. She calls for help, and they immediately usher me into an examination room. Moving to the head of the line in the emergency department is not a good sign. I worry that someone will be angry with me when they discover that all I have is intestinal cramps.

"Please undress down to your underwear, and put on this gown," the nurse says. "The doctor will be with you shortly."

I do as I am told. Changing is uncomfortable, and I am happy to Finally finish. Gently, I ease myself onto a gurney that floats in a pool of greenish light. I lie very still and begin to feel a little better.

A few minutes later, a woman approximately my age appears at the door and strides confidently into the room. Her sandy shoulder-length hair is unkempt and greasy. She wears wrinkled blue scrubs, and her white coat has iodine stains on the cuffs and tail. Her shoulders sag slightly from fatigue. Red puffy eyes suggest a night without sleep. "Hello, I'm Dr Johnson," she volunteers, offering her hand. "I'm the chief resident of family medicine here at Dungeness." I smile in sudden embarrassment. She does not appear to notice. "You're Jon?"

"Yes," I reply. "You know, this is quite a coincidence."

"What is?" she asks.

"I'm the chief resident of family medicine over at the university," I reply.

"No foolin'?" she says, her voice calm and conversational. "Okay, sure. That's why you look familiar. I think I saw you at the practice fair a few weeks back."

"Could be," I say.

"So, Jon, what brings you in at five in the morning?" she asks.

I let the time reference pass and begin to tell her about me odd way my body has been acting during the past 24 hours. She asks a few general questions. I answer.

"Well, Jon," she says, after finishing with my history, "you're a capable physician. What do you think is going on?"

"I'm pretty sure it's intestinal cramps of some sort, caused by food poisoning or maybe stress," I say. "The chief resident job is pretty stressful, as I'm sure you know." This is what I have been thinking this entire sleepless night, but it sounds a little silly now that I am saying it aloud.

"Come on," she says gently, "you don't really believe that." She sets down her note pad. "Well, let me examine you."

She moves close to me and starts to work. My head, neck, and thorax are briefly checked. Then she zeroes in on my belly. As she leans over me, I notice that she smells like a rough call night--musky and sour from sweat and anxiety. I doubt that I smell any better.

She pushes just above my pubic bone. The pressure creates an unpleasant sensation unlike any I have ever experienced. She removes her hand and the sensation briefly intensifies. The phrase "rebound tenderness" pops into my head, but somehow it does not accurately describe the experience. She straightens up. "I think it's pretty obvious, Jon," she says. "You have appendicitis."

I am not ready to concede that I might have something serious. The sensation does not feel strong or dangerous enough to be appendicitis. It dawns on me that she thinks I need to be cut open. "Is the exam over?" I ask.

She hesitates at my challenge. "Yes, of course," she says.

"You know, the surgeons at the university would have my hide if I called them in on a possible appy and had not done a genital or a rectal exam," I say. I want her to be complete, to please--please!--find a diagnosis that does not require abdominal surgery.

The muscles of her jaw contract, and her mouth briefly contorts, as if I have said something perverse. Suddenly, I wish I could take the words back. But then I see the idea begin to sink in, and her expression fades to one of resignation. "Okay," she says at last. "Whatever you think is necessary." She does not admit it might be a good idea.

She goes to the drawer and gets a pair of gloves. The snapping sound they make as they go on her hands is tinged with anger. She sets her face like a wooden mask as she finishes the examination. "Just as I thought," she concludes, with obvious satisfaction. "Everything is normal."

I feel panic starting to rise in me. "But if I have appendicitis, shouldn't something have been abnormal?" I ask, almost pleading. "Shouldn't the rectal at least be tender?" I desperately want to believe it is only cramps. "Besides, it's suprapubic. McBurnie point is way over here. Isn't it more likely to be a bladder spasm or referred sigmoid?"

"Look," she interjects sternly, "you have appendicitis, and I am going to call the surgeon right now." She walks quickly to the doorway, then pauses a moment and turns. She glares at me with her feet widespread and her arms folded, as if she is trying to block my escape. "And do me a favor when the surgeon gets here," she says with barely contained animosity. "Behave yourself!" She spins abruptly and disappears.