(groaning)
- This is making me crazy.
Listen to your patient and your gut.
Her gut is telling her something is wrong.
Her patient is telling her something is wrong.
Today we are reacting to a brand new show
that you have already recommended
as having some excellent obstetrics or gynecology content.
Season one episode two of "Transplant."
I saw Dr. Mike do a reaction to the first episode recently
and it actually had some interesting
obstetric information as well.
A case of peripartum cardiomyopathy,
which is extremely rare.
This video is also sponsored by Function of Beauty,
and we'll hear more about them in a minute.
(mellow music)
(sirens wailing)
- [Dr. Curtis] So how long have you had this pain?
- Two days, but it's getting worse every hour.
- Any other symptoms I should know about, fever?
Vomiting?
- Does dry heaving count?
- Have you experienced these symptoms before, Ms. Bennett?
- Cassie.
I have endometriosis, but this is way worse than normal.
- Right out the gate
I have a little bit of a problem with this.
This person is doing a pelvic exam
while getting information from the patient.
This is not the way this should happen.
You should be getting information from the patient
about how long they've had their symptoms,
what's going on, their history, all of that
before you're doing a very intimate exam.
- Have you spoken to your OB-GYN about these new symptoms?
- Yes, I have.
And they can't see me until next week,
but the last time I saw her
she just told me to get pregnant.
At least then I'd have nine months of relief.
- Right, well, I've heard that comes
with its own set of side effects.
- The patient has now told her
that she has significant pain that is new and different
than her typical endometriosis pain.
And also indicated that she has a real terrible gynecologist
who suggested she get pregnant
instead of treating the endometriosis.
Endometriosis is a pelvic disorder
which can be really significant,
can cause very significant pain,
but can also just be completely pain-free
and present as infertility.
It's something that is sometimes difficult to diagnose.
Technically to diagnose endometriosis,
you have to do surgery and get a biopsy.
Sometimes we will diagnose endometriosis preemptively
based on symptoms of severe pelvic pain
and try to avoid doing surgery.
But to have a true diagnosis of endometriosis,
it requires a surgical biopsy.
That is unfortunate, because it is one of the reasons
that endometriosis goes undiagnosed
for so long in many people.
- The adhesions for endometriosis can cause severe pain.
Unfortunately, it's a chronic issue,
and there's really not too much we can do for a flare up
here in the emergency department
.
- I know, I know, look,
and I know what you're thinking, okay?
Woman with endo comes in, suffering from a flare up,
is afraid of something worse and it never is.
And there's nothing you can do for her.
Look, I have been through this more times than I can count.
- Different things that I would worry about in this scenario
would be things like an endometrioma,
which is a large cyst on the ovary
that is filled with dark fluid that is kind of a mixture
of inflammatory fluid and old blood.
And that can be extremely painful on its own,
but it can also cause the ovary to twist over on itself
in what is called a torsion.
Now, the doctor here says the adhesions from endometriosis
can be extremely painful.
Adhesions is scar tissue.
She's right, but also not quite right.
So endometriosis actually can be very, very painful,
even in the absence of visual scar tissue and adhesions.
It is a disease that doesn't often correlate well visually.
You can have a patient who, like this, has severe pain,
and when you go in and do surgery and look in their pelvis,
all you see are teeny tiny little dots of endometriosis
along the pelvic lining.
You can also have a patient who just presents
with infertility and go in and do a surgery
to look at their pelvis and you see tons and tons
of adhesions, but they've never complained of pain.
- All right, I've been told to go home
and take pain meds and sleep it off.
And I have done all that.
And I...
(groaning)
- Are you here by yourself?
- Often patients with endometriosis do feel
that they are dismissed,
because they have a chronic pain issue,
and they come in and they are treated
as though you can't have flare ups
that should be looked into and treated.
And that's absolutely not the right attitude
with endometriosis.
If I were this doctor, I would be doing a few things.
One of those things would be getting some blood work,
I would want to do a pelvic exam, take a look,
make sure there was no abnormal discharge
or anything like that.
And I would absolutely, 100% want to be doing
a transvaginal ultrasound to look at the ovaries,
look at the pelvis and make sure
there was nothing acute going on,
meaning something new or different,
even if it's related to the endometriosis
that we can see on ultrasound.
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Now let's get back to the video.
- What's your story, Dr. Curtis, quickly?
- Emergency walk in, I'd like to do a lab
to isolate the cause of her pain.
- Endometriosis.
We both know we don't do elective procedures
for chronic problems.
- Yes but-- - Likely having a flare up.
- I did a transvaginal ultrasound and--
- Nothing's conclusive on that.
- There have been cases where
imaging has missed ovarian torsion, even a ruptured cyst.
Her abdomen's distended, she's in extreme pain,
and I am concerned it could be more than endometriosis.
- She's exactly right.
Ovarian torsions can be missed on ultrasound.
You usually would see at least a cyst,
it would be very unusual to have no findings at all
in someone who needed to have surgery.
So I do agree there.
At very minimum, because my understanding here
is that these are ER doctors,
they should be getting an OB-GYN consult.
- Are you fishing for a OR time?
- No, I want the operative time,
but that doesn't mean my patient is wrong
about the pain being acute.
- Dr. Curtis, endo is tricky.
- This person wouldn't be the one doing the surgery,
so I'm a little bit confused about why he's saying
she's just fishing for OR time.
That would be both unethical
and a unusual thing to accuse an ER resident physician of.
- Women can feel one thing one day
and something of a different the next,
the pathophysiology of uterine nerves.
- They're complex.
- And often don't correspond to what's happening internally.
- He makes some points that are true.
That pain can be really bad one day and not the next.
And like I said, symptoms can feel not very correlative
between how a patient feels
and what their pelvis looks like.
- And every time we go in there,
we run the risk of doing more harm than good.
Surgical intervention is not an option
in the absence of extremely clear evidence
which you simply do not have here.
She should follow up with her OB-GYN,
send them the ultrasound,
otherwise give her Toradol, send her home to rest.
- Wow, I hate him.
She needs a call OB-GYN and have them come down,
see the patient, look the ultrasound,
make a call from there.
And we need a pregnancy test.
- You're sending me home.
- Well, your imaging didn't didn't warrant further action.
I did give you some anti-inflammatories for the pain.
So if it gets any worse--
- What?
Come back?
It's already worse.
- Look, please, please don't be like the rest of them.
- Listen to your patient and your gut!
Her gut is telling her something is wrong.
Her patient is telling her something is wrong.
- You can take your time getting dressed.
(groaning)
- This is making me crazy.
(dramatic music)
- What happened?
- I got two blocks away and threw up.
You told me to come back if it got worse.
They just gave me this bucket and told me to wait here.
I was trying to make it to the bathroom, but I couldn't.
- Come on.
- I feel like they've done a really great job
of accurately representing what some patients,
many patients with endometriosis go through.
And I appreciate that they're talking about it.
I also feel like they're pretty accurately
representing the position a resident physician can be in
when trying to listen to their patient,
and advocate for their patient,
and also balance kind of the hierarchy of medicine.
- I need someone to fight for me.
- Yeah.
Okay.
Okay? - Yeah.
- All right, let's go
- For this patient in particular right now,
what I think she needs is a GYN consult
and what we call a diagnostic laparoscopy,
which is where we make a small,
two or three millimeter incision
just beneath the belly button,
or inside the belly button,
and use a camera to look into the pelvis
and see if anything's going on.
If a patient presents with acute onset abdominal pain,
particularly if there's an ultrasound finding
that looks like it might be cyst,
it is ovarian torsion until something tells me otherwise.
My gut instinct in this situation
is that this is a patient with endometriosis,
what she likely has is an endometrioma
or a large endometriosis cyst
that has caused the ovary to twist on itself,
cutting off the blood supply and causing acute pain
associated with the vomiting that she's describing.
She needs to go to the OR.
- The endometriosis patient I brought you earlier?
- [Doctor] I thought we sent her home.
- We did, and she's back in agony.
She's vomiting, she's hemorrhaging,
which we both do our sides of a ruptured cyst
and not just chronic endo pain.
She needs surgery now.
- Book an OR, stat.
- And I want to stay on to see this patient through.
- It's your call.
If it is ruptured, it's good we caught it when we did.
- A ruptured cyst is also possible.
I wouldn't expect to see, she said she's hemorrhaging.
That's kind of a, I don't know how to phrase this,
a non-specific sign.
Definitely agree that along with ovarian torsion
due to cyst, a ruptured ovarian cyst
causing significant pain or bleeding into the pelvis
can be what this patient has.
So that would be something else
that's really difficult to see on ultrasound.
(dramatic music)
- It was a difficult surgery.
In addition to the extensive scarring
from the endometriosis,
you also had a hemorrhaging ruptured cyst.
- I like that she's going in and talking to her,
but I wish she would sit down at the bedside
and chat with her on like a face-to-face level.
- And as a result of the damage,
we had to remove one of your ovaries.
- I lost an ovary?
- Well, the good news is we got in in time
to save the other one.
- The natural thought process in this is okay,
I lost an ovary, now I have 50% fertility.
It doesn't quite work like that.
Usually what happens is the other ovary
kind of takes over and will ovulate each month.
Most people will still have a cycle each month.
And most people will still ovulate each month.
There is a slight decrease in conception
if you are trying to get pregnant,
but it's not anywhere close to 50%.
I know most people think of the ovaries
as being attached to the fallopian tubes right there.
And when you ovulate,
the egg comes out and into the fallopian tube immediately,
but that's not really how it works.
The ovary is attached to the uterus,
so if you have the uterus here,
there's a ligament that attaches the uterus and the ovary,
and the fallopian tube comes out up here
a little bit separate.
The fallopian tube has what we call fimbriae on the ends.
Those have kind of a chemical attraction
to where the ovaries are sitting when ovulation occurs.
Actually each fallopian tube can often access
the ovary on the other side.
So this is why you don't see a direct correlation
of losing an ovary means 50% less likelihood of conception.
It does decrease a little bit,
you may have fertility issues related to this.
She may have fertility issues related to the endometriosis,
or she may not care about her fertility at all,
and just be frustrated that she's not being listened to.
But in general, that's kind of how we look at
loss of an ovary in relation to fertility.
- You told us that it was more serious all along,
and the system is just not good
at dealing with chronic pain.
- I have a little bit of a problem
with the way this is presenting, because in the timeline,
it didn't seem like that much time went by,
and with the hemorrhaging ovarian cyst,
it's highly unlikely that the difference
in when they went to the OR, being an hour or two,
would be the difference in saving her ovary.
It's not like the hemorrhaging cyst
suddenly becomes harder to get out
when more time has gone by.
If they had said ovarian torsion,
then I would have been on board with that,
because a large cyst that causes the ovary to torse,
The longer that is left, the less blood flow the ovary has,
and the more likely it is to die.
I think this patient should have gone to the OR earlier,
but I think she would have lost her ovary
whether she went three hours ago or when she ended up going.
And also the patient should never be surprised
if she loses an ovary.
That patient should have been counseled from the get-go.
We will do everything in our power to save your ovary,
but if it gets to a point where it is unsafe
to continue operating and trying to remove
a cyst from the ovary that's causing you to bleed
into your pelvis, then we will take the ovary out.
I attribute her surprise to poor counseling
prior to going back.
- You don't know what it's like to be dismissed and ignored,
told what you feel isn't real.
- Cassie, I just wanted you to hear
someone say you were right.
- I don't know, this is unfortunately a very accurate
representation of the despair that people
with severe endometriosis often feel in getting care.
And honestly, with any chronic pain condition,
this is how it goes.
And we have to work on making changes
so that this is improved upon.
- I know I was.
(dramatic music)
- Thanks for being here today.
If you have any questions about endometriosis,
leave them in the pinned comment below.
I would like to do an endometriosis video really soon.
Don't forget to check out our sponsor,
Function of Beauty, and their wonderful haircare products.
Be kind to yourself, to each other, to me,
in the comments be kind, and I will see you next time.