Train Wrecks
by Mike Litrel, M.D.

It doesn't take a genius to discern a medical problem when someone is unconscious or bleeding. But in a surprising number of cases, patients with numerous complaints are actually not ill at all, and some patients who feel just fine do, in fact, have life-threatening medical conditions.

The physical exam is the physician's first tool, the gathering of vital signs its first step. Heart rate, respiratory rate, blood pressure and temperature: they are called vital signs because they measure functions vital to life.

But every clinician eventually comes to understand that another diagnostic tool exists, not taught in any medical school. You can tell if someone is sick just by looking at their face. This was the case with a new patient who recently came to my office. Her face spoke volumes. She had the same terror in her eyes as the man I knew hit by the train. Her vital signs were stable, but it was obvious even before the exam that she was dying from something.

Her explanation for her visit was confusing, and she trembled with anxiety and sobbed intermittently. Eventually, the details fell into order. She had visited the emergency room a year before, after a sudden onset of pelvic pain. A ruptured ovarian cyst was found to be the cause. Other cysts on her ovaries had appeared on the ultrasound exam. But she had not seen a doctor since. And the pain was getting steadily worse.

In her heart, she confessed, she knew she was dying. Her mother had died from cancer a decade earlier. And she was terrified of the suffering that was to take over her life.

Cancer was my first concern, of course. But the physical exam turned up nothing suspicious. Furthermore, despite her complaints of severe pain, she showed no tenderness in any specific area. To confirm that everything was normal, and to put my patient's mind at ease, I repeated the pelvic ultrasound test. There was no evidence of cancer, and the cysts on her ovary had completely resolved and disappeared.

Profound relief washed over her face. She broke down and was unable to speak. I left the exam room to give her some privacy to sob and absorb her new prognosis. Fifteen minutes later a different person emerged. Terror and Death had vanished from her eyes, and in their place shone Life and Hope. She thanked me over and over. I felt awkward. It was a remarkable transformation, but I had done nothing.

We spoke a while longer. I strongly wanted to convey something to her that I felt it was crucial for her to understand. "It's better for your body to die, than for you to be paralyzed just by the fear of dying," I said. "You need to know that your soul is immortal - just like mine, just like everyone else's." But my words felt weak, and her perplexed expression confirmed that my explanation had missed its target.

As I struggle to become a more skilled healer and to understand the elusive pathway to health, this patient occupies my thoughts. Medical science offers no comment about God, or the immortality of the soul. Its advances have enabled doctors to perform amazing surgeries and prescribe seemingly miraculous drugs. But as we increasingly rely on science to prolong our lives and make them more comfortable, the absence of spiritual commentary is a vacuum that is slowly eroding our faith.

Science tells us only that we are biological organisms, our life on earth a tumultuous ride with a finite end. Along the way we encounter pain, illness, the death of ones we love, and in the end - our own death.

The vital sign that science ignores is Faith. It is a spiritual vital sign, essential for good health. The healthiest people I care for are those with strong faith in God, and in their purpose for being alive. The vernacular and traditions of their different religious traditions are not as important as the one factor: the insurmountable presence of their Faith.

At the end of the ride, they see past the wreckage of their mortal bodies - into the eternal journey of the soul.

Dr. Litrel is in practice at Cherokee Women's Health Specialists in Woodstock and Canton, and is a Clinical Assistant Professor at Emory University School of Medicine. He lives in Towne Lake with his wife Ann and their two sons Tyler and Joseph. (mikelitrel@attbi.com)

"Train wreck" is an expression used by Grady Hospital staff for a patient who is in notably bad shape. When I was a resident training at this Atlanta city hospital, the phrase "I have a real train wreck for you" coming from a superior was enough to turn my stomach. Taking care of a train wreck inevitably involved lots of decisions and very little sleep - not to mention a patient with a chance of dying on my watch.

Of all the train wrecks I cared for in those years of training, one was a man who was, indeed, hit by a train. He had passed out on the tracks, and apparently awakened just as the train came upon him. He didn't make it off the rails in time.

Remarkably, he was still conscious when he arrived at the Grady Emergency Room "red zone." The trauma team raced to stabilize him for surgery. His body was mangled, but - as was not uncommon at Grady - he still had the strength to fend off the medical team. The third year resident made repeated attempts to calm him: "Chief, you're gonna be okay - just lay down Chief - you're gonna be okay."

I was directed to the remains of the patient's foot. As a green medical student, I wasn't sure how to proceed with the bloody collection of bone and tissue, but it was obvious that everyone else was too busy to provide me with any instruction. So I jumped in with a voluminous quantity of bandaging and substituted any specific medical knowledge with good intentions and several minutes of vigorous wrapping. When I was done, the bleeding had stopped, and the foot, camouflaged like the appendage of some long-gone Pharoah, once again resembled a foot. I felt a surge of pride. I fixed his foot.

One minute later the man was dead. He was still fighting off my boss when his eyes widened suddenly in uncomprehending terror. An inarticulate noise issued from his throat, and he collapsed in an unanimated heap.

It was the first death I had ever witnessed - and one of the most dramatic. As I was to learn, however, most train wrecks are not so obvious.

Another I helped care for later that third year in medical school was an elderly man. He had underlying heart disease and diabetes, and a gall bladder that had just been removed on an emergency basis. I accompanied my Chief Resident to see the man after the nurses called us one afternoon. The Chief asked me how I thought the man looked.

The patient seemed a bit anxious, perhaps, but all in all, he looked fine to me, I answered. My Chief rolled his eyes and instructed me to count his breathing rate. It was more than one breath a second - three times faster than normal. In fact, he enlightened me further, the patient was in severe distress, and needed to be placed on a ventilator before he stopped breathing altogether.

I had the sudden recognition that I was stupid and inadequate: my first good assessment. Thus I learned that the first skill to develop as a medical student had nothing to do with treating patients or dressing wounds. It boiled down to figuring out if a patient was sick or not - and it wasn't as easy as it sounded. Fortuitously, my internship year consisted of seemingly endless months of assessing thousands of patients. And with each one, the question was the same: Is the patient sick or not?