Medical Mysteries

I’ve always known that there is more to Medicine than Agape, more than a wish to provide succour, more than a desire -a need– to help, to solve, to heal. It provides, for example, an opportunity to learn about others, extend one’s boundaries, explore and experience the Theory of Mind, not to mention the wisdom that accrues to practicing Biology.

But for me, one of the side benefits -and the one that keeps me coming back to the office each day- is the mystery of it all: the Sherlock-Holmesean challenge that confronts me, teases me, each time a new patient walks into the waiting room, or appears as if by fortuitous accident in the Emergency Department needing consultation. I don’t mean to make light of the problem expressed, nor diminish in any way the need for its resolution, but at the same time, it doesn’t always have to take on the sombre hues that surround it. This is not to impute Schadenfreude -although I love the word; it is merely to enjoy the hunt.

One of the joys of a Teaching Hospital is, well, teaching, and I think that one of the few things that I, as an older obstetrician can transmit that isn’t immediately dismissed as quaint by my Residents, is the sheer pleasure of solving ‘Situations’ as if they were puzzles. I’m always up for a Gordian Knot. I like mystery novels, and when I am actually able to follow what’s going on, constantly attempt an early solution. To the credit of the author, however, I rarely succeed and am forced to read to the end of the book for what always ends up as a surprise. Sneaking to the last pages doesn’t even work for me, because… uhmm, I don’t understand the ending without the clues. I suspect that it’s primarily for people like me that these kinds of books are able to stay alive and relevant.

But with Medicine and Medical Mysteries, I like to think I have a certain advantage however -a flair, if you will. On a good day and after a cup of coffee, I can sometimes make a diagnosis after only a few cleverly worded questions, and usually consider myself almost akin to a medical student if I don’t know what’s going on until I have the lab tests back. Back when I was one, we were told to answer any question in an oral examination with the preliminary disclaimer phrase: Well, after a complete history, a thorough physical examination and the intelligent use of laboratory and ancillary aids, I would… They didn’t like the idea of Mystery in those days, or at least didn’t want to let slip the notion that one might exist: patient confidence and so on… They still had a lot of unknowns then as I recall, though. But at any rate, as a result, I had to learn the art of reading the more subtle clues pretty much on my own.

As you might have guessed already, I like to present cases as mysteries to my Residents… on-going mysteries that require clue-gathering and inductive reasoning… or is it deductive? -I can never remember. Anyway -case in point- there was a ‘situation’ that lent itself to this approach the other night when I was on call in the Delivery Suite. We were called to the room of a woman who my resident and I had been following in labour. Things had been proceeding normally until the nurse noticed that the baby’s heart rate on the monitor began having episodes where it would drop to an eye-and-ear-catching level and then recover again as if it were all a mistake.

By the time we arrived, things had reverted again almost to normal; there were still some heart rate changes, but less severe, less worrisome. On further examination we determined that she was almost ready to commence pushing to deliver the baby. So, confronted with a more reassuring pattern and having access to the previous heart rate deceleration pattern on the seemingly infinite paper strip that disgorges itself from the monitor, we retired to the corridor outside the room to discuss it. I proceeded to probe the Resident’s grasp of the clues to which we were privy.

“So, what do you think Sheena?” I thought it was a clever way of asking her opinion without actually putting her on the spot for a diagnosis.

She looked at the heart rate tracing and then at the floor for a moment as she ran the possibilities through her mind. “Well…” she started somewhat tenuously, “The heart rate decelerations all seemed to occur with contractions and then recovered when the contractions finished…” She looked at me to see if she was on the right track.

I grabbed the tracing from her with what I hoped was a delicate move. Actually, I hadn’t noticed the relationship at first because the contraction pattern had been pretty well destroyed by the nurse moving her from side to side on the bed before we came. But when I thought about it, of course it made sense. “Very good, Sheena,” I said, nodding my head in agreement. “And what would that mean?”

“That the umbilical cord was being compressed by something -the head, I suppose- during a contraction.”

“Compressed against..?”

She stared at me trying to guess what I was after, but she remained silent.

“Compressed between the head and the pelvic bones, Sheena…” Gotta get them to follow the clues wherever they lead, so I didn’t feel bad for pointing the direction at this stage. She was young and inexperienced; she’d learn to follow them.

But she seemed to be enjoying solving the mystery so I smiled wisely and continued. “Anything else it could be?”

She looked puzzled, but just for a moment. “Well, the contractions are really close together now… So maybe there could be a separation of the placenta and the baby’s not getting enough oxygen…”

I tried not to roll my eyes. “See any blood? A placental abruption would likely show up with some visible bleeding from the vagina.” She shook her head. “And if there were something like that going on, why wouldn’t the baby’s heart rate just stay down and not recover like it did?”

She shrugged and looked at the floor again. “Anything else you think it might be, Sheena?” I didn’t want to push her too hard and discourage her from enjoying the game.

“Well, sometimes head compression itself leads to a heart rate deceleration with contractions.”

“So, is that what you diagnose then?”

After considering the problem for a moment, she shook her head. “No, I think it is related to the umbilical cord…”

I blinked slowly -for emphasis, I think- and opened the door to the room for her. “Of course it’s head compression on the cord,” I said with a smile. “Couldn’t be anything else when you see that particular pattern!” I tried not to sound too cocky and followed her into the room. The patterns on the monitor had become normal again and we could see the head appearing at the perineum as she pushed. “Heart rate patterns are like clues in a mystery novel; you have to solve them in context,” I said to the Resident and then turned to the patient as we put on our gloves and got the instruments ready for her imminent delivery. “We were just discussing how to read the clues that the monitor tracing gives us about what is actually going on in a labour.”

The patient looked concerned, despite the current normality of the fetal heart tracing and the reassuring metronome-like cadence of the heart beat that the machine produced. “We’re pretty confident that the cause for those heart rate changes was temporary compression of the baby’s cord by its head against the pelvic bones as it comes through the birth canal. Quite common actually; doesn’t seem to have any long-lasting effects on the baby either.” She still looked doubtful, so I added, “Just listen to how regular the heart beat is now…”

I turned to Sheena. “Learn to read the clues, Sheena,” I said softly, and the heart beat descended again as the patient gave a mighty push and delivered the head. “It’s satisfying to be able to reassure the patient about the cause with confidence, don’t you think?”I added in a whisper.

Sheena delivered the now vigorous and crying baby and put it on the mother’s chest as I busied myself with getting some instruments for her to clamp the cord. I couldn’t find the scissors and was hunting around for them with my back turned when I felt a little nudge from her elbow. “Ahh, doctor…” she said with an interesting tone in her voice.

“Yes Sheena?” I said as I continued my hunt for the evasive scissors.

“I’m not sure about those clues, actually…”

“Here, I found them,” I said as I handed the scissors to her, now searching for some more clamps to get the umbilical cord blood gases. “Clues are clues, Sheena,” I continued confidently, and turned triumphantly with the extra clamps in my hand. “You just have to learn how to read them…”

“I guess, but sometimes maybe we read ’em incorrectly…”

“Mmmh?” I mumbled, still living the victory of instrument discovery.

“Look at the baby’s umbilical cord,” she said, glancing at my eyes above my mask. “There, just a couple of centimeters from where it enters the baby’s umbilicus…”

I glanced at the baby and then the cord, wondering why she was questioning the way I had interpreted the clues; they were obvious. Even a medical student could have done it. But there, in the cord, not three centimeters away from the skin of the baby was a knot: a true knot in the cord itself. Any stretching of the cord would tighten the knot and decrease blood flow through it -would cause the baby’s heart rate to fall…

I looked back at the Resident, now grinning behind her mask, and blinked slowly. Confidently. Undeterred. You can’t always solve a mystery beforehand, you know. It’s why we read the books, after all.

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