#47 The Still Small Voice Versus the Gut

One of my favorite attendings in residency used to always ask, ‘Well, what does your gut tell you?’

Tonight, the still small voice won out.

I admitted a boy last night with a distended abdomen, a fever of 40.4 (105 F), vomiting and no poop for two days. He didn’t seem peritoneal. His typhoid test was negative, as was his urine test. We couldn’t test his poop because he wasn’t pooping. I didn’t bother testing him for malaria. I just put him on fluids, quinine, metronidazole and ceftriaxone. And I told the parents not to let him eat.

This morning, his fever was down to 38 (100.4 F), but he was still distended. I put my finger in his bum, but couldn’t find any poop there to pull out. We stuck to the plan.

This afternoon, he wasn’t really much better. So we put in a nasogastric tube.

This evening, the nurse came to me and said that he wasn’t much better and the father wanted to go home and had already signed the Against Medical Advice form. I talked to Danae about it, and we felt strongly that the kid should stay. Lyol had just fallen asleep, and we felt strongly enough about it to leave Lyol in bed and go together to see the kid.

We explained at length that if the boy went home, he’d probably die. We explained that surgery was risky. We explained that even in the states, we try to treat obstructions medically, without surgery.

The father finally agreed to stay and continue NPO, IV fluids, antibiotics, NG tube and observation.

A still small voice spoke to Danae. Danae asked me to go home and get the keys so we could do an ultrasound.

The ultrasound just showed a lot of gas in the belly, which is pretty much what we expected. We were prepared to stick to our decision of medical therapy.

But even after the ultrasound, the still small voice was still speaking to Danae. ‘You know, I don’t know what’s going on, but we need to operate.’

I explained our sudden change of direction to the father, ‘Er... well... this still small voice thing is right 100% of the time, so I really think we should operate.’

We took the boy to the OR.

As soon as Danae cut into the peritoneum, pus started gushing from this small boy’s abdomen. A liter of it was sucked up, but even more spilled around and onto the ground. The smell of pus and poop hung in the air. Inside the abdomen, everything was stuck together and a thick layer of pus and poop was stuck to every foot of intestine.

Danae skillfully and patiently picked her way around the abdomen while offering her scrub assistant $10 if he could find the hole before her. Doing what she had never been trained to do, she was led by the still small voice to the hole. She closed it, something she had never done in residency.

The boy is still alive. We don’t know what the final outcome will be. But the guidance of the still small voice keeps us up at night when we don’t listen to it. Right now, it says that it’s 1AM and time to sleep.