The Whimsy Of Serendipity

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Years ago, a longtime patient of mine came to see me with an odd complaint: he’d developed spontaneous bruising on the top of his penis.  “I honestly don’t know how this could have happened,” he said. “I certainly didn’t bang it on anything,” he added with a nervous chuckle.

He went on to tell me that the previous week he’d been on a bus when he’d been struck with a sudden pain in his left hip so excruciating they had to stop the bus and cart him off in an ambulance to a nearby emergency room. By the time he’d reached the emergency room, however, the pain had dropped to tolerable levels. The doctors there had examined him, x-rayed his hip (unremarkable, my patient reported), given him some pain relievers, and sent him home with instructions to follow up with an orthopedic surgeon and me. The bruising on his penis, he said, had developed only the day before.

I had him disrobe and examined him. The first thing I noticed was that he not only had a bruise on the top of his penis but also on his left thigh. When I had him lie down on the examination table, he seemed reluctant to lower his left leg, instead keeping it bent slightly at the knee. When I palpated his abdomen he displayed no tenderness, and I couldn’t feel any masses. When I moved his left hip, it proceeded through a full range of motion without causing him pain. That is, until I had him straighten his knee and lay his leg flat on the exam table, at which point he gasped in pain and quickly raised his knee back up.

“Where did that hurt?” I asked, puzzled.

“Right here.” He pointed to the lower quadrant of his abdomen on the left side.

“Sit up,” I told him. I pulled out my stethoscope to listen to his lungs. When I stood behind him to listen, however, I froze.

On the left side of his lower back sat a bruise about the size of my palm. I knew what I was looking at immediately. It’s called a Turner’s sign, named after the physician, Grey Turner, who first described it in 1920 in a patient with retroperitoneal bleeding from hemorrhagic pancreatitis. (The retroperitoneal space is a potential space that lies behind the intestines and houses the pancreas, the kidneys, ureters, bladder, the first part of the small intestine, and the two largest blood vessels in the body, the aorta and inferior vena cava.)

But pancreatitis seemed unlikely in my patient. He denied upper abdominal pain, nausea or vomiting, all symptoms you’d expect to see with pancreatitis. And given that the pain from pancreatitis is typically felt in the upper abdomen, why, I wondered, would laying his left leg flat cause him to experience pain in the lower abdomen? I didn’t know. One thing, however, was clear: he was bleeding internally somewhere. So I sent him down for an emergency abdominal/pelvic CT scan.

Thirty minutes later, a radiologist paged me. “Your patient has about a liter of blood in his retroperitoneal space,” he told me. That explained the Turner’s sign, as well as the bruising on his penis and thigh. Gravity had simply pulled the blood down from above through tissue planes to rest on dependent structures. But what had been its source?

“How does his pancreas look?” I asked.

“Fine. But he’s got a ruptured left iliac aneurysm.”

I was stunned. The iliac arteries are the two main arteries that branch off from the aorta in the mid-abdomen to supply blood to each of the legs. They’re major-sized and, like the aorta, are susceptible to enlargement (i.e., aneurysmal dilation). If they enlarge enough, their walls become weak and they can rupture. But also like the aorta, when they do, it’s a catastrophe: patients typically bleed out and die within minutes.

Based on the history my patient had given me, however, I thought the greatest likelihood was that his aneurysm had ruptured a full week ago, while he’d been riding the bus. How had he survived?

Apparently, the rupture had occurred in a tissue plane that brought it adjacent to his psoas muscle, the “marching muscle” that enables us to lift our leg directly skyward, like a soldier marching in formation. The psoas muscle sits directly on top of the iliac artery.  Somehow, my patient’s psoas muscle had acted like a pressure bandage on his iliac artery, significantly reducing the outflow of blood at the rupture enough to prevent him from immediately bleeding to death. What should have been a geyser of blood had been transformed into a mere trickle.

A trickle slow enough for him to survive to not only make it to my clinic but to develop the one sign—skin bruising—that enabled me to make the correct diagnosis quickly enough to save his life.

I had a team of vascular surgeons rush to radiology, where they met my patient, looked at his scan, and took him immediately to the operating room. There they drained 1.5 liters of blood from his retroperitoneal space and repaired a large rupture in his left iliac artery.

In retrospect, his inability to straighten out his left leg without pain had been an important clue. In the medical literature a “psoas sign” is found on the right side: when extending the right leg, the psoas muscle is stretched tightly over an inflamed appendix and causes pain. In my patient’s case, however, his inability to straighten his left leg amounted to a left psoas sign, indicating not an inflamed appendix, but an inflamed arterial wall.

That my patient survived represents the most unlikely sequence of events I’ve ever witnessed in my entire medical career, a sequence of events that I found frankly chilling. For they reminded me of an uncomfortable fact that most of the time my colleagues and I pretend isn’t true: despite the vast body of knowledge and experience we’ve accumulated in medicine, sometimes the reason we succeed in identifying life-threatening diseases in time is because of one small, critical detail that we happen to catch purely as a matter of luck. Had my patient come to see me even one day earlier—without any bruising—I most likely would have missed the diagnosis, and he would have died.

Medicine, unfortunately, is full of stories like this. In the current era of technological wonder, our minds reject the notion that serendipity might be involved in medical outcomes, but the truth is that no matter how advanced our science becomes, serendipity will always play a role. Certainly, in a direct primary care practice where physicians have far more time to ask pertinent questions and think about what they’re seeing, serendipity will play less of a role. But I’ve seen nearly as many medical problems delayed or even missed as a result of a string of what appeared to be good decisions at the time that nonetheless happened to be wrong (and circumstances that happened to conceal that fact until later) as I have problems caught early and cured.

So though I celebrated my patient’s survival, the path he traveled to it disturbed me. We can do everything right with the information we’re given and still fail to find and fix problems that are findable and fixable. We are, all of us, to a certain degree at the mercy of forces beyond our conscious control.

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