Case 3: Gallstones and Fixation Error

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[Triage Note: shortness of breath, can’t eat, abdominal pain and bloating in RUQ (right upper quadrant) after eating]

John Grover is a nice guy. He’s fifty-five, short, a little chubby, and he has a neatly trimmed red beard. He’s the kind of guy whose eyes light up the moment you walk into the room; The kind of guy who remembers your kids names, their ages, and their interests. I’d met him a few times before this presentation to the Emergency Room. He’d come in once  to refill his blood pressure medication because he couldn’t get into his family doctor’s office in time. I’d also seen him a week after his heart surgery the previous year. His wound was a little inflamed and he wanted to make sure it wasn’t infected, and that everything was healing alright.

This day, however, he wasn’t his jovial self. He was a little pale – ‘sallow,’ according to my clinical note, a word I’ve used so little, I had to alt-tab over to to refresh my memory (of a sickly yellowish color). He was already shaking his head when I entered the room. “Oh, man.” He put a fist into his upper abdomen. “I sure hope you can figure out what’s wrong with me.”

Sitting on a chair in the corner of the examination room, he looked small and weak. I leaned toward him, put a hand on his shoulder and asked what was troubling him.

“My stomach,” he said. “I can’t eat anything. I can’t eat anything at all. One bite and I feel bloated and sick.”

“How long have you felt like this?” I asked.

“A while.”

“Days or weeks?”

“Weeks,” he said, his lips sour. “Two or three for sure.”

“Have you had it looked at?”

“No,” he said, his eyes apologetic. “I thought it was indigestion – I thought it would go away by now.”

“Where does it hurt?”

He looked toward his stomach and stretched out a finger. He planted it on the right side of his upper abdomen. “Here.” He grimaced. “Right here.”

I questioned him. The pain had been there for a few weeks – worse after eating, occasionally associated with nausea and shortness of breath. There was no vomiting, no diarrhea. His bowels were moving fine. He’d had some fatigue, but was otherwise fine – no fever, no chills.

He’d just recently returned to work as a machinist after a year off. Two years prior, he began to notice progressive shortness of breath on exertion. After weeks of testing, he was found to have severe aortic valve stenosis – a narrowing of the heart’s outflow tract that impairs blood flow into the aorta. His heart began to work harder and harder, causing worsening breathlessness, dizziness, and fatigue. Weeks before surgery to replace the defective valve was scheduled, John went into heart failure. His heart could no longer pump blood effectively beyond the constricted passage. Fluid backed up into his legs, and eventually, into his lungs.

“That’s all fine now,” he said. “It’s my stomach now. I haven’t eaten in days.” He moved slowly to the examining table, lying onto his back and unbuttoning his shirt. He sighed and relaxed, moving a flat palm just below the zipper-like incision that divided his chest. “It’s here. Right here.” I put a stethoscope above his nipple. The mechanical valve clicked like an amplified wristwatch. He noticed my fascination and smiled. “I can hear it when I’m falling asleep sometimes.” His lungs were clear and his bowel sounds normal. There was only a trace of fluid in ankles that were once so badly swollen, he couldn’t even wear shoes.

I pushed just below the right side of his rib cage. He groaned and grabbed my wrist, holding his breath as if he’d been punched in the gut. “Have you ever been told you have gallstones?” I asked. He shook no. “Anyone in your family have gallstones?” No again.

Twenty minutes later, as I waited for his blood results to return, his belly was still sore from the exam. Morphine and Gravol settled him, until he was relaxed again, asking about my weekend plans. The blood work confirmed my suspicion. His white count was mildly elevated indicating infection. His liver enzymes were markedly high, characteristic of a stone blocking the passage of bile from the liver and gallbladder. “I can’t get an ultrasound tonight,” I said, “but I think you need to come in to hospital to see a surgeon.”

The following day, an ultrasound showed no stones. In fact, other than some mild, non-specific thickening of the gallbladder wall, the ultrasound was normal. In reviewing the clinical picture and lab results, the radiologist recommended a HIDA scan – a special test in which a radioactive marker is injected into a vein, then tracked as it flows from the liver, into the gallbladder, and then into the surrounding ducts. By following the radioactive tracer, blockages can easily be seen. Like many specialized tests, however, HIDA scans are  difficult to arrange. John was started on antibiotics as daily liver enzymes were ordered and tracked. As the days progressed, many tests were performed, all coming back negative: His hepatitis A, B, and C serology were negative. There was no reason to believe alcohol was the culprit, as he’d stopped drinking a half-decade earlier. There were no signs of familial or acquired liver disease. However, his liver enzymes continued to rise, and eventually, his red blood cell count dropped. He still couldn’t eat, and now, he was vomiting. He’d lost ten pounds. Antibiotics were increased with no benefit.

A week after admission, the HIDA scan was performed. It too was negative: radioactive markers flowed freely from liver, to gallbladder, to gut. A day later, jaundice set in: John’s eyes and skin were as yellow as a ripe banana. A CT scan of the abdomen was ordered and suggested early pancreatitis – another condition that can result from gallstones and duct blockage. Despite the normal HIDA scan, an emergent ERCP was booked. An ERCP is an invasive test in which a camera is fed into the patients gut (through the mouth), in an effort to find a blocked bile duct. Once the blockage is found, a stent can be placed to bypass the disruption.

His condition worsened. He developed increasing shortness of breath. His liver enzymes continued to rise. And then, a day before the ERCP, his legs swelled dramatically, fluid rising to his hips, and eventually, seeping into his lungs. Supplemental oxygen was given, and the need for a ventilator was considered. John was in heart failure once again.

Twelve days later, the gastroenterolgist wrote, in his discharge summary: “Presented with abdominal pain, an enlarged liver, abnormal liver function tests, and the possibility of gallstones. In retrospect, all symptoms were secondary to heart failure.” An echocardiogram showed leakage of fluid at the site of John’s prosthetic aortic valve. This had been the culprit all along; The fluid backed up to the liver, and the ensuing congestion caused symptoms and signs that almost exactly mimicked gallstones.

Fixation error can be deadly in medicine, as well as in other industries. On December 29, 1972 the experienced crew of an Eastern Air Lines flight en route from New York City to Miami became preoccupied with a landing gear problem. While resting in a holding pattern on autopilot, the crew became fixated over a malfunctioning light – studying it, wiggling it, taping it – failing to recognized that the plane was, in fact, slowly descending. Shortly before reaching its destination, it crashed in the Everglades, killing 103 of the 176 people on board.

In medicine, fixation error occurs when physicians concentrate on a single aspect of care to the detriment of other, more relevant aspects. In John’s case, there was an ongoing failure to revisit his diagnosis; each physician kept John on the erroneous path upon which I had initially embarked. His physical examination, blood work, and imaging studies were all interpreted to fit the initial diagnosis of gallstone disease. All this, despite John’s extensive, recent cardiac history, as well as his shortness of breath, which was incorrectly attributed to his abdominal pain. John’s case was an example of “this and only this” fixation, also known as “cognitive tunnel vision.” Some suggest that there is no simple fix to this type of human error in clinical decision-making.

Two months after surgery to revise the failing valve, John and I were both lucky enough to chat about his ordeal. Despite the delay in diagnosis, he was thankful for the care he received, simply happy that his condition could be corrected before things got too bad. “Looking back,” I told him. “I can’t believe so many of us missed it. It seems so obvious now.”

“If it happens again,” he said, “at least we’ll know what it is.”

Right, I thought. If John gets right upper abdominal pain again, it’s probably coming from his heart.

Either that, or gallstones.

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