Patient knows best

“No doctor, I am sure there is something in there. Please cut it open and check.” Mr. R kept insisting that there was some foreign object under the skin over his right elbow. A 32 year young man working in a local small scale factory in the village, Mr. R was in the clinic for the fourth time. He came for the first time almost a month ago. While returning from playing a cricket match one Sunday afternoon his motorbike had skid and he had fallen on the road. There was a deep laceration over his right elbow. He had gone to a local clinic near where he had fallen. They had cleaned up the wound and sutured it up. This had happened almost 15 days prior to his first visit to our clinic. He came with complaints of a vague pain over the elbow and watery discharge from the wound. When I examined the wound, it looked healthy. The sutures had been removed, and the wound had healed nicely. There was no redness, swelling or discharge from the wound. 

“There is no problem with the wound Mr. R. It looks healthy. It has healed well. Why are you worried?” 

“No doctor. In the morning when I take bath, I can feel a strange kind of pain in the area. When I squeeze the area, there is a mild watery discharge from there. I can also feel like some object is stuck in there under the skin. Can you please check.” 

I examined the skin over elbow one more time. The wound had healed, and the scar looked healthy. There was no obvious discharge. I touched the area and pressed it to see if there was something I could feel below the skin. The scar was thick and other than the thick rubbery consistency of the scar, I could not feel anything else there. It all looked normal to me. 

“No Mr. R. everything looks normal to me. You should not worry. When injuries like this heal, the nerve in the region regenerates. When the nerve regenerates, it can sometimes lead to such vague aches and pains and abnormal sensations. Don’t worry about it. It will become normal soon.” I reassured him and sent him home. Mr. R was not convinced, nevertheless he couldn’t say anything more and left with a dissatisfied look on his face. 

 

Mr. R lives in the same village where our clinic is located. I bump into him often on the road. One evening I was standing in the bus stand waiting for the local bus to Chengalpet. Mr. R was going in his bike. He saw me and stopped to say hi. 

“Hello doctor. Are you waiting for the bus? Shall I drop you in Tirukazhukundram?” In villages like ours where public transport is scarce, the practice of hitching bike rides with locals and sometimes with absolute strangers is very common. Any bike that goes towards the town will always have one or at times two members in the pillion, and mostly the pillion riders will be random people hitching a ride to the nearby town. It is not rare to hear people say “பைக்ல கை போட்டு ஏறி போவேன்” meaning “I will show a hand signal to a passing bike and hitch a ride” as though it is another mode of public transport. We are indeed an entitled bunch! It is a 5-7 minute bike ride to Tirukazhukundram. On our way Mr. R said, “Doctor, do you remember I came and showed you my elbow with the scar. I am still bothered by the vague pain and a foreign body sensation. I wish you can help me.” I am used to being consulted in all kinds of strange places in the village. Once I had gone to the chariot festival of the Thirukazhukundram temple. There was a huge crowd and the frenzy that is associated with such large festivals. In the middle of all that, someone had consulted me for their medical condition. People have consulted me in buses, trains, share autos, idly shops, and all kinds of places. But this was the first time I was consulted when I was the pillion rider in a bike! “Sure, let us check it out. Please come and see me tomorrow in the clinic. Let us see how we can help you.” I said that and got down in the bus stand. The bus to Chengalpet was getting ready to leave and so I dashed towards it and got on. 

 

The next day as promised, Mr. R walked into the clinic and sat down with full authority as he had taken appointment from me personally while doing me a favor! He held my right hand with his left hand and guided it towards his right elbow. “Touch here and see. Can’t you feel the foreign body sensation….here…here…right there…can’t you feel it?” 

I could not feel any foreign body. The wound had healed perfectly. There was thick rubbery scar tissue. I could not feel anything else. 

“Mr. R, like I told you last time, I don’t feel anything. It looks normal to me.”

Mr. R was starting to get frustrated. I could clearly see the frustration and anger on his face. 

“Doctor, with all due respect, I want you to cut it open and see. Please….i am sure there is something there.” 

“Mr. R, we cannot unnecessarily cut open and see. I think your mind is imagining a foreign body there because you are worried and constantly thinking about it. Sometimes, our mind can have such vivid feelings and experiences. Don’t worry.” 

The moment, I invoked the mind into the conversation Mr. R got angry. He thanked me with an angry expression and stormed out of the room. 

 

Cut forward to yesterday, Mr. R was sitting in front of me, his fourth visit in the past one month, and insisting that I should cut open the scar and explore. 

“If it had been on my left hand, I would have cut it and explored it myself. I am coming here repeatedly only because it is in my right hand, and I am helpless. Don’t do this to me. Please help me. Please cut it open and see.” Mr. R was literally pleading me this time. I decided to go with his wish. We went into the procedure room. I washed my hands, put on my gloves and opened a minor procedure kit. I gave local anaesthesia to numb the pain associated with cutting open the scar. Then using a blade I cut open the scar. The scar tissue was tough. It was difficult to cut through. I made a small cut less than 1 cm long. When I put my forceps inside the cut and started feeling around, the forceps grazed against a hard object there. It was not bone. The bone was much deeper. I had to cross some more tissue and muscle to hit the bone. I was not sure what I was rubbing against. It felt hard and let out a grazing noise. 

“Do you feel it now? That is what I have been telling you. Do you feel the hard object there? Do you feel the sound?” Mr. R was shouting in excitement that at least he was getting some closure to his problem. 

 

I couldn’t see anything in all the blood that was oozing out. I took the blade and opened the cut some more, slightly more than 2 cm. Blood was pouring out in a steady trickle. I mopped it clean with a piece of gauze, and I could see a shiny black object inside the cut scar. It was stuck firmly in the tissue. I took out a pair of forceps and pried it out. It came out and following it a gush of fresh blood oozed out. I cleaned the blood, then cleaned the wound and dressed it up with a tight bandage. Then I took the object and saw, it was a piece of stone, black in color, shiny. I showed it to Mr. R. “This was there in the scar.” 

Mr. R had tears of happiness streaming down his cheeks. He was right about a foreign body being there in the scar. It was not in his mind. It was a real foreign body. He was not going crazy. He really had a foreign body in his scar.

Mr. R took the piece of stone as a souvenir and walked out of the clinic beaming with happiness. I finished up the clinic and started to leave for home. My train trip back home gives me ample time for reflection. I was thinking about Mr. R, his experience and finding the stone in the scar. I understood that patients know best. The stone was embedded deeply within the scar tissue. The scar tissue was thick and rubbery and did not allow me to feel the stone when I touched it. But the stone was inside Mr. R’s body and he could feel it clearly. It was probably rubbing against the softer inner tissues of the skin over his elbow, deeper inside the thick scar tissue. I did not have the privilege of this sensation and so kept arguing with Mr. R that there was nothing. I am still not clear at what point I should have started trusting in Mr. R’s instincts and perceptions of foreign body in the scar. Was I too late in considering his lived experience with the foreign object? Did I disregard and dismiss his lived experience over my objective clinical examination skills? If I had heeded to his request and cut his scar open at first request, would I have been negligent? These are all questions for which I don’t have an answer. But one thing I learned from this experience is that patients know best about their bodies and their experiences. One more humbling lesson of life, learned from the most unexpected circumstances in clinical medicine.