Seasoned gastroenterologists can usually predict the site of internal bleeding based on numerous medical facts, but there are times that we are surprised or misled. Patients don't always behave according to the textbook presentations we learned.
At this point, which of the following options are most reasonable?
• Do not scope the stomach now as the patient is still sedated from the colonoscopy and cannot give consent. Once the patient has awakened and recovered, discuss the new diagnostic hypothesis and obtain informed consent to examine the stomach to look for a bleeding site.
• Forge ahead with the stomach scope exam while the patient is still sedated. Assume informed consent and proceed.
I opted for the latter option. Ethically, I felt that I was on terra firma as the patient had already consented to a colon exam to evaluate the bleeding. It seemed absurd that he would have consented for a colonoscopy but withhold consent for a stomach exam that was now deemed essential to pursue the same diagnostic mission. Moreover, the patient had received multiple transfusions so there was clearly a medical urgency to identify the bleeding site.
Assuming consent for a subsequent procedure that was not initially anticipated is rational and defensible if the test is clearly in parallel with the medical evaluation and there is a medical exigency present. Presuming informed consent, however, is an exceptional event. Physicians are not permitted to go rogue.
The blood in the colon didn't come from the colon, as I had wrongly suspected. It came from a duodenal ulcer just beyond the stomach, which I easily spotted with the stomach scope exam.
This patient didn't go by the book. Sometimes, we physicians need to deviate from established policies also.