In any patient like Graton, the number of possible offending agents is infinite. No list of possible toxic agents could ever cover all possibilities. Therefore, it is essential to enlist the patient in the search, as this case illustrates.
*Case shared by
Robert H. Latham, M.D.
Chief of Medicine & Chief of Infectious Diseases
St. Thomas Hospital
Nashville, Tennessee
Chapter Seventeen
Out of the Mouths of Babes *
When Curt Tribble was 12 years old, he often went on calls with his dad, the senior Dr. Tribble. His father, a surgeon, was director of the trauma service at the largest hospital in the city.
One night a call came from the ER saying that an elderly woman sitting on her porch had been shot several times with stray bullets. Young Curt raced with his father to the ER.
They were surprised to find the woman conscious, alert and with stable vital signs. By the ripped places in her clothing, they counted what appeared to be six bullet holes in the clothing. The fact that she was stable puzzled Dr. Tribble. He expected shock or at least a high pulse rate and/or a low blood pressure, but both measurements were normal.
He began examining the patient for bullet wounds, but — what’s this? — there were none. He ordered x-rays of her chest and abdomen, looking for bullets or areas of trauma. When the films were put up, again there were no bullets visible anywhere in her body. Exploratory surgery was the next consideration.
Young Curt, now thoroughly engaged in the puzzle, piped up, “Maybe the bullets passed under the loose folds of skin, like between her right breast and her abdomen.”
His father turned to him, “Now how on earth could that happen, smart alec?!?”
“Well, we heard she was on the porch,” the boy reasoned. “Maybe she heard the gunfire and bent over and the bullets passed in and out of the parts of her that were hanging down and then went on between her legs and ended up in the front of the house behind.”
The group of doctors looked at one another, thinking. Maybe their “smart alec” young friend just might be right. They decided someone should call a witness to the shooting for more details on exactly what happened.
Sure enough, the witness confirmed the boy’s theory. When the woman bent over, the bullets had passed through her clothing but not into her body. Surgery was cancelled, and the woman was discharged the next day in good shape.
A good surgeon must know when and when not to operate, something Curt Tribble learned at an early age. It’s no surprise that this astute young fellow followed his father’s footsteps into medicine. Today, he is a renowned surgeon.
*Case shared by:
Curt Tribble, MD
Professor of Surgery
Chief, Division of Cardiothoracic Surgery
Vice Chair, Department of Surgery
Medical Director of Transplantation
University of Mississippi
Chapter Eighteen
Keeping Secrets *
I was a second year medical resident in New York City at Columbia Presbyterian Hospital. It was late summer of 1956.
I turned the corner of the ward entrance and ran into Dr. Claude Hornsby, one of my attending physicians. He said, “I’ve been looking for you to ask a favor.”
He went into some detail about his serving as the company physician for a large manufacturing company. Many physicians in those days had such “retainer” contracts, making themselves available to be on call to treat the senior executives whenever needed. He then told me there was an upcoming convention in San Juan, Puerto Rico, he was supposed to attend but couldn’t. The company wanted an American physician with the group at all times. In need of a substitute, he wondered if my wife and I could get away and serve as the convention doctor in his place.
This sounded like heaven to me. A free trip and vacation! I raced to the office of my chief and, to my surprise, got his permission to be off duty for two weeks.
We would be staying at the Caribe Hilton in the full lap of luxury. I would have no assigned duties, only to be available 24 hours a day for the entire week of the convention. We had all sorts of group activities to join: deep sea marlin fishing, golfing, sightseeing around the old town of San Juan and mostly sitting around the hotel pool, basking in the sun. What a difference from hospital duties in New York.
I got to know most of the executives of the company and enjoyed hearing their life stories and experiences. Most started drinking in the morning and were sauced by late afternoon. Since I was on medical call, I declined any drinking in case I was needed. There was a dinner and entertainment every night.
On the last night of the convention, there was a special dinner with formal dress. Thus far, I had not been called to see a single patient. But just before dinner, I got a call from one of the conventioneers.
“Can you come check on my roommate? I think he’s just drunk. He’s been passed out. I just want to be sure he’s OK.”
I said I would be right there and left the banquet hall headed towards the hotel room.
The caller opened the door and led me to the couch where the man was passed out. He thanked me for coming and left to go to the banquet, leaving me alone with the stuporous man.
I brought my black bag, so I took the man’s blood pressure and pulse. Both normal. He was mumbling a bit, so I asked him several questions. All he ever said that I understood was, “Ok. Just need sleep. Leave alone.”
I pondered the situation carefully. Here was a man, obviously drunk and passed out. But what if it were not that simple? What if he had some serious disease masked by this drunken state — say, meningitis or some stroke or maybe heart failure or sepsis and on and on down a long list of possibilities. I tried to do a neurological exam, but the man was limp. I did get him to stick out his tongue and move his eyes in all directions. His reflexes were all present. He felt pain when I pinched him.
I thought back to the year before when I had to pronounce a man dead and was so worried about making a false diagnosis of death. Missing a diagnosis of death would pale beside missing a serious disease in a living person, especially since this was my one case during the entire week. The only reason I was at the convention was to safeguard the executives.
I sat there for several minutes wondering what to do. I hadn’t done anything all week and thought I should at least do something beyond just checking the man out. I remembered scenes from movies in which drunks were given coffee to bring them around. So I ordered coffee from room service and waited, listening to the man make deep snoring sounds. I kept going over and over what I might have missed.
When the coffee came, I poured a cup and offered it to the man. I propped him into a sitting position and spooned a few sips into this mouth. I added a touch of sugar, thinking it might taste better. Eventually, I managed to get most of the coffee down him between his mumbling, “OK, OK. I’m fine. Need sleep.”
Out of ideas at this point, I stretched him out on the sofa and covered him with a blanket, left the room and returned to the banquet to find my wife. I told her what had happened.
About 15 minutes later, my name came over the loudspeaker system. I was to find the nearest phone to take a call.
“Are you the one who was just in my room?” the voice on the phone asked.
I said I was just in room 413.
“Well that’s my room. I’m Charlie Johnson. Thank you so much. The coffee and sugar you added jarred me into consciousness just enough to take my sugar pill. I am a diabetic on insulin, and I was having a severe insulin reaction. Stupid me, I didn’t eat lunch. But I’m fine now, thanks to you. You saved my life.”
I was so taken back I didn’t know what to say.
“Oh, by the way,” he continued. “You have to swear you will tell no one that I am diabetic. I would get fired if anyone in the company found out. They do not tolerate any chronic illnesses.”
I tried to convince him he should tell his boss, that there could be anothe
r life-or-death situation and people around him should know what to do. Still, he refused. He said he would hold me to my word not to tell anyone — ever.
In a few minutes, Johnson appeared in the banquet hall and roamed table to table. He was clearly one of the most popular men at the convention, and everyone had heard about his drunken state. His roommate had told everyone that Johnson was passed out and how he had summoned me to make a “house call” for his inebriated friend. Each table burst into laughter as Johnson approached, completely surprised to see him conscious and so full of life. He kept pointing over at me each time as if to say, “He’s the one that did it. Best drunk doctor I know. ”
Johnson eventually made his way to my table, stuck out his hand and slapped me on the back. He laughed and gave me a big wink. “You sure know how to make coffee,” was all he said.
All through the banquet, many of the men came up to me, most wanting to know what I gave Johnson. “What in hell did you put in that coffee?” Or, “I want some of that.” Or, “You are really one hangover doctor.” And on and on. Each time I felt a mixture of feelings, mostly the suppressed urge to tell people what really happened.
From time to time in the passing years, I reflect on the events of that evening. I kept my vow to hide Johnson’s secret and told no one until now. It has been 56 years. I think I can safely assume Johnson is dead.
I cannot make any deep meanings out of the evening. But I am still in awe over how the happenstances worked to save Johnson’s life. Here I was on a paid vacation to luxury, a second-year resident in medicine, called to see an unconscious man. By luck only, I added sugar to coffee, only because I liked sugar in my own coffee, not because I thought of diabetes or hypoglycemia or any of that. I had missed the one condition I should have considered. Even for physicians — young ones like me, as well as the most educated and practiced ones — blind luck sometimes operates out of nowhere.
*Story told by Dr. Clifton Meador
Chapter Nineteen
2+2=Fortunate *
Carl Simons came home around lunch time and began cooking hamburgers.
Within an hour, the young man developed a severe headache, nausea and vomiting. He had a friend take him to the ER, where he was admitted with a suspected cerebral hemorrhage.
CT scan of the brain was normal, but he was admitted for observation and further studies. Simons, 28, mentioned to the admitting resident Dr. Clark Brown that, ironically, his roommate had also been admitted to the hospital’s Intensive Care Unit (ICU) that morning. A neighbor had seen the ambulance and called the hospital to check on him. Simons didn’t have any more details, because he had been working at his job at the time. Dr. Brown listened, but was mostly focused on his frustration over not being able to make a definitive diagnosis on Simons.
That evening, the Chairman of the Department of Medicine scheduled the first monthly orientation sessions for new housestaff. Attendance was mandatory. Conversations soon turned to which resident had the most interesting case. Dr. Blair Wiggins, a resident rotating on the Intensive Care Unit, told the story of a truck driver named Steve Rogers, age 29, who had been admitted to ICU that day from the ER. Initially, Rogers was unconscious and completely unresponsive. After intubation, he was placed on a ventilator. All blood gases and other studies were normal. As Dr. Wiggins was signing out to come to the orientation, however, the patient had begun to move his arms a bit. Wiggins said no one involved in the case had any idea what had caused Rogers to stop breathing.
Clark Brown, also at the meeting, began talking to Wiggins about other patient histories from the week. Brown was telling Wiggins about a frustrating case in the ER, a guy named Carl Simons, whom he couldn’t diagnose. Suddenly, Brown remembered what Simons had said about his roommate and told Wiggins. Rogers must be Simons roommate!
Wait a minute. Two roommates. Sick on the same day. Both with undiagnosed illnesses, one near fatal. The two residents immediately came to the same conclusion: There must be something toxic in the apartment.
Wiggins called the resident covering for him in the ICU. “I think we know what’s wrong with Steve Rogers. Get a carboxyhemoglobin stat!” He related Dr. Brown’s story of the roommate being admitted the same day. “And get one on Carl Simons down on 6-C, too.”
The carboxyhemglobin level on Rogers came back very high, proving carbon monoxide poisoning. The level on Simons was also high but significantly lower than Rogers’, indicating exposure to the poisonous gas but not as much.
The fire department was notified, and the young men’s apartment was inspected. Fire inspectors traced the source of the carbon monoxide to a second hand unventilated stovetop cooker the duo had purchased.
When Steve Rogers recovered, he told his story. He had come home from work and started cooking supper, but quickly developed a severe headache and nausea. He decided to lie down and rest but became sicker and sicker. Fortunately, he was able to crawl to the phone and call 911. When the EMT arrived, he was unconscious. They rushed him to the ER on 100% oxygen by mask.
Carbon monoxide is a gas that comes from incompletely combusted fuel. It’s odorless and tasteless. Most often it comes from poorly ventilated cooking equipment in homes or from exhaust fumes in automobiles. The gas binds tightly to hemoglobin, preventing oxygen from binding. The result is a very low level of oxygen in the blood. The victim can die from anoxia. The carbon monoxide can be displaced by breathing 100 percent oxygen. (As described in Chapter 4. Seasonal Disorder)
The perplexing thing about carbon monoxide poisoning is that the routine blood gas measurements are all normal even in the face of high levels of carboxyhemoglobin. Partial pressure of oxygen (P02) is normal. Physicians must think of carbon monoxide and order a specific test to measure the level.
This case was the confluence of several remarkable coincidences. Because both men wound up in the same hospital and the conscious roommate happened to mention his unconscious roommate, the two residents at the same housestaff meeting put the puzzle together. Both young men recovered. They did not, however, keep the cooker.
*This case was shared by
Jim Jirjis, M.D., M.B.A.
Assistant Chief Medical Officer for Vanderbilt Medical Group
Assistant Professor of Medicine
Department of Medicine, Vanderbilt University School of Medicine.
Chapter Twenty
A Korean Experience *
Dr. John Newman had just completed his medical residency in 1974 when he was called to active duty in the U.S. Army Medical Corps. His assignment was to be in South Korea as an internist in Mobile Army Surgical Hospital (MASH) Unit #43, located 20 miles from the Demilitarized Zone (DMZ) near the town of Uijongbu, about 10 miles north of Seoul. This was the last functioning MASH unit that descended from the Korean war, which ended in 1953. Many of the M*A*S*H episodes on TV were based on stories from this unit.
During his tour of duty, Newman had seen an accumulation of diseases that were almost never seen in their natural state in the U.S. He saw many rare cases, including raging hyperthyroidism in a young woman that had gone untreated for a year, blue baby syndrome in a teenage boy, all manner of intestinal parasites and advanced tuberculosis. He was struck by the power of Western medicine to treat these diseases.
One day during his last week of duty before leaving the country, Newman had finished sick call and was back in his hooch organizing and packing his belongings. He got a call from the ER that a farm woman wanted him to look at her daughter.
The Korean assistant calling Dr. Newman seemed overwhelmed by the intensity of the mother. She pleaded, “I think you should see, Captain Newman. Mother carry daughter. Cannot walk.”
Newman thought the patient might be a baby or child whose care would be outside his training in adult medicine. Still, he volunteered, “Have her bring the child to my hooch.”
The Korean assistant led the way, ushering a withered, stooped country woman in her 40s. She wore multiple layers of cotton clothing, plastic sandals and
saggy wool socks. They entered Newman’s hooch. “Mother name Eon Gangnam Kim,” the assistant said. “Daughter name Su Na Kim.”
Eon Gangnam Kim’s face was ruddy brown and leathery from working outside in the sun and cold for many years. On her back was a teenage girl as big as she was. The girl rode piggyback, clinging to her mother’s neck and shoulders. The older woman walked in a shuffle, not lifting her feet, but carrying the weight strongly.
Newman’s first thought was that this was a congenital disorder or cerebral palsy, but the girl had normal attention and looked very anxious and tearful.
“How long Su Na no walk?” Newman lapsed into the pigeon English so common to Americans when talking to non-English speakers.
“Five week.” the Korean assistant interpreted. “Many Korean doctors, no help.”
Newman became intrigued, realizing the problem was recent, still acute.
Newman had the mother unload the girl on his bed and examined her. She could not move her legs voluntarily. They were slightly stiff, but when he struck her patellar tendon with the rubber hammer the girl’s leg shot out and went into spasm.
Newman was stunned, since he had expected little or no reflexes. But he recognized these symptoms: The girl had spastic paraparesis of both legs. He had read about it, but never seen a case. This type of paralysis occurs when a spinal tumor blocks brain impulses to the legs but preserves lower neurological reflex arcs. The Korean assistant undressed the girl, revealing the problem: a large grapefruit-sized tumor under the skin on her spine in the center of her upper back.
Newman knew of a neurosurgeon assigned to the 121st Hospital in Seoul, the major Army Hospital in Korea. He spoke to him on the phone. Newman thought the girl had either a spinal tumor or a rare complication of spinal tuberculosis, called Pott’s disease. In Pott’s disease, the tuberculosis grows in the spinal disc and expands into the bone and compresses the spinal cord, mimicking a cancer. The neurosurgeon doubted Newman’s story but agreed to take the case. The MASH ambulance crew drove her down to the Yongsan base in Seoul.
Fascinomas- Fascinating Medical Mysteries Page 6
