As Newman was about to leave the MASH a few days later, he got a message that the girl’s problem was indeed tuberculosis and the infection had been decompressed surgically. The young girl was already getting partial recovery of her leg function.
Dr. Newman was struck by seeing something that existed only in textbooks in the States. By simple application of modern surgery plus antibiotics, they had saved and preserved the girl’s life — all thanks to a rubber hammer and a telephone call to the right doctor who knew how to use a scalpel around the spine. Remarkably, there were no CT or MRI scans, no labs, no computer notes, no consent forms, no liability risk, no HIPPA protection of insurability, no billing, no contracts, no consultants and no anxious hospital administrators.
As Dr. Newman boarded the helicopter headed back to Japan and the real world, he wondered if he would ever have so much fun and impact on people’s lives as he had during his tour of duty at the 43rd MASH unit in Korea.
* Case shared by:
John Newman, M.D.
Elsa S. Hanigan Professor of Pulmonary Medicine
Division of Pulmonary and Critical Care Medicine
Vanderbilt University School of Medicine
Chapter Twenty One
Gut Reaction *
Sheldon Smaldon, a 40-year-old executive, suffered from chronic and persistent anxiety since early childhood. For the past three years, he had frequent panic attacks so severe he finally stopped driving. Public transportation was his only means of travel. He did, however, manage to keep working at a billing and accounting firm.
Dr. Simon Sedon, a psychiatrist, started seeing and treating Smaldon. Over the past three years, he found Smaldon to be obsessed with self-doubt and negative thinking. On some visits, Smaldon went over and over the same issues. He seemed stuck in certain ruminations and patterns of thought.
Sedon used cognitive therapy to treat Smaldon for generalized anxiety disorder. He also prescribed Celexa 10 mgm daily and Xanax on a limited, as-needed basis. On this program, the doctor estimated Smaldon had a 50% reduction in symptoms.
In 2005, Dr. Sedon took a yearlong sabbatical, transferring Smaldon’s care to a colleague. When Sedon returned, he was surprised to run into Smaldon at a social gathering. He was even more surprised when Smaldon told him he had been cured of his panic attacks and anxiety. He had been able to commit to his girlfriend and they had married, which signaled a huge step forward in his recovery. His wife was now pregnant with their first child, he said. Smaldon then thanked Dr. Sedon for his previous and compassionate care.
Completely puzzled and taken back by this miraculous recovery, Sedon asked Smaldon how he thought this cure came about.
Smaldon said he had read about how anxiety can be associated with Celiac disease. Celiac disease is caused by sensitivity to gluten, a principal ingredient of wheat. Smaldon had himself tested and found he was, in fact, sensitive to gluten. Armed with this new information, he began avoiding all products containing gluten and found his anxiety diminished.
In a few months of this regime, he had recovered completely. He could now concentrate on his spiritual meditations, something he couldn’t do before. His fear of commitment had also dissolved, and he proposed marriage. Now, with the baby on the way, life was good.
Smaldon again thanked Sedon for his care and said he just wanted to be sure the doctor knew about gluten sensitivity and its association with anxiety. This was the first time Sedon had ever heard of the connection, he confessed. He thanked Smaldon for sharing the information.
The exact biochemical mechanism between gluten sensitivity and altered brain function and anxiety is unknown, but the relationship has been clearly established from clinical studies. Gluten testing will likely become another avenue for psychiatrists seeking answers to patients’ anxiety.
This case also demonstrates how sometimes the one with the most at stake — the patient — can become their own best sleuth. That said, with so much medical information and misinformation available on the internet today, doctors worry about patients self-diagnosing, doing real harm or, at the very least, scaring themselves needlessly. But, when explored discerningly, some of the information out there can also prove helpful. Smaldon, who at last report remained free of his anxiety, is proof of that.
*Case shared by:
Will Van Derveer, M.D.
Private Practice of Psychiatry
Boulder, Colorado
Chapter Twenty Two
Bite the Hand That Feeds You*
Cecil Norman was a character. A veteran of World War II, he served as an infantry soldier in the Battle of the Bulge where he was wounded in combat. His left leg was hit by shrapnel, but he recovered with no lasting limitations.
Since the war, Norman lived on a small farm in the poorest county in Georgia. He, his third wife and her mother shared a double-wide trailer on the rugged northeast Georgia land. He did odd jobs and barely eked out a living.
Norman had noticed a weakness in both legs that was getting worse, as well as a tingling, odd kind of pain in both feet. Walking was becoming more difficult. He wondered if the old war wound was acting up, so he sought medical care at the Veterans Administration Hospital.
The medical team at the VA Hospital was well defined. For each 20-bed ward, there were two interns, a medical resident and an attending senior physician. Paul Barnett was the attending physician on Norman’s ward. Dr. Barnett was in private practice of internal medicine and, like many private doctors, volunteered as an attending physician for a month, rounding three times a week.
Cecil Norman tried to get up from his chair when the team of doctors approached his bed area, but he couldn’t. He described in detail how his problem had begun with just the tingling. Then he said his legs got weak, and now he was having trouble even walking.
“Hell, I don’t want to be no cripple,” he said in a voice loud enough to entertain the other 19 patients on the open ward, “Not what you call a ‘parapleeg’ or whatever.”
The team listened carefully, laughing with Norman’s little jokes. He was clearly enjoying himself. Soon the whole ward was laughing, joining in the act.
Norman settled into the slow and measured pace of the workup process in the VA system. By the end of the first week, the blood work results were finally back. One of the interns on Norman’s case, Dr. Tom McElroy, reviewed them. In addition to the routine tests, McElroy had ordered vitamin B12 levels and some other measures that might point to the cause of Norman’s peripheral neuropathy. All tests were normal, which meant that the nerves to his legs were injured from some unknown cause.
Another week passed waiting on some other tests and a consultation with the neurologist. At the end of that week, Dr. Barnett, Dr. McElroy and the other interns entered the ward to check on their patients. Much to their surprise, Norman was standing by his bed.
“Hello, Doc!” Norman began. “I’m just sittin’ here doing nothin’ and gettin’ well at the same time. Just look at me walk now! Hell, I think I could run some if I had to.” Norman proceeded to strut up and down the length of the ward, saluting the other patients.
The team immediately examined him and found the signs of nerve damage were now much less. The feeling had returned to his feet.
“Doc, ain’t no sense in my sittin’ in this here hospital gettin’ well. Hell, I can do that at home,” Norman announced. “Besides, I can get me some beer and enjoy life there. I’m goin’ home this afternoon.”
His doctors tried to talk him out of leaving, but Norman insisted he was fine. That afternoon, he signed himself out AMA (against medical advice).
Three weeks later, Norman showed up in the emergency room in a wheelchair. Dr. McElroy saw him the next morning and listened to the story of how the tingling and weakness in his legs returned a week after he got home. It got progressively worse until Norman was close to complete paralysis of both legs.
“We need to see your wife and get her version of your illness.” McElroy told Norman. He wanted to take a ca
reful history of the home and surroundings. What toxins were in the home? Was the wife also having nerve problems?
A few days later, Norman’s wife and mother-in-law came for a visit. Norman had insisted they bring Buddy, his pet Labrador Retriever. They actually brought the dog right up into the ward.
When Dr. McElroy saw the dog, he couldn’t believe his eyes: Buddy had no use of his hind legs. The black lab had been fitted with a board on little wheels taped under his belly to support his hind quarters as he walked with his front legs,. All the patients in the ward gathered around to see this dog, who looked like a circus act dragging his little cart on wheels.
McElroy called Barnett into his office to tell him about the partially paralyzed dog. “We’ve got a man who almost gets well in the hospital, goes home, gets paralyzed again and now brings in a half-paralyzed dog,” McElroy said. “There are very few things that can paralyze a man and his dog. Poisons lead the list, and arsenic tops the poisons list.” Barnett agreed.
McElroy immediately ordered tests for measuring all poisons in Norman’s blood and urine. The test is called “a heavy metal screen.” That afternoon, the hospital’s maintenance crew showed up with what looked like a big metal fireplace screen and placed it at the foot of Norman’s bed. When Dr. McElroy came to do rounds that evening, the first thing he saw was the contraption at the end of Norman’s bed. He burst out laughing and couldn’t stop. Finally regaining a little composure, he called maintenance. “Well,” the man on the phone said, “we don’t know what they want it for. Nurse told me to get a heavy metal screen, so that’s what we done.” McElroy couldn’t wait to tell Barnett.
The real heavy metal screening tests on Norman’s blood and urine came back. McElroy’s suspicion was confirmed: There were very high levels of arsenic.
He shared the results with the patient. This time, Norman wasn’t making jokes.
“This weren’t no accident, Doc,” he said. “Got to be that bitch and her mother who done this. Spiked my food, they did. Hell, I know it. Then me feeding my food scraps to poor ol’ Buddy got him poisoned, too. They ain’t gonna get away with it. They ain’t.”
Norman was discharged from the hospital and recovered completely. He divorced his wife, who was convicted of attempted murder. She and her mother both went to prison for the crime.
Dr. Barnett told the interns there was a valuable lesson here: “When a man and his dog get sick at the same time, you better think of poisoning.”
In this case, both man and dog survived. Buddy also recovered and regained the use of his legs. No longer needing his little makeshift wheeled cart, it remained parked outside the double-wide where Norman lived alone.
*Case shared by:
Paul Barnett, M.D.
Associate Clinical Professor of Medicine
Department of Medicine
Vanderbilt University School of Medicine”.
Chapter Twenty Three
Remembrance of Things Past — Marcel Proust*
Dr. Curt Tribble was on call as a senior surgical resident when four adult patients were admitted to the University Burn Unit. He and three other residents were assigned to the patients, each resident caring for one patient. It would be the beginning of two months of nearly constant bedside care for Tribble, who was assigned to the sickest patient. The woman suffered burns over 50 percent of her body.
The first few days of caring for a severe burn are touch and go. The management of fluid replacement demands hourly calculations of the amount and type of intravenous fluid needed. The loss of fluids from the burned areas can be huge, and the need for replacement is critical.
Once the critical early phases pass, then come the needs for surgical wound care followed by skin grafting that goes on for weeks and sometimes months.
Another severe and sometimes fatal problem comes from the extent and nature of the infections that invade the raw area of the burns. The University Burn Unit was well equipped with precise and quantitative measurements of the types of infectious agents in the burned areas. This lab could also determine the exact need for the type and amount of antibiotics to match the infecting agents.
Dr. Tribble’s patient became infected with several bacteria, all treated with antibiotics. She also developed an infection with a fungus that led to generalized sepsis, high fevers and early clinical shock. Fungal infections are not treatable with ordinary antibiotics. They require a special drug called amphotericin. This drug must be given in large daily intravenous boluses. It’s well known for its toxicity and side effects; at best, it is a tricky drug to administer — so much so that its nickname among surgical residents is “ampho-terrible,” an apt name in the case of Tribble’s patient.
Each time the calculated dose of amphotericin was given, the patient went into deeper shock with blood pressures falling to very low levels. The infectious disease specialists insisted that the full dose was necessary if the fungus was to be killed. Despite suppressive drugs like Tylenol, Benadryl and cortico- steroids, the drops in blood pressure recurred with each administration of the amphotericin. It appeared she could either die from the fungus or die from the drug or die from both. Something had to be done or the young woman would die in fungal septic shock. She was near terminal.
In the midst of this crisis, Tribble remembered his senior days at Vanderbilt Medical School and being on call every other night in the hospital. One of his favorite spots during down time was the conference room of the department of medicine, located just outside the 24-bed medical inpatient unit. In that room was a filing cabinet that held “blurbs” written by medical residents. As part of their training, each resident was required to write a blurb on a particular subject. Collectively, they were a treasure of clinical information, and Tribble had free access to the short, but informative, jewels during his nights on call. He often spent time reading them and copying many on the nearby copy machine.
Now, somewhere in some remote part of his brain, he recalled reading one of those blurbs about correcting penicillin allergy. He had carefully filed the copies he made those many years ago and still kept them along with hundreds of reprints. Google had nothing on Curt Tribble.
He raced to his on-call room and found the blurb on penicillin allergy. There it was: the details of how to desensitize a patient to penicillin allergy so that penicillin could be used safely. The protocol called for beginning with minute doses of penicillin and progressively increasing the dose, while giving it continuously until the full dose could be tolerated without an allergic reaction.
The big unanswered question was whether or not this method could be used to desensitize the burned patient to the toxic effects of amphotericin. Could a method to deal with an allergic reaction be applied to dealing with a toxic effect of a drug? At first, the attending physicians thought the idea was too far out. But with the young woman near death, they all agreed to try giving the medication continuously, while gradually increasing the dose of amphotericin, just as one would gradually increase the dose of penicillin. This was new clinical ground.
Within a few days, the dose of amphotericin had been increased to the full daily dose, given as a continuous infusion, with no reaction. In a few more days, the steroids and other drugs were stopped. The fever went away and the fungal infection was cured. Although severely scarred from the burns, the young woman survived and was discharged after several months.
As this novel treatment proceeded successfully, Tribble recalled from his youth a memorable admonition from his father, a thoracic surgeon who had often told him stories of his cases. His father’s advice, which accompanied most stories, was, “In medicine everything you learn, every story you hear, may be lifesaving. Keep that in mind. This is a very different kind of memory from the tacit lessons of your current education. The lessons of algebra and French can be forgotten with little consequence. Not so with medical knowledge.”
Tribble wondered if there is some special part of the brain to store essential clinical information and some indelible n
eurological recording device to keep it accessible to recall. If so, the recollection of this blurb about desensitization, filed away years earlier and not thought of in the interim, certainly reinforced his father’s wisdom from long ago.
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 Twenty Four
Sometimes the cause for a disease can only be heard.*
Janet Sanderford, a mother of three grown sons, was transferred to the University Hospital for increasing shortness of breath. The transferring diagnosis was “suspected mitral valve rupture and pulmonary embolus (blood clots to the lungs).”
Mrs. Sanderford, 58, was accompanied by her husband Jimmy Sanderford, a cattle farmer in southern Indiana. He told the medical resident, “She ain’t been no good since that operation.”
The operation he was referring to was for a ruptured disc in the spine of her low back. She had undergone the surgery at the local hospital in Indiana about a week before and afterwards had developed swelling in both legs, which was diagnosed as deep vein thrombosis (i.e. clotting of the blood in her leg veins). Deep vein clotting is common after surgery, especially in patients who are obese like Mrs. Sanderford.
Her doctors put her on anticoagulation or blood thinners to prevent further clotting in the veins and to facilitate breakdown of the existing clots.
After a few post-operative days in the local hospital, she had developed increasing severe shortness of breath. It worsened at night, requiring her to sleep upright on pillows. Given her diagnosis of deep vein thrombosis and the possibility of a clot breaking off and going to her lungs, she was transferred to the University Hospital. Just prior to transfer, her surgeon also heard a loud murmur sound from her heart, suggesting the rupture of one of her heart valves. The murmur was not heard during her physical exam before surgery.
Fascinomas- Fascinating Medical Mysteries Page 7
