I went to the ER and met Amanda, a lovely young woman in her early twenties. She was thrilled to be pregnant, but was having some bleeding and right-sided pain. After examining her, we did an ultrasound test (using sound waves to examine her abdomen) and, indeed, it was an ectopic pregnancy. I immediately took Amanda to the operating room to do a laparoscopy (inserting a flexible periscope-like device into her abdomen to get a close look at her anatomy) and discovered that the ectopic pregnancy had already “exploded,” rupturing and destroying the right-side fallopian tube. Women have two fallopian tubes, one on each side, each connected to an ovary. Both tubes lead to the uterus. In a normal pregnancy, the fallopian tubes allow a woman’s eggs to travel from the ovaries to the uterus where the eggs become fertilized by a man’s sperm. In an ectopic or tubal pregnancy, the sperm go past the uterus, up into the fallopian tube, and fertilize an egg right in the tube. There is no room for a pregnancy to grow in the tube and there is no way to move a pregnancy that is in a tube to the uterus where it belongs. All a doctor can do when the tube is as damaged as Amanda’s right fallopian tube was, is remove the bleeding tube, saving the mother and allowing her to heal, which is what I did. When Amanda awoke from anesthesia, she cried because this baby was lost. Her other fallopian tube, on the left side, looked fine and I thought she would still be able to have all the babies she wanted to have. After surgery, she healed well and was discharged home.
About a year later, Amanda came to see me again. She was thrilled to be pregnant. I examined her. Everything seemed off to a good start, but when we looked with ultrasound to see how far along in the pregnancy she was, there was no baby in the uterus. I took her to the operating room and dis-
covered another ectopic pregnancy in her remaining fallopian tube, the one on the left side. This tube had not yet ruptured. I made an incision in the tube and cleaned the ectopic pregnancy out, hoping the tube would heal and she might have a successful pregnancy in the future. I was sad for her, but glad I did not have to take the whole tube out this time. That gave us hope she might still conceive.
Another year later, Amanda returned with yet one more ectopic pregnancy in the left fallopian tube. We were both so upset, but as difficult as this decision was, there wasn’t anything else to do except remove her remaining tube to save her life. I was so sad to leave this young woman sterile with no functioning fallopian tubes. We talked in great detail about options, including adoption and in vitro fertilization. These were not good choices for her. She had limited resources, with no money for an adoption and certainly no money for in vitro fertilization, a very expensive procedure. After she was discharged, I occasionally thought of her with sadness, but didn’t expect I would ever see her again.
Two years after that, Amanda appeared in my office, again pregnant! I asked myself, How could this be? I had personally removed both her fallopian tubes with confirmation from the pathology laboratory, where all surgical specimens are sent, that her tubes were, indeed, both entirely removed. We did an ultrasound, and to our astonishment and delight, the pregnancy was in the right place this time, in her uterus! I cannot imagine how her eggs could have made it to the uterus to be fertilized without fallopian tubes to get them there! Impossible? Yet it happened. Amanda considered this to be a miracle, and I couldn’t disagree. She went on to have a very normal pregnancy and a normal labor and delivery. Her little girl was perfect in every way.
Amanda remained my patient for many years after that. She is a terrific mom, and she never got pregnant again.
Date of event: Early 2000s
The Miracle of Good Information
Philip L. Glick, MD, MBA
Most referrals to my university-based pediatric surgical practice come from colleagues in the community or elsewhere at the university. This referral came from my rabbi, and the question he asked was not what one might expect from a rabbi. He needed my help finding an obstetrician-gynecologist who would perform a second-trimester abortion for one of his congregants. He told me that on ultrasound exam-
ination, this woman’s fetus was found to have a sacrococcygeal teratoma—a potentially very serious tumor at the lower end of the spine. The woman’s obstetrician told her that either the fetus or the newborn baby would very likely die, and recommended termination of the pregnancy.
I asked to see the mother. After much evaluation and counseling, and carefully reviewing all the risk factors, I advised the mother that I was cautiously optimistic. Considering all the findings on ultrasound and everything that had been published in the literature, I believed the advice she had received from her obstetrician was outdated and that the natural history for this fetus was favorable. The baby was not likely to die in utero (in the womb) or after birth, but would require major surgery very soon after birth. The baby would have a 20 percent chance of needing a drainage shunt to remove excess spinal fluid resulting from another birth defect frequently associated with the tumor. Shunts can have their own complications, including infection and obstruction, but generally are well-tolerated by babies and older kids. I also told the mother the baby would likely have problems with bowel and bladder function and may have difficulty walking because of impairment of the spinal nerves near the tumor.
After careful consideration, the mother and family decided to proceed with the pregnancy and hope for the best, recognizing now that this tumor was not likely to be a terminal diagnosis. The baby—a boy—was delivered by caesarean section with our pediatric surgery team in the room. Indeed, this very small baby had a very large tumor, equal to the size of the whole baby, on his lower back. Thankfully, my inclination was correct; the child lived, and the tumor was successfully removed surgically shortly after his birth.
As would be expected, he was left with a large scar from the procedure, and as he grew he developed a noticeable limp. However, he did not require a shunt to drain spinal fluid, and his bowel and bladder did not require major corrections. This was the best possible outcome, and we were all relieved this child had such a positive result.
This case proves that good information can make all the difference. Bad information can lead to wrong decisions and result in a devastating and tragic outcome. Knowing which information is accurate—especially in today’s world, where we are bombarded with facts and figures—sometimes requires luck, or even a miracle, such as the highly unlikely path this mother took to the right information.
We don’t always know what becomes of our patients but in this case, since the family’s rabbi was also my rabbi, I saw this boy regularly at Sabbath services. Thus, I got to watch him grow, always greet me with a wonderful smile on his face, attend regular school, and become a vital member of a loving family.
I was fortunate to be in the synagogue for his bar mitzvah recently, on the occasion of his thirteenth birthday. I happily cried as he walked up to the pulpit to pronounce the blessings for officially becoming a “man” in our tradition. I have no doubt that, as an adult, this boy who very well might not have made it into the world will make meaningful contributions to his world.
Date of event: 1981–1983
The Doctor-Patient Bond
Ann Schongalla, MD
Psychiatry residency training is different from all other specialties in that the relationship of the doctor and the patient is considered a fundamental treatment modality, along with medication, various psychotherapies, family therapy, etc. Great respect is paid to how to begin to work with a patient and, even more, how to end or “terminate” a treatment and say good-bye when necessary, for whatever reason. All residents (physicians-in-training) in all medical specialties have a built-in opportunity to go through this each year: on June 30 we finish a year of training and on July 1 we “graduate” to the next level. Of course, during a given year within our level we rotate on and off different services such as inpatient, outpatient, and intensive care units. Mostly, the good-byes are with staff we have become close with over weeks or months, because
the patients come and go so quickly. In psychiatry the rhythm is a little different because the illnesses are chronic and have fluctuating courses, and what you’re examining is how illness affects someone’s life—not a body part or a lab test. The only way to learn about bipolar disorder, schizophrenia, major depression, or any serious psychiatric illness is to watch people go through it or, rather, accompany them through periods of illness and wellness during a long period of their life.
During my residency, our second year of training was spent working with hospitalized patients (inpatients) who were very acutely ill. We learned how to get their symptoms under control as quickly as possible so they could get back to their lives with as little loss as possible. Twelve months later, on July 1, we began our next year of training in the outpatient clinic where the goal was to learn how to keep patients with these same illnesses well and out of the hospital.
By and large, these were people with major psychiatric disability who were unable to work, and whose treatment was paid for by Medicare/Medicaid in our hospital teaching clinic. They were experienced in “getting” a new doctor every July 1, having to start all over telling their story, anxious about how well it would go with another new doctor. They were a colorful group with difficult, dramatic illnesses and we residents learned from hearing about each other’s patients. At the end of that year, if we had time in our fourth and final year of training, we could continue working with a particular patient for the benefit of our education—often to the patient’s great relief about not having to start over with another therapist.
At the start of my third year, in the outpatient clinic, one of my “new” patients was a man in his thirties with chronic paranoid schizophrenia who had a history of violence toward others, but was now symptom-free on medication. My job was to meet with him monthly if he was stable (or if not, as frequently as necessary to adjust his medications); to ask whether his medicines were working (“Hearing voices?” “Worried that anyone might harm you?” “Thoughts of harming anyone or yourself?”); ask about his medicine’s side effects; and do everything possible to minimize his symptoms and help him live as unpsychotic a life as possible.
He was married to a professional woman, had two small children, and came from a college-educated family. Though also intelligent, he was prevented from getting a college degree or even a regular job due to his illness. You can imagine his feelings of humiliation. But you probably cannot imagine how frightening and real his convictions were of being followed and persecuted when he was ill.
Simply put, in schizophrenia, because of a mishap in wiring of brain tracts, people’s five senses perceive what everyone else’s senses do, but when they are ill, their senses also create false perceptions of reality. Only they experience that false reality and it powerfully overrides ordinary reality, especially if their senses “tell” them they are in danger. This is psychosis. You can’t argue someone out of it. You try to protect them until their false perceptions and beliefs subside, and they are back with us again in the “real” world we all experience.
Forty years ago we had antipsychotic drugs that were reasonably effective but infamous for their bad side effects. So when I met my patient those many years ago, he was stable on medication, not psychotic, and we could chat about all kinds of things. But he was terribly sleepy and even dozed off in the middle of a conversation. He walked stiffly, his physical manner was eerily still, his voice monotone, speech poorly enunciated, and his face expressionless. Even if he said something humorous you could only hear it in the words. I prescribed all the usual medications to relieve these side effects—which caused their own side effects—but they remained disabling and humiliating. He knew the medicines kept his psychotic symptoms away, but he hated how the side effects exposed him anyway. He was damned with the disease and damned with the treatment—living not even close to a normal life. Nevertheless, he looked forward to his appointments, as I did, and he kept them regularly.
Imagine my puzzlement when, perhaps seven months later, he arrived for his appointment smiling, alert, physically comfortable with easy movement, talkative and engaging. When I asked what had changed, he said, “Nothing.” He assured me he was taking his medication and had figured out how to manage the side effects. He denied any psychotic symptoms whatsoever. He came across as just a very ordinary, likable guy.
I said, “Okay, fine, if you say so. I am happy you are better but we still have to meet.” He was happy to keep his monthly appointments, happy to feel well and to function much better. It was hard to say there must be something wrong with positive well-being. At the end of that year, he was happy to accept my offer to continue working with him during my fourth and final year of training. All continued well!
Inevitably and unavoidably, 365 days later, July 1 came around again. Having finished my training, I had to say good-bye and introduce him to his next resident doctor-in-training. We knew this phase of treatment would come and had talked about it, in a way, from day one. At our final appointment, he came in with a standard-size shopping bag filled many inches deep with full pill bottles—all the medicines that I had prescribed for well over a year when he looked completely well. But they had never been touched. No psychosis and no miserable side effects. He explained that he had filled all his prescriptions because he was afraid that the pharmacy would know and would call me if he didn’t (okay, underlying paranoia). I was dumbfounded and speechless and, of course, worried because longstanding schizophrenia doesn’t just go away and allow people to get off their medication. However, he’d been fine for so long off meds, clearly felt and functioned much better, and planned to keep up with his new psychiatrist, just as we had, to make sure he did not get sick. He had the right, and seemed moreover to have earned it, to continue to stay off medication. He was competent to make that difficult decision.
I really did not know what to think. What was he telling me with this bag of unneeded medication? Was it the way we worked together that stabilized him? Was it just a good phase in his disease? Had he been lying, and in fact had low-grade psychotic symptoms all along—most likely, I thought—that he’d been able to manage with his own cognitive behavioral strategies? What should his new doctor do to watch him? He said he did not tell me until the very end because he was afraid he could not be my patient in the medication clinic if he was not taking medication.
A month later I was filled with dismay and sorrow when I learned that his auditory hallucinations (hearing voices) and psychotic delusions of being persecuted had suddenly come back full force, including dangerous, threatening behavior toward others (which I had never seen or worried about with him). The police were called, and he was involuntarily committed to a long-term facility. Imagine what he and his family lost!
Now at the end of my career, I understand much more. I have seen many times how people with bad illnesses, even when taking their medications as prescribed, can fall apart in the face of great loss or change, even “good” change. Psychiatry is built on how talk therapy is fundamental to working through life stresses, with or without medication. Today, we also do much more psycho education where we talk about a patient’s greatly heightened vulnerability to relapse when they are off meds and/or are faced with loss or change. We identify the target symptoms that signal relapse so they can restart medication—even a low dose—immediately (and then call the doctor). We may teach patients how to start a low dose anticipatorily when they see a life shock about to hit. With my patient who was stable on medication, today we might identify his early signals for relapse, and together—oh so carefully, given the history of violence—lower his medication to find the lowest effective dose that has side effects he could live with so that he would willingly take his meds. No way did he want to be a person who committed violence toward others. Simple things like getting regular sleep must be watched and safeguarded. Family members need to be the doctor’s eyes outside the office. There needs to be more frequent appointments and check-in phon
e calls in between. And now we have enormously better medications, though not perfect.
There are many more strategies all with the goal of giving a person the knowledge and tools to control his or her illness. However, the basic illness of schizophrenia has not changed in its varying types, the particular symptom group of each type, the “positive” and “negative” symptoms, the variable se-
verity and impact of symptoms on life course, and the wide range in responsiveness of symptoms to medication.
I am mindful that all treatment strategies work most powerfully when grounded in the healing effect of a relationship between a patient and physician, which provides comfort, companionship, and a safe kind of intimacy. That doctor-patient bond bears witness to life’s difficulties and losses, and celebrates one’s achievements and victories. It stands independent of curing. It is founded on respect and kindness for our patients and an abiding determination to help—even if nothing can be changed. And it gives as much to us as it does to our patients.
Date of event: 2000
Ski’s Legs
Bauer Sumpio, MD, PhD
Ludwig—known to his friends, of which I am proud to be one, as “Ski”—is a seventy-two-year-old man who retired to Connecticut in 2000. In his younger years, he studied at the RCA institute in Brooklyn, and during the Vietnam War he joined the Coast Guard, serving on their ice-breaker unit based in Alaska. After the war, he obtained a degree in agriculture from the University of Vermont. He was recruited by a giant computer technology company to work in their upstate New York headquarters, where he was an engineering manager for thirty years. His proudest claim to fame is that he was chairman of the committee of the Institute of Environmental Science that wrote Federal Standard 209, creating the guidelines for maintaining a “clean room” such as in the computer company’s wafer manufacturing plant, or in the operating rooms of hospitals.
Miracles We Have Seen Page 30
