Above all, the admitting ward was satisfying. Without utilization-review managers hovering over us in their immaculate white coats, we could do a proper physician’s job—that is, discover what was wrong with a patient and begin appropriate therapy. Often all it took was having enough time to do a thorough workup.
The workup, we’d been taught in medical school, was the rock upon which the diagnosis should be built. It had three parts. The first part was the “history.” This was the patient’s story, as told by the patient, and as elicited by the physician, with hundreds of potential queries regarding every possible symptom, from head (neurologic) to toe (orthopedic).
The second part of the workup was the physical examination: the methodical examination of the patient, also from head to toe. Over the centuries physicians had observed that it was possible to diagnose many diseases simply by observing the signs they left on the body. There were thousands of such signs—small and subtle, or striking and obvious—that could point to or even reveal particular diseases. In the mid-1960s they had been brought together in DeGowin & DeGowin’s Bedside Diagnostic Examination, which was, therefore, a kind of bible of the physical examination. Each of us—Dr. Romero, Dr. Fintner, Dr. Rachman, and myself—had one; and it looked like a Bible, too, with a red leather cover and crepe pages.
The third part of the workup consisted of the results of blood tests and X-rays. Originally, it had been the shortest part, almost an afterthought, but as medical technology invented more and more blood tests, and more and more ways to visualize the inside of the body, this third part gradually superseded the physical examination. Which was understandable. Most patients seen in most settings are early in their illness, before the physical signs appear on the body, and most physicians do not have the hour it takes to perform a complete physical examination. But at Laguna Honda it was different. Patients were far along in their diseases, and we did have the time—lots and lots of time—to examine them carefully. And, although I’d always respected the art of the physical examination, now I learned just how often the physical examination, or its neglect, could lead to, or miss, the diagnosis.
It was late afternoon, and I was up in the X-ray department when Dr. Romero came in to look at the X-ray of her newly admitted patient. She hadn’t examined him yet, but had rushed to get the X-ray taken before the department closed at four pm.
Did I want to look at it with her?
Sure.
She snapped the film up on the light box, and we both stepped back and scanned it. It was an X-ray of a chest—lungs, heart, ribs. The lungs looked normal, and the heart looked normal, but coming out of the ribs on the left was some huge thing that seemed to be a mass of bone fragments and tissue.
“Wow. That’s not good,” I said. “What is it?”
“I don’t know. I haven’t seen the patient yet.”
“Well, what does it say in the records?”
“It doesn’t say anything about a mass. All I know is that he’s been at the County Hospital for two months because he was weak and losing weight. They never figured out what was wrong with him, but since he was homeless, they sent him here.”
So we went downstairs to find the patient and take a look. We found Mr. Jackson in bed, pale, thin, and surprisingly scruffy, given how long he’d been at the County Hospital. Dr. Romero introduced herself and me and then pulled back the sheets. Mr. Jackson’s chest was thin, unwashed, and bony, and neither of us could see a mass. But then Dr. Romero rolled him onto his right side. And there it was, a stony lump as big as a clenched fist, growing right out of his back. It was obvious. Mr. Jackson had cancer, probably lung or kidney cancer. That was the reason for his unexplained weight loss and weakness.
Dr. Romero sighed. “The nurses must hate the interns at the County,” she said.
And what she meant was that, even if the interns and residents and attending physicians had never rolled Mr. Jackson onto his right side as we just had, the nurses must have done so, many times. They must have seen that lump. Did they never tell the interns about it, because they were angry, sullen, and felt abused? Or did they tell the interns—many times and many interns—but in the new system that protected the interns from sleep-deprivation by assigning them shifts instead of patients, did each intern just pass along the news of the lump to the next?
That same afternoon, Dr. Romero sent Mr. Jackson back to the County Hospital, and he never returned. Most likely that was a good thing. Probably the surgeons biopsied or even removed the lump, and the oncologists, with the marvelous miracles of modern medicine, successfully treated his cancer with chemotherapy and radiation. Mr. Jackson was probably discharged from the County Hospital, improved or even cured.
Regardless, Mr. Jackson had taught me something important. It was not that all patients should have X-rays, and that the X-rays should be personally looked at by the physician, although that was one lesson to be learned from his story. Nor was it that communication between nursing assistant and intern, doctor and nurse, was crucial for patient care, although that, too, was a lesson. What I took away from Mr. Jackson was: The diagnosis is written on the body—look for it. Turn the patient on his side; examine him thoroughly. Don’t miss the obvious.
This lesson proved its value to me many times. At Laguna Honda I would admit hundreds of patients for whom the key to diagnosis, and often to effective treatment, was just as easy to find as it had been with Mr. Jackson, if you knew where to look for it and did look for it. All those details of the physical examination in DeGowin & DeGowin: all those shadings of color; those patterns; those subtle sounds; the presence of abnormality; the absence of normality; and sometimes even the presence of normality, could, I learned in those first few years, save a life. Which is the most satisfying, doctorly thing of all.
There was the case of Mr. Grenz, for instance.
Lev Grenz was a young Polish man from Gdansk who’d taken to drink. And I mean taken—quarts and quarts of vodka every day. He was lonely; his girlfriend left him; he lost his job; he had no family—for whatever reason, he drank a good deal. During one exceptionally lonely time, he drank so much that the alcohol ate through his pancreas. This is often fatal, because the pancreas then spills its digestive enzymes into the belly, where they begin to digest the other organs—liver, spleen, intestines.
Mr. Grenz spent many weeks near death in the intensive care unit at the County Hospital. He had hundreds of blood tests, scores of X-rays and CT scans, and numerous tubes inserted not only into his natural orifices but into artificial orifices as well. A tube was inserted into his belly to drain it of its poisons. Another tube was put in to feed him. A tube was put into his arm, so that he could be given blood and antibiotics; and still another tube was placed inside his heart, so that the doctors could continuously measure its pressures. During that particular procedure, the tube punctured the great vein going into the heart, and there was bleeding into Mr. Grenz’s lung, and so another tube had to be inserted, this one into his chest to drain the blood and reexpand his lung.
But, finally, he stabilized. Modern medical technology had saved him, and, though he was still quite ill, he was no longer ICU material; he was Laguna Honda material. Or so the doctors at County believed. And here he was, my new patient for the day, for rest, recuperation, and rehabilitation.
When I went over to meet and examine him, however, Mr. Grenz surprised me. What surprised me was his tongue. His tongue had not been mentioned in his records.
Mr. Grenz’s tongue was very large. It was so large that it stuck halfway out of his mouth. It was beefy-red and dry, thick as well as long, and no matter how he tried, it would not, could not be fit back into his mouth.
Otherwise, Mr. Lev Grenz looked pretty good, all considered. He was only twenty-eight, but balding, with pale blue eyes and a short Polish nose. His neck was thick with many healed scars, and his body was flabby, an ex-muscular workman’s body. His face did seem rather too large for his body, and it was a bit dusky. But it was the tongue that t
ook me aback.
“How long has your tongue been like that?” I asked him.
It was hard to understand his response.
“Ip peen dike dat por a monpth,” he replied, in a Polish accent mixed with tongue.
It had been like that for a month? That was strange. I’d never seen anything like it before. Did they miss it at the County? Had the team of doctors changed so frequently that no one realized that this appearance was not the appearance that belonged to young Mr. Grenz? Did no one in the ICU step back and look at their patient as they were inserting those lifesaving tubes and monitors? Or did they know Mr. Grenz’s unusual tongue very well and simply leave it out of their records?
The large and dusky face, swollen tongue, and thick neck jogged something in my mind—a rare syndrome I’d learned about in medical school, called the “superior vena cava syndrome.” The superior vena cava is the large vein that brings venous blood, dusky and depleted of oxygen, from the upper part of the body—arms, neck, head, face—back to the heart. If it gets blocked by a tumor or an abscess or even by scarring, then the depleted blood builds up, and the face and upper part of the body get dusky and swollen. I wasn’t sure whether that would cause a tongue to swell, but it would certainly explain his swollen and dusky face.
I’d learned to put away such thoughts while I examined a patient, however; and so I continued to go over Mr. Grenz’s body. He still had the hole in his neck from the breathing tube that had kept him alive for weeks; and there was the scar on his chest from the tube that had drained his lungs of blood. The sounds of his heart were muffled. His belly was swollen and also scarred, with a feeding tube still in place. His skin was doughy, and his life force diminished; he was pretty sick, I concluded, but definitely alive.
Still the swollen, dusky face and the large tongue bothered me. Why would a tongue swell that much and stay swollen? I felt the tongue. It was thick, muscular, and firm, not doughy; it was a physiologic swelling, and not an allergic reaction.
It had to be the superior vena cava syndrome. If so, what was the cause? Scar tissue from one of his many procedures? An abscess? A tumor? Laguna Honda was not fancy; we had no CT scan and no emergency room, but I wondered if I might see something helpful with a simple X-ray. So I sent Mr. Grenz upstairs and followed right away to take a look myself.
Now, an X-ray is pretty limiting as to what you can see, which is why CT scans were invented. An X-ray only shows shadows. The shadows of Mr. Grenz’s lungs, I saw, were small; he wasn’t taking much of a breath, but his lungs were clear of infection, abscess, and tumor. The shadow of his superior vena cava did seem wider than it should have been; but it was the shadow of his heart that I didn’t expect. Mr. Grenz’s heart was very large, and it was oddly shaped—globular, kind of like an old-fashioned hot-water bottle.
It was one of those times that I didn’t know what I was seeing, but I knew that what I was seeing wasn’t normal. So I went downstairs to the doctors’ office to get some help.
Dr. Fintner was sitting at the little desk she shared with Dr. Romero. She was sorting through the patients’ records she’d piled on top of all the mail she saved, and she looked a bit frayed.
“Hey, Julie, come up and look at an X-ray with me. I don’t know what it is, but it’s something.”
She jumped at the chance.
On the way upstairs I told her about Mr. Grenz’s face and tongue, and she studied his X-ray for quite a while. Finally she said, “Victoria, it’s a pericardial effusion.”
Ah. Yes. Of course.
Now, a pericardial effusion means that there is fluid between the heart and the pericardial sac, which is that shiny cellophane I’d seen around Mr. Hickman’s heart. Normally there is only a small amount of fluid between them, just enough to lubricate the heart as it expands and contracts. A pericardial effusion means there is a lot of fluid in the sac; for a heart to be as large as it was on Mr. Grenz’s X-ray, there had to be a huge amount of fluid.
That extra fluid would put pressure against the heart and, in turn, on the superior vena cava, causing blood to back up into Mr. Grenz’s neck, face, and tongue. This would explain, perhaps, his superior vena cava obstruction. If so, I was possibly looking at an emergency, because whatever was filling up the pericardial sac might keep on filling it up until it put so much pressure on the heart that the heart could no longer beat. This is called “cardiac tamponade,” and it can be fatal.
The key question was: How fast was this happening? How long had Mr. Grenz’s heart been this big? A week, a month? Or a day?
It was never easy to track down a discharging doctor, and it took me a while, but, eventually, I did get hold of Mr. Grenz’s doctor. He was pretty sure that Mr. Grenz’s heart had been that big for some time.
How sure?
Pretty sure.
And the tongue?
“Oh, he’s had that large tongue for a month.”
That was reassuring. That made it less likely that I was looking at an emergent pericardial effusion, though it didn’t negate the possibility. It did, however, make it harder to rationalize sending Mr. Grenz back to the County for a large tongue and big heart that he’d had for a month. On the other hand, if I ignored those signs while Mr. Grenz’s pericardial effusion continued to increase ….
Suddenly I remembered. There was a way to tell how much of an emergency Mr. Grenz was. It wasn’t fancy, either. It was simple and nontechnical, and described in DeGowin & DeGowin. Because of the relationship between the beating heart and the expanding and contracting lungs, the blood pressure is not the simple measurement it has become. Before the steady beat called “systole,” there is a higher pressure at which a few beats first get through the inflated blood pressure cuff. The difference between that higher pressure and the pressure of systole is called the “paradoxical pulse.” It is easy to measure; all you have to do is take a blood pressure and listen for those first few beats. According to DeGowin & DeGowin, the normal paradoxical pulse was less than ten points. The higher over ten it was, the more likely that the heart was about to stop.
Now, it used to be that doctors themselves took the blood pressure of their patients. The first thing a physician would do when he saw a patient was take the “vital signs”—the blood pressure and pulse, the temperature and the respiratory rate. In fact, the vital signs were considered to be the most important, the most vital body signs of all. They measured vita—life—and taking them provided numbers for the beating of the heart, the heat of the body, and the vivifying breath. But by the late twentieth century, the prestige of the vital signs had tumbled down the slope, from doctor to nurse, to nursing assistant, to machine, and today they are rarely taken by a human. Instead, when a patient first arrives, a nursing assistant wheels the vital-sign machine out, attaches a plastic pincer to the patient’s finger, and reads off its face precise numbers for the blood pressure, pulse, temperature, and respiratory rate. The machine readings are instant and repeatable. But the machine is not programmed to take the paradoxical pulse. So the paradoxical pulse is never taken.
Dr. Fintner and I left the X-ray department and went back to the admitting ward. I found a blood pressure cuff and went over to Mr. Grenz, who was back in bed, looking exhausted and wan. I took his blood pressure. At 170 I heard the first few beats—that was the first measurement. At 140 I heard the rest of the beats of systole. Mr. Grenz had a paradoxical pulse of thirty points. His pericardial sac was filling up rapidly. It would soon cause cardiac tamponade, and his heart would stop.
When I told Mr. Grenz he was going back to the County Hospital, he was not happy. Neither was the County. Nevertheless, two hours later he was in the cardiac catheterization laboratory, where, under video monitoring and with the full luxury of modern medical technology, two quarts of blood were drained from his pericardial sac. This freed up his heart and allowed it to start beating normally.
As a matter of fact, it saved his life.
What the surgeon later speculated was that Mr. Grenz must h
ave had a slow leak of blood into his pericardial sac for weeks, probably because of the procedure that had punctured and collapsed his lung. That slow buildup of pressure gradually obstructed his superior vena cava and caused his face and tongue to swell. Now that the blood was removed, the surgeon thought that the pericardial sac would stick to the heart and not bleed again. Mr. Grenz’s face would return to normal, though he couldn’t say about the tongue.
Two days later, Mr. Grenz came back to me. He did look better. His color was pinker; his face not quite so big, although his tongue was about the same. He still had the open hole from his breathing tube and the tube in his stomach for feeding; and he still had that shocked look in his eyes that said: What happened to me? What is all this?
But he was young. Gradually his body reconstituted and repaired itself. The hole in his neck scarred down and closed. Then he was able to talk a bit around the tongue and eat. So his feeding tube could be removed. His strength returned, and he was able first to sit in a chair and then to walk. His eyes brightened, and his movements quickened. His tongue shrank, though never did it fit entirely back in his mouth. His girlfriend came back, and, after several months, I wrote Mr. Grenz’s discharge order.
I can’t say that he thanked us when he left. He was still angry and stunned; and he put the few possessions he’d acquired—a couple of folded shirts and slacks—into a paper bag and left without saying anything at all. He was still, I believe, angry about the tongue. Later I heard he’d found himself a lawyer and was suing the County for malpractice, though I don’t know whether he won his suit or lost, or whatever happened to his tongue.
He did leave me with something, however. What I’ve always kept in mind since Mr. Grenz is that even the most subtle physical finding—something as minor, as simple, and as rare as the paradoxical pulse—can save a life.
Meanwhile I was learning Latin.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 3
