A lucky accident

31 12 2010

John was a blue-eyed, blond 12 year old kid.  He was visiting grandma with his family in late summer.  John and his two sisters had gone out in canoes somewhere off the New England coast.  Unfortunately, the tide went out on their way back to shore.  John and the girls had to drag the boats across the mudflats to return.  It wasn’t easy.  John only had flip flops and pretty soon, sscchhlurp!  one of them got sucked into the mud.  Now he had to continue with only one flip flop.  Suddenly, ‘ouch’ John had stepped on something sharp.  It must have been a shell fragment or a neglected bottle cap.  The wound on his heel bled profusely.  It seemed the bleeding lasted for longer than it should have.  With pressure, finally the bleeding stopped and they all made it back to shore safely.  The next day John came to our Wound Healing Center.

After hearing the story, I was concerned about possible contamination of marsh mud to the wound.  Under the bright lights of examination, I could see the wound actually wasn’t that bad at all.  It was a small injury, clean appearing with out any signs of infection.  What caught my eye, however, were many small red dots in the skin over the whole lower leg.  I looked at the other leg and noticed the same thing.  These were ‘petechiae’ – small hemorrhages within the skin.  The parents then gave further history – he had frequent nose bleeds and tended to bruise easily.  John must have some sort of platelet disorder.  That would explain his prolonged bleeding episode.  We patched up his wound and sent him for blood work.

The results revealed John’s platelet count had dropped to a dangerous level – 5,000 platelets per microliter.  John would need platelet transfusions urgently to prevent any internal bleeding.  He had ITP or idiopathic thrombocytopenia purpura.  This was a little understood disease where platelets are destroyed by the immune system.  The disease had to be stopped from progressing.  He was given IVIG (immunoglobulin) which served to temporarily halt the consumption of platelets.  Later he would be treated with immunosuppressive medication for longer term control.

Now John’s platelet count has improved and the danger has passed.  I think of how lucky he was to travel to grandma’s and then step on that sharp shell!  It seemed to be more than a just a coincidence…

-RW





Fighting cancer – miracles needed

30 09 2010

Most of my posts recount something that’s already happened.  This case is one in progress.  I am hoping for a miracle here.

Mimi came to me with complaints of nausea, poor appetite and weight loss.  The one symptom I really didn’t like was her ‘taste’ abnormalities.  She didn’t like the smells of certain foods and reported her taste was ‘off’.  I suspected cancer immediately.

A good doctor should not show alarm to a patient.  The ‘art’ of an excellent bedside manner revolves around the human connection.  She was looking to me for help.  I needed to appear concerned but also confident something could be done.  Healing is a complex process that requires the right stimulation.  I believe healing can be promoted simply through words or emotion.  The attitude of the person or patient is very important.  It really can mean the difference between living life and suffering.

Mimi was sent for work-up and evaluation.  The CT scan showed extensive infiltration of her stomach wall and other organs in her abdomen.  It wasn’t good.  Who knew how much time she had?  Who knows how much time we have?

She admitted that at first she was afraid. The word ‘cancer’ is frightening.  After hearing the word, it is hard to absorb anything else…  The word ‘cancer’ is spoken and then there is a detachment, an internalization of ‘this could be it’.  Acknowledging our mortality is a difficult thing.

As a doctor, I am careful not to take away hope.  I remember as a medical student being lectured to by the head of the National Cancer Institute.  He told us about two cases where he had seen patients riddled with tumor suddenly heal spontaneously.  His explanation was ‘recognition’ of the tumor cells by the immune system.  What other system could so definitively rout cancer?  The power of the human immune system is so impressive when operational.  Part of what makes cancer so devious is its ability to evade detection.  Unaware of the problem, the immune system sits on the sidelines while the tumor cells grow at the expense of the patient. If the immune system could only be activated…  I try to encourage my cancer patients to take care of themselves.  Indeed, we should be doing that our whole lives.

Since my dad passed away from head and neck cancer seven years ago, I always try to give special attention to cancer patients.  The NCI director encouraged us to do our best for them.  They deserve special treatment.

Just tonight I was talking with Mimi.  She could look me in the eye and smile a genuine smile.  Her family and her friends gathered around to support her.  She has found ‘Peace’.

RW





Rosie saves a life

31 08 2010

Zahra was a teenaged girl who had just returned from a family visit in Pakistan.  She really enjoyed the trip as her aunts and uncles had spoiled her.  Karachi was an exciting place, ‘the City of Lights’, with so much to do and see.  The weather had been quite humid and it had rained for a number of days – this was because it was the height of the rainy season.  She hardly noticed the few mosquito bites she got, because everything was just so wonderful!

It was several weeks after she came home to Connecticut, when she first noticed the headaches.  She also developed an upset stomach and high fevers.  She went to the Emergency Department complaining of the symptoms.  The doctor requested blood work as routine:  A chemistry panel, a complete blood count and some liver tests to see if everything was ‘normal’.  To the doctor’s great surprise, she was called by the lab technician with an abnormal finding on the blood smear.

Now it just so happened that Rosie was working that night.  Rosie grew up in the Philippines and learned her lab skills there before immigrating to the U.S.  She had seen many different tropical diseases through the microscope.  Rosie called to report ‘ring forms’ characteristic of malaria in Zahra’s red blood cells.  This was a vital discovery, as malaria is a very dangerous disease.

The doctor was astonished, she hadn’t even consider malaria as a possibility.  Now Zahra would be admitted to the hospital for treatment to eradicate the infection. They called me late at night, but the challenge of making the diagnosis was over.  Malaria! I was amazed at Rosie’s skill.  How did she do that?  The proper malaria test had not even been sent, but Rosie figured it out.  I thought to myself ‘what if’ someone else had been in the lab that night?  Would they have noticed the strange ‘rings’ in the red blood cells?  Zahra’s life would be saved.  It was another ‘small miracle’  –shukriya Rosie!

RW





Another superhero

31 07 2010

I met Michael at 7 a.m. in the Emergency Department.  He had returned to the hospital because of a fever.  Just a few days before, he had been discharged home on intravenous antibiotics for a urinary tract infection.

Michael was no ordinary person. Eight long years ago he was involved in a motor vehicle accident that shattered his cervical spine and damaged his spinal cord.  He lived the life of a quadriplegic – unable to move anything at all from the neck downwards.  His urinary infection came about because of his paralysis – his bladder could not empty normally and was continually at risk for infection.  Now, there was another problem that required some investigation.  I talked to him, I examined him.  On his leg, just above his sock, I found the tatoo ‘No Fear‘ in blue ink.  To continue living with these conditions required an extraordinary courage.  My thoughts turned to other patients I had cared for who were quadriplegic.  One gentleman I was amazed to learn worked as a telemarketer — somehow by blowing through a straw he could make calls from his bed and sell stuff.  I decided at that time I could never again be rude to telemarketers.  What if?…

My thoughts returned to Michael.  He had no significant complaints and there was nothing ‘localizing’ in his examination.  He most likely had a ‘line’ infection – the IV tubing that provided his antibiotics must have become contaminated with bacteria which entered the blood stream.  He would need his IV line removed.

Over the next day, he improved dramatically.  I got to know him more while he was in the hospital recovering.  He seemed to be a regular guy – a real ‘dude’.  I don’t know exactly how he managed to live each day with his condition.  The problems in my life seemed small.  I felt inspired.

I thought of Christopher Reeve and the tremendous work he started for the disabled.  Christopher inspired me just like my patient.  What were the important things in life?  Family, friends.  Each day had value.  Too often we take for granted even the most basic things.

I smiled to myself to see Michael return home.  I knew he was living.

RW





Victoria’s Battle for Survival

30 06 2010

I got a call from a young doctor about a patient who wasn’t doing well. Victoria was a nurse who had been healthy for most of her life.  She was middle aged and slightly heavy, but prided herself on “never getting sick”.

Several days ago, she developed a painful sore throat and had diarrhea.  She resisted going to the doctor. Now, she felt dizzy and was found to have low blood pressure.  The young doctor was concerned and thought she needed to transfer to the ICU.

When I saw her she was already on a ventilator – a machine to help her breathing.  She was sedated and couldn’t respond.  I could see she was covered in a red rash over most of her body.  She needed three different medicines by IV infusion to support her blood pressure.  Things didn’t look good.

Her friend Nicole came up to me in tears, believing she had left things too late – neglecting to bring Victoria in sooner.  She felt guilty and begged me to do something.  I knew Victoria’s chances were exceedingly slim.  A patient in septic shock on three ‘pressors’ had very little chance for survival.  I tried to comfort Nicole – “just pray” I said “and let us do the work”.

I made sure she got the best antibiotics.  I checked her immune function and saw she needed immunoglobulins.  We optimized her therapy.  Now we would just have to wait…

The next day a culture came back from Victoria’s throat.  It was Group A Streptococcus – or the ‘Flesh Eating Bacteria’ as it is known in the popular press.  This explained her condition – why she was so severely ill.  This virulent germ was causing Toxic Shock Syndrome.  Victoria had all the signs:  low blood pressure, multiple organ dysfunction, a characteristic rash, and now isolation of the organism.  The fact that she was still here was a good sign – she was fighting for her life.

Victoria continued to surprise us.  On the second day in the ICU she actually opened her eyes and appeared to follow commands.  Over the next couple days, the medicines for blood pressure support were tapered off.  She was winning the war!

Soon the ventilator was no longer required – Victoria could breathe on her own.  Her organ systems were functioning again.  Her rash improved – with large sheets of dead skin sloughing off.  To me it was another small miracle!

About a month later she came to my outpatient clinic. When I looked in the room, I did a double-take, as I couldn’t quite believe this patient in front of me had walked in, unaided and was completely fine now.  Victoria had survived.  We both agreed that ‘Someone’ wanted her to go on.  She still had work to do.

That was a good day.  RW





Magnificent Nature

31 05 2010

It was mid-morning just a few weeks ago and I was out in the garden planting some raspberry bushes.  Raspberries are one of Nature’s superfoods – loaded with antioxidants, important nutrients including vitamin C, and fiber.  One of my favorite fruits!

It was a perfect sunny morning and except for the occasional faint rustling of leaves, there wasn’t much noise.

I had dug several holes for the bushes and was taking a rest.  Just then I heard a strange sound  – it sounded like a dog panting slowly right above my head.  I looked all around, and then straight up.  Above me were two very large birds circling.  They flapped in circles – maybe one hundred feet above the ground.  I could tell they were predatory birds – dark brown, with strong necks, aquiline beaks and stout legs with talons.  These were Red Hawks who were courting each other.  What happened next I would never have believed if I didn’t witness it myself:  the two birds embraced back to back  – their claws locked together.  They formed a winged ‘helicopter’ and whirled down towards earth, spiraling down, down, down.  The conjoined birds broke off only about 15 or 20 feet above the ground, which seemed frightfully close to impact.  The birds flew off together – soon out of sight.

To find out more, I went to a ‘A Place Called Hope’. The people there were wild life rehabilitators who cared for injured, orphaned or sick birds of prey in southern Connecticut. I was happy to see they were doing great work to care for these birds.

I felt so lucky to see such an amazing display of Nature! –RW





The challenge to be a good doctor

30 04 2010

What makes a good doctor? Obviously there are certain technical skills and standards that have to be mastered, but what else contributes to make a meaningful difference? I think it is something ‘human’.

My dad was a doctor who lived his profession.  He saw patients early, he saw them late, he worked on weekends, he made house calls.

This past week, I decided to follow in my dad’s footsteps and make a house call. I went to see Gary who was an AIDS survivor. This wasn’t a sad story, but in fact was a celebration of living. Gary had almost lost his life to a severe pneumonia that sent him to the ICU. Fortunately the doctors recognized the symptoms and put him on medications to stop the HIV virus. He slowly improved and was able to leave the hospital. That was seven years ago and he’s doing so well that I’m no longer concerned about his immunodeficiency. Measurements show his immune system is stronger now than ever. Instead, I’m more concerned about Gary’s elevated cholesterol and lack of exercise. With the antiretroviral medications we have today, I expect him to live for decades more.

I could see that my home visit meant a lot to Gary. I wanted to restore some dignity to the patient. I wanted to show I was listening to his concerns. I wanted to show his time was as valuable as mine. He was also a human being.

I wish I had time to visit all of my patients at home – the ‘old fashioned way’. Of course, in the 21st century, it’s much harder to do. What I’ve observed in the doctors I admire most, is that they actually listen: They make that connection where real understanding between two people occurs. That is where healing takes place. That is the path to greatness.

I’ve posted a few stories here on Small miracles about AIDS survivors and other patients. Of course all of their names have been changed to protect their privacy. These are real stories that inspire me to work harder and to be a better doctor.

Now I want to honor a few other ‘great doctors’ I know using their real names. I want to recognize them and say ‘thank you’:

Dr. Tim Babinchak – you taught me how to think as a young doctor in training
Dr. Joe DeSimone – you taught me what compassion really meant
Dr. Greg Kane – you inspired me to work harder than I ever thought possible
Dr. Chusana Suankrati – you amazed me with your dedication to patients and student education.
Dr. Jonathan Sporn – you are a beacon of hope for those in need
Dr. Alexander Palesty – you care deeply which is important to those around you

And to the many other doctors who I think of now…
You inspire me, RW