Sunday, January 4, 2015

Right Between the Eyes

Day one, case one, a shot right between the eyes, and in more ways than one. It was several days before the official start of my new duties as a neuro-hospitalist, but I had the solo weekend call, all new consults, at the level one medical center from Friday at 7:00 PM to Monday at 8:00 AM. The third year students had just started their twelve week Internal Medicine rotation and two were available each day to work with me. My main goal, my raison d'tre actually, to convince these students how taking a thorough patient history and doing a complete physical examination will determine the problem, would likely be apparent by the end of the first day.

There always has been a potential problem on these full 'call' days of getting too many serious cases. For years there has been one neurologist assigned to take all new consults in the hospital, the ER and surrounding ERs that have no neurology coverage. Often the weekdays numbers are overwhelmingly  "difficult".  The case load on the weekend is generally lighter, the main problem being the sixty consecutive hours of availability.

The day started well because I had not received a single call from 8:00 PM Friday through the graveyard shift early Saturday, and therefore experienced no sleep interruption. I went on my traditional short "loops"" cycling ride, staying close to home in the event I was called. Before the house was out of sight, the cell phone rang and within fifteen minutes I was on the way in.

The patient was in his fourth day of recovery after an elective knee procedure. For three days he had been complaining of a headache, which is usually nothing, but that morning he was noted to be confused, which is always something. The combination is additionally alarming.

The patient's CT brain scan, ordered by the attending physician, showed a small benign pituitary tumor. This is not a rare occurrence and if small, very unlikely to cause any difficulty.  The Neurosurgery team, who deal with tumors, had been consulted and had reassured the attending physician the tumor was  too small to be of any concern. I had been able to glance at the scan on line while getting dressed and agreed with their opinion. An MRI had been attempted but was not completed  because of the patient's claustrophobia.

When I arrived with my student in tow, we did a detailed examination confirming a mild state of confusion, an elevated temperature and a stiff neck in the forward direction, all suggesting meningitis. (Stiffness in all directions indicates other disorders). The detailed neurological exam showed no asymmetrical strength, sensation, tone or reflexes to suggest a stroke, and no visual abnormalities to implicate the pituitary tumor. A normal pituitary gland sits below the crossing of both optic nerves at the bottom of the brain, just behind the eyes and above the nasal structures and sinuses. If significantly enlarged by a tumor it will press on the optic nerves resulting in loss of vision.

The chart indicated the patient had received a spinal anaesthetic at the time of his orthopedic procedure four days earlier, which means the numbing medication was injected directly into the spinal canal. There is always a rare chance of introducing bacteria which days later could turn into meningitis. The onset of his meningitis symptoms, the headache he complained about within 24 hours of the injection, seemed a bit early, so I assumed he had some type of sterile irritation from the injection, a self limiting chemical meningitis, which we occasionally see after someone has a myelogram (dye study into the spinal canal to image the spine in conjunction with a CT scan). He had already been started on the appropriate antibiotics to cover the usual bacteria, so there was no rush to prove it with a spinal tap.

I planned to research the time sequence for bacterial meningitis after a spinal injection when I had a break during the day. Unfortunately the new patient requests were coming in at an all time thirty year record high pace, and it was 2:30 AM the next morning before I could get to my computer search. This research was done in "my office" also known as "the bed", which includes the computer, a pile of books and journals scattered on the floor creating quite an unattractive mess and a major bone of contention with my wife.  I was surprised to learn it was possible to get meningitis within 24 hours of a spinal injection. My patient therefore needed a spinal tap to exclude unusual pathogens. I was too tired to hold the needle much less point it in the right direction, not to mention I was already horizontal and down for the count. I slept four hours and returned early to reassess.

The spinal  tap was easier than I anticipated confirming  meningitis with a profile of cells, protein and glucose indicative of a bacterial infection, rather than a viral, fungal or chemical meningitis. No bacterial organisms were seen on microscopic examination of the spinal fluid sediment suggesting successful eradication with the antibiotics he was receiving. By the end of the day he had no temperature elevation and he was clearing up mentally. By the following  morning he was back to baseline with no complaints, up walking with the physical therapist and back on course to do the rehabilitation from his knee operation. I apologized profusely for taking so long to identify the problem while keeping his very nice wife in an uncomfortable state of anxiety. We said goodbye and I was off to work on the other patients.

Having spent an inordinate amount of time on the case, I  was a bit behind in addressing the needs of my other patients. I also had to drive over to the medical school for a three hour teaching stint and then drive back to my office to clear up some issues there as well as see a few scheduled  'out' patients. When I finally returned to the hospital I had quite a large number of patients on my list. I assumed my "meningitis" patient would no problem whatsoever as he was obviously on the road to recovery when last seen. I had officially signed off the case with the intention of stopping by as he was finishing his ten days of antibiotics recommended by the infectious disease team. Once stable he was moved to a room next to another person I was seeing and just by chance I saw the two of them, patient and wife, comfortably chatting as I was walking past their room. I stuck my head through the door and asked if all was OK. His wife replied he was doing fine except he had earlier in the day noted a new problem of blurred vision. This couple was the type who would have never complained to the staff much less demanded I be called to reevaluate . I thanked my guardian angel for steering me their way.

I was stunned by this compliant and knew it meant a time consuming complete reassessment. Mentally he was fine. All eye, face, throat and limb movements were normal and he had no abnormal reflexes. When testing his vision, however, I noted a subtle problem with his ability to see laterally (away from the nose) in each eye. This means one thing only: pressure from pituitary mass on the optic nerves, which cross about one to two cm above the normal pituitary gland. This impingement seemed impossible given the small size of the tumor. An urgent MRI was ordered and performed, this time with a pep talk backed up with an intravenous sedative as he was going into the machine. Sedatives administered this way carry a small risk of breathing difficulty, and I was therefore required to accompany him to the scanner, which takes forever!

This turn of events was a two edge sword. First, given the unanticipated time it was taking to do an urgent evaluation, there was only a slim chance of finishing my appointed rounds for hours. Secondly, it appeared my initial assessment was probably incorrect, likely with serious consequence. As the latter realization bounced around my tired brain, I started to get that sick feeling I have unfortunately suffered in the past,  and more than a few times. It starts as a nauseating burn in the gut which migrates up and down. As it reaches my head the demons pour out, clearly reminding me this feeling is here to stay awhile and good luck sleeping.

I started to pray, well, more accurately, I brought up the lyrics of  The Killers song: All These Things I've  Done  
         "You know you got to help me out, yeah
         Oh don't you put me on the back burner
         You know you got to help me out, yeah
          Your going to bring yourself down, yeah."

This seemed to work, because I soon received a text from the night time ''on call'' medical student who had finished her regular duties. She asked to accompany me on my rounds. I had some research to do on this particular patient in order to possibly solve the dilemma of what at first appeared to be an unrelated spurious sequence of events.  I knew the student to be very quick on the small computer she carried with her and we could research the complicated array of issues as we were rounding on the other patients. The MRI demonstrated the pituitary tumor was more than twice as high as it was wide, which is very unusual, and, as I had only recently suspected, was putting a significant amount of pressure on the optic nerves.

It was impossible for me to combine all the findings and complaints under one entity, which is my usual modus operandi when analyzing difficult cases, a variant of Oscam's razor ( i.e. entities are not to be multiplied beyond necessity).  First I re-consulted neurosurgery who recommended medical treatment with steroids, Then we did the research, or I should say, the medical student did, as I was writing notes. Fortunately, there were no unexpected problems with the other patients to distract us, at least for the moment. Initial research data confirmed my belief that if a patient with a pituitary tumor suddenly develops visual and other symptoms, a scenario labeled ''pituitary apoplexy'', there is always a bleed into the tumor. Bleeding shows up nicely on CT and MRI scans and he clearly did not have a bleed.

But when we put in a search "pituitary apoplexy" and "meningitis" we found two cases identical to mine. Both cases had a pituitary tumor, a picture suggestive of bacterial meningitis, and eventually other neurological problem including visual impairment. The spinal fluid cells, protein and sugar readings were also typical for bacterial meningitis, and not the other infectious and chemical entities mentioned earlier. The hypothesis, suggested by one of the authors, is the tumor has some type of insult, leaks protein like material into the spinal fluid, causing a chemical meningitis which for unclear reasons, mimics bacteria.  The pituitary gland then swells up and pushes on the optic nerves, which are notorious for not being able to take much pressure without permanent damage.

The next day he was significantly worse. Yuk. Looks like an error on my part was going to result in an incapacitating visual loss, likely both eyes, and in a patient I was supposed to be helping. Worse, the disabling problem, the visual loss, occurred after I was on the case,  With no response to the steroid medication, he underwent an emergent neurosurgical procedure which involves going through the nose and sinuses, drilling a small hole through the bone just beneath the brain and then removal of the tumor, which relieves the pressure on the optic nerves. If the pressure on the nerves is quickly recognized and the surgery is done in a timely, skillful manner, there is usually little permanent damage to the vision.

After this surgery, however, the patient's vision deteriorated further. I guessed this had something to do with all the inflammation from the chemical meningitis.  I last saw him at a rehab hospital two weeks later on my way home from work, with severe visual impairment in all fields of gaze, and in my opinion, unlikely to change significantly. His job required he drive all over the state and clearly he could not. This was no different than a gunshot right between the eyes, and as alluded to initially, I felt we both had received.

I was able to do my work over the next few weeks but not a day passed when I didn't think about the pituitary disaster. I vacillated between a feeling of incompetence to one of frustration over the bad luck of having too many cases to properly handle the one that mattered most. This was hardly my first bad outcome and I wondered how many more bad outcomes I could  take. Maybe it is just time to quit.

Back to The Killers:

               "I got soul but I'm not a soldier
                 I got soul but I'm not a soldier"

I have come to know the medical student who helped me on this case quite well over the last two years. She has successfully endured a tragic set of events in her own life which makes my tribulations seem trivial. She has been a great inspiration to my whining side. One night, weeks later, I was coincidentally rounding with this same student. We were at the hospital, well into the evening, looking at MRI scans on the computer after seeing all of that day's patients. My phone pinged a text from a number I did not recognized. When the message started:

                " We saw the Neuro Ophthalmologist earlier today....",

I immediately knew it was from the wife of the patient I had failed. Wincing with a sudden jolt of intense anxiety and a rekindling of that sick feeling in the gut, I squinted and grimaced as I let my eyes role to the bottom of screen to see the rest of the message. The wife was writing to tell me her husband had somehow made a late, near miraculous improvement in his vision and had been cleared to drive and work. She wanted me to know. I blinked, took a deep breath, and passed the phone to the student. She read the message, looked at me, smiled, and handed back the phone. I sent the wife a short reply:

                               "Thanks for letting me know".

Soon I was driving home in a quiet car with no music which is unusual. Convinced everything has meaning beyond the superficial, I tried to make sense of this last lightning bolt. Initially I could not get anywhere. There are equal merits to the argument I should quit now, to the one I should never quit. Then I asked myself:  "What do I do when I go to a bike race and suck?"  I always come up with a elaborate plan to get better and sometimes it is actually effective. When I run out of ideas to get better as a Neurologist, I'll know it is time to quit.

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