Wednesday, December 30, 2015

War(d) Buddies

I love movies and have always been inspired by the stories and characters. I should claim to be more guided by the great works of literature and religion, but that would not be true. War buddy movies have been a popular genre for decades and I was always drawn to the emotional bonding between the characters, especially when the bullets were flying and the situation seemed hopeless. The emerging friendships always seemed to transcend the predicament. Despite the dangers, I usually felt a desire to be embroiled in the same trenched warfare.

Many years ago, after a tumultuous year as an intern in Internal Medicine, where I had no help, few friends and many bad outcomes, I traveled from New York back to Florida to begin my Neurology residency. The transition from being an intern in one discipline, where I eventually gained some level of competency, to a resident in another, where I had forgotten the little I had learned as a med student, was a point of great concern. To make this monumental move from a Friday in New York to the following Monday in Florida was an additional challenge. The two hour plane ticket and the twenty four hour train ticket were identical in price. I chose the latter, feeling the geographic perspective would some how mitigate the professional chasm. With nothing to do on the train and no one to talk to, I manage to read the entire textbook Stupor and Coma by the famous Cornell neurologists Plum and Poser. This was somewhat helpful, but I still had a long way to go. I felt like one of our soldiers must have felt on the eve of D-Day heading towards Normandy. When the residency started, no one was actually shooting, but there were many potential causalities and metaphoric mine fields to negotiate. I needed a buddy.

Each in-patient Neurology Service in Gainesville was set up with two residents. The attending physicians provided some help at one of the hospitals and very little help at the other. Each resident rotated the duties of speaking to the referring physicians and arranging admissions, which generally involved arduous follow up care on these complicated patients. There was a finite amount of  work and the split was somewhat arbitrary. We had very little exposure to benign outpatient cases. We dealt almost exclusively with the very sick. Several residents in my program were famous for shirking their responsibilities and adding to their partner's workload.

I got along fairly well with everyone and even tolerated the few who did not pull their share of the weight. I did developed a very special relationship with a fellow resident named Ed, who started the same year as I did. We had completed our Internal Medicine training at separate locations and had never met, but found ourselves thrown together for the three year stint. We worked together on the wards many months throughout our stay in Gainesville. When this occurred, each of us tried to do 55% of the work. I always had the feeling, (as I expect he did) we had each other's back. We rounded together every morning on all the patients and took great care to go over each patient's physical findings and imaging studies, consistently providing constructive advice to one another. Though appreciative of specific advice he gave me, the fact I knew he was also " on the case" was critically important as it ameliorated the lonely, scary feeling of accepting total responsibility. I loved him for that. This was my first real 'Ward' buddy.

Now, thirty five years later, in my medical school faculty teaching duties with the first and second year students in basic sciences, I am encouraged to introduce some clinical issues to help the students grasp the subject matter. Often I find myself saying:
          "My friend the Eye doctor says.." or
          " My friend, the Sleep doctor says..".
Not surprisingly, these two guys are my main cycling partners. When not in the office and on our long rides we have plenty of time to share ideas and stories. Though neither has taught at our medical school, both are now well known there. The Sleep doc, Chuck, is also my 'sous chef ' when cooking pizza in the backyard. Since leaving our Neurology group ten years ago, he has built a very successful Sleep practice. I wish him continued professional success of course, but if at some point in the future there was a major technology breakthrough obviating the need for docs in the sleep world, I would not be too disappointed. I am confident I could talk him into joining me at the hospital. He always did like the intense stuff. We could then finish it out as we started, making rounds every morning with a good friend we totally trust, going over each other's cases in a meaningful and constructive manner, then off to do the individual consults. Just like in the movies.

I have come to see life as a set of concentric circles. The outside circle is the classic dust to dust for which I am prepared. Within that circle is the fetal position as an infant to the fetal position as a demented old person, which we all fear, Within that circle, potentially another, just as natural and for me, most desirable: 'Ward' buddies working together on intense cases at the beginning of our residencies, to 'War(d)' buddies decades later. In the same war. Just old soldiers.

Monday, December 14, 2015

Who Stole My Beautiful Jacket

I am aware of just how shallow it is to admit I love parts of my wardrobe, but I do. I love my Steve Jobs St. Croix black mock turtle neck shirts so much, I have five of them. I love my extensive eye glass collection and I suspect no one other than Elton John has invested in eye wear more recklessly. I love my sock collection which can't be equaled. But most of all I love my Florentine leather jacket.

My unique enthusiasm for this garment is easy to understand. Most importantly, it was a gift from my wife, Charlotte, who purchased it on our fortieth anniversary trip to Florence, where our relationship arguably began. Many years ago she did her Junior year abroad with a hundred or so Florida State students, one of whom was my brother Joe. Subsequently she returned to the USA, graduated and moved to Atlanta where I was on cruise control in my final years at Ga Tech. She gave me a call at my brothers suggestion. I "didn't get out much" so the rest  was predictable. It was a no brainer to pick ''Firenze'' for the major anniversary trip.

Florence has a lot to offer and it is easy to be entertained by it's treasures. Our personal favorite was Michelangelo's eighteen foot marble statue The David which we went to see every day even though we had to buy tickets each time. I concluded (and am not willing to take any other suggestions) it is the single greatest accomplishment of western civilization. One day upon exiting 'The Academy' where The David is housed, we went by a leather store featuring only Florentine jackets. Charlotte offered to buy me one to celebrate the trip. There were five or six different styles, in multiple colors and five different types of leather: cow, sheep, goat, deer and antelope. That translated to almost a hundred choices and after three hours of trying on almost all of them, I settled on a dark teal, doubled zippered, high collared, antelope jacket. Coincidentally it was the most expensive one in the shop.

I chose antelope because it was the lightest weight. A heavier jacket here in the deep South, where thermostats during the cool months are usually set quite high, typically needs to be removed once indoors. I have had an embarrassing history of losing a number of coats and sweaters while going floor to floor on hospital rounds, so I vowed not to take my Florentine, dark teal, doubled zippered, high collared, antelope jacket to the hospital. Never.

Recently I had the late call duty which usually involves a phone consult or two. Perhaps one in four nights I have to actually see a patient. Many of those are before midnight. We occasionally "take a direct hit" like a shot from a German U boat, and have to go into the hospital in the wee hours. Such was the case this particular evening. A nurse from the Neuro ICU called me about a problem she was having with a patient I had not previously seen.

She told me everything she knew about the case. The patient was a 34 year old man transferred from an outlying hospital five days earlier for sudden onset of confusion with a headache. He was not known to have any prior medical problems, was on no medications, had a negative drug screen, and only mild kidney damage demonstrated on his blood lab values. He had had several very high blood pressure readings at initial presentation which was surmised to be possible recording errors, because it dropped significantly with moderate doses of medication. He had an abnormal brain scan showing severe edema (swelling/fluid) throughout deep areas in the brain, including the brain stem, sparing only the surface grey matter. He was under close observation in the Neuro ICU and was back to baseline normal mental status for the last three days, without any change in the brain scan abnormalities. The radiologist's official interpretation of the scans listed a number of possibilities, but nothing definite. The nurse also informed me that during the prior the morning he become confused, but by the time he was seen by the daytime neurohospitalist, the patient was back to normal.

An unwitnessed seizure was felt to the most plausible explanation for the event on the previous day and he was placed on anticonvulsants. He was maintained on several blood pressure medications. At 2:00 AM the following morning, during my duty, he again became confused with trouble speaking and seeing. I was called when the difficulty persisted almost an hour. The nurse, who was at the bedside the entire time, was confident he had not had any type of seizure nor did he have any disturbingly high blood pressure readings. After listening to her story, I pulled up the chart on line with the feint hope of solving the problem without getting out of bed. I read all the notes by the multiple doctors who were on the case. I carefully looked at each of the CT and MRI brain scans, and reviewed all the blood tests as well as the spinal fluid results. I was stumped.

I quickly dressed and just before leaving, reached into the closet to grab what I thought was an old leather jacket of no real or sentimental value. While driving in and focused on solving the clinical mystery, I suddenly noticed I was wearing my prized Florentine dark teal, double zippered, high collared, antelope jacket. With just a flicker of attention, I decided to leave it in the car upon arrival. But distracted as I was by the details of the case, there was not a thought of the jacket for another six hours.

When I got to the bed side I found the patient to be awake and alert but definitely confused. He had no weakness or sensation loss. He had some difficulty comprehending what I was saying. He had partial visual loss on one side. I then looked into the back of his eyes with my trusty ophthalmoscope. This is always a challenge in an uncooperative patient with pupils not dilated by the drops which the ophthalmologists routinely use in their offices. We in Neurology, never dilate the eyes of a sick patient with possible increased intracranial pressure because to do so, would make the patient appear to be squeezing the brain from one compartment to another, necessitating emergent decompressive surgery.

Many years ago when I was an internal medicine intern, knowing I was going to later become a neurologist, I decided I needed to develop some "skill" which would later serve me well. This was decades before the movie Napoleon Dynamite conclusively settled the question on the importance of "skills". I vowed to make sure I got a good look at every single patient's fundus (the back of the eye one sees through the ophthalmoscope), without dilating the pupil, even if I had to wrestle with the patient for ten minutes to do so. Frequently it took that long and more often than not, it added little to the assessment. But by the end of my internship year I had acquired the "skill".

With some difficultly I was able to visualize his fundus, From what I read in the chart, no one else had been able to do so. The patient's fundus demonstrated classic finding of "hypertensive emergency" (formerly known as malignant hypertension), a condition where fluid leaks into the walls of all the small arteries (arterioles) in the brain causing a variety of neurological problems, including the ones he had experienced at the onset of this saga. Commonly on brain CT and MRI scans, fluid is seen only in the back of the brain, but not always. I concluded the man likely had had very high blood pressure for years (probably had not seen a doctor) and just before his admission, because of progressive kidney damage (admission labs) caused by the high blood pressure, he developed a sudden increase in blood pressure into the hypertensive emergency range which precipitated the clinical presentation and abnormal brain scans.

In regard to the immediate problem, I suspected with the appropriate anti-hypertensive treatment he was receiving, there was intermittently too much of a drop in his blood pressure. This often is poorly tolerated in a patient with longstanding high blood pressure. I had the nurse find the exact time earlier in the previous day when he was confused. We went over all the vital signs and discovered one hour before that episode, and one hour before the second episode after which I was called, he had a low but not critically low blood pressure reading. There is a beautiful physiology curve in standard textbooks demonstrating the relationship between blood pressure and cerebral blood flow (blood flow to the brain). The blood flow is constant even if the BP is very low or very high, with decreased cerebral blood flow occurring only if the blood pressure is extremely low.  When one suddenly stands up after lying down all night the blood pressure will drop but blood flow to the brain does not change and it would be unusual to have any trouble. On the other hand if one is severely dehydrated, the same maneuver may cause an otherwise normal person to be lightheaded or even faint from too little blood flow to the brain. When a patient has chronic severe high blood pressure, the curve "shifts to the right" and what appears to be normal blood pressure can actually result in very low blood flow to brain, causing the clinical picture he exhibited.

I told the nurse to lower the head of the bed, which increases blood flow to the brain and to give him extra intravenous fluid, which would increase the blood pressure and blood flow. I predicted he would likely come around and I drove home. When I called at 5:00 AM the patient was almost back to normal. I slept from 5:00 to 7:00 AM and when I awoke, I thought of the jacket and panicked. I quickly surveyed the closet, most of the house and finally the car. I knew once again I had left a nice piece of clothing at the hospital.

Fortunately I had been only to one unit and not much time had elapsed since my departure. I remained calm, phoned the hospital and asked the new shift, which started at 7:00 AM, to look for my beloved Florentine dark teal, double zippered, high collared, antelope jacket, stating I would call back in ten minutes. Another search through house and car was fruitless. I called back and was informed it was not in the unit. I then had a major temper tantrum, with loud cursing while throwing magazines, books and shoes at the front door, careful to miss the glass part. Without any warm up the activity was violent enough for me to pull one of my butt muscles (gluteus maximus). Barely able to make it back to the phone. I called the unit and told the new nurse I was coming in. I wanted him to contact the hospital police, the Macon police, the GBI, and have them meet me there. In my mind this was a crime requiring a well coordinated law enforcement effort.

To my amazement no one was dusting for finger prints when I arrived twenty minutes later. In fact there were no law enforcement agents present. They must have felt I was joking which was not the case. I looked all over the unit for the jacket in vain. I surmised it was gone for good and I was particularly irritated by the likelihood it was stolen by someone working the night shift, who had to have known it was mine.

I was heartbroken at the loss and annoyed at myself for having mistakenly worn my beautiful jacket to the hospital. To salvage some good feeling I went to the patient's bedside to confirm he was doing well. He was alert, completely oriented, able to understand everything I said and had no visual impairment. He claimed he had never seen me and had no recollection of our encounter hours before. What he did have to my complete amazement and delight was my Florentine, dark teal, double zippered, high collared, antelope jacket, which I had probably left on the chair next to the bed. Likely he had used it for additional warmth after my departure.

He surrendered it without argument. I walked, well, limped off, with a smile proudly wearing my absolutely favorite piece of clothing, vowing to risk freezing to death before making the same mistake again.