I recently heard about an amazing case that seems to be filled with lessons for doctors. Not claming to be Homer, my paraphrasing will be modest, but let me tell the tale anyway. Then we'll try to decipher the moral of the story.
Once upon a time a 19 year old man woke up feeling ill. He complained to his mother of nausea, fatigue, loss of appetite and dizziness, and called in sick to work. Within 48 hours his family noticed him to be withdrawn and confused. They brought him to the emergency room where he was examined by the attending physician and found to be nearly obtunded. He underwent a battery of blood tests and imaging studies, including an MRI of the brain, chest x-ray, lumbar puncture and blood cultures, all of which were non-diagnostic.
The man was hospitalized in the intensive care unit and seen by the intensivist and consultants from infectious disease and neurology. Several possible causes of his near-coma and laboratory abnormalities were considered, and treatment with antibiotics were begun. He showed no signs of improvement, and an uneasy sense of gloom began to drift through the ICU. A hematologist was asked for his "curbside" opinion the night before but had no new ideas to contribute. The doctor's notes became scant, ending with question marks. The hematologist was consulted formally on a weekend afternoon, and to hear him squawk one would think he was just about to sink a putt for the Masters championship when he was interrupted. Nevertheless, he delayed the rest of his important plans and drove to the hospital.
Within ten minutes (this has to be an exaggeration, but I wasn't going to argue) he had deduced the diagnosis and written the proper orders in the chart.
Why was he successful in solving the mystery, and not the other physicians? It had nothing to do with intelligence or diligence (although those two traits are not universally wielded by all doctors - did I say that?)
I think the moral of this story is also the reason why the hematologist, the fifth physician on the case, was able to identify the young man's illness. Click below to uncover the thrilling conclusion to our story.
The reason why the hematologist was able to come up with the correct diagnosis, thrombotic thrombocytopenic purpura, was because it wasn't the first time he had ever seen this extremely pernicious disorder. Since untreated TTP has a mortality rate of around 90% he had seen patients like this in the past who were not diagnosed in time to save their life and had adopted the following maxim as a way to try to avoid being an actor in the same tragedy again and again:
"When you lose, don't lose the lesson."
Sounds like great advice to me - I should probably get it tattooed on my biceps but I'm afraid it would get lost in the forest of inky masterpieces undulating there.
Comments
I see a House script in the making...
Posted by: John S. Wilkins | October 15, 2007 10:24 PM
you had me hooked with the first line. Great case. and advice. Thanks!
Posted by: TBTAM | October 15, 2007 10:49 PM
dude.......your the first doctor with a giant dragon tatoo and pierced nipples.
Posted by: Charanjeet Singh | October 15, 2007 11:30 PM
Category: Humor (I acquiesce)
Sounds a lot like the problem that ended my chemotherapy experience. Some say the confusion is still evident to date.
Oh! I am asking for it, aren't I? Will I ever learn?
Posted by: Debara | October 16, 2007 12:46 AM
"Fortune favors the prepared mind."
-Louis Pasteur
Nice post.
Posted by: Bruce | October 16, 2007 6:18 AM
Obtunded?
Posted by: Alex | October 16, 2007 8:41 AM
great post!
Posted by: Ali | October 17, 2007 9:25 AM
Thanks, as a pre-med student, these kind of stories give me nightmares. Doesn't this also illustrate the importance of consultations? We don't really want every physician to have to make a mistake like this once to learn the lesson.
Posted by: Theodore | October 17, 2007 12:35 PM
Without faux humility, I made the diagnosis after the first two paragraphs. I suppose the presence of the hematologist was the clue. Nonetheless, TTP is usually pretty high up on the differential diagnosis of confusion with a normal MRI, and it is surprising that the neurologist did not consider it.
Much clinical experience is hard-earned. In my own situation, the first abnormality one excludes on an ECG is S1Q3T3, and that every patient with chest pain has to have dissecting aneurysm first considered!
Interestingly, I have had a situation where a hematologist fell short in diagnosing heparin-induced thrombocytopenia in the post-operative setting; embarrassingly, the correct diagnosis was arrived at by the infectious disease physician.
Posted by: dreamer | October 18, 2007 7:55 AM
wow.....these are the types of cases that make it worthwhile to be a doctor. You should post more cases like these, I love to read about them.
Posted by: Charanjeet Singh | October 25, 2007 8:17 PM
Great case history. Should come up with a list of unmissables - ACS, PE, TTP, acute appendicitis etc.
Have one of my own to illustrate - missed by myself (an intern then on my 2nd month on the job) and the resident but deduced by the registrar on call.
A thin middle aged construction worker was admitted to the respiratory ward complaining of cough, increased sputum production, a low grade fever and dyspnea. He had a long history of being a heavy smoker but was not known to have COPD. On examination, he was borderline febrile at 37.6 and in mild respiratory distress - RR 18, sats 96% on RA which improved to 99% on controlled oxygen therapy. Auscultation of the lungs revealed a few scattered crepitations in the lower bases. No cyanosis was noted.
An erect CXR showed bilateral hazy peri-hilar infiltrates, hyper-expansion and a long tubular heart shadow. A blood gas was not available at the time of initial assessment. At the A&E, a trial of nebulized salbutamol and ipratropium had made him feel subjectively better.
Resident and I did an ABG which showed borderline hypoxemia. We started a cycle of nebs, steroids and a course of oral antibiotics and treated as for an acute exacerbation of COPD.
..... The registrar reviewed the patient 2-3 hours after we'd seen him. She re-took a history, re-examined the patient and even repeated the blood gas herself. Crucially, she uncovered multiple visits to commercial sex workers during which he'd engaged in unprotected sex. A CD4 count was dispatched and returned - less than 200. She diagnosed him with PCP pneumonia, and likely HIV-AIDS. And she started him on IV bactrim.
Humbling experience. Lessons learnt - never assume a common presentation's always linked to a common condition and always always take a detailed history.
Posted by: diwakar | October 27, 2007 12:36 AM