Savoring success, despite poor taste

The toenail continued to grow out slowly, the fissure gradually began to heal. Eighteen months later the split is all but gone; only a remnant remains near the leading edge of the nail. As an added bonus, the course of therapy cleared up a chronic case of tinea pedis as well. I was pleased — but this is not the end of the story; for in medicine, like the Lord of the Rings trilogy, clinical tales never end; they merely morph into other, more puzzling dissertations.

Readers can access the rest of this clinical tale — In Poor Taste — in the Online Journal of Community and Person-Centered Dermatology, a free, post-publication peer-reviewed, full text, open-access, online publication that addresses all aspects of skin disease that concern patients, their families, and practitioners.

Getting to the bottom of it

Next month this boy will celebrate his 18th birthday and segue into young adulthood. Despite that fact, he’s here with his father today, mostly for moral support, I suspect. Even though I’ve known him since he was a newborn infant, at his age he’s a bit uncomfortable discussing his medical problem: a pain in the bottom.

Read the remainder of this adventure in the skin trade, A Pain in the Bottom, in the Online Journal of Community and Person-Centered Dermatology, a free, post-publication peer-reviewed, full text, open-access, online publication that addresses all aspects of skin disease that concern patients, their families, and practitioners.

The bend in the great river

One generation passeth away, and another generation cometh, but the earth abideth forever. The sun also riseth, and the sun goeth down, and hasteth to its place where it rose. The wind goeth toward the south, and turneth about unto the north; it whirleth about continually, and the wind returneth again according to its circuits. All the rivers run into the sea; yet the sea is not full. Unto the place from whence the rivers come, thither they return again. Ecclesiastes 1:5-7

“He’s had fever for two days. He’s been so fussy, he won’t let me put him down.”

This mother looks exasperated, exhausted as well. And she’s not a new mother. This 7-month-old infant was her caboose. Up until today, she’s only brought him in for well-child care.

“Has he been eating?”

“Not well. I could only get him to take 4 ounces all day.”

“Vomiting?”

“No, no vomiting—just extreme fussiness.”

“How high has his fever been?”

“102 to 103.”

I study the infant in her arms while we talk. At this point he seems comfortable. He even smiles at me, always a good sign in my book of clinical diagnoses.

“Any one else at home sick?” I ask, reaching for my stethoscope.

“No, not at home. But we did take him to see my husband’s grandfather in the nursing home a week ago. He was bedridden with pneumonia.”

I nod and listen to the baby’s back and chest. Nothing but normal breath sounds greet my ears, another good sign.

“Let’s lay him down,” I say, standing at the head of the exam table with otoscope and tongue blade in hand. The mother pins her infant son’s arms at his sides while I peer into his ears and throat. The tympanic membranes appear pearly grey, but the throat is red and swollen with a small amount of exudate on the tonsils.

“He’s got a sore throat,” I announce. “Let me swab it and run a quick test.”

“I knew he had a sore throat from the way he was acting,” the mother muses. “He cried every time he tried to swallow.”

Even without running the test, I know that this infant has contracted a virus. It’s exceedingly rare to see strep throat in such a young child. But I need confirmatory evidence to prove it.

By the time I return with the news that the results show no strep, the baby has calmed down. Even his fever has dropped — another good sign. I tell this seasoned mother that in all likelihood her little boy will turn the corner in 24 hours. “Give him some acetaminophen, hang in there and call me tomorrow morning to let me know how he’s faring.”

“By the way,” I say, “what did his great-grandfather think of him?”

“He was pleased to see him. Could the baby have picked up pneumonia from him?”

I pause to ponder her question. “Do they know what sort of pneumonia he had?”

Tears fill the mother’s eyes. “Terminal,” she says. “He wanted to see his great-grandson before he died.”

Pneumonia, the dying man’s friend. It settles into the lungs of the exhausted aged bedridden patient and whisks him away in the night.

“When did he pass away?”

“Ten days ago.”

“I doubt that the baby contracted pneumonia from him,” I say. “The incubation period is too long, and there are no signs of a lung infection on exam.”

The mother seems reassured. She will follow my instructions and call me in morning.

One generation makes its entrance while a former one fades away. Standing at the bend in the great river, I look upstream and marvel at how the new white water cascades down over the smooth rocks as downstream the current meanders around the far oxbow and silently slips from sight.

“Pine Creek” 2011 © Brian T. Maurer

Some things happen for a reason

“We’ve got one more patient coming in,” the medical assistant calls down the corridor.

The words sting in my ears. From where I sit behind my desk, I can see the clock on the credenza: 6:50 PM. By rights, in ten minutes we should be closing up shop and heading home. The last thing I want to hear at this juncture is that I will have to stay past posted office hours to see a straggler.

“The father called at 6:15 PM,” the receptionist tells me. “He said he would be here in fifteen minutes. I don’t understand why he’s late. According to the chart, he lives in town, just a couple of streets over.”

I stare out the front window. The few remaining cars in the extensive lot are covered with snow. Despite several passes by the plough there’s still a good bit of slush on the pavement.

“The temperatures were supposed to drop this evening,” I say. “Maybe the roads are beginning to ice up.”

I retire to my office and finish the last of the charts from a busy day. I’m tired and spent. I would like to go home and have my dinner. I wonder why people always seem to wait until the last minute to call.

The cleaning crew arrives. The father and son team begins to collect the trash from the examination rooms and wipe down the counters with disinfectant. I look up at the clock and shake my head: 7:00 PM.

At 7:05 PM the father stumbles through the front door with a diaper bag and his infant son in the car seat carrier. “Sorry I’m late,” he mutters. “I just got a new car, and already it’s acting up. It quit on me twice on the drive over.”

The medical assistant escorts the father and infant to an exam room. I hear her ask him the reason for the visit. The father starts in, describing the onset of nasal congestion one week ago. Evidently, the child didn’t eat well today. He’s vomited several feedings. Perhaps he needs an antibiotic to kick the cold, the father says. Everybody else at home is sick.

The medical assistant hands me the child’s chart. “There’s no fever,” she says. “98.8.”

I open the slender file. The child is just three weeks old. The father brought him in for the congestion last Saturday. From the note it appears as though the baby might have had conjunctivitis. The father has been putting an antibacterial ophthalmic ointment in the baby’s eyes. I close the record and ease to my feet. It’s now 7:10 PM. With a little luck, I might be out of the office by 7:30 PM.

I recognize the father immediately when I see him. He was in fact a former patient in our pediatric practice, an intellectually limited young man.

“I’m sorry I’m late,” he starts in. “My car is acting up. I can’t understand it, I just got it last week. I had the baby in to see the other doctor a couple of days ago. He told me to come back if the baby got worse. He didn’t eat much today. The little he did eat he threw up. Maybe he needs some kind of medicine to help him get better. What do you think? Does he need a antibiotic?”

While listening to the father’s words, I observe the infant on the exam table. His respiratory rate is in the 80s, he’s retracting with each breath. The area around his mouth looks dusky. I place my stethoscope on his chest and count the heart rate: 180 beats per minute.

I pull the stethoscope from my ears. “I think we’ve got to get him down to the hospital,” I say. “He’s having difficulty breathing. At the very least he needs a chest x-ray and some oxygen.”

The father looks at me and then at his son. “He wasn’t this bad earlier today,” he says. “Honest, he wasn’t.”

I place my hand on the father’s shoulder. “Little babies can get sick quickly over a short period of time,” I tell him. “You did the right thing bringing him in.”

“I don’t think I can take him to the hospital in my car,” the father says. “It quit on me twice driving over here. The roads are slick—”

“Don’t worry,” I tell him. “We’ll get an ambulance to take him down. You can ride along with him.”

“Can I call my mother? Maybe she can meet me at the hospital.”

“Go ahead. We’ll arrange for the ambulance in the meantime.”

I walk out to the front desk and ask the medical assistant to make the emergency call. Our receptionist turns beet red.

“I’m so sorry,” she says. “If I had known he was going to be this late…”

“Forget it,” I say. “If you hadn’t had him come in when you did, he might not have lasted the night.”

A new used car that is on the blink. An intellectually limited father. Icy roads in the aftermath of a winter storm. A belated telephone call at eventide.

Sometimes a string of events portending disaster can lead to a satisfactory outcome.

The ambulance arrives to collect the infant and his father. Soon they disappear into the night. The cleaning people have taken out the last of the trash.

I turn out the lights, step through the side door into the chilly air and throw the deadbolt.

Some things happen for a reason, I think, as I slide in behind the wheel of my car. I hit the switch, and the engine roars to life.

A litany of symptoms solved

If you are an avid reader of medical narratives, you may have come across Dr. Lisa Sanders’ invitation to participate in solving the diagnostic dilemma of a 76-year-old woman suffering from chronic weakness, fatigue and mood swings posted in yesterday’s New York Times.

Over 500 readers, both lay and medically trained, weighed in on the differential diagnosis over the course of the day.  I submitted my two cents as comment #358.

The resolution of the case appears in today’s Times at this link.

You can read my final thoughts about the clinical case presentation here.

Hats off to Dr. Lisa Sanders and Times columnist Tara Parker-Pope for putting together this thought-provoking diagnostic exercise!

From the Patient’s Perspective

Most of us who spend our days in clinical practice focus on establishing proper diagnoses, formulating evidence-based treatment plans and following up closely with care of our patients. Seldom do we consider illness from the patient’s perspective. Yet viewing illness through the patient’s eyes gives us invaluable knowledge that we can use to help the patient heal—if only we would pause to listen and reflect.

Lately, I’ve come across three poignant pieces on the web which provide deep insight into what living with illness is like for the individual patient and the family unit. more»

The Poetry of the Commonplace

In her recent New York Times column, Compelling Stories, If Not Literature, Dr. Abigail Zuger bemoans the recent outpouring of health-related memoirs. “Few of these efforts rise to the level of great literature,” she writes. “None of these books comes close to succeeding according to the usual standards. The language is clumsy and full of clichés; the dialogue is stiff and unreal; the pacing is way off.”

Dr. Zuger also has something to say about doctors who have taken to writing their own stories: “the great majority are sentimental and predictable, and a few manage to be as pedantic, self-important and annoying as, one ventures, their authors must be in person.” Her conclusion? “Most of these books aren’t great literature either.”

Still, Dr. Zuger confides, she has a soft spot in her heart for such books. In the face of all of her prior criticism, you have to ask yourself why. Is Dr. Zuger merely being sentimental? Or does she identify with the sentiments of her patients and colleagues?

In my opinion, what Dr. Zuger fails to recognize is that the patient’s story, no matter how ineptly told, becomes an integral part of the healing process itself.

Medicine’s great 19th century humanitarian physician William Osler remarked that, dealing as he does with poor suffering humanity, a good doctor has to keep his heart soft and tender, lest he develop too great a contempt for his fellow creatures. Osler reflects on what he terms “the poetry of the commonplace”—the ordinary man, the plain, toil-worn woman, their love and their joys, their sorrow and their griefs.

According to Osler, such tales serve to sustain the weary-worn clinician in his daily work. They also serve to sharpen his compassion for his fellow creatures.

My collection of clinical tales in the art of medicine, Patients Are a Virtue, might not be great literature. Few practicing clinicians and fewer patients will ever read it. Most likely it will eventually be relegated to the dustbin of narrative medical writing. And yet I take heart when I receive that occasional communication from cyberspace, such as a brief e-mail from a doctor in rural western Pennsylvania, who wrote that, after reading my book, he felt energized and renewed in his commitment to his patients. He felt so strongly about it that he purchased additional copies for his colleagues and encouraged them read it as well.

Is every patient and practitioner a poet? Dr. Zuger asks. In his consideration of the poetry of the commonplace, I believe that Dr. Osler would answer her rhetorical question in the affirmative.