Monday, November 22, 2004

Before Thanksgiving

I think it was the lateness of the hour, combined with the notion of family festivities, that reminded me of the third worst day in my life.  Perhaps there were other things, too, that caused me to remember that particular event, at this particular time.  One would not expect, under more typical circumstances, that a happy event, such as a wedding, would bring to mind such an unpleasant memory. 

Yesterday, about 7 PM, I put on the yarmulke that was handed to me by a young boy.  About 11:30, the wedding party almost over, I headed back home.  The house was dark, and quiet.  My wife had gone to bed already.  She hadn't come to the wedding, because her leg was sore.  (It was broken several months ago, and hasn't quite healed yet.)  So I was a bit lonely, too; perhaps that also was a reminder.  I put the yarmulke down on the kitchen counter. 

Thanksgiving is coming up in a few days. 

When I was a second-year resident, I spent a couple of months on the Neurology service.  There was a lady there who had had a small stroke.  She also seemed rather depressed, so I was chosen to be the one to take care of her.  I talked to her about her depression.  She had low energy, loss of interest, had psychomotor retardation, poor appetite, and basically just seemed kind of down all the time.  What I noticed, though, was that she was not particularly sad.  Yes, she had had a stroke.  Yes, she was in the hospital, a couple of days before Thanksgiving.  It was snowing outside, though, and she had a nice view of the newly-redesigned hospital courtyard.  Actually, the view was quite nice.  She appreciated the view, with a richness that one ordinarily would not expect to see in someone with clinically-significant depression.  All this made me suspect that there was some kind of underlying illness that was causing the symptoms that looked like depression. 

I was on call the day before Thanksgiving that year.  I told my mother that I could come over for dinner, but I could not be sure what time I would get out.  Having been through this before, she understood. 

Some tests came back.  The person who had had a stroke had a little bit of blood in her urine.  Her body temperature when up a little bit each evening, then came back down.  Stroke, hematuria, and daily fever suggested that she might have a source of infection somewhere, causing little blood clots that could break off and travel in the bloodstream, causing a bit of damage to various organs.  Oh, did I mention, she had an artificial heart valve?  I drew blood cultures.  She might have endocarditis.  That would explain all of the findings, including the listlessness.

Thanksgiving came the following day.  There I was, getting ready to go for Thanksgiving dinner.  Everyone was waiting for me. 

People who have been through medical training already know what happened next.  My pager went off.  I looked at the number on the display:the microbiology lab.  Those who have not been through this need to know a little background in order to understand.  I was on call the day before Thanksgiving, not on the holiday itself.  But the tradition is, that if one of your patients is in the midst of an acute problem, you stay and take care of it.  You can't hand the problem off to the person who is just coming in, especially if that person does not know the patient and is not up on the latest developments.  If would be bad form to do so, not to mention being dangerous for the patient. 

There was only one reason for the micro lab to page me.  The blood cultures were positive.  I would not be able to leave for several hours, at least.  The lab informed me that the culture was positive for micrococcus.  That was significant for two reasons.  One, it was a known cause of bacterial endocarditis, particularly around prosthetic heart valves.  Two, it could not be a contaminant.  Sometimes, blood cultures have false positives, if bacteria from the skin contaminate the blood when the blood is drawn.  But that would not explain the micrococcus, so there was no chance that the result was a false positive.  It was real, the woman had endocarditis, and I was not going to be getting out of the hospital anytime soon.

In any other circumstance, this would be exciting, in a mildly perverse way.  It would have been a "good case."  Good cases are good because they are rare, and good teaching opportunities.  Only rarely is it good for the patient.  (See A Great Case, by Dr. Jerome Groopman, for a perspective on this.  He found out, on a Fourth of July weekend, that his son had intussusception.)  

A surgical resident in the emergency room began taking the history. Suddenly, an intern in scrubs burst into the room. "What have you got in here? What is it? A good case?"

I fixed on the intern's expectant eyes and lost control. "Who the hell are you? My son is not a "good case!'"

The intern stood frozen.

"Get out of the room!" I bellowed. "Out!"

I called the Infectious Disease fellow, who was very nice, despite having been called on a holiday.  He told me that I should call the thoracic surgery fellow, since a prosthetic valve was involved.  The surgeon was obnoxious.  First he told me it probably was a contaminated blood culture.  Then I told him that it was micrococcus.  Ruined his Thanksgiving, too.

Then came the inevitable turf struggle.  It was clear that the patient no longer should be on the Neurology service.  But should she go to the Internal Medicine Service, or to Thoracic Surgery?  More phone calls.  Medicine won this time, so I had to call the the intern for the medical service that would take her.  We met and I gave a quick rundown of the case, wrote a sign-off note, and finally got to leave.  There was heavy snow by then, and it took a while to get to dinner.  The dinner had to be reheated, but I was glad to be there. 

Families are good; diseases are bad. 

Yesterday, I was present at the forming of a new family.  In a few days, I will be with my own family, as we get together again for Thanksgiving.  By, then, hopefully, I will have forgotten about that day, 16 years ago, when I almost missed the whole thing.