Men in America Hugging

It was jaw dropping, two American men embracing on the front steps of a house in North Dallas, Texas, on a Fall day in 1970.

I grew up in the 1940’s & 50’s.  Men did not hug.  We did see it among the French in those picture magazines such as Life and Look.  It probably started here in the here in the 1960’s, but I did not see it.  Medical school, medical residency and the U.S. Army shielded me.

The etiquette of the masculine hug, unlike the handshake remains vague, and at times I hug without reciprocity and at times with embarrassment. 

Last week, however, we were awash in unrestrained hugs from men and women.  It was a reunion for our residency program.  From over 350 graduates 100 of the most eager huggers returned.  Between sessions it was a veritable hug-in.  I now embrace men embracing men.  It do it, and I am sorry that I missed the 1960’s!

Help, He’s Bleeding

All physicians who are airline travelers have stories to tell, stories of “is there a doctor on board”.  I have several, and this is my best.

I was returning to Oregon from a meeting in Europe.   The airline was SAS, famous, at least to me, for giving out those small bottles of aquavit.  I had had one followed by an obligatory Danish beer.  I was just settling down for a nap while enjoying the incredible expanse of Greenland’s whiteness when the message came over the loudspeaker. 

It was a really big plane, and I figured that there were lots of doctors on the flight, so I ignored the first request.  It came again.  I got up and went to the gallery.  There were two lovely Danish flight attendants.  One said, “Help, he’s bleeding!”.  They took me to a short, stocky, very black man in a dark business suit with a white shirt and tie.  The shirt was stained with bright red blood. 

The man spoke excellent English with an identifiably West African accent.  He told of how he was on a trip to the USA to meet his daughter, a nurse.  She had arranged for him to have, in her hospital, a surgical resection of part of his prostate gland.  His prostate had been causing him problems.  He had had trouble urinating, and it was now so bad that he had taken to catheterizing himself.  He used the pointed half of a disassembled ballpoint pen.  This had worked well for years.  However, on this trip he did not have a pen that could be taken apart. 

His bladder became full, and he became desperate.  He tried to use a BIC, a solid ball point pen.  The BIC caused damage to the lining of the penis and to the prostate that lead to substantial bleeding. 

He and I went into the restroom.  In that limited space I was able to examine him and to determine that the bleeding had nearly stopped.  His bladder however could be percussed all the way to his umbilicus.  What were we to do?

I reasoned that the closest thing to a urinary catheter to found in the plane was the tubing for the audio for music and videos.  I asked for one.  They brought me one from the first-class section that was electronic.  I said, “Please get me one from coach.”  They did, and with a knife from somewhere I carved a pointed tip. 

I held up my impromptu catheter before the patient and said, “Do you want me to do this, or do you want to do it?” He chose to do it himself.  This was good judgment. 

With the catheter in his bladder, draining blood tinged urine, we placed a small airline pillow between his legs, and he pulled up his pants.

The last I saw of him  he was waddling off the plane to greet his daughter.

In the past when I had done doctorly deeds for airlines they had rewarded me with a bottles of champagne and once a sizable amount of air miles.  So I awaited my thanks from SAS with some anticipation.  It came.  It was a carefully packaged ballpoint pen imprinted with “SAS”.  

The Parable of the Quality Pie

Until it was closed in 1992 the Quality Pie was a cafe known for its always-open hours, its decent coffee, excellent pies, doughnuts, hamburgers and breakfasts.  It was across NW 23^rd Avenue from the emergency entrance of my home-hospital, Good Samaritan.  When you walked from the Hospital door the air was redolent of doughnuts.

When I came to Good Sam in 1980, NW 23^rd Avenue was a street of seedy taverns and diverse enterprises, from doctors’ offices and banks to music and paraphernalia shops attractive to a dwindling population of aficionados of the1960’s counter-culture. 

The Quality Pie welcomed all of these businesses and their customers.   From the outside the QP resembled the scene of Edward Hopper’s Night Hawks.     Day or night it was the place, for coffee breaks.

Some time within memory, a QP waitress developed ongoing bloody diarrhea, and her physician referred her to a Good Sam specialist.  After a thorough evaluation she was diagnosed as having idiopathic ulcerative colitis.  In this case, idiopathic meant that no cause was found or the ulcers in her colon even after biopsies and laboratory studies.

Her diarrhea did not get better with standard treatments, but she was able to continue to work serving patrons from Good Sam and NW 23^rd Ave.  After weeks, the diarrhea worsened and she was given corticosteroids.  Her pain worsened.  She was sick.  The gastroenterologist had had cases like this before, and he called a Good Sam surgeon.  Her colon was removed. 

The colon was inflamed and ridden with ulcers.  It was put under the pathologist’s microscope.  The walls of the ulcers and rest of the colon were found to be infested with Entamoeba histolytica.  She had chronic amebic dysentery.  Her colon and her stool had been alive with this parasite. 

Amebic infections can be contagious.  

Good hand washing makes this unlikely.  The waitress must have heeded the warning on the bathroom walls, for no other cases of amebic dysenteric were recognized on NW 23^rd.

The removal of her colon might have been avoided.  There is a simple and inexpensive test for invasive Entamoeba histolytica infection.  It is very accurate.  Her test most certainly would have been positive, and she would have been successfully treated without surgery.  She would still have her colon. 

The message of the Parable of the Quality Pie:  even rare and unusual diseases deserve diagnosis, and sometimes hoof-beats are zebras and not just horses. 

Conscripted

Before Dallas, I was in El Paso, Texas, in the US Army at Ft. Bliss.  At that time, 1968-1970, Ft. Bliss was a Basic Training Post.  As you may remember this a period of Universal Conscription, I know, I as a conscripted physician.

Early on in my Army career I was assigned as a General Medical Office to a clinic where I did “sick-call” for Army Basic Trainees.  These were previously certifiably healthy young men.  They lived in barracks, just like the ones you have seen in the movies.  I saw the usual and predictable illnesses.  Contagious respiratory infections were common.  Aching joints and muscles were common.

Early one morning a well-developed and well-nourished young man came to the clinic.  He complained of shoulder and arm pain.  His shoulders and arms were tensely swollen and tender.

I asked him, “What color is your urine.”  He replied, “Like Coca-Cola”.  I said, “What happened”.

He, as many basic trainees, had done exercises.  Push-ups had been forced upon him unrelentingly.  How many?  Too many.

He had exertional rhabdomyolysis of his shoulders and arms.  The proteins of the damaged muscles went to his kidneys.  It was the muscle proteins that had colored the urine to look like Coke.  These proteins damaged the kidneys.  He developed kidney failure.  He required hemo-dialysis.  His kidneys never recovered, and the dialysis became permanent.

He had just graduated from law school.  The Army had enough lawyers.  He had been conscripted and was being trained to be soldier.

I was lucky to be conscripted as a physician.  

Ambiguity

It was 1972 and after finishing my internal medicine residency at Parkland Memorial Hospital, I was doing a fellowship in infectious diseases.  Part of the training involved working in a research laboratory  at the University of Texas Southwestern at Dallas.

James was a middle-aged, amiable, black man who kept the lab running with clean glassware, fresh reagents and healthy mice.

Late one Friday afternoon I was reading at my desk, and I smelled popcorn.  I went further back in the lab and there was James with freshly popped corn.  Beside him I saw a plastic bag with red, green, purple and blue kernels.

I asked James if that was colored popcorn.
He replied, "No, you can have some."
I had some.

The Diving Reflex and Sudden Cardiac Death

But first, why “drenched doc”?  Here’s the connection.  It is from an earlier chapter of my life--my life as an interesting case--an FUO.   We wrote it up. and it was published in the New England Journal of Medicine in 2007.

The Drenched Doctor 

Daniel R. Kaul, M.D., Mark B. Orringer, M.D., Sanjay Saint, M.D., M.P.H., and Stephen R. Jones, M.D.N Engl J Med 2007; 356:1871-1876 May 3, 2007 http://www.nejm.org/doi/full/10.1056/NEJMcps065377

I’ve lived happy and well since the discovery of that tracheal-bronchial fistula by Dr. Frank Baumeister and its surgical resolution by Dr. Larry Eidemiller and Ed Irish.  A important part of my recovery was the care I received in the hospital and at home from Beth.  That’s why at age 72 I was brave enough to go snorkeling.

Cardiac arrest and snorkeling, here’s the consensus of what happened to me.  There is a well-known physiological phenomenon known as the diving reflex.  It is activated when the face is placed in water that is less than 70 F.  This elicits a series of neurologic responses that cause apnea and a decrease in heart rate, sometimes as low as 20% of baseline in extreme responses.  Under normal circumstances, this causes a compensatory increase in blood pressure to insure sufficient circulation to the heart and brain.  However, rather than increase, my blood pressure decreased, likely due to my pre-existing pulmonary hypertension and the medications that I take.  As a result, there was no effective circulation of my blood.

It is likely that the diving reflex partially abated on the way to the pier while Beth supported my circulation with CPR.  My circulation was further normalized by the intravenous infusions that they gave me at the emergency clinic in Zihautanejo. 

The Mexican clinicians, and my cardiologist, Dr Jack McAnulty, made sure that the more usual causes of sudden cardiac arrest did not apply:  pulmonary embolus, or ventricular fibrillation from coronary occlusion.

Since writing my first piece I have talked with several people who have family members with symptomatic slowing of the heart rate when their face is in cool water. 

Background:

1.     http://en.wikipedia.org/wiki/Mammalian_diving_reflex

2.     JAMA. 1965;192(8):25-27. doi:10.1001/jama.1965.03080210089047.

3.     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2279457

4.     http://www.scientificamerican.com/article.cfm?id=breath-holding-dive-reflex-extends

Our Mexican Vacation--The Day of the Death

Beth and I went on the fifth day of our vacation-- well we went snorkeling.  I put on the fins, the mask and put the the snorkel in my mouth and jumped from the boat.  The water was a pleasant, not cold.  I cleared a little water from the snorkel and replaced it.  Face in the water I paddled to the nearby coral reef.  I saw two or three divers at the reef watching a few fish.

I began to feel light-headed.  I swam back to the boat and asked Alberto, Hector's nephew, for help.  He could not pull me in.  Beth came to me.  I lost consciousness.  Help came, and Beth, Hector, Alberto and two other men pushed and pulled me into the boat.

In the boat Beth found me without detectable pulse or respiration.  I was purple-blue.  She started chest compressions.  After a few minutes she was joined by another woman competent in CPR.

Alberto drove the boat back to the Zihuatanejo Pier while the women continued breaths and compressions.  On the trip back I regained slow ineffective breathing.  An ambulance was waiting.  I was taken to Mediciel Hospitalizacio at 6 Morelos Avenue.  There I awoke to find them infusing saline and dopamine.  I asked Beth repeatedly to tell me what happened.

After air transport to the Real San Jose Hospital's ICU in  Zapopan, Guadalajara, two days later I was flown back to my home ICU, the Kern at Good Samaritan Hospital in Portland, Oregon.  Now ten days after snorkeling I am home.  I am doing OK.  Well, as you see, more than OK!