A Tale of Three Young Men on a Spring Afternoon

It was one of those rare spring days in the Pacific Northwest that really was like spring, fair skies, warm breezes, and the sun.  It was also a long weekend on-call for me and two fellow medical residents at the Seattle Veterans’ Administration Hospital.  We were inside looking out. 

At that time, nine of the University of Washington second-year residents staffed the Hospital’s Medical Services.  The leader of our training program was Dr Robert Petersdorf, one of the world’s premier teaching physicians.  We considered ourselves to be among the elite.  The patients and nurses did not share that idea.

We each were assigned a service of about 15 patients, and we worked alone, without interns or medical students.  We each had an attending physician who we saw infrequently, usually three times each week for sit down teaching rounds, usually a mini-lecture on a subject within their expertise.  They were subspecialists on the faculty to do research.

During the week we were on long-call every third day for about 33 hours, and then every third weekend for two nights and two days. 

That spring weekend the three of us working on call were all white guys in our late twenties.  There were no women or people of color in the Program.  Our age and skin color is where our similarity ended.  Fred was a devout Adventist from Southern California.  He came from wealth and brought some with him.  He lived in a real house and drove a nice car.  He was perceived to be really smart, but perhaps rigid, in our parlance a tight-ass.  Mac to the contrary was an irreverent iconoclast.  He was forced to wear a necktie, as we all were, but he never really tied his properly.   I suspect his family was wealthy as well, but he did not bring it with him!  He had attended a prep school and an Eastern college and an Ivy League medical school.  I was solidly from Iowa.  There was no chance of bringing wealth with me to Seattle.  My working wife and I shared a small apartment with our toddler daughter.  She drove me to work in our Volkswagen Beetle and picked me up after call.  But, enough whining, I was a bystander to this story.

Setting the stage, most Veterans Hospitals at that time had only a few private and two-bed rooms, and most beds were in rooms of four to eight.  That afternoon, Fred, Mac and I each had a patient in the same four-bed room.  All of the patients were sick, and today would be in an intensive care unit, or at least on a nursing unit surrounded by a team of nurses, respiratory therapists, phlebotomists and others.  These patients had only us—one-on-one. 

Mac admitted a cirrhotic man with a belly full of fluid, and after inserting a large trocar and needle, he had removed bottle after bottle of clear pale-yellow fluid. Working alone, he placed the bottles on the tiled windowsills. 

The hospital rooms were cleanly tiled:  floor, lower walls and window frames.  The window ledges where Mac had placed the bottles were generously wide.  The bottles were clearly labeled, but only as vacuum bottles.  They were designed to help remove fluid from body cavities

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Shortly after Mac had removed the fluid from his patient, Fred was called to the bedside of his patient, who had been found by the nurses to have the sudden onset of confusion and a dangerously low blood pressure.  Suspecting that the patient had an infection with severe sepsis and that shock was at hand, Fred decided to give fluids intravenously.  He needed plasma or serum albumin immediately and saw the bottles on the windowsill.  They looked like serum albumin.  He gave them, first one, and then a second to his patient. 

Either Mac or I returned to the room to find the peritoneal fluid disappearing into the circulation of Fred’s patient.  Mac howled with indignation, and frankly, also with delight.  The dazzlingly self-assured Fred had made a mistake, a medical error.  I stayed back against the tiled wall:  thinking no harm—no foul. 

This was a classic medical error—it was egregious.  However, it went unreported.  Mac and I thought that it was hilarious. Fred was completely humiliated.  Mac was at fault, but Fred was not about to report him.

 

The error was both individual and systematic.  Who let these guys work without supervision?

Problematic Effects of a Pacifying Potion

For years I was a physician to members of his family and had known this 59-year-old executive.  I was surprised when he was admitted to our hospital for palpitations and weakness.  

I knew that he used to drink alcohol socially, and when that became a problem, he had quit sixteen years ago.  I was aware that he took pride in his health.  He was proud that he ate organic and natural foods.  At admission we learned that he consumed nearly a quart of yogurt each day, and also each day drank ten to twenty cups of herbal teas.

His personal physician had seen him regularly for routine health matters.  He prescribed a medication for anxiety.  He had found that his blood pressure was high, and it proved to be somewhat difficult to treat. Three drugs were used in a step-wide fashion during the next 18 months. 

Now, because of the palpitations and weakness, he had gone to the emergency room of our hospital where his serum potassium was found to be 2.2 millimoles per liter.  Such low levels of potassium (hypokalemia) are dangerous and can lead to ventricular fibrillation and death.  He was admitted to the hospital for close observation and treatment. 

Potassium was administered intravenously and his serum potassium level increased somewhat to 2.8 millmoles.  His palpitations disappeared.

His hypokalemia most certainly was the cause of his symptoms, but what was causing his potassium to be so low? As a thiazide had recently been added to his blood pressure medications, the hospital’s clinicians briefly considered that this might be the culprit.  However, he was on an appropriately low dose of the thiazide that ordinarily would not cause this level of hypokalemia. 

Over the next few days he remained markedly hypokalemic despite additional potassium.  Multiple physicians examined him for other conditions that might cause hypokalemia, particularly those which cause hypertension too.

Hyperaldosteronism was one such diagnostic hypothesis.  Although not common, this can be a serious disease.  Hyperaldosteronism is the over production of a salt retaining hormone, aldosterone, which may occur from an adrenal gland tumor or from severe narrowing of an artery to the kidney, i.e., renovascular disease.  Other less common causes of hypokalemia and hypertension were also considered, some of them seemingly benign, such as excessive amounts of licorice in the diet, but the patient denied a fondness for licorice.

After extensive testing, neither hyperaldosteronism nor any other cause was found.  He was a diagnostic puzzle, but, he felt well, and he was sent home when his potassium returned to normal. 

Shortly after discharge, at the request of his in-patient internist, he brought in his herbal teas.  In each licorice root was a major ingredient!  The mystery was solved.

As you recall, he had mentioned at the time of his admission to the hospital that he had been drinking ten to twenty cups of these teas per day for many months.   These were taken to calm his nerves after tense days at the office. Even though they were intrigued by the extraordinary amount of herbal teas that he drank each day, his clinicians were unaware that some herbal teas contain licorice.  He had denied licorice use. 

He stopped drinking the teas.  He was seen again in the clinic thirty days after discharge and he said he felt terrific.  His blood pressure was 104/64 and his serum potassium was 5.1 millimoles per liter.  Antihypertensive medications were reduced and eventually discontinued. 

Eating licorice is an uncommon cause of the syndrome of hypertension and hypokalemia. In the past few decades with the virtual disappearance in the United State of candy that contains true licorice root; it has virtually disappeared.   However, it is important to note that other sources of true licorice root are still available.  These sources, including herbal teas, should be considered in patients with unexplained hypertension and hypokalemia.  

My Mother’s Last Weeks

Madolyn, my 98 year-old mother had been treated for her indolent B-cell lymphoma for about four years, first with neck and mediastinal irradiation and then retuximab.  

To digress from the central story, we were all together for Christmas 2009 in our home on the Oregon Coast when Mom confided to my wife, Beth, that her eyes had become increasingly more swollen each morning.  She now could not see when she awoke.  After she had been up for a few hours the swelling disappeared.  I found that she had prominent lymph nodes in her neck and above the collar bones.  It seemed likely that the mediastinum was similarly involved, and that she had a Superior Vena Cava Syndrome.  This is caused by lymph nodes compressing the veins  in the center of the chest.  A CT scan confirmed this.  She had irradiation and retuximab and the nodes grew smaller.  The neck and facial swelling subsided.

Then all went well until about four years later, when in August of 2013 she noted an increasing mass of lymph nodes in her right upper neck and a mass in the back of her throat on the same side.  She reluctantly consented to another round of irradiation.  The therapist carefully constructed a hard plastic mask that fit over her face and neck.  The x-ray beam was then directed upward from the front of right side of her neck to the mass on her palate. The irradiation was was finished in early October.  

Adamant that she would accept no more treatment, she signed up for hospice care in early November.  In mid-November she complained of fatigue, and she decreased her activities.  On November 16^th she did not get up from bed and had become very somnolent.  She was worse on Monday, and Beth drove to the Coast to help care for her.  She was bedfast and unresponsive.  Beth activated hospice care and a team worked with the family.

   

We had our Thanksgiving meal at the Coast, and Mom was in her hospital bed near us as we ate.  She was unresponsive.

  In early December although still bedfast, she responded to voices and was able to identify us.  She asked “what happened?”.  I had to tell her that I did not know.  She then lapsed back into sleep.  She awoke for sips of water, coffee and custard.  Her somnolence continued and by early February she was unable to take any food or nutrition.  She died February 6^th.

A few weeks later I was making hospital teaching rounds, and an eighty-eight year-old woman was discussed.  She had had total cranial irradiation for lymphomatous meningitis.  Approximately a month after her treatment ended she became somnolent and then unresponsive.  She was now recovering. Her oncologist discussed her case with us and confided that he thought that she had had the syndrome of post-irradiation encephalopathy or somnolence.  My colleagues with me on rounds had never heard of this syndrome, and I had not either.

Post brain-irradiation encephalopathy is more commonly seen in children because they more often than adults get brain irradiation for their leukemias.  It comes on suddenly four to six weeks after radiation therapy.  After a variable time, most  patients recover.   My mother was frail and her prolonged coma made her more frail.  It was not possible for her to recover.