Thorough

A Thorough Physician

My nearly ninety year-old mother was failing.  She had always been more active than her age-defined cohort, she had cooked, quilted, hooked rugs and was a star personality in the local Presbyterian Church.  She was proud of herself:  her skills, her know-how and her energy.  Now she had become too tired, too fatigued to enjoy these skills.  

Although in part we could attribute her condition to advancing age, her internist, an excellent physician, took our observations earnestly; he was by all standards an earnest man.  She may have not complained to him, but I did, and years before I had been his Chief of Medicine and he my Chief Medical Resident (CMR). Our CMR’s were chosen from among their peers to assist the teaching faculty.  Nearly all CMR’s have been luminary physicians both on the wards and in the clinic.

The physical examination, and the routine focused laboratory examinations were normal:  no anemia, kidney failure, diabetes nor an occult cancer, nor evidence for polymyalgia rheumatica.  The thyroid stimulating hormone level was within the normal range. After this thorough inquiry and examination, he had no explanation for her failure. He was earnestly puzzled

Months passed and repeated evaluations showed no change.  Then he retired and a new physician took his place.  She as he before him had been one of our CMR’s.  

While assisting with the transition of Mother’s care, I told her of the downhill trajectory.  Before Mom was see in her clinic, her new physician had reviewed the medical records, and she found no new data, but she reinterpreted existing data:  although the thyroid stimulating hormone (TSH) level had always measured within the normal range, in the last years it had fallen from a high normal to a low normal level.  

TSH, which comes from the pituitary, the master gland, is lowered by thyroid hormone (TH) which comes from the thyroid gland, and in normal events they act in feedback to each other to balance the levels, much like a teeter-totter.  

Using a graphing function embedded within our new electronic medical record (EMR), she tracked a dramatic steady linear decline in Mother’s TSH.  Her observation that the TSH had persistently fallen meant that the TH had probably risen during that same time to a higher level. TH levels are not routinely measured unless the TSH is in an abnormal range.   In response to the trend of the falling TSH, she measured the TH and it was high.  Mom’s thyroid was overriding the low TSH.  The thyroid gland had become an autonomous force not responding to the signal from the master gland that enough was enough.  

My mother had hyperthyroidism, and additional testing and consultation with an endocrinologist, a thyroid expert, confirmed this.

Mother’s condition is known as Apathetic Hyperthyroidism.  It is unusual, and when it happens it is almost always in old people.  The usual presentation of hyperthyroidism has to do with the TH’s stimulation of the sympathetic nervous system, best know as for the production and release of epinephrine.  This explains why hyperthyroidism usually presents with the tremors of sweaty hands, sleeplessness, and overactive reflexes.  It resembles a case of continuous performance anxiety.   In old people, however, the sympathetic nervous system has usually, to a great degree, withered away, and epinephrine is not abundantly released.  Old patients therefore don’t present with the usual outward signs of the condition, but with manifestations common of old age:  loss of weight, loss of energy and apathy. 

My mother’s highest praise for a doctor was that they had been thorough.  She seemed to reserve this adjective exclusively for physicians.  Both of her physicians had met her approval as thorough, and they were.  Her second physician just happened to synthesize a fresh look at old data using a new tool, the EMR.  

Near-Death by Peaches, (Well Perhaps)

A sixty-two year-old woman was admitted to the hospital with hypotension, metabolic acidosis and acute renal failure.  She had been in her usual stable but poor health until two days prior to her admission. 

Because of Crohn’s Disease with colitis she had had a proctocolectomy with an iliostomy seven years prior to admission.  This was followed by persistently high output from her iliostomy, a folate-deficiency anemia, hypocalcemia and hypomagnesium.  She had frequently required outpatient saline infusions because of volume depletion, approximately once weekly.   She required oral supplementation of calcium, magnesium and vitamins.  She recently had had an upper endoscopy with duodenal biopsies and both the gross and the microscopic examinations were interpreted as normal.

 For the two days before admission she had had an abrupt increase in the volume of fluid in her iliostomy bag that she described as profuse and watery.   She also was nauseated, had abdominal cramps that were then followed by leg cramps.  She attar

ibuted this illness to having eaten “too many peaches”.

At admission her blood pressure was 99/64 and the pulse 126.  Her neck veins were not detectable when she was supine, and she was thought to be volume depleted.  The sodium was 136; potassium 3.6; chloride 106; and the bicarbonate 16. The creatinine was 5.2 which  four months earlier had been 2.3 mg/dl.  The anion gap was calculated to be 4.  The serum albumin was 3.1gm/dl.  The venous lactate was mildly elevated at 2.3 mol/L.

She was given large amounts of saline, calcium and magnesium and her vital signs normalized as did her creatinine.  The iliostomy effluent returned to her normal 3 bags per day. 

She wondered if the peaches had been tainted, but others in her household who also ate the fruit disagreed and no one else had had diarrhea, nor did the peaches have an abnormal odor, taste or consistency. 

More likely, the peaches did cause her illness, and this was most likely due to their high sorbitol content.  The average peach contains 3 grams of sorbitol, and she ate four, therefore, she ingested ~12 grams of sorbitol. As a laxative sorbitol is usually given in a 70% solution or 70 grams in 100ml of water, and the usual dose is 30 to 150ml or 21 to 105 grams.  

The sorbitol packed into the four peaches that she ate cannot alone explain her acute illness.  It seemed obvious that something else must be going on.  I suspect that after her colectomy she has developed chronic small intestinal bacterial overgrowth (SIBO). 

People with SIBO have excess production of fermentation products, gases such as hydrogen and methane, and are bothered by gut distention, flatulence, belching and diarrhea.  There is some evidence that the distended small bowel releases cytokines and other vasoactive molecules and that these cause extra intestinal symptoms such as nausea, anorexia, and vague neurologic symptoms often referred to as “brain fog”.

Avoiding easily fermentable carbohydrates ameliorates these symptoms.  These are referred to by the acronym FODMAP for Fermentable Oligosaccharides, Disaccharides, Monosaccharide’s and Polyols.  Sorbitol is a potently fermentable disaccharide and is found in among other foods the so-called stone fruits such as peaches and these are forbidden for people with SIBO.  I believe that this patient has undiagnosed SIBO and that the four peaches abruptly in creased the level of fermentation products in her small bowel.

As it turns out, Crohn’s Disease is regularly associated small bowel bacterial overgrowth and should be considered and a breath test obtained. *  I can find no reliable data about SIBO in patients who have had a colectomy.

*Jochen Klaus,Ulrike Spaniol, Guido Adler, Richard A Mason, Max Reinshagen and Christian von Tirpitz:

Small intestinal bacterial overgrowth mimicking acute flare as a pitfall in patients with Crohn's Disease

BMC Gastroenterology 2009; 9:61

This is a case from the notes that I keep from my Chief Service Rounds.  For these last four years I had been content with the catchy title “Near Death from Peaches” and I did not look into the actual sorbitol content of peaches.  The patient has disappeared from our clinics, and now I need to find her, and to see if my hypothesis can be tested with a breath test looking for excess hydrogen and/or methane after she drinks a solution of a standard dose of a fermentable carbohydrate such as lactulose. 

Brisket Disease

Shortly after moving to the scenic mountain forests of western Arizona, near the border with New Mexico, a friend of mine, a middle-aged woman in previous good health, began to experience progressively worsening shortness of breath with exertion. She had been vigorously active helping her partner tend acreage, and she was unable to keep up this effort.  The altitude of this land is over 7,000 feet above sea level.

She was evaluated by her family physician:  a thorough physical exam, a chest x-ray, and ECG and screening laboratory tests were normal.  He found no cause for her dyspnea.

Her symptoms worsened, and she was referred for pulmonary function tests that were interpreted as normal.  The arterial blood gases were normal for the altitude.

She saw a cardiologist who performed an echocardiogram.  The valves were normal; the ejection fraction was greater than 60%.  There was mild pulmonary hypertension.  She was considered to have become a victim of her own imagination.

I talked to her partner, and I reviewed her medical records, and I suggested that she might have high-altitude pulmonary hypertension, and I recommended that they should try living at a lower altitude.  This idea was resisted until winter when they vacationed in Florida:  after a few days at sea level her dyspnea greatly diminished and then disappeared; it returned when they returned to the mountains.

Her pulmonary artery pressures were never measured, but based on her medical history, I felt, more likely than not, that she had high altitude induced pulmonary hypertension.

It turns out that some humans are more susceptible to hypoxic pulmonary hypertension than is the general population; perhaps she was one of these individuals.

Susceptibility to constriction of the pulmonary arteries when exposed to reduced levels of oxygen is modeled by a dramatically instructive animal condition known as Brisket Disease of Cattle. 

Cattle ranchers with herds in the Rocky Mountains are well acquainted with Brisket Disease of Cattle. As their herds are moved from lower winter pastures that are less than five thousand feet to the high altitude pastures above 7,000 feet in the spring and summer. There, some of the herd, as many as twenty per-cent, develop high altitude pulmonary hypertension and as a consequence failure of the right side of the heart. 

In cattle the congested state caused by right heart failure does not cause swelling of the ankles and legs, known in humans by the archaic term dropsy, instead the fluid gravitates to their most dependent part, the brisket.

Beefeaters recognize the brisket as that cut of meet from the chest muscles, the pectoralis major and minor.  The brisket is the preferred cut for barbecued beef and is used as well for corned-beef and pastrami.  

          

Above, The Bovine Brisket

Below, a Bovine with Brisket Disease

                             

Colorado ranchers take brisket disease seriously because of its grave economic consequences, and in the spring a veterinarian goes up to the high altitude pastures with the herd.   The vet then does a right heart catheterization on each of the bovines, and if the pulmonary artery pressure is at all elevated, these animals are returned to lowland pastures and feed.

Well, my friend never developed overt right heart failure with dropsy, and she was never interested in getting a right-heart catheterization, but the ameliorization of her dyspnea when she lived at sea level, convinced her to avoid the mountains, and they moved to Iowa altitude 1,503 feet above the sea level. 

Recently, while on vacation from their new home they returned to visit old friends in the mountains.  In a few days her dyspnea returned, and they promptly returned to Iowa.  Her dyspnea again disappeared.

Premature End of Life Care

I had returned to the Hospital following my longest-ever vacation, four weeks in Portugal and Southern Spain and was renewing my “management by walking around” skills when I dropped by our Medical Intensive Care Unit (MICU).  There was a buzz in the air, a friend and colleague of mine had just signed-off as the physician of an 87 year-old woman who was intubated and had been on a ventilator for several weeks. 

This was a transitional time in the history of critical-care medicine.  We were moving from open to closed units.  At that time general internists were allowed to admit and care for their own patients with or without consultation with a pulmonologist or cardiologist. Inpatient medicine has evolved, and most MICU’s are now closed, and critical care specialists manage nearly all MICU patients. 

 The day of my visit was during the good-old days of the open unit.  My colleague caring for this elderly woman was an excellent general internist and a truly humanistic individual.  He had been confronted with a seemingly insoluble end-of-life crisis.  He, along with concerned medical and nursing clinicians, believed that her endotracheal tube should be removed so that she could die.  She was unresponsive and a feeding tube, intravenous lines and a bladder catheter were also supporting her.

When I learned that she had no physician, I volunteered to take over her care.  In my formal medical training in the 1960’s there were no critical care units.  Unstable patients were cared for in the usual four-bed rooms.  Curtains separated the beds, the respirators were primitive, but the nurses were the best, although not formally trained in critical care.

Standards have evolved over the last quarter-century:  the physical units changed and now patients have private rooms; there is one-on-one care by specialty trained and certified nurses; the physicians are Board Certified in critical care; there are clinical pharmacists who help manage complex regimens of medications; and respiratory therapists are on site. 

Importantly, healthcare ethics has evolved along with critical care, and the clinicians are familiar with ethical principles.  If necessary, expert consultation is available.  Families are encouraged to come to the bedside and to talk with the nurses and physicians. When I volunteered to help that day, a quarter of a century ago, critical care had impressively evolved, but most certainly not as far as today.

This woman posed an ethical dilemma.  The hospital staff agreed that the current care that was sustaining her life was futile.  Her three children disagreed and wished to continue the intubation, ventilation, nutrition and hydration.  The major family decision-maker was a physician daughter, an academic pediatrician, who lived an inconvenient distance from Portland.  The son was a postal worker and the other daughter was the caregiver for the mother.  Their home was in a pleasant middle-class neighborhood.  End of life decisions had been appropriately delegated to her family, as she had been unresponsive since her admission for pneumonia weeks earlier. 

That was the stage set as I opened the sliding glass door to her room.  At her bedside I confirmed her physical exam, and then I attempted to arouse her:  “Mrs. X wake up…open your eyes”.  There was no response.  I then took a hearing assistance device that resembles an old-fashioned hearing aid from the pocket of my starched white coat, placed the buds in her ears, hooked up the leads and turned it on. 

Again I asked, “open your eyes Mrs. X”, and this time she did.  She looked directly up at me, and I asked her what she wanted.  She bent her right elbow and put her hand to the endotracheal tube and motioned it forward.  It was obvious that she wanted the tube removed.  After consultation with the nursing staff, all agreed that she clearly had the capacity to make decisions for her self.  We did as she directed. 

After we removed the tube she was certifiably awake.  She went home and lived for many months with the care of her daughter and son.

Deafness is a major problem in the care of the elderly.  I have helped manage more than one patient who had been thought demented but instead were extremely hard of hearing, and who, like our seemingly comatose patient, had simply tuned-out of life. 

What Did You Do? Additional "Interesting" Patients

Each Tuesday morning I am honored to talk with patients at their bedside.  I am advantaged to see them after they have been stabilized and are thinking more clearly with less anxiety than immediately after the crises of their admission, and I am not obligated to take a complete history or do a complete exam; I may ask them non-urgent and seemingly irrelevant questions.  My go-to query is to ask what they did for a living, and if a work history seems unlikely, to ask them what they have done with their life.
Nearly all of the patients I see were born shortly before or during the post World War baby boom and are now in their seventies, most often they are retired.  Younger people on our wards often suffer from serious mental illness that has led them to practice the serious use of tobacco, alcohol or more dangerous street drugs.  
Over the years I have made brief note of a few of their memorable answers:

From a playful 70 year-old man, “I made weapons of mass destruction.”  Parenthetically this response came during the half truths about “weapons of mass destruction” formulated and spread by our Nation’s deadly duo, Cheney and Rumsfeld, concerning the nature and the threat of Sadem Hussein’s arsenal.  The patient had worked in Albany, Oregon, at the Wah Chang plant that isolated purified zirconium from beach sand.  Zirconium is used to clad the reactors for our nuclear submarines, indeed a weapon of mass destruction.

A wrinkled eighty-three year-old woman, who had been admitted to the hospital to help with her symptoms of tobacco-related lung disease, was proud that she owned and operated a honky-tonk bar on the outskirts of St Helens, a community that, with tongue in cheek, I refer to as the Appalachia of Oregon.  There on a daily basis she tends the bar. 

An eighty-two year-old Japanese-American woman who remembered that as a teenager she had walked from her family’s village into the rubble of bombed-out Nagasaki two weeks after it had been the target of our second atomic attack.  She apparently had suffered no ill effects.

An eighty-two year-old woman was admitted for acute pyelonephritis and proudly reported that she had smoked marijuana since the mid-1960’s when she had also raised enough for her children.

A frail elderly Jew who had been imprisoned for nine years in a Siberian gulag, ironically he had been arrested almost immediately after the Russians had liberated him from a Nazi concentration camp.

These are stories from the people, the patients, which have strengthened my advocacy for teaching at the bedside.  These stories have allowed the house staff, students and me to recognize additional dimensions of the humanity of those for whom they care.

Gloves---a Touching Story

Gloves---a Touching Story

I have become dedicated to bedside teaching, and by that I mean at the bedside—not outside the patient’s room or at the nursing station or in a room with a white board.  At the bedside, next to patient, hearing the patient’s story and examining him or her often open undiscovered and unexpected insights.

Faith Fitzgerald, professor of medicine at University of California at Davis, wrote of such a bedside experience.  Planning for attending rounds she was told by her house staff that they had “no interesting patients”.  Mildly protesting,  I am sure, the team departed for the bedside breaking through the usual centripetal forces.  They went to the room of an “uninteresting woman” who they discovered was a survivor of the sinking of the Titanic!  The following narrative is not as dramatic but is lovingly instructive.

I am now retired and have the privilege of making teaching rounds each Tuesday morning with an inpatient team:  a teaching hospitalist, a senior resident, a first-year resident, and two medical students.  This Tuesday the group was mobilized reluctantly, as they had “no interesting patients”, and we went to beside of a frail elderly woman recently admitted from a long-term care facility.  She was said to be demented she was immobile, sitting upright in her bed she reeked from the stool in her incontinence pad, her head lolled to the side and her toothless mouth was agape.  Her eyes followed but she did not respond to questions or commands.

We discussed the metabolic derangements and the resulting delirium that had brought her to us.  We examined her head, neck, chest, legs and fingernails.  We discovered nothing unknown.  We returned the bed to a low position and dimmed the overhead lights, and as we moved toward the door, she called us back.  She lifted her head, she opened her eyes, and with her dry tongue spoke “no gloves—no gloves”.  I returned to her side and without gloves I touched her arm, and she said, “No gloves, yes I want to be touched”.

Appropriate touching is important to humans, and even more so for the vulnerable and needy.  It appears that it has become standard to put on thin purple gloves to examine all patients at the bedside.  This seems to have been progressively ongoing for the last thirty years, prompted by the HIV/AIDS epidemic and now MRSA and C. difficle.  Before the mid 1980’s we had gloved on occasion for syphilis, viral hepatitis, various skin infections, and of course the rectal exam.  Now clinicians routinely glove with any expectation of touching the patient, including the physical examination.

Human touch is important.  The literature, old and new, medical and non-medical, has encouraged appropriate touching.  As an example, the late Lewis Thomas, widely read essayist, physician and investigator, wrote in 1983 “…the oldest and most effective act of doctors, the touching.  Some people don’t like being handled by others, but not, almost never, sick people.  They need being touched...”.  This is the lesson relearned from this “uninteresting woman”.



2/6/2017

Priest-Induced PTSD

It was a Sunday summer twilight, just the time to switch on a few lamps, when she asked that we leave the living room couch, which had been our home for hours and days.  Her parents were away, and we had been kissing and fondling--only above the waist.  Her parents were often away, and we often had the house to ourselves for kissing and fondling.
We were young, sixteen and fifteen.  We had been a couple for two years.  Our lovemaking was intense but limited in scope.  It was 1956 and society was still a short decade away from the Sexual Revolution.  Two years before, she had been the white-dressed May Queen of her Catholic parish. She actually had led the dance around the May Pole in the grade school playground. She was the youngest in an impressively Roman Catholic family.  Of the nine children, two were nuns and one a priest.  She was pretty, fresh and clean, my virginal American Dream.
  
I had been raised in this same small town, and my family attended the Baptist Church.  Sex was never actually mentioned in the Church, but you could tell from the people of authority there that they thoroughly disapproved of it and personally did not have much to do with it.  They did publically disapprove of dancing, suggesting that it would lead somewhere.  My mother implicitly endorsed the Baptist manifesto.  She inserted into my mind a series of aphorisms “sex was dirty”, “… was “disrespectful to women”, “would you want someone to do that to your sister?”  A hit song of this period was Love and Marriage with the refrain:  “you can’t have one without the other.”  Yes, I really believed those lyrics---I was a Baptist.

Back in the twilight, while turning on the lights she took my hand and said that she wanted us to go into the bedroom so that the neighbors could not see us.  I agreed without hesitation but with eager anticipation.  Of what, I was not entirely sure. 

The bedroom was dim and cool.  The bed was large.  I took off my shirt and she her blouse and previously unfastened bra.  She pushed me onto the bed and onto my back.  She perched on me and undid my belt and started to unzip my Levis.  

At that very moment all hell broke loose. There was a clap of thunder.   Both the Baptist and Roman Catholic Gods had found us.  The knocking on the front door was thunderous pounding. Voices screamed for her to unlock and open the door.  A face appeared at the bedroom window. 

She blurted out the obvious, we MUST get out.  She pushed me through a narrow hallway to the kitchen toward the back door.  Simultaneously she was dressing as I tucked in my shirt.   And then they were on us, her mother and her brother, Father Tom.  He slammed her back into the wall while getting into my face yelling, “… get out and if you ever come back I will send you so far up the river you will never come back.” Over and over I shouted at him that I cared for her, and that seemed to inflame him further. I retreated, hitting the road home, shaken and sick.  My mother and the Baptist Church were right.  Sex is so wrong. 

A close friend of mine lived across the street from her family, and Father Tom interrogated him about my character.  Perhaps his endorsement kept Father Tom from pursuing me further.  

She was grounded for the spring and summer.  I was only able to glimpse her at the girls’ softball games that were played across the street from her home.  Uncharacteristically I went to many of these games that summer.

With the school year, we resumed dating.  We were delighted to be with one another again.  Soon though, the fall and winter turned weird.  On the way to the first school dance of the year, she came out the door of her home, gripped my hand and pulled me to my family sedan, the 1954 lime green Plymouth Savoy.  She told me to drive away quickly, and I did.  She slumped to the floor, and curled into a fetal position.  She shrieked, “Help me” over and over again.  I quickly found a quiet side street and parked the Plymouth.  As I coaxed her back into the seat she calmed.  She cried, she sobbed, but she could not explain.  She quietly calmed but ignored my questions.

We went on to the dance in the school cafeteria.  We danced holding each other close.  After the dance we found our favorite “parking place”.  We kissed until our lips were sore, and then I took her home.  

The next Friday we went to the dance after the football game.  It was a delight until during a slow dance with a tight embrace her head went back, and she became limp.  I carried her off the floor.  The dim lights prevented others from seeing us.  After some time on the sidelines she recovered but would not talk about it.  We left soon and on the way to the car she murmured “no, no!” and again she slumped to the ground.  Struggling, we made it into the car and onto the front seat.  
These episodes continued during the fall.  In the time between the spells and spasms, she was more or less her old loving self.  And yet, she was not herself.  Gone was the special look in the eyes that love brings.  Gone was the softness of her embrace, gone her appetite for chaste teenage lust.  As before, I didn’t want much but I needed authentic and reciprocal love.  That was gone. 
As the fall turned into winter the behavioral episodes continued.  After yet another dance, I drove to an alley, and we sat with the snow falling around us on the car windows.  I broke-up with her. 
  
I have thought of her a great deal over the last 60 years.  We have learned a large amount about the Post-Traumatic Stress Disorder (PTSD) during this time.  While I don’t know explicitly what happened between her and Father Tom, from my few seconds with him, it is my opinion that she was emotionally abused and perhaps physically traumatized.

When she returned to me that fall I think that she manifested many of the hallmarks of PTSD.    She displayed severe emotional distress and physical reactions when circumstances reminded her of that summer evening, i.e., being close to me.  She avoided talking about what happened after I left and what he did to her, i.e., the traumatic event.  She seemed to have become negative in her thinking and mood.   She seemed unable to experience the positive emotions that had once been her, and in a relative way she seemed emotionally numb.  She was always on guard for danger and was easily startled.  In aggregate, these behaviors now suggest to me that she suffered from PTSD.

Nudging my memories, trying to honestly review our story, has widened my scope of reflections of PTSD.  As stories are told, it is clear that PTSD does not always mean a shell-shocked soldier; it may affect a naïve teenage girl.  The trauma may not come from shells and mortars of battle, but from a sanctimonious brother-priest.