Читать книгу Who's Killing the Doctors? II - Alex Swift - Страница 15

A very handicapped young girl with Down’s syndrome who resided in a group home had had seizures since her first year of life. Her parents were unable to care for her and Social Services took over her residence and all her needs. At some point at the age of 6, after she had been followed for years in the University Hospital Pediatric Clinic by Dr. Carlo Porky -due to ‘not getting along issues’ between him and the group home's staff- they asked Dr. Martin if he would take over the care of her seizures. Though she was covered by Medicaid -of course- and the reimbursement was for Dr. Martin at a loss both (for the periodic visits AND for her EEGs) he agreed to see her. Bertie Bones was her name (changed, of course; she is print #18 in the non-fiction book FRANKLY, to which this is its Sequel).

She was no problem and her seizures (Grand Mal) were not very frequent. She was then on Phenobarbital and Tegretol. He figured he would need to see her no more often than once every 6 months… But not too long after that, she began to have the spells every month, almost by the clock; and they started to be harder and longer… When they called him from the group home he suggested that they bring her to the E.R. He saw her as such a couple of times. No significant changes were made except a minor adjustment of her meds. In a third similar visit to the E.R. her physical exam revealed no significant changes from her basic Down’s condition; but her blood work was… fine… except -unusual!- that of her electrolytes, her serum Sodium (= her Na+) was a bit low; it is normally in all of us around 140 mEq/L, but hers was only 130 mEq/L. It is known that low Sodium (called by doctors hyponatremia) can cause seizures, especially it it dips down to the 120s. She was admitted to the pediatric ward, upstairs. Dr. Martin would be her attending for her seizures and the pediatric residents would monitor any general care needs.

With her law Na+, and with no apparent reason for it, the peds resident called the Pediatric Endocrinology attending who came to see her with his team (a resident and two students). Extra tests of her adrenal and kidney functions were done. He thought that the Tegretol she was on, was most likely the cause of her low Sodium. But with the girl being unusually small and slender, even for a child with Down’s syndrome, Dr. Martin ventured that she might have mild adrenal insufficiency causing the drop in her Sodium and that a pinch of steroids taken on regular basis might be what she needed. The endocrinologist shook his head. ‘I don’t think so, Frank. I think it is just from her Tegretol.’

No big deal: ‘Why don’t you switch her to a different drug for her seizures?’ So our compliant Dr. Martin switched her from Tegretol to Dilantin and he discharged her… It was all well… but like previously, in another month exactly she had another, big and long Grand Mal seizure. Back to the ER, her serum sodium was again low, this time even lower, just 126 mEq/L. She was again admitted to the floor. Her anticonvulsant blood levels were fine. This time Dr. Martin mentioned in somewhat stronger terms that she probably had adrenal insufficiency and instead of changing her anticonvulsants again, suggested to start her on Prednisone. Without listening to Dr. Martin for that, the peds resident called again the endocrinology team. And again the big guru balked, shaking his head: ‘This is NOT adrenal insufficiency Frank! Try her on something else.’

So again Dr. Matin cowed and went along against his gut feeling, took her off the Dilantin -though this drug is not supposed to change sodium serum levels- and placed her on Depakote instead. ‘Perhaps the next time this happens I’ll see her just myself in the E.R. without bringing her to the floor and I’ll be the one in charge!’ he thought.

And as he anticipated, exactly again a month later, our little Birtie Bones had another huge seizure. This time, when he brought her to the E.R. he kept her there without calling the pediatric resident for an admission. Her serum Sodium was again low, at about 127 mEq/L. This time, once her seizure was stopped (with I.V. Diazepan, that is Valium), he started her as he had suggested earlier, on steroids. ‘Steroids insufficiency’ -that is, adrenal- is commonly accompanied by a low Sodium level. It was NOT a crazy thought of his. She was fairly small, nearly squalid, and his hint of an insufficient adrenal gland was not off the wall. So he placed on just 10 mg of Prednisone by mouth to be given initially daily, every morning, but just for 10 days. Then that would be cut back to just every other morning, equivalent to 5 mg daily – steroids cause less side effects -if given on long term basis- when they are taken just on alternate days.

So he ordered, no one there to tell him no, and so it was done.

And it worked! She went for three months without any seizures. When then he saw her in the office without going to the ER (as she was no longer having spells) he even dared to take her off the Dilantin and leave her on the older Phenobarb… plus he kept her of course on her steroid, Prednisone 10 mg by mouth every other day!

He had been right in spite of his fellow academicians. In retrospect, Dr. Martin could have reported the case -and his management- to a medical journal, but he decided not to. It had been indeed quite an unusual case and going by just his gut feeling against his colleagues had worked!

On the negative side, though he had kept quiet about his management of the little girl’s seizures with Prednisone and did not tell the pediatricians on the floor, his unusual management of the girl’s seizures with a steroid was reported to them by the visiting nurse who checked the group home weekly. Eventually the news reached also by word of mouth the pediatric endocrinology attending who had opposed the steroids. He was outraged, of course. And Dr. Martin’s precarious reputation amidst his academic colleagues only got worse; eventually it would damage him beyond help.