Читать книгу Revenge - Sheldon Cohen - Страница 8

“Hi, Betty. Anything happen since we last spoke?”

“No change,” she reported. “The seizures stayed under control with the Diazepam 20. His pulse rate increased to 128, regular, and his last blood pressure was 114 over 60. He hasn’t regained consciousness.”

“Good description.” Pollard turned to the medical students and told them, “They found this man after he was missing for two days. Most unusual.”

He was about to speak again, but he glanced at the patient lying unconscious on the table and froze. He shook his head. He seemed unsure of what to do next, an unusual state of mind for this self-assured physician. He took Cowan by the arm, took her to a corner of the examining room and whispered something in her ear. As he did so, she turned to look at the patient and the same type of startled look crossed her features.

Pollard took a position on the patient’s right side. The medical students stood next to the patient’s cart on his left side. Pollard took his thumb and placed it on the patient’s bony ridge above his right eye. He pressed hard, but there was no response from the patient. Without looking up at the students he said, “Do you know what I’m doing?”

“Testing the patient’s response to pain stimulation,” said Amanda.

“Right. Am I getting a response?”

The students observed the patient while the pain stimulus continued. He did not move or wince. “No,” they said together.

“Right. What does that tell you?”

“The coma is deep.”

“Good. We have the history of seizures and high fever. That’s all the history we have, except for the fact that he was missing for two days, plus we just learned he’s in deep coma by his failure to respond to intense pain. What should I do next?”

Before his students could answer, he placed his hand under the patient’s head and tried to flex the neck. The unconscious patient’s hips and knees flexed. “What do you call that sign?” asked Pollard.

The students looked at each other and remained silent.

“Brudzinski’s sign,” said Pollard, and in a non-deprecating manner he added, “Did you forget all your physical diagnosis already?”

He then flexed the patient’s right leg at the hip and then attempted to flex the patient’s right knee, but had difficulty as he met considerable resistance.

“And what do you call this sign?” Hearing nothing he added, “Kernig’s. You’ll never forget these signs now. What we read about we easily forget. What we witness or perform ourselves we never forget. What are these two classical signs indicative of?”

“Meningitis,” said Barry.

“What causes those signs you just witnessed?” Pollard asked.

“Meningeal irritation?” asked Barry.

“Close enough. It’s thought to represent irritation of motor nerve roots as they are put under tension and pass through inflamed meninges. At this point, I have to confirm this strong index of suspicion of meningitis because we need to identify the organism causing this disease. We have made a clinical diagnosis, and that diagnosis is important and serious enough that we have to confirm it and start therapy. We have no time to lose. How will I confirm it?” he said.

Pollard continued his methodical way of examining the patient while talking to the students without looking in their direction. Here was a man focused on the task at hand. All other thoughts suppressed as his mind and hands worked in close collaboration like the first violinist in a symphony orchestra.

“You do a spinal tap,” said Amanda.

“Perfect,” he said.

Gail entered the room at that point and Pollard, out of the corner of his eye, saw her coming. “Gail, I’m going to need a spinal tap tray stat.”

“Here it is.”

Again, without looking up, he said, “You see. Now do you believe what I said about her before?” He winked at Gail. “She knows what I’m going to need before I know it. I’ll need the usual blood work up. A complete cbc, and full profile stat plus an immediate blood culture times two.”

“Yes, doctor. The lab’s on the way.”

Then he reached for an ophthalmoscope and looked into the eyes of his patient. “Why am I doing this?” he asked.

There was no answer.

“I’m trying to rule out evidence of a mass lesion that would cause severe enough increased intracranial pressure making a spinal tap hazardous. It could cause a cerebellar herniation if I relieve some pressure doing the tap. I get a rough estimate of the pressure by looking at the optic disc.” Examining as he talked he continued, “No. There is no papilledema, or swelling of the optic nerve disc. Does that rule out a brain tumor?”

Both students looked at each other, but no answer came forth.

“The answer is no,” said Pollard. We don’t have time for a CT scan. We’ve got to act fast.”

The students felt the tension. It was clear that Pollard was dealing with life or death.

With the patient positioned on his left side with hips and knees and chest and neck flexed as much as possible, Pollard asked Barry to hold the patient in that position. Pollard sat down facing the patient’s lumbar area. Before he performed the tap, he noted a half-inch superficial abrasion exactly at the insertion site. It appeared recent. There was a spot of dried blood present.

I wonder what that’s doing there? Has he seen a physician? Could he have hurt himself? I’m sure that’s it. I have to go in close to the abrasion, he thought. There’s enough viable and healthy skin that will enable me to miss it. Good enough. I’ll use plenty of antiseptic.

He took the long spinal needle and inserted it between the spinous processes. Normally the cerebrospinal fluid is crystal clear, but when he took the trochar out of the hollow spinal needle he noted that the emerging fluid was very cloudy and the pressure by manometer was 280 (normal 100-200). He collected the fluid in several test tubes and said, “We’ve just confirmed our clinical diagnosis: meningitis it is.” He held one of the test tubes of fluid up to the light and shook it so the students could see the marked cloudiness. “If I did a spinal tap on either of you right now, the fluid would be crystal clear. What does the cloudiness represent?” He asked.

“Bacteria,” said Amanda.

“Or fungus, perhaps, or malignant cells. I’m sure you’re right, but the lab will confirm this soon. Gail, take these tubes and send them to the lab. We need a culture for bacteria, Tb, and fungus. Do a gram stain for bacteria, and an acid-fast stain for Tb, and an india ink for cryptococcosis. Get a cell count, glucose, and protein. Read it back please.”

Satisfied, he said, “Okay, we’re done. Let’s go write treatment orders and call his personal physician if he’s got one. If not, we’ll get hold of the internist on call. We need to keep the patient on his side now and put up the guardrails. He’ll have to be admitted to Intensive Care stat. His situation is urgent. Let’s move.”

When they arrived at the nurse’s station, he told the two medical students to go to his office and wait there for him. When he was sure they left, he turned to Gail and said, “Do you believe what just happened? Are we being cursed?”

“What a shock,” she said shaking her head. “Why the heck would Dr. Spann get meningitis?”

Pollard shrugged his shoulders. “You’re guess is as good as mine. Most of the time we see meningitis in college epidemics, or in ill patients with some underlying disease process and/or a compromised immune system. We both know this man. He was in great shape as far as I knew. But that’s what medicine is all about…one surprise after the other. And the truth of the matter is that with his depth of coma we’re dealing with a very poor prognosis. Now we’re confronted with the second physician from the Medical Executive Committee; the first one, Harrison, dead, and Dr. Spann in extremis. What the hell’s going on?”

“My God, you’re right. This has been a terrible few days,” said Gail. “Two Medical Executive Committee members; one dead and one dying. I can’t believe it.”

Pollard stared down at the floor and rubbed his forehead with his right hand. After a short while he said, “Were you able to get hold of his wife?”

“Yes, I did, and what a story I got. She told me he went out to the pharmacy two nights ago, and he never returned home. When he didn’t return the first night, she called the police and they told her they couldn’t do anything until someone was missing for twenty-four hours. I suppose they figured another wayward husband out on a fling. But she called again after an hour had passed, and the police interviewed her and put out a search for him. This morning a motorist saw a car parked on an off ramp with a man slumped over the wheel. He called the police and they called the paramedics and that’s when we came in.”

“So the wife will be here soon?” asked Pollard.

“Yes, in about thirty minutes.”

“Did she tell you who his doctor was?”

Gail responded, “She said he had a complete physical from Doctor Baehler not too long ago. I called his home and his wife says he’s on the way to the hospital. I was just about to call his cell.”

“Go ahead. See if we can get him. Let me talk to him,” said Pollard.

As it turned out, he was only a few minutes from the hospital when he received the call. “John?”

“Jason? If I’m hearing from you first thing in the morning I’ve got a feeling I’m in for a bad day.”

“Your patient, Arnold Spann, was just here.”

“Arnold? Was just there…in the emergency room?”

“Yes, he’s on his way to Intensive Care and I’ve put him in isolation.”

“Oh boy, give me the bad news.”

“Oh boy is right. He’s got a fulminating meningitis and is in extremis.”

“You’re kidding.”

“I wish I was.”

“Why the hell?” said Dr. Baehler.

“That’s the big question. Has he been sick? Is he immunosuppressed?””

“No. I only saw him for a general physical not too long ago. He was in great shape. This is unbelievable.”

“You haven’t done a spinal tap lately?” said Pollard thinking of the abrasion he identified.

“No way.”

“Did you refer him to a neurologist?”

“No. Why do you ask?”

“He had an abrasion on his back by L4 and for a moment I thought it might have been from a recent tap, but I’m sure he just injured himself.” Pollard continued, “His spinal fluid was confirmatory. It looked like pure pus. The pressure was elevated. He had seizures and is in deep coma. This is a bad prognosis. I would call infectious disease stat.”

“Okay, I’m pulling in to the parking lot. Thanks, Jason.”

“You’re welcome. All the lab work is pending. His wife is on the way to the hospital. After I speak with her, I’ll send her up to Intensive Care. Good luck. Keep me posted, please.”

Pollard hung up the phone and drew a big sigh. “Gail, I’m going to the office to talk to the students for a few minutes. Bring Mrs. Spann to me when she gets here, please.”

He entered his office, his head down and his right hand still stroking his forehead. He sat down and looked at the students, their eyes burning a hole in his forehead. He said, “We don’t often start our day with such a bang. If you noted surprise registered on my face it was because I happen to know this patient. He is a physician and a member of the Medical Executive Committee. He paused. “But let’s get on with what you could learn.”

They spent five minutes discussing the various types of meningitis: bacterial, viral, fungal. They reviewed the typical symptoms and signs, the confirmatory tests, the treatment, and the prognosis.

Then Pollard said, “But I have a bigger question for you to ponder. Why the heck did he get meningitis in the first place? Before I came back to the office I spoke to his physician who said that he was a very healthy man and enjoyed good health.”

“Will we ever know?” asked Amanda.

“I hope we find out by means other than autopsy, but we may not. Believe me at this point it’s very confusing. You saw me examine his ears nose and throat because I was looking for a source of infection. You saw me checking the whole length of his vertebrae as well for the same reason. There are two ways that bacteria can reach the meninges: first by extension from nearby infections, such as from sinuses, nose, throat or ears, or along the vertebrae such as an epidural abscess; second by hematogenous spread, that is by reaching the meninges through the blood stream from some distant site. I couldn’t find any obvious source from either route. Granted I was in a hurry to examine him and so I didn’t do a thorough detailed exam. It’s a mystery, but we can’t let pondering about a source stop us from starting a full course of treatment. This man’s life is at stake.”

At this point, the phone rang in his office. He picked it up. “Hello. Oh good. Let’s hear.” His right hand again stroked his forehead. “Staph? How much? Okay thanks. His wife not here yet? Bring her in the minute she gets here. Yes, call Baehler now. He should be in Intensive Care. Bye.” He leaned back on his swivel chair.

“That was Mrs. Cowan. The gram stain is back. The bacteria are staph. Could you believe it? Staph aureus. That’s very unusual and at the same time very bad. We’ve discussed the more common organisms. Also, his complete blood count is back, and it’s normal except for a four thousand white blood cell count. You remember the normal? What is it?

“Five to ten thousand.”

“Correct.”

“It should be high because of the infection,” said Amanda.

“Yes, that’s right,” he said. “So what does a reduced white blood count tell you?”

“Could it be a lab error?” asked Barry.

“Not much chance. These tests are all automated and it’s near impossible to make a mistake.”

“If it’s accurate then I would think that for some reason he’s unable to launch a white blood cell response. Is something wrong with his bone marrow?” said Amanda.

“Probably not,” replied Pollard. The blood count and the platelets are within normal limits, so that tells us that the bone marrow is capable of manufacturing those cells. But you’re on to it. He has a reduced white blood cell count in the face of a severe infection. One would expect a count of twenty, thirty thousand or more in a case like this. The bone marrow is working overtime launching white cells to attack the invading bacteria. This has been such a massive effort that the bone marrow can’t release any more white blood cells, and when that happens it is a very poor prognostic sign. It means that he is no longer able to utilize his first line of defense: his white cells. Without those, it wouldn’t surprise me if the bacteria take over and this patient is now in septic shock. Without white cells you can replace his blood with antibiotics and it won’t make a difference.” He sighed and got up from his chair.

As the students stared wide-eyed at Pollard he said, “In the Emergency Department things don’t grind to a halt after a gut wrenching experience. Let’s get back to work.”