COLD CASE FILESCOLD CASE FILES

REFLECTIONS ON TWENTY REFLECTIONS ON TWENTY FIVE YEARS AS A GENERAL FIVE YEARS AS A GENERAL

INTERNISTINTERNIST

A WALK IN THE WOODSA WALK IN THE WOODS

MUSEMUSE

To become absorbed in thoughtTo become absorbed in thought To wonder, marvel To wonder, marvel Something to do with your head Something to do with your head

between Middleton and EastTowne between Middleton and EastTowne five days a week for the last twelve five days a week for the last twelve yearsyears

Works better with coffeeWorks better with coffee May result in speeding tickets May result in speeding tickets

There are no rules for musingThere are no rules for musing You can muse backwards and forwardYou can muse backwards and forward Sometimes it helps to have a vague idea where Sometimes it helps to have a vague idea where

you are headedyou are headed Everything mused upon for this talk has to do Everything mused upon for this talk has to do

with medical cases I have knownwith medical cases I have known The real meaning of a case may not bubble into The real meaning of a case may not bubble into

your head immediately. Sometimes things your head immediately. Sometimes things happen in medicine that don’t make any sense at happen in medicine that don’t make any sense at all. Sometimes they start to make more sense as all. Sometimes they start to make more sense as time goes by. time goes by.

A case is always in some way about a person and A case is always in some way about a person and another person who just happens to be a doctoranother person who just happens to be a doctor

WHY AM I A DOCTOR ?WHY AM I A DOCTOR ? This is an important question to ask yourself. This is an important question to ask yourself.

Frequently. The answers will sustain you when Frequently. The answers will sustain you when you are mired in concerns about RVU’s and you are mired in concerns about RVU’s and whether ‘tis nobler to prescribe Flonase or Flomax whether ‘tis nobler to prescribe Flonase or Flomax or the formulary drug du jouror the formulary drug du jour

There are times when we all wonder as David There are times when we all wonder as David Byrne from Talking Heads wonders “This is not Byrne from Talking Heads wonders “This is not my beautiful house, this is not my beautiful wife. my beautiful house, this is not my beautiful wife. How did I get here?”How did I get here?”

The answer most often lies in the cases we’ve The answer most often lies in the cases we’ve seen and the situations we find ourselves in.seen and the situations we find ourselves in.

Find time to muse about them. This has been an Find time to muse about them. This has been an interesting exerciseinteresting exercise

MY FIRST CASEMY FIRST CASE

The first case is full of meaning. It is The first case is full of meaning. It is special. Every time it turns over in special. Every time it turns over in our mind it reveals something new.our mind it reveals something new.

I wasn’t a doctor – in fact I had no I wasn’t a doctor – in fact I had no idea I’d become oneidea I’d become one

ABDOMINAL PAINABDOMINAL PAIN

Amar was a twenty seven year old Amar was a twenty seven year old school teacher in Dolakha Nepal. He school teacher in Dolakha Nepal. He became ill with nausea and diffuse became ill with nausea and diffuse abdominal pain. Within 24 hours he abdominal pain. Within 24 hours he was critically ill with gross abdominal was critically ill with gross abdominal distention and excruciating pain.distention and excruciating pain.

The doctor was called.The doctor was called.

ON THE HORNS OF A DILEMMAON THE HORNS OF A DILEMMA

The Peace Corps had a fairly explicit The Peace Corps had a fairly explicit policy regarding medical evacuations policy regarding medical evacuations

I decided to send a message to I decided to send a message to Kathmandu- a short wave telegramKathmandu- a short wave telegram

THE MESSAGETHE MESSAGE

VERY SICK STOPVERY SICK STOP

DYING STOPDYING STOP

SEND HELICOPTERSEND HELICOPTER

THE AFTERMATHTHE AFTERMATH

As Ricky often said to Lucy on the old As Ricky often said to Lucy on the old

“ “I Love Lucy”I Love Lucy”

““YOU GOT SOME SPLAININ’ TO DO”YOU GOT SOME SPLAININ’ TO DO”

LIKE PEELING AN ONIONLIKE PEELING AN ONION

Belief vs KnowledgeBelief vs Knowledge Rich vs PoorRich vs Poor What is a healer?What is a healer? What happens when cultures clash?What happens when cultures clash? What if? What if? Would I do now what I did then?Would I do now what I did then?

I returned home knowing what I wanted.I returned home knowing what I wanted.

TIME MARCHES ONTIME MARCHES ON

Kaiser Foundation HospitalKaiser Foundation HospitalSan Francisco, 1979San Francisco, 1979

JF was a twenty seven year old man who JF was a twenty seven year old man who presented to the ER in respiratory distress. He presented to the ER in respiratory distress. He was diagnosed with pneumocystis pneumonia. He was diagnosed with pneumocystis pneumonia. He recovered and followed up with me in the recovered and followed up with me in the continuity clinic. Four months later he returned to continuity clinic. Four months later he returned to the hospital in respiratory failure and died.the hospital in respiratory failure and died.

We never knew why. We never knew why.

FAST FORWARD-THE TURNING FAST FORWARD-THE TURNING POINTPOINT

Meriter Hospital 1994Meriter Hospital 1994 MadisonMadison

JK was a 29 yo grad student with AIDS. I had JK was a 29 yo grad student with AIDS. I had followed him in the primary care clinic since followed him in the primary care clinic since moving here in 1992. In spite of treatment with moving here in 1992. In spite of treatment with AZT and ddI his CD4 counts declined and he was AZT and ddI his CD4 counts declined and he was admitted to the hospital with jaundice. A liver admitted to the hospital with jaundice. A liver biopsy demonstrated extensive infiltration with biopsy demonstrated extensive infiltration with histoplasmosis. In a last ditch effort to save him histoplasmosis. In a last ditch effort to save him we started amphotericin and a new drug we started amphotericin and a new drug saquinivir obtained on a compassionate use saquinivir obtained on a compassionate use petition. In 1996 JK moved to Florida to start a petition. In 1996 JK moved to Florida to start a business with a friend.business with a friend.

AIDS TIMELINEAIDS TIMELINE

AIDS TIMELINEAIDS TIMELINE 1978 11978 1stst signs in US, Sweden, Haiti of the disease which is to signs in US, Sweden, Haiti of the disease which is to

become AIDSbecome AIDS 1981 June, 5 gay men die in LA of Pneumocystis pneumonia. On 1981 June, 5 gay men die in LA of Pneumocystis pneumonia. On

July 4July 4thth 26 cases of Kaposi Sarcoma reported. In 24 months 8 had 26 cases of Kaposi Sarcoma reported. In 24 months 8 had dieddied

1982 CDC links disease to blood, press secretary to President 1982 CDC links disease to blood, press secretary to President Reagan joked about AIDS, and President Reagan hadn’t yet Reagan joked about AIDS, and President Reagan hadn’t yet mentioned AIDS in public. 853 deaths attributed to AIDS.mentioned AIDS in public. 853 deaths attributed to AIDS.

1983 HIV Virus isolated. 2304 deaths attributed to AIDS. President 1983 HIV Virus isolated. 2304 deaths attributed to AIDS. President Reagan hasn’t mentioned the word AIDS in public.Reagan hasn’t mentioned the word AIDS in public.

1985 HIV antibody test. 5636 deaths. President Reagan mentions 1985 HIV antibody test. 5636 deaths. President Reagan mentions AIDS for the 1AIDS for the 1stst time-when asked about it at a press conference. time-when asked about it at a press conference.

1986 President Reagan mentions AIDS in a message to Congress. 1986 President Reagan mentions AIDS in a message to Congress. Surgeon General Koop released a report on AIDS calling for sex Surgeon General Koop released a report on AIDS calling for sex educationeducation

1989 AZT released. Ronald Reagan in an address to the ACP finally 1989 AZT released. Ronald Reagan in an address to the ACP finally calls AIDS “Public Enemy #1”calls AIDS “Public Enemy #1”

TIMELINETIMELINE 1990 Ronald Reagan apologizes for his neglect of the 1990 Ronald Reagan apologizes for his neglect of the

epidemic during his Presidency.epidemic during his Presidency. 1991 ddi introduced. FDA starts accelerated approval 1991 ddi introduced. FDA starts accelerated approval

process for new drugs in the pipeline. AIDS deaths in the US process for new drugs in the pipeline. AIDS deaths in the US 20,454.20,454.

1992 ddc.1992 ddc. 1993 d4T.1993 d4T. 1995 Saquinavir 11995 Saquinavir 1stst Protease inhibitor released. Protease inhibitor released. 1996 Nevirapine, Ritonavir1996 Nevirapine, Ritonavir 1997 Annual AIDS deaths dropped in the US. By this time 1997 Annual AIDS deaths dropped in the US. By this time

AIDS is a global epidemic with AIDS deaths at 6.4 million AIDS is a global epidemic with AIDS deaths at 6.4 million and over 22 million with known HIV infection.and over 22 million with known HIV infection.

2002 Cumulative deaths in the US. 2002 Cumulative deaths in the US. 2005 World AIDS Day. 40 million infected worldwide. In US 2005 World AIDS Day. 40 million infected worldwide. In US

14000 die each year. Worldwide 3 million people die each 14000 die each year. Worldwide 3 million people die each year- almost 6 people every minute.year- almost 6 people every minute.

A CASE OF CRUEL IRONYA CASE OF CRUEL IRONY

Kaiser Foundation HospitalKaiser Foundation HospitalSan Francisco 1979San Francisco 1979

Chan was a 32 yo Chinese immigrant diagnosed Chan was a 32 yo Chinese immigrant diagnosed with promyelocytic leukemia who practically lived with promyelocytic leukemia who practically lived in the hospital during my internship year. I spent in the hospital during my internship year. I spent hours with him when things were slow or when he hours with him when things were slow or when he was undergoing yet another transfusion or fever was undergoing yet another transfusion or fever crisis. What I’ll never forget is his stoicism in the crisis. What I’ll never forget is his stoicism in the face of pain and more importantly in the face of face of pain and more importantly in the face of death which was inevitable and cruel given all death which was inevitable and cruel given all that he had endured to be there.that he had endured to be there.

Remembering ChanRemembering Chan

Chan was orphaned as a young boy. He had been born a Chan was orphaned as a young boy. He had been born a peasant in mainland China. He lived by his wits and made peasant in mainland China. He lived by his wits and made his way to Kowloon by the time he was fourteen. He his way to Kowloon by the time he was fourteen. He describes staring over the strait between Kowloon and describes staring over the strait between Kowloon and Hong Kong, marveling at the lights and dreaming of Hong Kong, marveling at the lights and dreaming of freedom and prosperity. One night he couldn’t stand it any freedom and prosperity. One night he couldn’t stand it any more-he dove in and swam over a mile to arrive in Hong more-he dove in and swam over a mile to arrive in Hong Kong.Kong.

A few years later he started to dream again and paid all A few years later he started to dream again and paid all his savings to stowaway in a container destined for his savings to stowaway in a container destined for America. All alone he worked and worked and finally America. All alone he worked and worked and finally opened a small tourist shop in the city. He met a girl and opened a small tourist shop in the city. He met a girl and married. He got a green card and dreamed of becoming a married. He got a green card and dreamed of becoming a citizen.citizen.

In 1979 he became ill and in less than a year he was In 1979 he became ill and in less than a year he was deaddead

Greg 1985Greg 1985

18 yo boy presented to my office 18 yo boy presented to my office with a cough and weight loss. CXR with a cough and weight loss. CXR revealed hundreds of pulmonary revealed hundreds of pulmonary nodules. Physical exam revealed a nodules. Physical exam revealed a small tender nodule in the testicle.He small tender nodule in the testicle.He received a platinum based regimen received a platinum based regimen and would have miraculous brief and would have miraculous brief remissions but finally died after a remissions but finally died after a difficult year. I was invited into his difficult year. I was invited into his home and was there when he died.home and was there when he died.

Testicular CancerTesticular Cancer

In 1970, 90% of patients with In 1970, 90% of patients with metastatic disease died of their metastatic disease died of their cancercancer

By 1990, 90% are curedBy 1990, 90% are cured

GA 1987GA 1987 76 yo had retired to Tucson after a life as 76 yo had retired to Tucson after a life as

a petroleum attorney in Oklahoma City. He a petroleum attorney in Oklahoma City. He had grown up on a poor ranch in had grown up on a poor ranch in Oklahoma, worked on wildcat rigs, fought Oklahoma, worked on wildcat rigs, fought in WWII, and studied under the GI Bill. In in WWII, and studied under the GI Bill. In his spare time he wrote pulp fiction and his spare time he wrote pulp fiction and was looking forward to this in retirement. was looking forward to this in retirement. At our 1At our 1stst meeting I noticed mild jaundice. meeting I noticed mild jaundice. Workup revealed a hepatoma which Workup revealed a hepatoma which turned out to be wildly anaplastic. He died turned out to be wildly anaplastic. He died in three months. I still treasure an in three months. I still treasure an autographed copy of “Ambush at Cibecue autographed copy of “Ambush at Cibecue Creek.” Creek.”

Mabel 1982- A Curious Case of Mabel 1982- A Curious Case of Chest PainChest Pain

Mabel was a jolly 60 yo obese street person Mabel was a jolly 60 yo obese street person who used to show up in my resident’s who used to show up in my resident’s clinic at the old County Hospital in clinic at the old County Hospital in Milwaukee. She was in remarkably good Milwaukee. She was in remarkably good health but every now and then her social health but every now and then her social worker would drag her in for a “check up”worker would drag her in for a “check up”

On this particular day she actually had a On this particular day she actually had a complaint- a sharp intermittent pain on complaint- a sharp intermittent pain on the right side of her chest.the right side of her chest.

A CASE OF SYNCOPEA CASE OF SYNCOPE

32 yo burly construction worker 32 yo burly construction worker presented to my office with a presented to my office with a complaint of mild urinary urgency.complaint of mild urinary urgency.

An Unusual PresentationAn Unusual Presentation

OP was a 52 yo man who was brought OP was a 52 yo man who was brought into the Milwaukee County ER by a into the Milwaukee County ER by a bus driver who noticed him never bus driver who noticed him never getting off the bus. He found him getting off the bus. He found him with a sign hanging from his neck.with a sign hanging from his neck.

THIS MAN CAN’T TALK OR THIS MAN CAN’T TALK OR NOTHINNOTHIN

CULTURE SHOCK?CULTURE SHOCK?

78 yo Vietnamese woman presented to my office 78 yo Vietnamese woman presented to my office on referral from a friend. She was confused and on referral from a friend. She was confused and lethargic and was admitted to the hospital where lethargic and was admitted to the hospital where we found her to be quite hyponatremic. We did a we found her to be quite hyponatremic. We did a fairly standard workup and suspected SIADH due fairly standard workup and suspected SIADH due to recent infection. Her serum sodium responded to recent infection. Her serum sodium responded to treatment but she wouldn’t wake up.to treatment but she wouldn’t wake up.

She developed some peculiar signs that She developed some peculiar signs that suggested catatonia and ultimately responded to suggested catatonia and ultimately responded to antidepressants and Seroquel.antidepressants and Seroquel.

A CAUTIONARY TALEA CAUTIONARY TALE

67yo physician was admitted to 67yo physician was admitted to Meriter Neurology service with a Meriter Neurology service with a complaint of dizziness. MRI revealed complaint of dizziness. MRI revealed a solitary lesion at the right occiput. a solitary lesion at the right occiput. He asked me to assume his internal He asked me to assume his internal medicine care. Metabolic workup was medicine care. Metabolic workup was negative, alk phos minimally negative, alk phos minimally elevated, and PSA normal.elevated, and PSA normal.

The Case of the Sleepy ArtistThe Case of the Sleepy Artist

CM was a 60 yo water color instructor from CM was a 60 yo water color instructor from the University of Arizona. When I first met the University of Arizona. When I first met her she made it known that she didn’t care her she made it known that she didn’t care much for doctors. They had never treated much for doctors. They had never treated her well and never helped her much her well and never helped her much anyway. She fell asleep right in my office. anyway. She fell asleep right in my office. Her TSH was 180 and her polysomnogram Her TSH was 180 and her polysomnogram revealed severe OSA and desats into the revealed severe OSA and desats into the 60% range much of the night. I was to 60% range much of the night. I was to learn the power of CPAP and thyroxine.learn the power of CPAP and thyroxine.

WHY BECOME A GENERAL WHY BECOME A GENERAL INTERNISTINTERNIST

10. There are a million stories in the Naked City and these are some of them.10. There are a million stories in the Naked City and these are some of them.9. What could possibly be more interesting?9. What could possibly be more interesting?8. You will be privy to the innermost thoughts, hopes, and concerns of those 8. You will be privy to the innermost thoughts, hopes, and concerns of those

patients you engage with.patients you engage with.7. Every day you will work with wonderful colleagues who share your devotion 7. Every day you will work with wonderful colleagues who share your devotion

to the care of patients and the teaching of students.to the care of patients and the teaching of students.6. You’ll meet and come to know people from all walks of life and every corner 6. You’ll meet and come to know people from all walks of life and every corner

of the globe.of the globe.5. As a generalist you can learn something new and different every day. For as 5. As a generalist you can learn something new and different every day. For as

they say about subspecialization, the more you know about less and less they say about subspecialization, the more you know about less and less the less you know.the less you know.

4. You can take care of more than you think you can and can resist having that 4. You can take care of more than you think you can and can resist having that caregiving taken away from you. You can reclaim being the primary care caregiving taken away from you. You can reclaim being the primary care giver.giver.

3. The more you give the more you get. You can become very rich in the most 3. The more you give the more you get. You can become very rich in the most important ways.important ways.

2. The essential part of the job doesn’t change. You begin to work when the 2. The essential part of the job doesn’t change. You begin to work when the exam room door closes and you greet your patient. You never know where exam room door closes and you greet your patient. You never know where that conversation will take you.that conversation will take you.

You will always have something to You will always have something to muse aboutmuse about

25 years was spent preparing this 25 years was spent preparing this talk and at least half of it was talk and at least half of it was

(a)musing(a)musing

Level 4Level 4