The Power.

 "You always had the power!"  

~ Glenda the Good Witch

My office is next to that of one of the smartest people I know.  My friend and fellow Grady doctor, Lorenzo D., is the kind of scary-smart that makes your eyes narrow and your head hurt at the same time. But the thing about it is. . .he's not obnoxious-smart or annoying-smart at all. He's just a medicine nerd that gets all wild-eyed and foaming at the mouth when a patient comes in with a real puzzler.  And, trust me.  This dude can almost always come up with something very close to striking distance of the diagnosis, and in most instances, he hit the bulls eye.

I like knowing that his office is next to mine because I always learn something when I lean into his doorjamb.

Today I did just that.  I stopped in the doorway and propped an elbow on the frame.  He looked right up and gave a big, boyish smile. Then, he said what he always says.

"What's up, Kim Manning?"

The way he says that always makes me smile--especially the way he runs my name together such that it sounds like "KIMMANNING." 

"Nada mucho," I answered, which is what I always say whether there is something going on or not.

I asked a few residency program related questions and we both commiserated a bit about how behind the eight ball we both were with regards to resident orientation.  Next we got on to the favorite discussion of all medicine nerds -- patient care.

"I saw the most AMAZING case in the clinic yesterday!" Lorenzo exclaimed. "Like, seriously. . .  it was really amazing, KIMMANNING. I almost fainted."

Okay.  Let me just digress for two seconds to mention something that just popped into my head.  No matter who you are, you never, ever want to be the subject of a "great case."  "Great Cases" usually signal badness. . .or such rare and scary things that, by definition, the outcome just can't be good.

Now, interestingly, Lorenzo chose the word "amazing" instead of "great" which immediately made me wonder if it meant that it was not necessarily horrible but more of a stumper.  Looking at Lorenzo's giddy, medicine-nerdy smile I knew I was about to find out.

Fellow medicine-nerd Lorenzo D. today in his office

Lorenzo went on to describe this unusual complaint in a very young immigrant gentleman.

"It was weird. . . . he was seen in a few emergency rooms, and each time they discharged him home. No one could get to the diagnosis. But the why of the story just didn't make sense to me."

He explained that he kept asking the resident physician questions but was having trouble making sense of it all.  "I decided to go in and just repeat everything," Lorenzo said shaking his head.

Next, he told me that the resident seeing this patient was excellent.  I'm sure this (excellent) resident was quite frustrated with his barrage of queries and downright annoyed with the twenty minutes he was about to spend duplicating the entire encounter.

"Has this happened before?" Dr. D asked the patient.  The patient nodded and shared that once or twice this problem happened in his country.  Hmmmm.  After a few more questions he then discovered that this man had lost some sixty pounds--without trying. Not normal.

Next came a careful physical exam.  Then more careful historical questions.  And BOOM!  The light bulb came on in the medicine-nerd light house. He was waving his hands all wild-like as he walked me through the moment when he figured out what was wrong with this patient.

"Man! It was AWESOME!"

He said "awesome" in the Teenage Mutant Ninja Turtles kind of way, or better yet, in that way that is almost always preceded by "totally."

"Dang. I don't think I would have known that, Lorenzo."  And I meant that because this scary-smart friend of mine pulled this diagnosis from way down deep in the cob web part of the senior resident board review section of the brain.

"But you would have been bothered enough to wonder what the heck a twenty-something year old dude was doing with such horrible weakness and unusual labs, for sure.  And then you would have dug deeper and asked questions until you figured it out."

I stepped into his office and sat on the end of the chair across from him and thought about what he was saying.  The more I thought, the more I realized that he was right.  Even if that obscure answer wasn't in my fund of knowledge, I probably would have found it after doing a literature search for things causing this constellation of symptoms, findings and lab values.

Dorothy: "But why didn't you just tell me?"  

Glenda the Good Witch: "You had to learn it for yourself."

When I was a resident, I was rounding with one of my medicine-nerd heroes, Dr. Rick Blinkhorn.  I'd just presented this patient who had fever of unknown origin and a bunch of nonspecific other complaints.  I knew that Dr. B was pretty hard core at the bedside, so I had tried my hardest to come up with a working diagnosis for this patient, but no cigar. I felt like a failure when I finally finished up the presentation with "Assessment:  Fever of Unknown Origin."  Because this otherwise healthy young woman did have a fever, and as for the origin of it, I had no idea.

Now check it.  Dr. Blinkhorn strolled into that room all suave and debonair-like. . .white coat starched so hard it could cut you bad and salt and pepper hair in a signature military buzz. . . .and commenced to show me how to do a sho' nuff and bona fide history and physical. This dude asked questions I never even thought of asking and next did a head-to-toe examination on her that was so fluid and thorough that it made my head spin.

"Let me ask you," Dr. Blinkhorn said to the patient with a furrowed brow, "do you have any pain in your legs?" 

And I remember that this lady prepared her mouth to reply but before she did he added, "Specifically, do you have pain in your thighs?"

And she widened her eyes and said, "You know WHAT? As a matter of fact I do.  It's weird. I told that man in emergency that I had this weird ache on the front of my thighs, but not the back!"

Blinkhorn looked over at me, in front of my whole team of interns and medical students, and said, "Dr. Draper, if I say 'anterior thigh pain and fever,' what should be the next word out of your mouth?"

I squeezed my eyes shut and google-searched my brain for something, anything.  "Influenza? Wait, no that's calf pain. Umm. . .rhabdomyolysis?" I shook my head knowing that it wasn't that, either. "But Dr. Blinkhorn, her muscle markers were all normal so it can't be rhabdo, right?"

He stared me in my eye without flinching.  "Bilateral anterior thigh pain and fever," he repeated.  I held his gaze and shook my head. I had nothin'.  Dr. Blinkhorn knew I was a medicine-nerd so he wouldn't give me the answer.  Instead he turned back to the patient and began inspecting her legs some more.  He removed her socks and studied her feet.  Closing one eye he glanced over his shoulder and asked, "What happened here with your toenail?"

The woman explained that she'd had a pedicure technician that was a bit overzealous while pulling hangnails.  "It was bleeding and everything," she said with a shudder.  "But it's fine now."

After a few more words with the patient, Dr. Blinkhorn put his eyes back on me.  "Anterior thigh pain and fever in a patient who had a distortion in the skin's integrity."

I sighed hard and shook my head.  "I just don't know."

"Find out," he replied matter-of-factly. "Better yet, go check her labs again and you will know the answer."

I knew he had just heard of this patient for the first time less than ten minute before.  What did he mean by, 'Go check the labs?'  I kept staring at him for a beat and then escaped to the nearest computer to recheck the latest labs.  After a few key punches the screen popped up.  Nothing new.

I held my hands up and mouthed, What the hell is he getting at?  Before I could say another word, the area clerk handed me a slip of paper with a "critical lab value."

"Preliminary Result:  Blood Culture two out of two bottles growing gram positive cocci in clusters."

I couldn't take it. I needed to know what he was talking about.  Searching the pre-Google internet, I went to PubMed to enter the search term:  "Anterior Thigh Pain", "Fever", "Bacteremia."

Up popped the answer.  "Anterior thigh pain as an indicator of bacteremia."  Published right there in the Archives of Internal Medicine.

"Damn!"

I immediately covered my mouth, forgetting that I was in earshot of my attending.  Then I said it again as I skimmed the abstract to that article.  The second time, I didn't even bother covering my mouth. This "damn" wasn't a "damn, I should've known that!" kind of "damn" either.  It was a "damn, this dude knew what was wrong with this patient just from the bedside."  Or better yet "damn, when I grow up, I'm TOTALLY going to roll up on a patient's bedside and nail a diagnosis just like this." 

When I went back to Dr. Blinkhorn and told him what I'd learned, he smiled and put his hands on both of my shoulders.  "You're a very good doctor, Dr. Draper, because you're curious. Medicine isn't about knowing everything. It's about being so curious that you hunt until you find the answer."

I nodded and smiled, respecting the Mr. Miyagi and the Jedi Master all up in this moment. Then he added these words of wisdom:

"Stop. Look. Listen. If you do that, you will almost always get to the bottom of what is going on with your patients."

I never forgot those words. Ever.


Turns out that Lorenzo's "AMAZING" case was something completely treatable and reversible.  It was also something that could have been life threatening if someone hadn't stepped in and used the power that you get long before medical school:  To stop. To look. To listen.

***

"Curiosity may have killed the cat, but it saved the patient."

~ A Medicine Nerd (me)