Archive for September, 2020

TRYING TO AVOID PITFALLS

September 26, 2020

A recent article in the medical section of the Times told the story of a man with chronic buttock pain who ended up with being diagnosed with Crohn’s disease with sacroiliac arthritis. 

It only took 10 years. The cause was discovered by accident when the man had a colonoscopy and an alert GI doc noted that the ilieocecal valve was scarred. He passed the scope further into the distal ileum and found inflammatory changes consistent with Crohn’s disease. The patient has since done well with strong anti-inflammatory agents. He had never had overt symptoms of Crohn’s. So many of the things I once learned in medicine have been shown not to be true, or to be different from what I originally had learned. So many of the conditions that were once untreatable now are. 

I remembered from medical school being told that a barium enema (which is how we imaged the colon back then) had to reflux into the ilium or the appendix to be able to say it was complete. It’s not enough to say the cecum—the beginning of the large bowel— was viewed.  What looked like the wall of the cecum in one instance was a large tumor. Had one not looked for the appendix, which was impossible in that situation, or the ileocecal valve, which was very difficult to find, the tumor itself might not have been appreciated.  Cecal tumors themselves are difficult to pick up.  I learned that lesson.

I thought of the good specialists who told us medical students about conditions in their field we didn’t want to miss. That bailed me out in my internship the night I examined a scrub nurse in the ED with a scalpel wound to the palm of her hand.  Everything looked fine; she could move everything and feel everything, and there was minimal bleeding.

I called the hand surgeon anyway. I had learned that puncture wounds of the palm were dangerous.  He came in, thanking me for calling him.  A few weeks later, I happened by the nurse, who took me aside and thanked me for saving her hand.  I was surprised and asked her what happened.

“I had a significant hematoma drained,” she said. “Had nothing been done quickly, I could have lost significant function and might not be able to work. Thank you.”  I had forgotten about that day.

Or the patient who complained of something in his eye where nothing was found. I either had to find the object, find a corneal scar, or call an ophthalmologist.  Something was wrong until proven otherwise when a person complains of a sensation that something is in his eye.

Or the Fireman 1/c on board my ship, who had a red eye that might have passed for conjunctivitis, except the inflammation encircled the iris. He had acute iritis, and I had to treat him with steroid eye drops. Iritis is not something one wants to miss. I would never see another case. But I found that one.

Or the patient with progressive loss of vision that was felt to need glasses.  The only problem was that the pupil had a very poor reaction to light on that side, but reacted briskly when light was shone into the other eye.  This meant the optic nerve was compromised, called an afferent pupillary defect, since the afferent pathway is involved.  In this instance, the patient had a meningioma compressing the optic nerve. Another trick to screen for optic nerve disease is to look for red desaturation, have the patient compare the degree of redness with each eye. The afflicted eye will not see the red nearly as bright.

It can also work in reverse.  Many with poor visual acuity may have remarkable improvement looking through a pinhole, which can be easily made. When such improvement occurs, the visual problem is always refractive, for visual defects of optic nerve origin do not improve by looking through a pinhole.

Or the man I saw in the Morenci, Arizona clinic, 3 hours’ drive from Tucson, whose neurological exam was fine, but he had a soft lump on his cheek. These look like sebaceous cysts that should be drained, but I was taught well about parotid gland tumor presentation, and the one thing one never does with parotid tumors is stick a needle into them, for it will enhance spread. He was sent to Tucson where a surgeon cured him.

Hoarseness?  The patient has two weeks to get better before one must do a laryngoscopy looking for vocal cord paralysis due to recurrent nerve injury perhaps due to a condition like a malignant lung tumor.

Possible pneumothorax?  Get an inspiration-expiration film, where the difference is sufficient to show air where it does not belong. I can still remember what room I was in at Denver General Hospital when I saw a case on a Saturday morning, the second month of my internship, 46 years ago.

When I was in practice, a patient with a cerebellar infarct was admitted to the floor. I put in a call to a neurosurgeon, because while at the time the patient was in no distress, the affected brain can swell and compromise the lower brain stem quickly, leading to death.  Potentially enlarging cerebellar lesions are dangerous and deserve respect.  I asked the nurses to “check frequently,” without needing to take vital signs, which saved them time and underscored the need to watch the patient often. The next day, I found the patient post-op in the ICU, awake. The swelling had become significant, the brain stem was becoming compromised, and the swollen, infarcted cerebellum was removed. He made an excellent recovery.

My wife had two cases where there was a clearcut breast malignancy on the mammogram but nothing found by either the surgeon or pathologist.  In the former, missing the malignancy led to a second mammogram—uncomfortable to go through post-operatively—and a subsequent change in the hospital system, so that X-Rays were required to be taken of the specimen before closure, to ensure that the lesion was in the specimen and not still in the patient. In the latter instance, the pathologist was told he had to go back and find the cancer, because it was in the specimen, and it was cancer. It was found.

On the psychiatry rotation I learned never to be shy about asking about suicidal ideation, and I asked about it scores of times in practice, to evaluate depression. Not one person was ever angry with me for asking. Virtually all had thought about suicide; very few had gone to the next step, which was determining how they would do it.

Or, the routine physical exam which I did on a sailor before he left the Navy. I felt his abdomen, something I had done hundreds of times, and the large mass I felt surprised me. The sailor had been unaware of it. He would turn out to have lymphoma.

While I have long forgotten the details, I remember calling in consults to orthopedic surgeons using words like “valgus” and “varus,” rotational deformity, distracted or overriding, and discussing vessels, skin, nerve, tendon, joint, and muscle, for that was how I was taught. 

I learned that when I argued with myself about whether I should do a spinal tap, just do it. More than once, I discovered something that was useful. Sometimes, one had to get the spinal fluid a different way. I had an obese diabetic with a stiff neck at 2 am in the ED one night. A spinal needle could not reach her meninges through the back, so I punctured the skin just below the base of the skull, “walking” the needle down the occipital bone, until I reached the cisterna magna, finding white fluid indicative of a bacterial meningitis. She did survive.

I hope along the way some of my teachings may have been useful, like checking level of consciousness by “What does it take to arouse them?” “What do they do when they are aroused?” and “Are they getting better or worse?”  The last was an attempt to remind people that being medically stable requires at least two observations, not one. I don’t know if the same approach is used today in teaching medical students, but I hope they do finish training knowing not only the potential pitfalls in their specialty but many of the ones in other specialties, too.

CAMPFIRE STORIES, FEATURING…THE FIRE

September 7, 2020

We pulled up to the empty campsite on Knife Lake, just east of the Eddy Lake portage, and I hopped  out of the canoe to check it.  Mark and I were doing a sweep of the District during a week’s time, checking permits, people, campsites, picking up litter, digging new latrines and covering old ones, but mostly taking a long canoe trip and being paid for it.  Earlier that day, we came upon a group of seven young women and an older man leading the trip.  Mark said to the guy, “I want your job.”  When the guy heard what we were doing, he said, “I want yours.”

I saw something on the site that I still vividly remember, nearly three decades later: a fire was burning well outside the fire grate, the flames high, fed by the wind, and about to reach the grassy area nearby.  Fire inside the fire grate is almost friendly.  Fire outside the grate, burning uncontrollably, is not.  

We both used our hats to get water, shovels, and Pulaski to gradually get the fire under control and then out. Had the summer been much more drier, this fire would have been off to the races. There was no Knife Lake Fire that year, and we continued our trip uneventfully towards Fraser Lake.

Later that summer, I did a trip on the Kawishiwi River and fully a third of the sites we visited had a fire area with outright active fire or warm ashes.  

I was taught that a campfire burns itself out overnight.  We left sites that way.  Finally, one time I decided to check that proposition and burned myself on hot ashes.  I learned what has been said for a lot longer than I have practiced—put the fire dead out, drown it, and don’t leave until the ashes are cold to touch. 

Five years after the Knife Lake incident, I was on a volunteer trip with the late Mike Manlove.  We came into Good Lake, and at the first site there was a tent up but nobody there and a fire burning. I still remember the leader of the trip’s coming back to the site while we were there and apologizing. As Mike wrote him a $100 fine for an unattended fire, the man was upset and embarrassed, saying he had spent over four hundred nights in the Boundary Waters and nothing like this had ever happened. I wonder how many unintended fires he had during that time.

Back then, I was pushing 200 nights and knew clearly that on day trips, one was better off not building a morning fire. Drowning it would make it harder to start that evening.  Eat a stove heated breakfast and save the fire for evening.  I’m now over 300 days, will never hit 400, and I still canoe that way.

Three years ago, I took a backpacking trip to the coast with one of the premier leaders in the Club. The area was nice, but the trip didn’t work for me. I learned that the leader’s sleep schedule and mine must be in synch.  Ours weren’t. The leader sat around the campfire drinking whisky at night and slept until 9. By 9, I have been up for 3 hours, eaten breakfast, taken a walk on the beach and was ready to go somewhere else. 

That’s not a criticism of the leader. But when we were leaving the site, he kicked some dirt over where the campfire had been and scattered the logs.  I went over and put my hand on the ground.

It was hot.  Ouch hot. That is a criticism. Shameful. That is a criticism of the leader.

It wasn’t easy getting water, since we were on a bluff over the ocean. I did work my way down to a stream for two trips and got enough water to make the area cooler.  I had to move quickly, however, because others on the trip were leaving the camp for their cars, and I didn’t want to miss my ride home. I left the site better, but worried for a full day that maybe the fire had burned under ground and would come up somewhere.

I was stunned: how could a leader leave a fire area hot?  The prior day, we left the campsite about 10, and I realized that I had not checked the campfire, perhaps because I hadn’t sat around it and assumed the leader would have put it dead out.  Wrong assumption.

I haven’t been on trips with this leader since.  I invited a Club member on a canoe trip with me in 2017; he drank Canadian Club at night and slept in the next morning.  It spoiled the trip.  We got on the water late, and the best time of day had passed.  Paddling lakes in the early morning is special.  The wind isn’t usually up, birds and other animals are more likely to be out, and there is a stillness that won’t last but a couple of hours. 

Two weeks ago, I was with the Crew doing trail work in the Diamond Peak Wilderness when a two young women backpackers came by us, having hiked up from Corrigan Lake, one of several nice lakes on the west side of that wilderness.  They commented that they had put out an abandoned campfire that morning on their way out. They knew it was there because they saw it the prior night.

“Why anyone would have a campfire in these temperatures is a mystery to me,” one said. I thought there was a campfire ban, but it was beginning the following day. Still, talks of imminent campfire bans are a good reason not to have campfires.

We thanked them for their help and continued working our way towards the lake.  I then remembered that the Club had had a backpack into Corrigan that very week.  The same leader was leading that backpack, mentoring another, and I wondered whether it had been their campfire. 

When we returned to town, it wasn’t clear to me whether they had had a campfire.  I wrote a board member with my concern, not proof, because others could have been at Corrigan, although not many, since it is a small lake.  I mentioned my concern and the issue on the coast three years prior.  I also mentioned that I had heard that one fire almost had gotten away from that same leader up in the Cascades. That was hearsay, and I admitted that.  I got a reply that the board member had seen pictures on Facebook of the group with two different campfires.  He took that information to others and the Club now bans all campfires.  If one wants to build a campfire, we can’t stop them, but it is not allowed on a Club trip.  That may not stop people, but it protects the Club.  I can think of three other violations I’ve heard about on Facebook.  Be careful what you post.

And put the fire dead out when you leave the site. Fires start fast, and it only takes seconds for a fire to be high enough in a tree that you will never reach it.

Corrigan Lake with Diamond Peak