Tales of Survival: A Formidable Foe

September 12, 2009

bellevue.jpgBellevue Hospital, the nation’s oldest public hospital and the heart of our residency program, provides unique and unforgettable training for new physicians.  It is probably safe to say that every resident who trains at Bellevue graduates with a lifetime of stories about the experience. “Tales of Survival” was created to convey some of those stories.

Judith Brenner MD

Many years have passed since I was first an intern on the Bellevue wards. The details are blurred into a hodgepodge of images: running to codes, drawing blood, beepers, waiting for elevators. But for me, the particulars that emerge are always about patients. Patients are the greatest teachers and the hospital wards and clinics, the best classrooms. The first MI, the first PE, the first sepsis-we learn medicine one patient at a time. The experiences never fade, but rather crystalize and forever influence the way we approach disease. Enter, pneumococcus…

It started off innocently enough. I was an intern and we were called to the Bellevue Hospital ER at a time when the ER was more of a makeshift trailer, where a curtain separated the main treatment area from “the slot” and which came as close to being “in the trenches” while still remaining on US soil. “We’re admitting a patient with pneumonia” my resident said. As is not uncommon, before meeting my patient, I saw his x-ray. Indeed, there was an opacity overlying the RML. We walked into a room with 3 other patients, each one separated from his neighbor by a sheet. We pulled the curtain back and met a young man. He was 24 years old, handsome and appeared to be in no acute distress. His chart told us that he had been febrile, very febrile to 104F earlier, but acetaminophen had worked its magic and he looked fine. As he spoke, we heard the paroxysms of cough that interrupted his story.

“I’ve had a fever and a bad cough for 3 days”

“Yes, the cough was productive” he answered to our questions. In fact, he actually used the word “rusty” to describe the sputum. His exam could have come out of Bates’-increased tactile fremitus, dullness to percussion and ‘e’ magically transformed to ‘a’ as we examined his RML.

We walked away from the patient and discussed the next step, which in the early 1990′s meant going to the lab with the patient’s sputum and trying to make a diagnosis under the microscope. And so we did, gram stain and all, and found gram positive cocci in pairs and chains with PMNs all over the slide.

My hands were still purple from the stains as, almost giddy, I told my resident: “Our patient must have read Harrison’s. This is why I love medicine”. We couldn’t have been prouder of ourselves for making this diagnosis. We half-heartedly discussed options for antibiotics. Should we treat broadly or should we be elegant and treat with penicillin for the diagnosis we were confident in? We remained resolute and wrote the order for penicillin. Yes, penicillin! This was the era when resistance was just emerging and “broad treatment” would have been appropriate had we not been sure of our diagnosis.

The patient was safely tucked into his bed on 16N when we went home that night.

Walking out the door, I felt really good-probably too good, bordering on smug-at having outsmarted pneumococcus.

But pneumococcus proved to be a menacing opponent. The next day, our patient remained febrile. As we rounded that morning, we made note of his temperature of 102 F, but told each other that “he looked good”. My memory is clouded now-what exactly did “he looked good” mean? I know that his vital signs were stable, but clearly, his “guest” was still present. Did I wonder about making a change in his management? Again, that’s a question that’s clouded now by the events that followed.

By day 3, we walked in and were told that he remained febrile to 103 F overnight. A sick feeling came over me as I walked toward the doctor’s station to meet my team. The words were about to come out of my mouth when my thoughts were interrupted by a page—oh no, it’s the 16W nurse’s station. As we turned the corner, our patient was standing at the elevator, IV pole in hand, pulling at the IV’s and tubing attached to his arms.

“What are you doing out here” I asked? “You should be in bed.”He looked at me strangely with barely a hint of recognition.
“Who are you?”"Where am I?”
“Get me out of here!!!!”

Within a few minutes, the hospital police arrived and escorted our patient back to his bed. He eventually moved to the ICU after the LP revealed meningitis and stayed with us in the hospital for weeks after his endocarditis was diagnosed and successfully treated.

The patient was ultimately cured of his Austrian syndrome, the triad of pneumonia, endocarditis and meningitis caused by Streptococcus pneumoniae. He was intact, but what he left behind were doctors humbled and forever changed after caring for him.

What did I learn from this experience? Circa 1994, our initial management was sound, but pneumococcus is indeed a fierce opponent that may appear relatively innocuous on the surface, but indeed is not. Pneumococcus gave us clues that we failed to recognize, but should have reacted to. We labeled the patient as “he looks good”-a three word phrase that is filled with meaning for a house officer. When someone is labeled as “looking good”, we allow the gestault to guide our management rather than attend to the small details which we should have: the fever that’s still present, the white count that’s not quite at baseline.

Our team was rightly humbled by this experience. I remember discharging him, so pleased that he was returning to his family and the life that he knew before admission to Bellevue. What I didn’t understand at the time was the influence his case would have on the way I treated other patients. I didn’t appreciate that talk of “pneumococcus” would forever conjure up the image of this patient and the battle we fought in conquering his disease. I never imagined that I might still be thinking about him 15 years later. Were others saved because of the experience of “my first pneumococcus”? I have to believe that’s possible.

So, the morals of the story: Pneumococcus is a formidable foe. Medicine is learned one patient at a time.

Dr. Judith Brenner is an Associate Program Director and Associate Editor, Clinical Correlations

Musher Daniel M, “Chapter 128. Pneumococcal Infections” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2867097.

Dalal A, Ahmad H. Austrian Syndrome: A Case Report. American Journal of the Medical Sciences. 336(4):354-5, 2008 Oct.

One Response to Tales of Survival: A Formidable Foe

  1. DR.GANGADHARAN NEDUNGHAT M.D. on September 20, 2009 at 2:03 pm

    With out a full case history,it is difficult to comment whether the SOP have been followed. Fever is a valuable clinical tool, often suppressed by compassionate use of antipyretics. Starting with the patient first, using the time honored clinical methods, might have led on to earlier recognition of the cardiac involvement. Once a diagnosis is made, especially when a young patient with Pneumonia needed hospitalization, considering the possible complications would have saved the day. I do agree, there are a lot of learning points, as gracefully accepted by the author!

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