A Country Doctor Writes:

Morbus Iatrogenicus

From Latin morbus (disease), Ancient Greek iatros (doctor, healer), -genēs  (born) – similar to Latin genus (kin): Disease caused by the physician.

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“There are some patients that we cannot help; there are none whom we cannot harm.”

Attributed to Arthur L Bloomfield

John Fernald in room 4 was clearly not right. He seemed drowsy, weak and disoriented and he had a low-grade temperature. His wife and I had to help him up on the exam table. His chief complaint was chills.

John was a tall man, generally very healthy. He had an enlarged prostate and took pills for his urinary frequency. Over the past eighteen months he had gone for a couple of PSA tests and they were steadily rising, but just barely over the upper limit for a man his age with a good size prostate gland.

Three days before, he had undergone a prostate biopsy by his very competent urologist at Cityside Hospital. John had received the usual antibiotics after the procedure, but he sure looked septic to me.

John said very little, but his wife, Zena, was in complete agreement with sending him over to the hospital for admission.

Across the hall in room 1, John’s contemporary and neighbor, Bill Boland, sat awkwardly in the exam room chair with an expression somewhere between pain and motion sickness.

He had a habit of always sassing me for knocking on the exam room door before entering. “Don’t knock, for Pete’s sake, it’s your room!” he usually yelled as I entered the room. Then, he would always stand up from his chair to greet me with a firm handshake.

“Pardon me if I don’t get up”, he moaned.

He was in my schedule for back pain.

“What happened to your back?” I asked.

“I have no idea. It’s been aching for a week now, and it’s just getting worse.”

“Any injury? Did you fall or lift anything heavy?”

“No, nothing.”

“Any pain or tingling down your legs?”

“Negative.”

“Do you feel better when you lie down?”

He shook his head. “No it aches the same…”

By that time I was worried. When a man in his age bracket has back pain, it is more likely to be something ominous than it is in a young or middle-aged person. The fact that his pain didn’t get better at rest was particularly disturbing.

I flipped through his chart. When was his last blood count, chemistry panel? Any risk factors for cancer? Had he had his screening tests for colon and prostate cancer? Nothing seemed unusual or less than up-to-date. In fact, he had just had a colonoscopy a month earlier by our top gastroenterologist to follow up on precancerous polyps removed three years before, and this time his scope had yielded two more polyps but no cancer.

On his physical exam I noted there was no pain when I tapped over his kidneys. Tapping on the lower spine caused him severe discomfort, but there was no muscle spasm or tenderness. He had drops of sweat on his forehead, but no fever.

I ordered bloodwork and an MRI. Autumn was able to get his MRI for the following afternoon. Bill and I agreed to touch base the next morning about his results.

John Fernald with his fever got settled into the hospital and Bill Boland with his back pain went to the pharmacy for some pain medication. I kept thinking about the two neighbors as my day continued.

Two days later, John was still in the hospital and on intravenous antibiotics. His blood cultures were positive and in all likelihood his blood poisoning was a direct complication to his prostate biopsy, which turned out to be negative for cancer.

Bill, my back pain patient, sounded uncomfortable when he answered the telephone. His bloodwork showed signs of inflammation and his MRI showed osteomyelitis of his lumbar spine. We arranged for admission to the hospital for blood cultures and intravenous antibiotics for him, too. I had never seen a bone infection develop as a complication from a colonoscopy before, but I had read about the possibility. Could this be what was going on with Bill?

That was almost three years ago. John Fernald’s PSA is a little higher than it was, but neither his urologist nor John are eager to go ahead with another biopsy. Bill Boland still has back pain, but it is mild and seems to get worse when he stands at the workbench in his shop too long. He has noticed some blood in his stool a few times lately and, technically, he is due for another colonoscopy.

“I’m not having one of those again, Doc, I’ll tell you that. You can’t tell me I got that spinal infection from anything else but that scope test!

John is now of the age when he is less likely to die from a newly diagnosed prostate cancer than something else like a heart attack or stroke. Bill faces a 2% ten-year-risk that any new precancerous colon polyp will turn into a cancer. And in ten years he’ll be 80 years old.

First, do no harm.