A Country Doctor Writes:

The clues are usually there, even in the hardest of cases. They just aren’t presented to you on a silver platter.

Gwen Stephenson had an ill-defined polyarthritis and had been on methotrexate for some time. Her rheumatologist, Norm Fahler, had tapered her off the medication while keeping an eye on her inflammatory markers and they had leveled off at just above the normal range.

Seven or eight years ago, Gwen had suffered a bad bout of sciatica, and a few weeks ago, she had told me her sciatica was bothering her a little again. “Not enough to have those injections yet, mind you”, she had said with a grimace and a gesture indicating the length of the needle her pain specialist had used to deposit the steroid in her lumbar epidural space.

The visit when she mentioned her sciatica was a diabetes visit, full of bookkeeping tasks – keeping track of her eye exam, foot exam, microalbumen, blood pressure readings, blood sugar log, lipid management and cardiovascular review of systems.

I accepted her assessment that her sciatica was not of the magnitude that it required any immediate intervention.

After Gwen left, Autumn came into my office to pick up some forms I had signed, and she said:

“Did you notice that Gwen’s temperature was 99 for the second time in a row? I wasn’t sure if I should have pointed that out to you.”

I had not noticed it. Looking back, I saw that a week earlier, when she had come in just for her B-12 shot, it had also been 99.

“I’m not sure if that means anything”, I remember saying.

Two days later, Gwen came in with a nasty cough and I thought I could hear some very faint rales in her lower left lung. Her temp was 99.4 and I put her on antibiotics for pneumonia. We didn’t have X-ray available that day, but it was obvious at that time she needed an antibiotic.

The following evening I was on call. Gwen phoned the answering service around 9 pm and asked if an axillary temperature of 103 was high enough to be alarming. She hadn’t been able to take an oral temperature because her teeth were chattering with the terrible chills she was having.

She was admitted to the hospital, where intravenous antibiotics were started for her apparent pneumonia. Her fever didn’t come down, and the radiologist disagreed with the initial emergency room reading of her chest X-ray. So she became a “fever of unknown origin”. The blood cultures that were drawn in the emergency room grew staphylococci, and, because her back pain kept getting worse as she lay in bed day after day, she had an MRI of her lumbar spine. This showed a possible discitis at L5-S1 and a psoas abscess.

They teach you in medical school that early imaging isn’t indicted with back pain or sciatica, unless there are “red flag symptoms”. Fever is one of them. But Gwen’s back pain was recurrent, and had been there for a while, and her fever was borderline when I saw her, and it developed after the back pain. Still, I was quite humbled. I wasn’t actively connecting all the dots, and I was too focused on the housekeeping tasks of her diabetes care to see the subtle manifestations of her smoldering infection.

It started with a sore thumb and ended with a lifetime of medication. In between there was an emergency room visit at one small hospital, an ambulance transfer to a big hospital, a Medevac flight to Massachusetts General Hospital, multiple invasive procedures and a diagnosis of an often lethal condition. And I was not the one who made that diagnosis.

Paul Allard had developed severe heartburn and indigestion earlier this fall, and had just recovered from a bout of wrist pain when I saw him a month ago. The pain and swelling had been there for a week or so, did not seem to be caused by any trauma or overexertion. It had cleared up after just three days of prednisone, and his rheumatology blood profile was completely negative.

This time, Paul had a pain along half of his left thumb and in the web space between his thumb and his index finger. It was sharp, burning and persistent.

As I asked all kinds of questions and checked his hand strength, skin temperature, monofilament and temperature sensation, arm strength, neck movements, axillary and supraclavicular lymph nodes, Paul clearly seemed uncomfortable. His partner, who usually seemed a little disinterested in Paul’s medical concerns, was leaning forward in his chair watching our exchange and my exam intently.

“I’m not sure what’s going on”, I said to the two men. “It could be something arthritic, like that episode of wrist pain, or maybe some type of vascular inflammation in a very small vein or even one of the four arteries that supply the thumb, but it could also be a pinched nerve, especially because it involves the space between the thumb and index finger.”

I suggested that Paul finish the course of prednisone he had been able to stop early when his wrist pain resolved. Paul and John agreed and we set up a five day followup.

That was Friday. Monday morning, my inbox had the next several installments of the story:

Late Friday night Paul suddenly developed nausea, severe abdominal and left flank pain, and went to our small hospital emergency room. They did a CT scan of his abdomen, which showed an infarction of his left kidney. When that happens, the cause is usually a blood clot, so they transferred him to Cityside Hospital for evaluation by the vascular surgeons.

A CT angiogram showed a large clot in Paul’s thoracic aorta. He was started on a heparin drip and airlifted to Boston. There, they didn’t see a clot in the thoracic aborts, but it had apparently just moved down to his abdomen. The clot was removed surgically, and while his kidney showed signs of recovery, and several specialists were working out his diagnosis, his left lung suddenly filled with blood. He had three quarts of blood drained through two chest tubes and was finally allowed to return to Maine with a diagnosis that explained what had happened and committed him to a lifetime of warfarin to prevent future blood clots.

“So, you have Lupus Antigen”, I said, rhetorically. “But they didn’t think that you have lupus?”

“Right”, Paul and John answered in unison.

“Sure, the wrist pain could have been something else. What did they think of the thumb pain, a small embolus in one of the four little arteries that supply the thumb?”

“They weren’t sure”, Paul answered.

“Who would have known…”, was all I could say.

“He could have died, they told us”, John said.

“Most people with this kind of clot do”, Paul filled in.

I half shook, half nodded my head as I punched in Paul’s warfarin dosing order in the computer. I thought, not for the first time, about how you see things on the front lines of medicine that turn out to be the first sign of a condition that other colleagues diagnose hours, days or even weeks later, as symptoms evolve and the clinical picture comes into clearer focus. It is a humbling experience.

It has been said about the Lupus Antibody Syndrome’s sister condition, “If you know lupus, you know medicine”.

Theresa arrived in a cloud of noise and commotion.

She had called after four o’clock the day before, but I hadn’t noticed the new message in my electronic inbox before I left the clinic.

Her almost brand new alprazolam bottle and her pain pills were missing, and Theresa was reeling. As she walked down the hall to the exam room, I heard her explain to Autumn how she had been to Walmart and a couple of other stores, slinging her big handbag over her shoulder, opening it to pull out her wallet, stuff receipts and her reading glasses away and fumble for her asthma inhaler.

In my exam room she repeated her story and demonstrated how she had held the bag open, pulled things out of it and then put them back in, and then realizing that her two pill bottles were missing. She proceeded to also show me how she rummaged around for the pill bottles and even emptied the large, brown bag with its purple lining.

In a loud voice and with oversized gestures, she replayed every conversation she had had about her missing pill bottles with store clerks, her girlfriend and her pharmacist in the last thirty six hours.

I sighed. Theresa had a small amount of pain pills on hand, which she could safely go without, but she was one of those patients who had seemed stable and truly helped by her long-term alprazolam. This was endorsed for selected patients at the psychopharmacology courses I had attended in Boston many years ago, but it has now fallen out of fashion.

“Well, Theresa, you know these controlled substance agreements you’ve had to sign always say that lost or stolen medications will not be replaced”, I said.

“But this has never happened to me before.” Her voice was as shaky as her large, bony hands. “I’ve been on alprazolam for years, what happens if I stop it suddenly? I took my last pill last night, one I had saved in my nightstand.”

“You’re right. Stopping alprazolam suddenly can actually be risky”, I agreed. “Here’s what I can do: I can give you half your usual dose, in weekly refills that you will have to pay for yourself, and I’ll see you back every Wednesday until your next regular prescription is due. Then we can assess how you’re doing.”

“Okay.”

I entered the new dose in the computer and clicked with my trackball on the “print” button. I doubted that Theresa was trying to scam me with diversion or addiction, but rules were rules. Obviously, I didn’t want risk withdrawal seizures.

Later that night I thought about Theresa again. I couldn’t completely ignore a slight shade of doubt. Was she becoming addicted or irresponsible with her medication? A mental black hole lay open but I resisted falling into it.

The next day, I heard Theresa’s resonant voice again, talking with Autumn somewhere down the hall. A short while later, Autumn appeared at my door. In her hand she held three pill bottles.

“Remember Theresa’s missing pill bottles?”

Without waiting for my answer, she continued:

“Well she was just here with that big handbag of hers. She lost her cell phone last night, so she emptied out her whole bag again and found a five inch hole in the lining. There, between the lining and the outer shell, was her cell phone, her two pill bottles and one of her spare pairs of reading glasses!”

The black hole was real, I thought, not in my mind, but in that big handbag of hers.

“I don’t know why Dr Brown took my license away”, the 92-year old man said. He was visibly shaking with anger. “I’ve been driving since I was a young boy, and I could find my way to California without a map”.

My associate, Dr. Wilford Brown, had sent in a State Driver Profile a few months ago, and made reference to an attached letter by a family member, which in his words would be “very damning, if true”. Apparently, the Department of Motor Vehicles had thought so too, as the elderly man explained their action through clenched jaws.

“I called them up, and they said that if you wrote to them, they would give me my license back”.

“They did, huh…” I said, while mousing and clicking my way back and forth in the documents section of the electronic medical record in search of the damning letter. I could not find it.

“How could Dr. Brown say that I’m not a good driver? What does he know about that?” The man raised his trembling hand and pointed in the general direction of Dr. Brown’s office.

“He says I have memory problems. My memory is excellent. I remember everything!”

I looked at his problem list, where “Dementia” was the first diagnosis.

“Maybe someone contacted the DMV about your driving”, I said cautiously, thinking I wouldn’t want to cause conflict or mistrust in the family by revealing everything I knew about the letter. “Maybe someone didn’t like the way you drive”, I tried, wondering if perhaps the missing letter might have been inaccurate or exaggerated.

I looked at his birth date on the computer screen and did a quick search in my memory bank about old cars.

They were still making Model T Fords when he was a little boy. Maybe he even learned to drive in one. I pictured traffic around here in those days, and my mind suddenly switched to the tourist traffic on Route One every summer weekend.

“My memory is excellent”, Mr. Gordon said again.

“Well, it’s not just memory, it’s eyesight, hearing, reaction time, judgement and reflexes”, I started.

“I am a very careful driver”, he interrupted. “When I come to an intersection, I stop, even if the light is green, and I look both ways before I go”.

As in a movie flashback, I saw him as a young boy, sitting next to his father, honking a rubber and brass horn and proudly maneuvering a Model T on an empty country road, surrounded only by cow pastures and potato fields.

“Well, Mr. Gordon”, I began. I knew what I had to do.

Earnest Tipp was very overdue for his blood pressure follow-up. Almost a year and a half overdue, as a matter of fact. The last few times I had refilled his medications, I had added “needs follow up” to the signum on his scripts.

The other day I finally saw him in my schedule. I thought about him all morning. A tall, muscular 90-year old widower with an appetite for golf and fine food, he always exuded contentment and gratitude over his good health.

After Autumn had checked him in, I looked at his vital signs screen. His weight was stable and his blood pressure was still well controlled.

“He’ll tell you why he didn’t come back sooner”, she said. “And he’s pretty smug about it, because you had joked with him about staying away from doctors!”

I remembered. Somehow, the topic of health screenings and medicalizing common ailments had come up and I had jokingly, as I often do, said “and stay away from doctors“.

As I entered the exam room, Earnest told the story of how he had taken my advise seriously and stayed away from all doctors, including me.

It didn’t take long to establish that Earnest seemed to be in good health, and, at age 90, how you seem to be is generally all that matters. No screening tests are indicated at that age, even whether and how to treat many diseases and risk factors for disease is usually controversial in that age group.

I remember the nephrologist I send my toughest hypertension patients to sometimes points out how little we actually know about treating people over 80 years old. That is even more true when it comes to 90-year-olds.

The other thing I remembered about my previous visit with Earnest was how he had told me he was about to have lunch with his prom date from seventy years ago. I asked him if he was still seeing her.

“Yes, we see each other almost every week”, he smiled.

I renewed his prescriptions and asked him to come back in a year. “Keep your good diet, play lots of golf this summer, enjoy your prom date…”

“And stay away from doctors”, he interrupted.

“Yes, by all means”, I answered. He stood up and offered a firm handshake. I have nothing to teach this man, I thought to myself.