A Country Doctor Writes:

I introduced myself and continued “and you are Annika LeBrun?”

“Ja, det stämmer”, she answered in perfect Swedish.

I had suspected from her first name that she might be Swedish. She continued in an accent that suggested roots near Stockholm, the area where I was born:

“With a last name like that and a license plate in Swedish, I knew where you were from.”

We continued the visit in our mutual mother tongue. I had to think fast to find the right Swedish medical terms after working as a physician for thirty-three years in this country and not having spoken Swedish for a couple of years except a few phone calls to a couple of aunts in Sweden.

My new patient had also been away from Sweden for several years, and she ended up asking me how to describe a few of her medical concerns in Swedish.

The word “cataract” came up, and it took me a few seconds to retrieve “grå starr”, and I couldn’t help myself but went on to also talk about “grön starr”, glaucoma.

Swedish has two medical nomenclatures, one newer internationalized one, where “cataract” is “katarakt”, and an older one with Swedish or Germanic words.

The word “starr” dates back to the 1600’s and derives from ancient Germanic words for “stiff”, and indirectly also to “stirra”, which means “stare”.

A cataract affected eye has a gray pupil due to clouding of the lens, whereas glaucoma, a term derived from the Greek “glaucos”, which means “blue-green”, may have a greenish hue, but sometimes may look normal or cloudy.

We finished our visit, and I struggled for a split second to find the right words for “stop at the reception desk and make a follow-up appointment”.

I mused silently about all the quaint Swedish medical words I haven’t heard or used for thirty years: “bukspottkörtel” (belly spit gland) for pancreas, “ros” (derived from Dutch and German words for red), for erysipelas, “bältros” for shingles. The English word “shingles” is derived from the Latin cingulus, which is a straight translation of the Greek “zoster”, meaning “girdle” (from the way the shingles rash can encircle half the body; the Swedish prefix “bält-” means “belt”, just like it sounds).

Later, on my way home, I thought about how you can use your second language so much that your first language, even though you may have a deeper understanding of it, can seem harder to use in some situations. But, to be perfectly honest, sometimes it is still my first choice, for example when counting.

I arrived home feeling as if I had traveled far today – 3,000 miles to Stockholm and thirty-odd years to my early days in medicine. It’s been a long but interesting day.

In these virtual pages I have written about medical mysteries, the frustrations of today’s healthcare, and the human dramas we encounter in the practice of medicine.

Below are updates to three previous posts, one from each of these three categories: “The Great Imposter”, “Calling Mrs. Kafka”, and “Invisible Ties”. Readers who don't remember these posts may want to follow the links to catch up on the beginning of each story.

A TALE OF RED HERRINGS

“The Great Imposter” ended in clinical uncertainty:

“And so I leave Norman Sprague in the competent hands of Dr. Brown, who returns from his vacation tomorrow. Norman’s lung nodules and lymphadenopathy still remain to be diagnosed, and he still may have gallbladder disease, but he also, again, has the original working diagnosis of herpes zoster, the great imposter.”

The other day I saw Dr. Brown walk Norman Sprague down the hall. Afterward, I asked whatever happened with his possible shingles, gallbladder pain, lung nodules and mediastinal lymph nodes.

“The PET CT looked pretty benign”, said my octogenarian colleague, “and nothing came of that pimple you saw on his back. He still has his gallbladder and Roger White is pretty sure it's sarcoidosis. Interesting, though, that the Lyrica samples you gave him when you thought it was shingles cut his pain at least in half, but the pain is on both sides of the midline…”

“I don't know why it's working, then”, I said.

“Neither do I, but I kept him on it. He's meeting with Roger next week to discuss treatment options, probably steroids.”

“Pretty sure, huh”, I muttered to myself.

A PYRRHIC VICTORY

In “Calling Mrs. Kafka”, I went to bat against the insurance company for Harriet Black. She really did have a terrible case of shingles, and Lyrica was the only thing that really helped her pain; the gabapentin and her regular pain medication had not been enough.

After my call to the surreal Mrs. Kafka in the Prior Authorization department, I asked Autumn to call Harriet and tell her the drug was approved. She was very grateful on the phone. Some time later she came in for her follow-up appointment.

“How’s your shingles pain”, I asked.

“Still pretty bad”, she answered.

“I thought the Lyrica was working pretty well”, I said, confused.

“I can't afford it. The copay is too high”, Harriet said, her voice trailing.

So much for getting a medication approved by the insurance company…

MOTHER AND CHILD

Four years ago, in “Invisible Ties”, I described how Kirk Donner, adopted at birth, went to the State Capital to look for his birth mother after he turned eighteen. He knew she had an unusual name, Suann:

“Kirk took the elevator to the fourth floor. He was alone. As the door slid open, he stepped forward and almost collided with a tall, dark-haired woman with designer jeans and a plain, white blouse. Her eyes met his as he stopped and apologized. They were large and kind. She flashed a smile as he swerved around her, embarrassed and eager to get to the registry.

He walked up to the receptionist and stated his errand with words he had practiced in his mind the whole trip.The clerk handed him a form and as he reached for a pen he saw a stack of similar forms in front of her. Reading the top one upside-down he saw the name: Suann Walker.”

Mother and child made contact soon after that day, and each found peace in knowing what had become of the other. Kirk met his half-sister, also raised by an adoptive family.

Suann and her fiancé attended Kirk’s college graduation in May, and this summer Kirk spent a lot of time at their house while he took a summer course in the southern part of the state.

“Finding her and learning what she is like has helped me understand myself better, it makes me feel more whole”, Kirk has told me.

Many of my vignettes on this blog end with unanswered questions or unstated uncertainties, just like any typical physician’s patient encounters. These updates moved the plot forward in just three cases, but even these are not the final installments in the history of each patient’s own journey. Medicine, even practiced over many years of physician-patient continuity, is but a glimpse into the lives of a few fellow humans.

This week I suddenly felt transported back to my earliest years in medicine back in Sweden. In the last few days I have seen almost a dozen children with rashes. We have a Hand, Foot and Mouth epidemic in our little town, hitting the second and fourth grade children hardest.

One eleven year old boy had looked like an early strep throat a few days ago, but he came back today with subtle red spots on the palms of his hands. He was in the room across the hall from his two-year old cousin, who had a full blown case of HFMD, the worst I have seen all week. His aunt had sore, itchy palms with no rash. I don’t know if it’s a sympathy reaction or if she is next to come down with it.

Mixed in with the rest of them was a two year old from out of town with a sketchy immunization history and a bad case of chickenpox, and a handful of children with colds and worried parents. One little boy with a runny nose had one single macular lesion on his thumb – too soon to tell whether he is coming down with Hand, Foot and Mouth disease or not.

Working acute care in Sweden, I saw a lot of rashes, and in those days we did not have all the immunizations we have now. I remember feeling pretty confident with my differential diagnosis of rashes – measles, German Measels, scarlet fever, things we don’t see much of anymore. Scarlet fever, associated with streptococcus infections, was common then but is rare these days. We also saw enough post-streptococcal nephritis that I routinely brought strep patients back for a urinalysis after their sore throat had resolved.

I remember the varied reactions among parents during the small epidemics I witnessed in those early days. Most parents took things in stride, expressing gratitude that their children got their “normal childhood diseases” over and done with. Some parents even sought out chickenpox cases in their neighborhoods and had chicken pox parties in order to have some control over when their children got the disease. I just read somewhere that the Swedes still aren’t immunizing children against chickenpox, apparently for cost reasons.

When I worked in student health here in the U.S. in the late 1980’s, we had a measles epidemic at the university. Because the students had been immunized as children, they tended to get milder and atypical forms of the disease. I remember being called in to see my colleagues’ cases all the time as the local expert on the rashes of “childhood diseases”.

Hand, Foot and Mouth disease was first described in New Zealand (or Australia by some accounts) in the 1950’s. I don’t remember running into it often back when I used to see measles and German measles. I remember just calling it a coxsackie virus rash. Recently I have read that the Swedes call the disease “höstblåsor”, or “autumn blisters”. I do remember seeing more “herpangina”, which looks the same and is also caused by a coxsackie virus, but is limited to the mouth.

There is no widely available vaccine against Hand, Foot and Mouth disease, and antiviral drugs are ineffective against it, but it tends to be a very benign illness. Some of the eleven viruses that can cause the disease are more aggressive, and in other parts of the world, for example Vietnam, the disease can more often be associated with neurological complications, from minor twitching to convulsions.

The way our society reacts to the mild form of the disease that we usually see is interesting. People worry about second graders missing a week of school – something I have a little trouble with. The economic burden of working parents missing work is a valid concern, but with so few “childhood diseases” left to contend with, a week of reading, watching movies or playing games at home isn’t the end of the world.

Our few remaining “childhood diseases” take the time they take to get through, and we have no shortcuts. They offer us an opportunity to understand that we can’t control everything in our lives.

Hand, Foot and Mouth disease usually only strikes once, so unlike the common cold, it has not become big business for purveyors of useless remedies, and unlike influenza, we have no big-ticket disease modifying drugs, so we are left to practice good home care, humility and the ancient art of just “being sick”.

America’s favorite mid-century pediatrician, Dr. Benjamin Spock, wrote the following about the “childhood diseases”:

“There are only two things a child will share willingly — communicable diseases and his mother’s age.”