Reaching Down the Rabbit Hole (4 page)

My experience told me that Arwen Cleary’s echocardiogram had missed something, not just once, but twice. I turned to Hannah after we had left the room, and asked her this crucial question: “Can you put your finger on what’s different in this case?” She replied that it was the angiogram, which showed the alarming number of constricted blood vessels and cutoffs in the cerebral arteries.

“No,” I said. “It’s the recurrence of many, many small strokes
over time
. That’s what’s different. You have to think about what could cause this. There must be a cardiac source for the emboli. Do the echo over. It was wrong. If it doesn’t show something abnormal on one of her heart valves or in one of the chambers, I’ll eat my hat.”

Medical textbooks teach you what tests to do to make a diagnosis, but they do not dwell on the simple reality that humans are interpreting
the tests. Hannah ordered the echocardiogram yet again. This would be the third one. The hospital would have to eat the cost. The cardiology fellows initially balked, but when we showed them the echocardiogram from the other hospital, they came around. It was incomplete. By way of proof, the repeat TEE showed a mass sitting on her mitral valve—a papillary fibroelastoma, the second most common benign tumor of the mitral valves, and one which took the shape, as I had predicted, of a peduncular (or branched) growth. I wasn’t entirely right. The cardiologists did not think it was consistent with an atrial myxoma, a very different kind of tumor, but at least I didn’t have to eat my hat.

The course of treatment seemed clear to me: the tumor would have to be removed as soon as possible, before another stroke occurred, and her mitral valve would have to be replaced. Although this seemed to be an answer, when I ran it by the head of cardiothoracic surgery, he balked. “There’s too high a risk she’ll have a cerebral hemorrhage on the heart pump. We’ll have to wait six weeks so her last stroke won’t turn into a brain hemorrhage.”

Alice in Wonderland
is an absurdistan story. Beyond fantasy, it’s ridiculous. That’s neurology in a nutshell. Your patient disappears down a rabbit hole. You’ve got to do something. You can’t just sit there, so you go down the hole after the patient. Sometimes you can do it right away: you go to the gynecologist and say, “Take out her ovary,” and that gets her out of the hole. It may not get her back out the same hole she went in, but in a case like Cindy Song’s, it gets her out relatively quickly. Same with Vincent Talma. We brought him out, not quite as good as new, with a slight speech deficit that most people wouldn’t even notice, but we got him out. With Arwen Cleary it would be a longer journey. Although it went unmentioned at morning rounds, her case would offer a sobering reminder that there are significant
limits to our knowledge of diseases of the human nervous system. Anyone expecting a clean resolution and a quick turnaround was in for a disappointment.

Arwen Cleary remained on the ward for five weeks. She did suffer a cerebral hemorrhage, but it resolved with almost no consequence. The fibroelastoma that looked so ominous on her TEE somehow disappeared, or perhaps it wasn’t a fibroelastoma to begin with. Because of the blood thinner we gave her, she suffered no more strokes. Eventually she went to rehab, and from there she went home. She did not get the heart surgery. She would have to stay on the blood thinners for the rest of her life, and I may never be able to say what caused her problem, or whether it was still a problem, until she suffers the big stroke that wrecks her.

Six months later, she came to the outpatient clinic, her speech much better, but still frustratingly limited. Her vision had not fully returned. She was making very slow improvement.

“What’s your account of what’s going on?” I asked her.

“I think it stinks.”

“Are you optimistic you’re going to get better?”

“Yup.”

“Can you tell me what you think of your experiences in the hospital?”

“I feel like I’ve never left here. Some days, I can wake up and say, ‘Oh, it’s going to be a very good day.’ Then, it sucks.”

“What kind of person were you before all these strokes, and what kind of person are you now?”

“I . . . I was always on the go. Four hours of sleep. Upbeat. Dancing . . . Yeah. I used to walk. Now I can’t see clear.”

“That’s because you’re missing the right side of the world. You might not be aware of it, but your vision on the right is diminished because of one of the very early strokes. Are you a different person now?”

“Once I’m home, I’m good. Like, I just . . .” She trailed off.

“Are you very weepy?”

“Kind of.”

“I think this will settle down and there will be a new equilibrium where you’re better than you are now. And I hear you, that the dizziness is what’s driving you crazy. I know it’s frustrating, but your kind of case can’t be solved by a book, or it would have been solved by now.”

“It’s not simple,” I tell Gilbert, the third-year medical student, “almost nothing is routine, but if at the right moment you can combine experience, logic, and leaps of imagination, you’ll get your patients where they need to go.”

That’s the pitch. Gilbert has to decide on which specialty to choose by the end of the year, and that is the extent of the effort I will make to sell him on clinical neurology. Rounding on the ward will either appeal to him or it won’t. It’s not for everyone. Among the residents on the team, who have already chosen neurology, some will concentrate on research and try to find the causes and cures of Parkinson’s disease, Alzheimer’s, or multiple sclerosis. Some will go into pediatric neurology. Others will become epilepsy or stroke specialists, some will go into psychiatry. But a few special ones, like Hannah, will carry on the clinical tradition, one case at a time.

Back on the ward, she comes up to me with the patient list. I am waiting at the nurses’ station with the rest of the team. “Elliott thought you ought to see this lady first before we make rounds,” she tells me. “Her name is Mrs. G, and she’s making me nervous.”

“Why?”

“She’s the lady with the hydrocephalus.” In other words, she has too much water in the cavities of her brain, a serious problem.

“Lead on,” I reply. “I’m at your service.”

2

Like a Hole in the Head

Where baseball and neurology converge in a game-saving, over-the-shoulder catch

On Tuesday, at Chief’s Rounds, a weekly ritual that takes place in the department library, Elliott handed me two tickets to the Red Sox–Mariners game, a 7:30 p.m. start. Like every home game, this one was sold out, but Elliott has season tickets. Although temperatures had already hit the 90s, by game time they would be in the low 80s, then back down into the 70s by the stretch. With clear skies and a crescent moon, it promised to be the kind of idyllic Boston evening that you dream about in mid-February, and feel entitled to by early July.

Elliott is an odd duck. No one else in the department wears monogrammed shirts with cuff links, sports a Patek Philippe watch, or knows as much about pari-mutuel betting. He started in private practice and was such a good neurologist that we hired him into the academic group, where he had a meteoric rise from instructor to professor. Not one to gossip, he nonetheless seems to have a wealth of inside information. He knows what the residents are up to, what the administration is thinking, who is the next to be fired. He is a classically handsome man in the
GQ
sense, square-jawed, still maintaining a
wrestler’s build into his midforties. He went to a state university and to a less-than-name-brand medical school, and is unimpressed to the point of indifference by his current affiliation with Harvard University. He comes and goes as if he has something better to do, and apparently he did have something better to do than Chief’s Rounds, because when I turned to thank him, he was gone. The tickets were three rows behind the visiting team’s dugout. I would be wrapped up here by 5:00 p.m., I was thinking, unless something went terribly wrong. Which it did.

Late in the afternoon, I was pushing the rolling cart with the patients’ charts around the semicircular nurses’ station on the tenth-floor ward. As I put the finishing touches on the last note in the last chart, a floor nurse rushed out of room 41 West and asked me if the team was going back in to see Mrs. G, the woman admitted last night from the intensive care unit, the very patient that Hannah and Elliott had been so concerned about. Mrs. G was Sofia Gyftopoulos, and her condition—hydrocephalus, also known as water on the brain, accompanied by a history of meningitis—was serious, but not critical.

“No, we saw her an hour ago on our afternoon walk-rounds,” I said, “and she seemed fine except for a headache. Would you like me to take another look?”

“Yes, I think her breathing is shallow.”

If not for the unusually high number of admissions over the holiday weekend, I would have been home, resting up for the game. It would have been Hannah’s problem instead of mine. But I go where I’m needed.

I walked in and briefly greeted Mrs. G’s husband Nick, who was sitting at the foot of the bed reading
Entertainment Weekly
, not looking at all concerned. Neither was Mrs. G, but then she wasn’t conscious, and her breathing was forced. I called her name and shook her shoulder, but was unable to rouse her. I checked her pulse, found it to be thready and barely detectable, and when I pried open her right eyelid, I saw that the pupil was enlarged and had lost its natural reflex
of constricting in response to light. We call this a blown pupil, and it is a neurological sign that the brain is about to collapse. Nick was on his feet,
Entertainment Weekly
was on the floor, and the nurse was standing about three feet behind me when I turned to her and said in a loud but controlled voice: “Call a code!”

Within the next two minutes, a dozen people would rush into the room, none of them having a precise idea of what was happening inside Mrs. G’s head, why her brain structures were shutting down one by one. While the code team focused on other things, like keeping her heart and lungs going, my job was to get to the root of the problem, and fix it. As for the Red Sox, they would have to start the game without me.

In the clarity of hindsight, Mrs. G’s event was entirely predictable: not so much the
when
as the
why
, and the
how
. The stage had been set earlier in the day at morning report, when Hannah informed me that there were thirteen admissions to the neurology ward during the night and only three discharges. Two of our patients were sent to the ICU; one had coded three times overnight, and the patient list, usually no more than a page and a half, had lengthened to three full pages. Flavio, a second-year resident and a key member of the team, was stuck in Madrid with a visa problem. To add insult to an entire roster of injuries, an aging rock star, a Boomer legacy act, was scheduled to arrive sometime that morning and be whisked to a pavilion suite on the sixteenth floor, shielded from the prying eyes of the press under a pseudonym. He was going to want our full attention. Which is to say we were short-staffed, overbooked, and had a celebrity admission to boot. It was a potentially dangerous situation, not for our rock star, but for some of our higher-risk patients like Mrs. G. And I had only myself to blame.

For years now, I have scheduled myself for “the service” during the first two weeks in July and the last two weeks of December, meaning that I sign up to serve as the attending physician on the neurology
inpatient ward and the neuro-ICU, partly as a favor to those who would rather not work through the big holidays—the Fourth of July and Christmas—and partly to show them up. I don’t mind. I’m happy to do it even though these tend to be slow times on the wards. To compensate, I encourage the residents to admit as many patients as they can. “Keep an eye out for interesting cases!” I tell them. “Go walk up and down the sidewalk in front of Au Bon Pain and see if you can spot anyone who can’t walk straight.”

It was July 3, the third day of my service. I had taken over from Elliott, who was now on neurological consult to the Emergency Department. I had been relieved to learn that I would be getting Hannah as my senior resident. She had started her rotation a week earlier, so she was up to speed on most of the patients. As for the rest of the team, I never know who is scheduled until they show up. Given the situation with Flavio, we had been forced to go to the bullpen and come up with two first-years from Children’s Hospital, who would have to be tutored in the Brigham’s arcane medical ordering system, written in DOS sometime during the Ford administration.

It should not come as a shock that the daily routine at a teaching hospital does not much resemble the tightly choreographed one-hour dramas that dominate prime-time TV schedules. The sheer numbers of patients, their tendency to pass in and out of our service due to medical rather than plot-driven priorities, restricts our time with each one of them, and sometimes scatters our focus. During those two weeks, Hannah would often tell me that if she simply had the time, she could crack some of our most baffling cases. If not for the paperwork and the bureaucratic overhead, perhaps she could have. But time is a luxury, and sometimes it feels as though our primary function is just to check off boxes on a never-ending punch list. As I said to one of the new residents, “You may get the idea that we’re constantly draining the swamp.”

That morning, like every morning, the neurology team had gathered in the conference room on the tenth floor of the hospital tower—a
cramped, windowless, cluttered way station where the various medical teams convene to discuss their cases, order lab tests and consultations, and steal an occasional power nap. The room is a study in off-whites: an uninviting, fluorescent-lit, purely functional space. Melamine counters and computer workstations run along the right side, white boards dominate the left, and a conference table with office chairs is crammed into the middle. A fifty-inch LCD flat screen mounted on the far wall is used to display scans and test results. There was barely space for eight of us and the food we had brought: enough bagels, doughnuts, muffins, Danish, and coffee to ensure an elevated glycemic index for the next eight hours.

As she handed me the patient list, Hannah informed me that one patient, a Mr. Williams, the man who had coded three times in one night, should never have been sent to the service in the first place, and had kept Elena’s hands full. As the overnight resident, Elena had had almost no downtime on her shift, was clearly drained, and was now ninety minutes away from the end of her mandated maximum of fourteen consecutive hours. For the next hour and a half she would complete the “handoff,” an unfortunate, policy-driven ritual in which the doctor who knows the most about the new patients, the only one who has actually met and examined them, presents the essential details of the cases to the rest of the team, and then leaves, often unwillingly. If all goes well, the baton passes smoothly and we don’t break stride. But every now and then we miss a step, or drop the damn thing. It would take us over two hours to run the patient list that morning, and during that time we would squeeze in speed rounds early so that Elena could go home and get some rest. “Just the news,” I kept telling the residents, “not the weather.”

Among the new admissions, one patient worried me: Mrs. Gyftopoulos, a fifty-year-old mother of three. Was she stable enough to be here? I didn’t think so. As we headed off on rounds, I said to Hannah, “We’ve got too many patients. This is getting a little unsafe.”

Elsewhere on the ward, we had Mrs. Newlin, a ninety-year-old
woman with such explosive headaches that Elliott suggested putting her on a terrorist watch list. We had two drug abusers sharing a room, one a burnt-out addict with horrible teeth (he had thrown away his toothbrush because it reminded him of his wife, who had left him six months ago), the other a pure drug seeker in his early twenties, who I had admitted from the outpatient clinic after he exhibited such excruciating sciatic pain that I felt I had no choice. Later in the day, Elliott informed me that he had seen the guy down in the lobby eating a fruit cup while perched on the edge of an armchair. “No evident signs of distress, in fact quite the opposite,” Elliott informed me. It would take a concerted team effort and a final bribe of intravenous Dilaudid just to get rid of the kid.

We had our aging rocker in the luxury suite, accompanied by a small retinue, including a personal trainer, an aromatherapist, and a bodyguard (strictly against hospital rules). In turn, I brought my own entourage of residents and med students, most of whom had never heard of the guy, having been born well after his last album had gone gold. Back on the ward, we had Doc Vandermeer, with the lemon-sized tumor in his frontal lobe. As patrician a man as one might meet, he had the endearing habit (or infuriating one, depending on your outlook) of never saying anything directly that could be couched in clever circumlocution. When Hannah asked him if he needed anything to make him comfortable, he replied, “No, but my equanimity and support services appear to be compromised in a telling way, and to get back my life would be gratifying.” It was already clear to me that he would not be getting much of his life back unless we removed his tumor, and even then it was not a sure thing.

Nearby we had a larger-than-life, left-leaning economist and activist who, with very good reasons that I worked hard to deflect, harbored a destabilizing conviction that she was experiencing the onset of Lou Gehrig’s disease. Next door, a Boston firefighter was coming to grips with the fact that he had a glioblastoma, a rapidly growing, incurable, and inoperable tumor that would kill him within six months.
Down the hall, a sham epileptic was manifesting theatrical seizures that registered nary a blip on the EEG. And scattered here and there were a variety of ischemic and hemorrhagic strokes, both catastrophic and benign, one a Wernicke’s aphasia and one a Broca’s aphasia, the first of which plays havoc with word selection, the second with speech production.

Then there was Mrs. G herself. The details of her case were presented at morning conference by Callie, a second-year resident with an MD and PhD from Yale, who would have looked more at home on Melrose Place than on Chapel Street. Callie spoke with an up-lilting intonation, and delivered the patient history with a curious mixture of arcane medical nomenclature and L.A. street slang.

“She’s a forty-nine-year-old woman with a history of basilar predominant severe lepto-meningial inflammatory syndrome that’s been worked up up the wazoo. At baseline, she can kind of shuffle. She has some intermittent diplopia and dysarthria, and she’s presenting with increased difficulty with walking, and also a gnarly occipital headache. She can’t walk without two people assisting her. For the last six days she’s had to concentrate a lot more than usual. Of note, in addition to this lepto-meningial inflammatory syndrome, she’s had chronic hydrocephalus.”

More plainly put, Mrs. G had serious problems, had been in and out of the hospital, and was nearing a kind of crisis. Her scans, when Hannah put them up on the flat screen, looked so unusual as to be alarming.

“What’s going on there?” I asked. Clearly, we were coming into the middle of a very complicated case. I was immediately bothered by the pear shape of the ventricles, the fluid-filled cavities in the middle of the brain. I had seen this before in brains in which the spinal fluid was under very high pressure. The team seemed to appreciate that the ventricles were enlarged, but did not pick up on the fact that they were also under substantial tension. I took this as a cue to look for worrisome signs when we finally got around to the bedside.