I presented the case to Dr. Greco and this time we were in complete agreement. The underlying problem was the progressive global brain deterioration we refer to as dementia, probably Alzheimer type. However, there might be other problems accelerating the process such as vitamin deficiencies, chronic infection, thyroid problems or other chemical imbalances. We would run the standard tests and bring the patient back in two weeks for follow-up. I could only hope that the same caregiver would accompany him. We also hinted that the family should begin to think about meeting to discuss what might be the most safe living environment for Mr. Weinkopf in the future. I could tell right off the bat that Jillian was not happy about bringing that news home to her parents…
And so the day passed without further vehicular accidents, clinical humiliations or other revelations of gaps in my medical knowledge. Dr. Greco seemed satisfied and with a wave said,
“You’ve done enough for today, why don’t you take off a bit early and do something besides medicine?”
I didn’t have to be told twice. I packed up my laptop, said thank you and “see you tomorrow” to the staff, strode out the front door to the parking lot and…
Holy crap.
There she was. Jillian Weinkopf. A million thoughts went through my head as I wondered what she was doing in the parking lot. She’s here because she couldn’t get her mind off me she wants to go out with me life is good I’m the luckiest guy on earth I wonder if Abuela will like her maybe I can get a residency in this area…
“I want to talk with you about my grandfather.” She did not have the look of love in her eyes.
“Um, Okay. I mean, Hi. What did you want to ask me about?” I stammered.
“Can we sit down somewhere?” She continued to look intent, not romantic.
The office seemed somehow impersonal and if we sat in one of our cars that would seem…well…not to allow enough space for two people who had just met.
“Look I’ve just had a long day and I was just going to get some Italian ice,” I offered hopefully. “Do you mind if we meet at that place in the center of town that serves flavored ice in cups?”
“Okay, but don’t get any ideas. We’re going there to talk about my grandfather. You’re not my type, and besides, I already have a boyfriend.”
The PFFFFFT sound I heard at that moment was the air going out of my balloon.
Chapter 9
I arrived at the Italian ice stand to order my favorite flavor, but they didn’t make a size large enough to take the sting out of my bruised ego.
As I turned from the service window, I looked across the street to the park where I somehow knew she’d be sitting. I noticed that she was drinking only bottled water. Maybe she thought I’d take her less seriously if her tongue and lips were colored brilliant red from cherry water ice.
“So, what did you want to talk about?” I asked as I cautiously took a seat next to her at a respectfully professional distance on the park bench.
Her demeanor softened a bit as she turned her gaze directly at me. It was as if she was assessing whether to take me into her confidence. I must have passed the test, because she got right to the point.
“Dr. Vega, you said…”
“Hold on a minute, we’re sitting under a tree in a park and I’m not even a doctor yet. How about if you call me Carlos?”
“Very well, Carlos, you explained a lot about my grandfather’s problem today and took a lot of time with us and I do appreciate that. But you didn’t say much about what it would take to get him better or how long it would take. You also implied that he might have to live someplace else. Did you mean like a nursing home?”
I was hoping we could answer these questions after I got the test results back, but I decided to give it my best shot.
“First off, may I call you Jillian? Ms. Weinkopf is hard to say with my tongue half frozen from the ice.”
She shrugged. Tough audience but I’ll take that as a yes.
“Okay, first of all, there are two pieces to this problem. First, your grandfather likely has underlying Alzheimer’s Disease. This means his brain has started to have a gradual overall functioning problem in terms of memory, processing, perception and judgment. There are medications to treat this that can help improve or at least stabilize his ability to remember and process information. We are usually successful in reducing things like his worries that he is going to be robbed by cable repairmen and keep him from seeing or hearing things that aren’t really there. These medicines can have side-effects, however, and we need to take some time going over all of them in detail.”
“And the second piece?” she really wanted to keep me moving.
“The second piece is actually the best part, and that is that he seems to have gotten worse more quickly recently. That may sound bad, but it implies that something outside of the Alzheimer’s is happening too. Those kinds of things, anything from infections to vitamin deficiencies to thyroid problems to other chemical imbalances, are more quickly correctable and could help him faster.”
“But you have to wait for the test results?”
“Right. That won’t take long, though”
“You still haven’t answered my question about the nursing home. Do you really believe he can’t live in the little apartment attached to my parents’ house?”
I really hate trying to answer this question. “The honest answer is that it’s too early to tell. If we correct some deficiencies, treat the Alzheimer’s, have Memorial Hospital Home Health come in for a consult to design some features to improve home safety for Mr. Weinkopf, he might be okay. What do you think about his safety right now? If nothing changes, do you think it is safe for him to be by himself during the day?”
Jillian’s response was not what I expected. She had been so direct and sure of herself up to this point that I thought she had an agenda. I was sure she had some specific demands of me and Dr. Greco.
Instead, she started to cry.
Chapter 10
When she looked up at me again, Jillian’s eyes were rimmed with red and I knew then and there I was going to find out why she had waited for me in the parking lot earlier in the day.
“Carlos, my grandfather retired as a violinist with the Philadelphia Orchestra. He started teaching me to play when I was four years old. I am in my fourth year at conservatory and now I am hoping to land a job as a professional musician as well. He may not know what month it is, but he still can coach my technique and play practically every part in every concert he performed in since his career began.”
“To this day, he and a group of his retired musician buddies get together every Saturday to play in a string quartet. They do not perform for anyone—only for the pure joy of the music. They have played so often that most of the time they can play from memory without sheet music. If he had to go to some type of home, I am certain it would literally kill him. Is there any way we can keep him in our house for as long as possible?”
Wow. This was a plea that I desperately wanted to grant. And yet even with my limited experience, I knew somehow that it had little to do with my skills as a health care provider, the tests I could order or the medicine I could prescribe. So, I turned to the ultimate source of help that healers have called upon from the dawn of time.
Dear God, I know I haven’t been to church in ages, but I swear if just this once you will help me pull this miracle off, I will never EVER ask for anything else as long as I live and I will be there for holiday masses with Abuela…Amen
Then, I took a deep breath and said, “I can’t promise anything but I can tell you that Dr. Greco and I will do our absolute best.” I managed what I hoped was a reassuring smile and continued, “Now, are you allergic to Italian ice or do they just not serve any flavors you like? Allergy to Italian ice is clinically quite rare you know, but we could pre-medicate you with antihistamines if you have been known to develop hives after consuming it.”
She wiped her eyes with a tissue (why do women always seem to have those an
d men never do?—I remember, it’s because we have sleeves) and allowed me just the slightest smile.
And my heart went right up to the sky.
Chapter 11
Each day at Dr. Greco’s office brought new challenges. I still wasn’t sure I was living up to his expectations. In the second week of the rotation, I finally had a chance to show that I was learning what he was teaching. Do it from the beginning. Use the fundamentals. Don’t take anything for granted.
I saw a 40 year old high school teacher as a follow up from the emergency room. He had been diagnosed 3 days earlier with pneumonia and had the chest xray to prove it—right sided infiltrate with pleural effusion (fluid around the lung)—but wasn’t feeling any better. He was being treated with an appropriate antibiotic and had enjoyed very good health all his life prior to this.
“I still have sharp pain right here when I take a deep breath,” he said, pointing to the lowest ribs on the right side of his chest. “And I get short of breath when I walk from one side of school to the other”.
I examined the patient and noted as expected that he had decreased breath sounds over the right lower lung. He did not have a fever. I was about to go talk to Dr. Greco…
Hold on a minute. Do it from the beginning. Use the fundamentals. Don’t take anything for granted.
“Sir, can you tell me how this problem all started?”
“Sure,” he winced, “About a week ago I woke up with this pain in my side every time I took a deep breath. If I’m just sitting, my breathing isn’t so bad, but if I get up and walk for more than a short distance I feel short of breath”.
“Any other symptoms?”
“No, that’s really it”, he assured me
“No cough, no fever, no leg swelling.”
“None of the above, Dr. Vega.”
Then, I crossed the hall to Dr. Greco and presented the case. “Sir, this just doesn’t add up. He’s being treated for pneumonia, his chest x-ray kind of looks like pneumonia, but his symptoms don’t sound like pneumonia and he isn’t getting any better on antibiotics.”
Dr. Greco looked at me with an expression that told me I was dead-on.
“So what do you propose, Dr. Vega?”
“I think he needs a CT angiogram, to rule out a pulmonary embolus. But I don’t want to start a wild goose chase”.
“You’re not chasing geese Dr. Vega, you’re closing in on a blood clot in that man’s lung. Congratulations.”
It’s a long fly ball to deep center field, way way back, it’s outtta heeere.
Chapter 12
Clinical challenges came in all shapes and sizes during my family medicine rotation, and I soon learned that the difficulty of the case didn’t always have to do with the complexity of the disease. A prime example was three-year-old Jonah Fogle. Jonah came in with a four day history of nasal congestion, cough, fever to 101 and right ear pain. He had a history of ear infections in the past. I was practically gleeful as I walked into the exam room. All I would have to do was ask a few more questions, look into his ear, calculate an antibiotic dose and the visit would be successfully completed.
I greeted Mr. Fogle and turned my attention to Jonah. His body language should have warned me from the start. The corners of his mouth turned down into something between a skeptical glare and a determined frown. His arms were crossed in front of his chest. He was the picture of pre-school defiance.
As if further explanation were needed, Mr. Fogle noted, “Ah, sorry Doc, but Jonah has never liked anyone looking in his ears.”
I tried to turn on my best impersonation of charm and reassurance, “Oh, Mr. Fogle, I’m sure we’ll get young Jonah here to help us out, won’t we Jonah?”
The boy’s angry stare did not waver for an instant. If he had been willing to talk, he would have said, “Bring it on, junior doctor.”
“C’mon Jonah,” I cajoled, “Won’t you let me take a quick peek into your ears?”
The reply was a silent slow side to side motion of the blond curly head.
The father walked over to the exam table with hands extended as if to try to hold Jonah’s head. This elicited an even worse response. Jonah began to kick his legs and cry with his hands held firmly over both ears.
“Excuse me a moment, Mr. Fogle,” I said as I escaped into the hallway leaving the sobbing child and the embarrassed father. I couldn’t believe it. I had come so far in solving difficult clinical issues in my training and I was about to be defeated by the inability to examine the ear of a three year old!
There was nothing else to do but make the humiliating walk down the hallway to Dr. Greco’s office. As I presented the case, he just smiled and shook his head.
“Dr. Vega, remember what we said about trust being a powerful tool in healing? Well, that applies to all ages. Let’s go see Jonah and I’ll show you some things I’ve done to gain trust with children his age. Only once he trusts you will you be able to examine him.”
We entered together and I saw Mr. Fogle relax right away but Jonah remained fearful and visibly tense.
“Hi Jonah,” said Dr. Greco as he took a seat on the stool and motioned for me to sit beside him. “You sure are getting big. How old are you?”
Jonah wasn’t going to let him off that easy. He just shook his head and stared in another direction. But Greco wouldn’t give up.
“Are you this many?” Greco inquired, as he held up two fingers.
Our pre-schooler made a face and shook his head as if insulted that anyone would think he was a mere two year old.
“Are you this many?” Greco now held up four fingers.
Jonah, now realizing there was a game going on, almost let himself smile before he remembered he was supposed to be uncooperative. He shook his head again.
“Are you this many?” Greco tried one more time holding up three fingers.
This time Jonah looked at his father who was gently smiling. Jonah started to smile too and nodded his head.
“THREE!” Greco made a big show of learning Jonah’s age. “You can’t possibly be three. Are you sure you didn’t skip two?”
Jonah knew you didn’t skip any years and he began to giggle and shake his head no.
Dr. Greco then asked Jonah, “Your daddy says you’re here because your ear hurts. Can you point to which ear hurts?”
Jonah pointed to the right ear.
“Well,” Greco continued, “Jonah, I can help your ear stop hurting but I need to look into it first. Which ear should I look at first?”
Jonah was about to choose an ear when he remembered he wasn’t going to let anyone look in his ears. So he shook his head. Remarkably, Greco took this in stride.
“Okay, should I look in this ear?” and he pointed to Jonah’s knee.
Jonah giggled again and shook his head.
“Why not?” asked Greco.
Jonah finally spoke, “’cause that’s not a ear” and he laughed again at what he thought was Dr. Greco’s anatomic confusion between the knee and the ear.
“Alright, then which ear do I look in?”
That’s when Jonah turned his head and pointed emphatically to his right ear, “That one.”
Greco looked in the right ear and then Jonah automatically turned his head so the left could be examined. The remainder of the exam passed without incident. We reviewed my antibiotic calculations and gave instructions for pain relief.
As Jonah and his father started out the door, Mr Fogle said, “Thank you for having so much patience with Jonah. How can I get him to be less fearful at the doctor’s office?”
Greco reassured him, “In time the fear will pass on its own. But there are some things that can speed things up a bit. Do you have pets?”
“Yes, we have 2 cats.”
“Okay, then, the next time you bring your cat to the veterinarian, bring Jonah, too. Tell Jonah that you’re bringing him so the kitty won’t be scared at his check-up. It may help Jonah to be less scared at the doctor’s office.”
“That’s a gr
eat, idea, Dr. Greco. We’ll try that. Thanks again.”
As they left, Greco looked at me. “Your instincts were very good, you know. You could have forced the situation and you didn’t. Many is the time when I have come running down the hallway to see a student who has directed a parent to actually hold down a screaming child for an exam. That should be the very last resort. No matter the age of the patient, never forget the value of establishing trust, Dr. Vega.”
Later, after the Fogles left, I was feeling pretty good and ready for the next challenge—and it wasn’t long in coming, but the results would prove to be not nearly as satisfying.
Mrs. O’Malley was a 45 year old overweight woman who had noted for months that after eating she would have episodes of pain in the right upper side of her abdomen. Her mother, aunt and sister had all had gall bladder surgery before her, so she felt she was just putting off the inevitable until she had more time for the operation and recovery process.
One morning, she looked in the mirror after a shower and was shocked to discover that her skin looked yellow. Even the whites of her eyes were yellow.
She came to Dr. Greco’s office early enough in the morning that I was able to schedule blood testing and an ultrasound almost immediately. I felt pretty confident that one of her gall stones had gotten stuck in the main drainage tube from the liver. This would cause the yellow bile fluid to back up into her blood and turn her skin and eyes yellow—a dramatic but not particularly grave outcome.
We got the call about an hour later and Dr. Greco put it on speaker so we both could listen:
“Sorry to break this to you boys,” Dr. Patel said from the radiology suite, “but your patient has a 3 centimeter obstructive mass at the head of the pancreas with both extra- and intra-hepatic biliary ductal dilation. There are also multiple masses in the liver suggestive of metastatic disease. I would advise a CT scan for further clarification.” In other words, instead of the impacted gall stone we had expected, poor Mrs. O’Malley not only likely had a particularly nasty form of cancer, but it had already spread. We would refer her to a cancer specialist. She would get treatment. We would all hope for the best. But the truth was that her chances didn’t look very good.
Dr. Greco and I looked at each other. I could see from his pained expression that no matter how often he had heard news like this, it didn’t make it any easier to break it to a patient.