…There is, it seems to us,
At best, only a limited value
In the knowledge derived from experience.
The knowledge imposes a pattern, and falsifies,
For the pattern is new in every moment
And every moment is a new and shocking
Valuation of all we have been.
T.S. Eliot, East Coker (Four Quartets)
It was a good day today. There are not many occasions when you recognise the clues, feel bold enough to make a diagnosis, and see admiration in the eyes of your colleagues – some of whom didn’t even know who you were.
The patient came in with fever, he was referred as just another pneumonia or a urinary infection, but I noticed that one of his blood results was unusually high. The eosinophils. This led me to ask about his travel history, because these cells often go up when there are parasites in the system. And indeed he had travelled, a fact that no one else had thought to ask. I looked up the country in which he had spent time, and worked out what sort of parasites could be involved. But I knew which one already. The symptoms seemed to fit what he was describing, to the letter. Fever, abdominal pain, some weight loss, and especially breathing difficulties that he had developed just before coming to hospital. It all fit.
So I looked up the treatment, called the pharmacist to make sure we had it in stock, and prescribed it. By the end of the day he was already feeling better. It made all the study seem worthwhile. But it was a special memory that served me so well today. I had seen a patient just like this one during my elective, in Africa. I even wrote about it in the report that we had to hand in, so it stuck in my brain. Strongyloides. I suppose, over a whole career, many such images and stories will find a place in my memory, to be retrieved at a later date. Nothing wasted, they all find a niche. A good day.
I went straight into see him as soon as I arrived. He was grateful, and asked how long it would take him to get better. I said I would refer him to the tropical disease specialist, as they see more of this sort of thing. And of course I explained that we needed to confirm the diagnosis, even though I was pretty sure about it. I reviewed his blood tests, and saw this kidneys weren’t working so well. He must have got very dehydrated before he came in. His breathing had settled slightly, but he was still struggling. I didn’t want to come across as an expert, because I have only ever seen one other person with this. But he’s on the right track.
I was disappointed today. His kidneys were worse, despite the fluids that I prescribed. My consultant didn’t have any new ideas, she was pretty happy to go along with my explanation. But she was keen to see confirmation of the diagnosis. The antibody tests will take days, they have to be done in London. She asked me whether it could be any other parasite, or any other type of infection full stop. Perhaps she doesn’t quite trust my impression. It made me think, and reflect. But I’ve seen the list of parasites, and none of the others that he might have acquired in Africa present like this. So I suggested that we push on with the current treatment. It worked last time, I explained.
Weird. He was confused today. This parasite can affect the brain though. I spent 45 minutes on the phone trying to get through to a tropical disease expert, to see what they thought. They agreed, yes, Strongyloides can go into the brain. So I arranged a scan, and it’s happening after hours tonight. The anti-parasitic agent we’re giving him will kick in soon.
I went to see him but he wasn’t there. I ran into another SHO in the corridor who had been on call overnight and he told me he’d been transferred to the intensive care unit. I almost ran. When I got there I found him unconscious, on a ventilator. He was surrounded by other doctors. There was a neurologist, examining his eyes. I asked what was going on. He had blown a pupil, I was told. It didn’t make sense. I saw a nurse returning from one of the computers. She was shaking your head. ‘What!’ shouted one of the other consultants, a rheumatologist. ‘They must have done it!’ he said. I faded into the background, but I continued to listen. What angered him was the fact that during the patient’s entire admission, no one had sent off a vasculitis screen. As soon as I heard that word, vasculitis, my heart dropped and the muscles in my legs grew week. I had to sit down behind the nurses’ station. I realised that I had made a huge mistake. For vasculitis is another main reason for eosinophils to be raised. I knew immediately what is the diagnosis was. Churg-Strauss syndrome. I had missed it completely.
I met with my clinical supervisor today. I had asked for the meeting. I told her what happened. I could tell that she thought my mistake was a bit stupid. She asked me what my thought processes were on the day the patient came in. I explained the whole story, how it rung bells in my mind, how the words that he used, and the clinical examination findings, had taken me back to a vivid moment in my training. And I had questioned the data, and I had tested the hypothesis, and it all seemed to fit.
‘But what about the differential diagnosis?’ she asked
‘Did you develop one?’
‘I did, I think. I’m n…’
‘Did you write it down Emma, in the clerking? Did you test for anything else?’
‘I didn’t think I needed to. It was so clear.’
‘Well, to be fair, the patient saw a lot of other people, and more senior than you, before he got really ill. No one really challenged the diagnosis. There’s a lesson for all of us. But it shows you the power of a positive diagnosis. Especially one that appears to be supported with confidence. You’re a junior doctor, but you see how much weight people give the opinion of anybody who seems sure of themselves. Yes, diagnoses should be challenged by more senior doctors as they review patients, but it is not uncommon for them to defer to the opinion of the first doctor who really got their teeth into the case. And that was you. You made a plan, it made sense, the patient even got a little bit better at first. Sometimes, I think, there is really one chance to set things into motion in the right direction, and that’s on the first day of admission. It’s a big responsibility. Am I making you feel any better?’ She smiled. Then she asked, ‘What would you do differently next time?’
‘I won’t be so confident.’
‘That would be a shame, if you are right.’
‘Well if I really think I’m right, I will make my case confidently. But I will make sure there are caveats, and that other avenues aren’t closed off right at the beginning. Perhaps in this case, because he had raised eosinophils, he should’ve seen a rheumatologist anyway, even if I really thought he had an infection.’
‘I’ll tell you what I take away from this. The power of anecdote. In your mind there was a clear story, and narrative that you had seen played out before, one with a happy ending. You were sucked back into that memory. If you’re like me, your memory works best when it’s embedded in stories. But I guess that might be a disadvantage, if you can’t stand back and approached each case with pure objectivity. Attack each case with fresh eyes, but use the stories that you recollect to remind you of all the possibilities.’
‘I hear you.’
‘And one more thing. The Procrustean Bed.”
‘His confusion. It challenged your hypothesis, it didn’t make sense, but you rationalised it, and made it fit your idea – a parasite in the brain. Procrustes chopped or stretched travellers who encountered him until they fit the size of his bed. You not only fell into the trap of anecdotal memory, but you tailored your interpretation of the data so as to support it…’
‘There is one more thing.’
‘I was pleased with myself, on the first day. I elated, to make a difficult diagnosis.’
‘That may be the most valuable lesson of all. It’s seductive, the warmth that being right gives you. But don’t worry, you’ll experience enough reverses in your career to learn that pride is never to be entertained. I think you’ve learnt enough from this particular case, don’t you! How is he by the way?’
– – –
Note: This case report from the CLEVELAND CLINIC JOURNAL OF MEDICINE explores the clinical scenario in more detail.