The Croup

The Croup

In my career in Medicine, I have seen many challenging patients. I remember one particular little girl in my early years. The dedication and skills of the doctors treating her made a great impression on me. This is her story.

It was 1990, and I was doing my internship year after graduating from medical school. I was at the Ahmadu Bello University Teaching Hospital in Zaria, Nigeria. Our Internship was also known as the ‘Housejob’ and involved us rotating in the different departments of Surgery, Pediatrics, Internal Medicine and Obstetrics and Gynecology.

After 3 months in Surgery, I had come to Pediatrics. My good friend and former classmate Kabir Abubakar had already been in Pediatrics for a couple of months and quickly showed me the ropes. He took me around the EPU (Emergency Pediatric Unit) and introduced me to the patients. He taught me how to calculate doses of medications for these small children and how to obtain intravenous lines.

Kabir was my friend, and also a great teacher. I had a good first day, but towards the evening, we heard a small commotion in our intake area where the Pediatric emergencies were brought. It was a frantic Mom, with her 4-year-old daughter. Her daughter had developed a cold followed by breathing difficulties.

Both Kabir and I rushed to her side. She was having difficulty breathing. We diagnosed croup with epiglottitis. This is an infection of the trachea that can become serious in small children. We tried conservative measures initially, but she was not getting better. We called our anesthetist to intubate her. Intubation would be difficult as she was so small and likely had inflammation in the trachea.

While waiting for the anesthetist, Kabir told me that we should be ready to do an emergency tracheostomy (a small hole in her neck) if she gets into acute distress. Have you done one before, I asked him. No, he said, but this is an emergency, and he had his scalpel ready. He also told me to have a large bore needle we could stick in the trachea as an alternative. I was nervous, and I marveled at his calmness as he continued to provide the child with oxygen and other conservative measures.

Suddenly the Anesthesia team showed up. They rushed the child to the Operating room and intubated her. She was subsequently moved to the Intensive Care Unit. With her airway restored she became much more calmer and was breathing comfortably. Eventually, she was taken off the ventilator and remained comfortable with the breathing tube in place.

Our Pediatrics team continued to follow the patient. During this time Kabir rotated off Pediatrics, and was replaced by another close friend and classmate, Adoyi Ameh. At this time, an attempt was made to remove the breathing tube, but she immediately went into respiratory distress and had to have the tube reinserted.

Another course of antibiotics and steroids followed, but she again failed attempts to remove the tube two more times. Subsequently, our team decided to see if she could be evaluated by an Ear Nose and Throat Surgeon. Unfortunately, we did not have one on staff at that time and we decided to take her to see one in the nearby town of Kaduna.

We arranged an ambulance to take her there, and our senior registrar decided that one of the house officers will accompany her. I was chosen even though that would mean that poor Adoyi would be manning the Emergency Pediatric Unit alone at the height of the meningitis epidemic. However, Adoyi is an amazing guy and with great grace, simply said “Go, I will take care of everything here”.

So, I sat in an ambulance for the first time in my life for the one hour ride. We saw the ENT doctor who said he could do a tracheostomy, but said he did not have the ability to provide her the care afterwards. Defeated, I came back to our hospital. Adoyi had managed all the admissions alone for that day superbly.

Our Surgical team then decided to do the tracheostomy and take out the tube themselves. The child did very well and was able to be eventually discharged home. At a subsequent follow up, the tracheostomy tube was removed and the child made a full recovery.

About a year later, I was walking in the local Sabon Gari market, when I heard an excited voice shouting ‘Doctor’! I turned around and it was the mother of the child. I asked her how her daughter was? She turned around to show me the clothing store she ran in the market and inside was a happy little girl playing. A small scar on her neck was the only reminder of her illness. The Mom thanked me profusely. I reminded her that I was just a small part of the large team of doctors that took care of her daughter.

Kabir went on to become an Orthopedic Surgeon, Adoyi Ameh a Pediatric Surgeon. I came to America and became an Infectious Disease Physician. I will however never forget the selfless way in which all those doctors came together to help this child who is probably a grown woman today.

Zia with Kabir in the EPU 1990, inset is Adoyi Ameh.

Walo Black

Walo Black

On October 1^st 2004, my dear friend Auwal Abubakar was killed in a car accident along a highway linking the cities of Kaduna and Kano in Northern Nigeria. This was devastating news for me as he was very dear to me. Amongst my many memories of Auwal is one that involves the same highway on which he eventually lost his life. Here is that story.

We called him Walo in our class tradition of having nicknames that ended in “O”. I was thus “Sifo” (from Asif). However, we had another Walo in our class. In order to differentiate them from each other, one became “Walo black” as he was slightly darker complexioned and the other became “Walo white”! While both were my close friends, this story is about Walo black.

It was in 1990, and I was doing my house job at the Ahmadu Bello University Teaching Hospital in Zaria, Nigeria. The hospital assigned us apartments with two house officers to an apartment. Walo was my roommate. While we rotated in different departments, we were both posted to the Internal Medicine rotation at the same time. I moved to Obstetrics and Gynecology from Internal Medicine. Auwal (Walo black) had now moved to Pediatrics.

I had gone to the Internal Medicine office to pick up my evaluation. The secretary asked me if I would take Walo’s evaluation to him as well as he had not picked it up and he was my roommate. It was sealed in an envelope, but with a twinkle in her eye, she told me that his evaluation was much better than mine.

I loved Walo, but in order to punish him for doing better than me, I decided to play a trick on him. I went home to my portable typewriter (we did not have home computers in those days) and typed up a letter.

The letter was addressed to Auwal Abubakar from the Medical and Dental Council on a plain piece of paper (of course I did not have their letter head). It said to the effect that “We are sorry to inform you that because of your poor evaluation in Internal Medicine (attached), the Medical and Dental council regrets to inform you that your medical license is cancelled”! I signed it with my own signature and enclosed both his sealed evaluation and this letter in another envelope and put it in his mailbox in the Pediatrics department. It was such an obvious forgery, and along with his good evaluation, I thought we will both laugh about it later.

Unfortunately, it did not go as planned. Later that afternoon, I ran into Walo in the hallway in the hospital. He looked very unhappy, and he instantly accosted me and said in an aggrieved tone “Do not Laugh”! Confused, I said, Laugh at what? You know what you did he said in a severe voice. What happened I asked?

Apparently Walo had got to his mailbox that morning and read the letter. He saw his perfectly good evaluation and felt very upset at the letter supposedly from the medical council. He went immediately to his Pediatrics team and told them about the letter and that he had to go to the office of the Medical and Dental council right away to sort this out.

Unfortunately, that office was in the neighboring town of Kaduna, which was an hour bus ride away along the Kaduna - Kano highway, (which passed through Zaria). He left for that office immediately by bus. After a long hour in a crowded bus, he got there and started arguing with the staff there as to how dare they send such a letter for a perfectly good evaluation.

The Medical Council told him that they had issued no such letter. It was then Walo took a proper look at the letter and realized it was fake. He saw my signature and knew that I was responsible for this deed.

To add insult to injury, when he got back, he had to tell his Pediatrics team what had really happened, and they burst out laughing. Instead of getting sympathy, everyone was laughing, and Walo was mighty upset at me.

I did not laugh at that time but apologized profusely. I told him I never imagined that that he would not realize it was fake. I had even signed it with my name! In the end he forgave me, and as penance, I took him out to dinner at our favorite restaurant “Shagalinku”.

We did laugh about this afterwards. I eventually left for America and lost touch with him. Walo became a specialist in Pediatrics and was a Consultant at the time of his tragic death. It was the same highway, but this time he was going the other way towards Kano.

I pray that his soul rests in perfect peace.

                                              Walo and Me at Graduation in 1990

Drying Up Of The Vine

Drying Up Of The Vine

I recently saw an elderly patient of mine. He was in his late eighties, but he stood tall and was sprightly. He was in excellent health for his age. The only evidence of his advancing years was a hearing aid in one ear.

We took care of his routine health needs. On one visit, he talked about how things change over time. I asked him how? He then told me his story.

In his younger years, he had moved to a very small town in Georgia. This town was established in 1820 and was one of the oldest towns in that area. In 1887, the railroad came through and the town boomed. People moved there and businesses were established.

In the 1920’s, this area became a favorite visiting place for the future President Franklin Delano Roosevelt. FDR loved the wide open areas and the multiple springs beneath the land. He kept visiting until his death in 1945.

This area continued to do well, with cotton mills and some manufacturing plants. Almost forty years ago, my patient opened a hardware store there. He ran it with his wife and worked every day except Sunday. Both husband and wife knew most of their customers by name and business was steady.

Unfortunately, a few years ago the main industrial plant in town shut down. This was a food processing plant, and with it came the loss of several hundred jobs. Many people moved out and businesses started shutting down.

His hardware store also started to decline. This was hastened by the opening of a large chain department store in a nearby town. My patient was getting older and the store, in his words, was bleeding money. He decided to try to sell it.

There were no offers on the store. He finally closed the store and auctioned the inventory. The town agreed to buy his building, and they used the building as a medical office. My patient was now officially retired.

He finally decided to move away from his small town and move closer to where his children and grandchildren were living. While he is much older, he remains in good health. He spoke with a little sadness of the decline of his store and his small town. His description of it struck me. He said it was like the “Drying up of the Vine”.

This was a beautiful way of expressing his thoughts. I later found out that this expression comes from the Bible; “The vine is dried up and the fig tree is withered; the pomegranate, the palm and the apple tree, all the trees of the field are dried up. Surely the people's joy is withered away”. (Joel 1:12).

After our visit, I looked up his old town. It had declined to a population of less than a thousand. However in recent times there had been a renaissance. Tourism had remained popular as many people would come to see President Roosevelt’s cabin. This fairly modest cabin was known as the ‘Southern White House’.  This term has been used for many presidential retreats, but this is probably the most modest.

Some of the old stores were renovated and antique shops were opened in them. More recently a Korean auto parts manufacturer has opened a plant in that area and the population is slowly increasing.

My patient is also doing well. He is a little bored in retirement but is content. His phrase ‘Drying up of the Vine” has stuck with me.

However it now appears that the vine is growing again!

                                    President Roosevelt's Southern White House in Georgia

The Denial

The Denial 

Health care coverage has changed these days. In the old days, if you had medical insurance, you went to the doctor, and perhaps had to pay a small co-payment. If you had a deductible, it was fairly small. Over the last few years, this has changed. Now most insurance companies have large deductibles. A deductible means that you have to pay the first several thousand dollars of your medical bills, before the insurance company will pay anything. There are also ever increasing lists of reasons for denial of payment for specific services.

This improves the insurance company’s bottom line, but the effects on the patient can be devastating. I have seen many people forego appointments and tests, simply because they found the deductible too expensive or coverage was denied. Here is one such story that I found particularly heart wrenching.

Several months ago, I was seeing a new patient in my office. He was in his fifties and came in with his wife. He had developed abdominal pain several months ago, and had difficulty keeping anything down. He had lost considerable weight of about sixty pounds and felt very unwell.

He had been to two other doctors. They had done lab work on him, but this did not show anything. A CAT scan had been recommended, but not done, as he had been concerned about both his deductible and the insurance company coverage.

When I examined him, the weight loss was very concerning to me. I told him that I too would like to get a CAT scan of his abdomen. He was concerned about the costs. I however reassured him and was fairly confident that insurance coverage would not be a problem.

My patient however was very despondent. He felt something was seriously wrong with him, but he was concerned about his high deductible and he knew that he would be unable to pay for the scan if insurance would not cover it. He was so resigned that he told me that he would prefer to die rather than go into debt that potentially his wife and four teenaged children may have to pay.

I obtained a prior approval from his insurance company and he went for his CAT scan. I still remember that day, because I got a call from the Radiology department. His insurance company had suddenly denied coverage of the scan for no clear reasons. My patient had been sent away. I was just being given a courtesy call.

I was incensed. I called the insurance company and told them right there that I was ordering the scan for possible cancer of the colon, and if the insurance did not cover this, they would be responsible for anything that happened to my patient. This was of course a possible cause of his symptoms.

The effect of this was instantaneous. The CAT scan was approved and my patient was immediately called back in to get it. Two hours later, the radiologist called me. He did have cancer. He had a large mass in his colon. Now, I was totally taken aback. This was the last thing I had wanted to find.

I immediately called my patient and gave him the news. He was more relieved at finding the diagnosis, rather than being upset. He wanted to know what would be the next step to take.
I called our surgeon that afternoon and he agreed to see him the next day. He was scheduled for surgery within a day or two and the mass was removed from his abdomen. Pathology of the mass confirmed cancer, but it was localized and had not yet spread.

My patient made rapid progress thereafter and regained his appetite and weight. He went back to work. He came to see me several months later. There was no sign of the cancer and he was doing extremely well.

I thought this was a happy ending, but it was not to be. My patient kept regular appointments with the Gastroenterologists and Oncologists and there was no signs of the cancer. About a year and a half after his initial diagnosis, he came to me with complaints of abdominal pain. I immediately repeated his CAT scan. The report showed multiple areas of cancer in his liver. He had just had a colonoscopy which was negative, so the cancer in his liver probably started at his first diagnosis but was too small to be detected at that time.

His cancer doctors could only offer him palliative care and he declined. He went into hospice care and died five months later. I will forever wonder if the delay in his initial treatment contributed to the seeding of the cancer in the liver.

There are many others that also do not end well. They have delayed diagnosis or treatment because of their high deductibles or insurance denials, and this is for people with insurance. I hope and pray that this state of affairs changes in the future.

CAT scanner

The Kinkajou

The Kinkajou

In my work as a physician, I often get situations that are new to me and I have to figure out how best to handle them. Here is one such story. It was a regular day on the Infectious Disease consult service. We had several people on our team as these days we often have students and medical residents attached to us as part of their clinical rotations.

On this day, we got a call about a patient who had been bitten by an animal on her hand. Her hand was swollen and not responding to antibiotics as expected. Infectious Disease input was requested to help manage this patient, and the case was assigned to one of our students. The student typically gets the detailed history then presents this during rounds.

At our rounds later that day, our student presented the case. The patient was a lady in her forties. She worked at a gas station and had noticed one of the people filling up there had an extremely cute furry animal on his shoulder. She thought that this was a very cute pet and went up to the owner and asked him about it. He said it was his pet Kinkajou.

A ‘kinka’ what I asked? I had never heard of this kind of animal before. Our student was a very bright young lady and had already done her research on it. “It is an exotic pet from South America, and is related to the Raccoon family” she said.

Our patient had tried to ‘pet’ the kinkajou, which apparently, the kinkajou did not like and it bit her on her right hand. Startled, she ran back into the gas station and put her hand in running water. When she came out, the kinkajou and its owner were nowhere to be found. Her hand became swollen and painful, and she went to the Emergency Room. She was started on antibiotics and discharged home.

Her hand did not get better and over the next three days, became even more swollen. She went back to the Emergency Room and was admitted this time and started on strong antibiotics. Unfortunately, the hand was still not getting better and the next day, the Infectious Disease team was called.

On examining her, her hand was quite swollen, with small teeth marks at the base of her thumb. We did a scan of the hand, and this just showed the swelling, but no obvious abscess or fluid collection. At that time, I was not sure what to do next. As in most unusual cases, we subsequently did a search on the literature about kinkajou bites.

The first article that came up was about the famous socialite Paris Hilton who was bitten by her pet kinkajou. Since the kinkajou is related to the raccoon family, a concern of possible rabies is present. One can euthanize the animal and examine the brain for rabies. Paris Hilton refused this and apparently both she and her kinkajou did well.

Based on our research, we decided to treat our patient like she had a wild raccoon bite. We gave her broader antibiotic coverage and also immunized her against rabies as an added precaution.

Our patient did well, and the swelling in her hand came down. Three days after admission, her hand was almost back to normal and she was discharged home on oral antibiotics and instructions to complete her series of rabies vaccination. At her discharge, she told me that she would not be attempting to ‘pet’ strange animals in the future, no matter how cute.

I am glad she did well, and now, I know what a kinkajou is. If Paris Hilton ever gets bitten by her pet again, I am ready to treat her!

A Kinkajou

Morgellons

Morgellons

In my years as a physician, I have seen many interesting and strange conditions. Here is a story of one such patient.

She was a neatly dressed lady in her fifties. She was referred to me by her primary care physician for an Infectious Disease consult. She said she was infested with bugs and that they were crawling under her skin. This caused intense itching. She said she was able to scratch at those areas and was sometimes able to dig out the bugs.

She brought a tissue with her with small dark objects stuck on it which she thought were the dead bugs. I looked carefully, and they looked like tiny flecks of dead skin to me. Over many months, she had seen several doctors including Dermatologists. She had undergone a skin biopsy, but no diagnosis was confirmed. Her primary physician finally sent her to me for an Infectious Disease consultation.

I took a detailed history and examined her carefully. Her skin showed signs of intense scratching, but was otherwise normal. I examined her carefully, specifically looking for possible scabies which causes itching but usually in specific areas of the body. I also looked for ‘cutaneous larva migrans'. This also causes intense itching and is caused by the dog and cat round worm, but she did not have the classical skin presentation associated with it.

I looked at her biopsy reports and these just showed a nonspecific inflammation of the skin, with no parasites seen.

I could repeat her biopsies, but I doubted they would show anything. I thought she had a condition known as “Delusional parasitosis". This is a rare disorder in which affected individuals have the fixed, false belief that they are infected by “bugs" such as parasites, worms, bacteria, mites, or other living organisms. As with all delusions, this belief cannot be corrected by reasoning, persuasion, or logical argument. Many affected individuals are quite functional. For some however, delusions of parasitic infection may interfere with usual activities.

A lay term for this condition is Morgellons disease. The name was coined in 2002 by Mary Leitao, a mother who rejected the medical diagnosis of her son's delusional parasitosis. She derived the name from a letter published in 1690 by Sir Thomas Browne who was a physician. He had described an unexplained rash in children.

Leitao and her "Morgellons Research Foundation" successfully lobbied members of the United States Congress and the Centers for Disease Control (CDC) to investigate the condition in 2006. CDC researchers issued the results of their multi-year study in January 2012, indicating that there were no disease organisms present in people with Morgellons and concluded that the affliction was likely a “delusional condition”.

The Morgellons Research Foundation subsequently shut down. The different causes of delusional parasitosis can however also include certain medical conditions, such as a true parasite infestation, thyroid disease, diabetes mellitus, vitamin deficiencies, syphilis, HIV infection, hematologic disorders, and prescription-drug side effects. These have to be ruled out.

Treatment is challenging. If there is an underlying medical problem, then it needs to be treated. For the others, anti-psychotic medications are the treatment of choice assuming you can make the patient take the medications. I usually would prefer to refer to a Psychiatrist, but here again, convincing the patient is very difficult to say the least.

A case in point, this patient was most unhappy with my assessment. She told me that I did not know what I was talking about. She was very sure she had bugs under her skin. I offered to refer her to another Dermatologist as I did not dare bring up a Psychiatrist at that time. She angrily declined and stormed out of the office and I never saw her again. I hope that she is doing well today.

I continue to see similar cases intermittently. One recent patient had to be admitted after her intense itching cased a bacterial infection of her back. The infection was easy to treat, but the underlying condition is something that I am short on answers on.

Probable case of delusional parasitosis

The Peace Widow

The Peace Widow

Recently I saw one of my regular patients. She was a smart lady in her early-forties. She was telling me that she has a lot of fun on the weekends when she looks after her one year old grandson. She told me that her husband has to fend for himself when she is busy with her grandson. I replied that he should not mind as it is his grandson too. He does not mind, she said, but he is technically the step grandfather. The grandson was from her son from her first husband.

Does your ex-husband get to spend time with his grandson too, I asked? She was quiet for a while, then said “no, he is dead”. I was taken aback, and said that I was very sorry to hear that and asked “when did he die”?

He was killed in Northern Iraq in 1994 she replied. I thought for a minute, then asked “but the first Iraq war ended in 1991, how was he killed in 1994. She then told me the story of the “Black Hawk Shoot Down” incident.

The 1994 Black Hawk Incident was a friendly fire incident over northern Iraq that occurred on 14 April 1994 during Operation Provide Comfort. This was an attempt to establish a no-fly zone over Northern Iraq. The United States Air Force was trying to protect Kurdish civilians from Saddam Hussein’s Air Force. 

The pilots of two United States Air Force F-15 fighter aircraft operating under the control of an airborne warning and control system (AWACS) aircraft, misidentified two United States Army Black Hawk helicopters as Iraqi Mi-24 "Hind" helicopters. The F-15 pilots fired on and destroyed both helicopters, killing all 26 military and civilians aboard, including personnel from the United States, United Kingdom, France, Turkey, and the Kurdish community.

My patient’s husband was 22 years old and was in one of those helicopters. He was one of those 26 people that were killed. Apparently, the AWACS operator had been told of the presence of the two friendly helicopters, but he failed to make a note this. Subsequently, when the F-15 pilots requested the AWACS for identification of these helicopters, they were unable to do so. The F-15 pilots were required to fly close by to see the helicopters visually. They misidentified them as Iraqi, despite two large American flags painted on each side of the Black Hawks.

The only person ever court martialed for this incident was the AWACS operator, and he was not punished. My patient became a very young widow with a new born baby son. The Army later gave my patient videos of the whole shoot down incident. The rear helicopter was shot down first. Her husband was in the lead helicopter and she saw it take evasive action to avoid being shot down, but the missile still hit it. She saw it go down in flames with her husband inside.

My patient was devastated after this. The Army gave her full benefits as a widow of a soldier killed in action, but no other compensation. The families of the foreigners killed in this incident were given $100,000 each as compensation by the United States department of defense.

My patient devoted her life to bringing up her son. She said that there were many men who expressed an interest in her, but she turned them all down. Her son grew up and got married and had a son of his own. This was the grandson that my patient was spending her weekends with.

Twenty years after she became a widow, my patient was in her forties. She then met a wonderful man. He had the same first name as her deceased husband. She fell in love and finally decided to get married. As soon as she got married, the military took away all her widow benefits. She is however content with her life today.

While I was happy that my patient had finally been able to move on with her life, I felt sad as to the circumstances of her becoming a widow. Even though her husband was killed in action, there was no war going at that time. He was also killed by his own side, in a ‘friendly fire’ incident. Most inappropriate to call it that because there is nothing ‘friendly’ about being fired on, no matter by whom.

Women who lose their husbands in war are often called ‘war widows’. In my patient’s case I felt it more appropriate to call her a “peace widow”. However, she is now no longer a widow, and I hope she continues to do well and finds ever more peace and happiness.

                                      The remains of the 26 victims of the Black Hawk 

                                      shootdown arrive at the U.S. Army Mortuary Center.

The Surgeon

The Surgeon

A memory of William Dayton Shelly, 2/17/43 to 4/13/08

Recently hurricane Matthew came through North Carolina. It caused widespread flooding and destruction. Many roads and bridges were destroyed. Homes were flooded and there were widespread power outages. Several lives were also lost. I was lucky. I lost power for only three hours, and was not personally affected. I however saw the devastating effects of this hurricane around me. This led me to remember another hurricane many years ago and a remarkable physician.

It was September 1999. I was working as an Internal Medicine physician in a small hospital in Eastern North Carolina. Hurricane Dennis had just passed through, causing a lot of rain, but no significant damage. The ground was however waterlogged, and we heard of another hurricane forming in the Atlantic. This was named Hurricane Floyd. I was not too worried. It was categorized as a category 2 and that did not seem too bad.

On September 16th, 1999, Hurricane Floyd made landfall in North Carolina. I lost power in my home that night as the winds howled around me. A large pine tree in my yard fell, but it fell away from the house. In the morning my home was intact and I still had running water. My neighbors came by and helped me clear the fallen tree. The power came back on later that afternoon and I thought the worst was over. I was wrong.

The ground was waterlogged from Hurricane Dennis when Floyd came onshore. The rains caused widespread flooding and nearly every river basin in the eastern part of the state exceeded 500-year flood levels. In total, Floyd was responsible for 57 fatalities and $6.9 billion dollars ($9.8 billion in today's dollars) in damages. Due to the destruction, the World Meteorological Association retired the name Floyd.

My office was closed because of the storm, but the next day was a Friday and I was on call for the weekend. I got a call mid-morning about a patient that had been brought in and needed to be admitted.

It was a sunny day as I drove to the hospital. I knew from the news that many surrounding areas had flooded. Waters had continued to rise as many streams and rivers overflowed their banks. I also knew that the National Guard had been called in. I was however unprepared for the scene that greeted me as I got to the hospital.

A large and very loud Chinook helicopter was landing in front of the hospital. It was bringing people evacuated from the floods. They were supposed to be taken to shelters from there, but many dazed people were walking aimlessly around. There were also many National guardsmen in their Army uniforms. It felt surreal, almost like a scene from a war.

I went in to see my patient. She was an elderly lady in congestive heart failure. Her heart rate was 30, which is very low. She was in a medical condition called a heart block. She needed a pacemaker. We put pacer pads on her chest and started to electronically pace her heart. Unfortunately, this was only a temporary measure. I had to get her to a Cardiologist so that a more proper pacemaker could be placed. This meant getting her transferred to our local teaching hospital.

I called our nearby teaching hospital and explained the problem. The operator told me they were on diversion and transferred my call to the chief of staff. I knew the chief of staff, and he told me that he would love to help, but they had lost power and running water. Their generators were running, but the flood waters were rising and those generators were about to be flooded. He said he would be happy to try to get her transferred once things got more stable.

With dismay, I realized that I was probably on my own for now. Luckily our patient was stable. I was however worried as I walked out of the hospital. Sitting outside the hospital was our surgeon. He had moved a few years ago from a practice in Pennsylvania to our small hospital. His motto was "love what you do so much that you never have to work a day in your life". He was sitting outside because he was smoking. He used to smoke fancy brown ‘More’ cigarettes. What is the matter, he asked?

I told him about the situation with my patient. He said, oh I can put trans-venous pacer wires in. This involves putting wires through a central line into the heart. I would have to go into the operating room with him and use the cardiac monitors to assess if the leads were placed in the right place and working properly. This is only done by Cardiologists today, but our surgeon said he had done this many times before. 

So for the first (and last) time since 1993, I put on scrubs and went into an operating room. He put the leads in through a central line into the heart, and I used the cardiac monitor to guide him. The pacer started working immediately and the patient’s heart rate improved. Her symptoms also improved later that evening. The next day, we were able to transfer her to another teaching hospital in a stable condition. That day my respect for our surgeon increased significantly

As hurricane Matthew came through, I thought about hurricane Floyd so many years ago and our remarkable surgeon. He has since passed on, but I will never forget his skills on that day, and I try to follow his motto of loving what you do so much, you never have to work a day in your life.

                                                   Effects of Hurricane Matthew

Syndrome de Munchausen

Syndrome de Munchausen

In my many years as a physician, I have seen many unusual cases. Some of these have been very difficult to diagnose or treat. Some of the most challenging ones have been those thought to have the Munchausen’s syndrome. I say ‘thought to have’, because this is a difficult diagnosis to confirm.

I remember one patient who was a man admitted with an infection in his blood. He was in his 50’s with no major medical problems. I was in my fellowship training in Infectious Disease at that time. We were called to see him in Consultation, because the bacteria growing in his blood was very unusual.

He had no risk factors for developing a blood infection. I took a detailed history on him and we could not find a reason for the bacteria to get into his blood.  While the bacteria was unusual, it was fairly sensitive to antibiotics. We treated him with intravenous antibiotics and the infection resolved and he was discharged.

A few months later, I was back on service, and we were consulted on the same patient. He had developed another infection of the blood. This was a different bacterium, but also very rare and unusual. We did a detailed work up on him, including an exhaustive history, but could find no cause. He was treated with antibiotics and recovered and was discharged.

In the next several months, he was admitted two more times. Each time he had a blood infection, but with a different bacterium. He responded well to antibiotics. On his fourth admission, he told me that these repeated infections were making it difficult for him to work and he had applied for disability.

My attending physician sat down with me to re-evaluate this patient. He had no risk factors for repeated infections. The bacteria involved were very unusual, but also different each time. My attending asked me if I noticed anything in common with his repeated infections. The only thing I saw was that these were unusual infections from different bacteria that we rarely saw.

He then pointed out to me that all these bacteria can be found in stools. How would they get into his blood, I asked? His theory was that our patient was injecting himself with toilet water, in an attempt to get disability. But how are we going to confirm that, I asked? Let us ask him he replied.

We went back to our patient and asked him. He became very defensive and angry. He told us that if we do not have the ability to diagnose and treat him, then he prefers to be discharged. We did treat him with antibiotics and cleared the infection. He was discharged and was not seen again in our hospital. We were never able to confirm a cause of his repeated infections.

While we were not able to prove it, we thought that the above case was an example of Munchausen’s syndrome. This basically means a disorder imposed on one’s self. The incidence and the reasons for this are often not clear as patients will deny it when confronted. The presence of this condition usually points to a deeper underlying psychological condition or some kind of secondary gain.

Baron Von Munchausen was a fictional character created by a writer in Germany in the 1700’s. It was based on the real life exploits of Hieronymus Karl Friedrich von Munchhausen, a German nobleman in those days, who was famous for his tall tales.

Baron Von Munchausen riding a cannon ball.

Thus fabricating symptoms or imposing a condition on one’s self used to be called Munchausen’s syndrome (or Syndrome de Munchausen in French). The modern term for this condition is now ‘Factitious Disorder’, but the term Munchausen’s is still commonly used.

As for our patient, I do not know what happened to him. I hope he is doing well today.

The Amputator

The  Amputator

It was 1991. I was a newly minted doctor and was starting my residency in Trauma and Orthopedic Surgery in our local Teaching Hospital in the town of Zaria in Northern Nigeria.

I was one of two new residents who would share call. Accidents on the roads in Nigeria are common and many injured would be brought into our Emergency Room. I learnt to deal with many types of fractures and was also learning how to do Orthopedic Surgery.

It must have been my second time on call that I was called to see a young man. He had fallen off his bicycle and broken his leg. His family took him to the local bone setter, who splinted the leg with a splint made of wooden sticks. Unfortunately, these were tied on too tight, and the leg became gangrenous.

They went back to the bone setter, and he told them that they had displeased the gods and that is why his leg was rotting away. The desperate family then brought him to our hospital.

Even before I got to him, I could smell the strong sickly smell of rotting flesh. As I unwrapped the splints, I could see his leg had become gangrenous and would have to be amputated.

I broke the news to the patient and his family, and they were naturally upset. The patient then asked me to do what needed to be done. I called the operating room and the anesthetist. I had assisted in several amputations before, but this was the first I would do on my own.

He was wheeled into the operating room and the anesthetist put him to sleep. I was assisted by one of our surgical technicians. I prepared his leg with antiseptic solution, then draped the leg and began the amputation.

It is easy to do an amputation, but making sure that the patient has a good stump that will make using a prosthesis easy is however quite technical. I marked out the flaps and started cutting. I found the large blood vessels and tied them to prevent bleeding. A saw was used to cut the bone. Finally, the flaps were sutured closed.

The patient did well, and eventually he got a prosthesis that enabled him to ambulate well. I ended up getting these types of patients frequently and did regular amputations. I was so frequently in the operating room with an amputation, that one of the General Surgery residents (a close friend) decided to call me “The Amputator”. This was a play on the title of the 1984 Arnold Shwarznegger movie “The Terminator”. The name stuck, and from then on, many of my friends used this as my nickname.

One day, a three-year-old girl was brought in with gangrene of her leg. She had developed rickets, a disease caused by a dietary deficiency of vitamin D that is common in children in West Africa. This had led to bowing of her legs. She was an only child and her parents had waited many years before being able to have her. Her mother wanted her legs to be perfect and straight and decided to take her to a local bone setter.

He broke her legs and tied them straight with the wooden sticks. Unfortunately, one leg was tied too tightly and caused gangrene. The little girl was quiet and stoic when I examined her. However, when I broke the news to her mother that the leg would have to be amputated, she started wailing loudly as her husband tried to comfort her.

I proceeded to amputate the little girl’s leg. It was a very traumatic experience for me. That little girl’s quiet bravery affected me deeply. Amongst the many patients I often wonder about is this brave three-year-old, who should be a grown woman now. I hope she is doing well.

                                                Traditional Bone Setter Splint

Risus Sardonicus

Risus Sardonicus

I have seen many patients in my career in Medicine. Some of these stay in my memory long after my interactions with them. This is the story of one such patient who still haunts me today.

It was the early 1990’s. I was a newly graduated doctor in the Northern Nigerian city of Zaria. I had started my internship at our local teaching hospital. It was a very exciting time for me as I was finally working and every time I was addressed as ‘doctor', I felt a great sense of satisfaction.

I was assigned to Internal Medicine Ward Two. This was one of our four wards. The patients on admission had a wide variety of diseases, and I was kept very busy.

One day, a new admission came in. He was a young boy, perhaps fourteen years old. Some days previously, he had sustained a cut on his leg from a rusty piece of metal. The wound festered a little, but he did not seek medical attention.

About a week later, he developed spasms in his muscles. These were the classic signs of tetanus. The bacteria get into the body by a deep penetrating injury. They then subsequently produce spores which produce the toxin that causes the muscle spasms.

This disease is practically unheard of in developed countries because of widespread immunization against tetanus. Even today, if you go to the doctor in the United States after a cut, you may be given a booster tetanus vaccine, although everyone gets vaccinated as a child. This young boy had never been vaccinated. The mortality in such cases is very high.

He was having frequent spasms when he came in. We gave him large doses of valium to stop the spasms and also gave him anti tetanus serum intravenously. This was supposed to help neutralize the toxin. However, this did not help and he kept having frequent spasms.

We had a meeting of the Internal Medicine team. It was decided that we will attempt to inject anti-tetanus serum into his spinal fluid. This would hopefully get at the toxin better, and was a technique that had been used successfully in other patients. I was his house officer and was assigned to do the lumbar puncture and administer the serum. I was proficient at lumbar punctures and had done many during my training.

This was however a different challenge. Usually in order to do a lumbar puncture, we get the patient to bend forwards so that the needle can easily be passed into the spinal fluid. In this patient however, he was having muscle spasms and he was arched backwards. This was the opposite of the position we wanted him to be and is known as ‘opisthotonus’, which is another sign of tetanus.

I was however fairly confident in my ability to do the lumbar puncture. I gave him a large dose of valium to help relax his muscles and got the assistance of some of the ward nurses to help position him. It was difficult as he remained very stiff.

I got my lumbar puncture kit ready and was elated to get the needle in on the first try. I drained some of the spinal fluid and then injected the anti-tetanus serum. It took a few seconds.

As the serum went in, I suddenly realized that his spasms had stopped. I quickly turned him over and realized that he had stopped breathing. Such periods of apnea or lack of breathing are known to happen in tetanus patients. We called an emergency response and tried to revive him.

I still remember the look on his face while we were attempting to do a cardio pulmonary resuscitation on him. His face was contorted by the spasms and appeared to be smiling sardonically. This is a classic sign of tetanus and is known as ‘Risus Sardonicus’.

This word has it's roots in the Mediterranean island of Sardinia, and derives from the appearance of raised eyebrows and an open "grin”, which can appear sardonic, or malevolent to the lay observer. This was first observed in people poisoned by the ancient poison ‘hemlock’, but is more usually seen in patients with tetanus. Another name for this in lay terms is 'lockjaw'. This refers to the tight clenching of the jaws due to the muscle spasms.

We were unable to revive our patient. His eyes were open and glazed over as he died with the smile still on his face. On that day I became painfully aware of my own limitations as a physician. That sardonic smile still haunts me and will be forever etched in my memory.

 Risus Sardonicus in a tetanus patient.

The Girl in the Tobacco Barn

The Girl in the Tobacco Barn

In my Internal Medicine practice, I see many remarkable people as patients. Many of my patients are elderly and sometimes their stories represent another era in time. I often try to seek out these stories as I find them fascinating. Here is one such story.

The story starts in the early 1940’s in a tobacco farm in a small town in Eastern North Carolina. In those days, tobacco was a major cash crop and tobacco farms were everywhere.

The tobacco was harvested and brought to tobacco barns. There the tobacco leaves were sorted and hung out to dry on sticks that were placed on the rafters and the sides of the barns. The process of sorting the tobacco leaves was time consuming, and very hard work. It was particularly difficult in the high heat of the summer when temperatures would soar.

These barns still exist in North Carolina and dot the landscape, but they are no longer used and are usually seen in various stages of disrepair.

In one of these barns was a young girl, maybe 15 or 16 years of age. She was helping out in the family tobacco farm. The tobacco had been harvested and she was helping sort it out and hanging it up to dry. She remembers that her hands were covered in tobacco tar, she was in a work dress and her hair was messy.

It was then the iceman showed up, delivering blocks of ice for the icebox on the farm. In those days, before electricity was common, this was the form of refrigeration. He was a young man, perhaps 17 years old. His eyes fell on this young girl and he fell in love with her.

He asked her parents if he could take her out. They agreed, but in those days going out meant having a chaperone with you. They went out and got along very well, but war clouds were rolling over and after the attack on Pearl Harbor, our iceman signed up to join the navy.

In the navy, he was on a destroyer manning an anti-aircraft gun. At one time he saw a torpedo heading straight for the ship. As he and his crew mates braced for the impact and possible death, a strange thing happened. A wave lifted the ship and the torpedo passed harmlessly underneath. He later attributed this small miracle to his mother’s prayers.

That night he wrote a long letter to his tobacco girl expressing his feelings for her and his desire to marry her. She never got the letter.

In the meantime, she had also met another suitor who was interested in her, but she could not forget her iceman. She also wrote a letter to him, but unfortunately he also never received the letter. Fate had however destined them for each other and she decided to wait for him.

They met again when he got back and eventually got married. This was seventy years ago. They are still married today.

 They both began to work at a local mill in town. They eventually had six daughters. They were both very religious and regular members of their church. They lived in his childhood home. All their daughters grew up to be strongly religious women. They all got married and had their own children and grandchildren.

At their 50^th marriage anniversary, their church had a special event for them. At that time the former iceman recounted how he fell in love with his wife after seeing her hands stained with tobacco tar, and that she remained the love of his life.

His wife is now in her late eighties and recounted this story to me when she came to see me as a patient. She acted mildly annoyed that the main thing he remembers about that first meeting was her tar stained hands. She however continues to love him deeply.

He is now in a nursing home after developing dementia. She lives with one of her daughters and is increasingly frail. She however brightens up at the mention of her husband and can recount in detail the story their initial meeting and courtship.

Such stories may seem out of place in today’s fast paced world, but I find it extremely heartwarming. The love and affection my patient still has for her husband is absolutely wonderful to see.

An old tobacco barn

Hands stained with tobacco tar

Blind Love

Blind Love

In my work as a physician I have seen many remarkable stories of love. It could be the love of a mother for her autistic child or the love of a son or daughter for their elderly and disabled parent. However, the story that I most often recall is the tender and caring love between one particular couple. This is their story.

Some years ago, I saw a new patient in my clinic. He was in his late fifties when I first saw him. He lived in a nursing home. He had been born with a defect in his eyes and did not have good vision. He ended up growing up in a nursing home. He did have some limited vision and could walk around on his own. What struck me most about him was his very cheerful nature. His personality was such that I took an instant liking to him.

We got along very well together. He asked me if I would be willing to take on his wife as a patient. I was surprised. You are married I asked? Yes, he told me. His wife had also lived in the nursing home since she was a baby. She is blind too he told me. I told him I would be very happy to take care of his wife.

At his next visit, the nursing home brought his wife with him. She was in her sixties and had developed blindness as a baby. Her family then left her to be brought up in the nursing home. She had lived there all her life. She married my patient a few years ago after he moved to her nursing home from another facility.

How did you become blind I asked? She told me that she had been born with jaundice. Babies with jaundice are often treated with bright lights which help in reducing the jaundice. Unfortunately, in the 1940’s, it was not known that a baby’s delicate eyes can be damaged by the bright lights if not protected. The bright lights damaged the retina of her eyes, and she became blind. Today, if a jaundiced baby has to be put under bright lights, then their eyes are carefully covered with padding to protect them from the lights.

She had a lot of other medical problems. She often had difficulty sitting in my office because of severe back pain. I would then see her husband taking care of her and trying to get her to be more comfortable. He took amazing care of her. He helped her with everything. I can still see him helping her walk to the bathroom even though he himself had limited vision. Every time she cried in pain, he would hold her hands and would do his best to comfort her. Here was a blind man completely devoted to taking care of his blind wife. I never saw him look frustrated or upset.

A few months after they became my patients, the wife fell ill and died. When my patient came back to see me, I braced for him being sad and depressed or even angry at the loss of his beloved wife. However, I was surprised. He came in smiling.

She is in a better place, he told me. She is no longer in pain and he said that he looked forward to meeting her again in heaven. He also told me that he could no longer bear to live in the same nursing home with the memories of his wife. He was moving to another nursing home in another town. He would be getting another doctor and wanted to say good bye to me.

I never saw him again, but he is the most remarkable example of selfless love that I have ever seen. I hope that he is doing well today.

                                         A jaundiced baby with protective eye padding today.