The Consult

The Consult

It was spring and I had just returned home from a long day at work, when the phone rang. It was my mother calling from Florida. My father had taken ill suddenly and had to be rushed to the hospital. He was in his eighty's and had been in poor health for a while. He had heart disease and Diabetes and had been undergoing treatment for diabetic foot ulcers.

I called my sister who lived close to them. She was in the hospital with him. She said it did not look good. Both his heart and kidneys were failing and he was being admitted to the intensive care unit. I immediately arranged for a flight to Florida the next day. My brother and other sister were also rushing there.

The next day all four siblings met at my father's bedside in the hospital. It had been several months since all the siblings had been together. The doctors told us that he had suffered another heart attack, and this time he had badly damaged his heart. His heart was failing and his kidneys were failing too. He continued to decline and having difficulty breathing. After three days in the intensive care unit, we as a family decided to make him primarily comfortable.

He was placed on morphine and moved to a regular room. He looked much more comfortable and we all took turns staying at his bedside. He was then moved to a hospice center. I was sitting next to my father in a darkened room. He looked quite comfortable, and I was reflecting back on his life, when suddenly I received a text message on my work phone. It was from one of our resident doctors back in North Carolina.

He had an interesting patient. It was a visitor from Africa, who had come down with Malaria. I was the only Infectious Disease physician in my hospital and thus the request for advice. I texted back my suggestions for treatment. Doing this actually helped me deal better with my father's illness. Early next morning my father passed away peacefully in his sleep. I and one of my sisters were at his bedside.

After this, we got busy with funeral arrangements and taking care of my mother. My colleagues at the hospital were very kind and send many condolences. One of the residents at the hospital even got a collection of money from the other residents and made a donation in my father's name to the Diabetes foundation. They also arranged for a tree to be planted in his name at a state forest. I was very touched by these gestures.

The day after the funeral, I thought about the Malaria patient again. I had the ability to do a 'teleconsult' using my phone and a tablet computer at the hospital via a secure connection. Medical residents and my physician assistant would examine the patient, then connect me online, so I could directly communicate with the patient.

I did do the consultation and speak to my patient. While he was from Africa, he was of Indian descent. He reminded me of my father, who spend decades in Africa but was also of Indian descent. In a strange way, taking care of him helped me deal with my Father's death. The patient was doing better and the malaria parasite had been cleared from his blood.

Our patient told me that he had come to our small town in North Carolina because apparently this was a manufacturing center of agricultural equipment for the type of large cotton farm he ran in Africa. He was subsequently discharged and went back to his hotel room in town.

A few days later, I was back at work. In the hospital we were consulted again on our Malaria patient. Back in his hotel he had developed abdominal pain with persistent nausea and vomiting and been readmitted. The scan of his abdomen showed a significantly enlarged gall bladder.

At our consultation, we determined that his gall bladder enlargement was a complication of his malaria. The malaria had been cleared, but he had developed this condition called “acalculous cholecystitis”. This is a very rare complication of malaria.

We asked our surgeon to remove the gall bladder, which he did. After the surgery, our surgeon told us that the gall bladder had been removed just in the nick of time as it was close to rupture. Our patient made a complete recovery and eventually went back to Africa.

This was a very rewarding experience for me. Watching this patient's complete recovery helped me heal from losing my father.

I hope this patient continues to do well and is successfully running his farm today.

                                                    

Anopheles mosquito carrier of Malaria

The Akan Man

The Akan Man

I was rounding in the hospital recently when one of our Physician Assistants approached me with an unusual request. She asked me to cosign a consent form for a toe amputation on a patient as he was unable to give the consent himself.  This was an unfortunate case and here is his story.

Several months ago, a man was brought to our Emergency Room. He had been left at a local clinic by two men with whom he worked with on a farm. Those men disappeared soon afterwards, and the clinic sent him to our hospital. The only history we were able to obtain was that this man had become confused and walked outside into a grass fire, developing burns on his feet. He was unable to speak and appeared not to understand what was said to him. He was in his late fifties.

The medical term for this was expressive and receptive aphasia. The Emergency Room made sure he was not under the influence of alcohol or drugs and a CAT scan of the head confirmed a diagnosis of multiple strokes. A recent stroke had affected his speech and ability to understand any spoken words.

He was subsequently admitted to the hospital for further treatment of his strokes and his burnt feet. He had a brief period of lucidity in which he was able to state that he was a farm worker originally from Ghana in West Africa, and his mother tongue was the Twi language. He had no family in the United States. He was unable to explain how he ended up working in the small farm in North Carolina.

I have grown up in the West African country of Nigeria, but I had never heard of the Twi language. I looked it up. It is a language of the Akan people of south and central Ghana. It is a dialect of the more well-known Ashanti language. It is spoken by 6 to 9 million people.

The hospital was able to get a translation service with a Twi speaker on the phone. Unfortunately, that was not very useful as he still could not speak any words and appeared not to understand what was said to him. He had no social security card or any legal papers. His foot had developed gangrene in some toes, and these toes needed to be amputated. However, we could not communicate with him to obtain consent for the surgery.

I was asked to see him for Infectious Disease consultation about the gangrene in his feet with possible infection. I was able to advise on antibiotics, but he still needed an amputation.

The hospital social workers contacted the embassy of Ghana who offered no help. Department of Homeland Security as well as the United States Immigration services were equally unhelpful. In the end, the Physician Assistant taking care of him in the hospital asked me to be one of the three physicians to co-sign the consent form on his behalf.

I signed the consent form along with two of his other physicians and finally on the 98th day of his stay in the hospital, his gangrenous toes were removed. He was able to walk around but was still unable to speak and does not appear to understand anything said to him, even through the Twi translator.

Our discharge planners worked tirelessly trying to get him to a nursing home. However, without any legal papers, those homes had not been willing to take him. They were however able to get him temporary medicaid and after 130 days in the hospital, he was finally moved to a nursing home. He was moved back to the hospital after 3 months when his status could not be confirmed. He lived on the third floor of the hospital for many more months until Immigration finally confirmed he was a legal permanent resident and he was finally moved back to a nursing home.

He is still very far away from his family and birth place. In his almost two years stay in the hospital, he has had no visitors, and does not appear to have any close friends.

I wonder how he must feel, unable to speak and also not understand anything said to him while in a place that is so far from his home.

It is however amazing to see the dedication and hard work from his team of doctors, podiatrists, nurses, physician assistants, social workers and others. They have taken great care of this man, selflessly and with tremendous dedication. This makes my faith in humanity stronger than ever before. I hope and pray that our patient is in a place that will provide him equal care and comfort.

Gye Nyame - a symbol of the Akan people of Ghana

Frank

Frank

Recently we were in the process of moving from one home to another. I was going through a file of old papers, when an envelope fell out and caught my eye. It was addressed to me in such neat handwriting that it appeared printed. It was dated May 1st, 1998. I saw the return address was a Nursing Home. The name on the address instantly took me back to a very memorable patient of mine. His name was Frank. This is his story.

I first met Frank in 1996, when I was a second-year resident in Internal Medicine. I was asked to start seeing a patient who was described as being difficult and had fired two other residents from taking care of him. I did not want to have the same result, so I thought I would try to find out why he was so unhappy with his care.

Frank was a thin and short man. He had a closely cropped hair cut and looked really neat and clean. He had been admitted with an exacerbation of emphysema which caused breathing difficulties. This was mostly from a long history of smoking. He had never married or had any children. His only brother had died several years ago. I asked him why he was so unhappy with his care.

His main concern was that he liked to follow a schedule in everything. His food should be at a particular time as should his medications and breathing treatments. He even was very concerned about being able to go to the bathroom at least once a day, and he had been constipated since being admitted to the hospital. In his opinion the previous physicians had not taken these concerns seriously.

All my life I have been around family that have obsessive compulsive traits, and I realized that Frank was probably somewhat obsessive compulsive and felt the need to have more control in his life. I talked to his nurses and got him on a more rigid schedule. I even put him on laxatives and his bowels became regulated.

He did not fire me. On the contrary when he was ready to be discharged, he became my clinic patient and started to follow me as an outpatient. We became great friends. He told me stories of his career as a fireman and even shared pictures of his younger days with me. I realized then that he did not have any close family or any real friends. This may have been partly due to his obsessive compulsive personality.

Unfortunately, his emphysema continued to progress and he could no longer live on his own. We spoke at length about this and decided that a Nursing Home may be the best option. He was naturally sad about this. I would also no longer be his doctor as the nursing homes have their own doctors. We said our good byes and he was emotional, as I was. I did not know if I would ever see him again.

It was Christmas 1997, and I was pondering on my list for sending out cards. For some reason I thought of Frank and I mailed him a card to his nursing home. I was later informed that he had moved to another nursing home and was not sure if he ever got that card.

Several months later I received a letter in the mail. It was from Frank. In that letter he mentioned being pleased on receiving my card, and also described (with his meticulous handwriting), of all the problems he had in the nursing homes. He was moved from one to the other all over Eastern North Carolina. He was finally at a place he liked. In that letter he said very nice things about me, and this touched me greatly.

I later looked up the address of his nursing home, and realized that his small town was coincidentally very close to the small town I was going to be starting a new job in.

Soon after I started my new job, I did go to visit him on a Saturday afternoon. It was a typical nursing home. Quiet, dark and with a musty smell. The nurse on duty was surprised that Frank had a visitor. She led me to his room, and there he was, in a wheelchair with an Oxygen canula attached to his nose.

He was surprised, and appeared very pleased. He hugged me and we sat and talked for a while. He told me that he was quite content at this current nursing home as things were done as he liked. I promised I would visit him again.

However, soon after my visit, Frank passed away. He died peacefully in his sleep. I have kept his letter all these years and hope and pray that he remains at peace.

Excerpts from Frank's letter

Honey and Placentas

Honey and Placentas

I was reading a recent article about how a type of honey called Manuka honey from New Zealand has been found to have antibacterial properties. It is not necessarily effective as an antibiotic when eaten, but more so when applied locally over wounds. As a dressing it was found to be more effective at healing wounds than some of the more expensive dressing materials.


This took me back to my medical school days in the town of Zaria in Northern Nigeria. It was thirty years ago, and I was doing a General Surgery rotation. Our Senior Registrar was Dr. Vincent Odigie. A handsome young man, he was bold and assertive and always supremely confident. He was also very smart and often did things in an unconventional way.


One day we were seeing an elderly man with an infected diabetic foot ulcer. Conventional treatment with antibiotics and traditional dressings had not helped for several months. Dr. Odigie said we need honey. We students were incredulous. Honey? Yes, honey he said. He told us that traditional honey had natural antibacterial properties and bacteria could not utilize honey for food. I still remember him telling us that only bees, humans and bears could use honey for nutrition.


He asked the patient’s son to go and get some traditional honey from the local market. The store bought honey is not as effective he told us as it has additives. The patient’s son soon came back with a jar of local honey. It did not look too clean and we students were not very optimistic. Dr. Odigie laughed and assured us this will be sterile.


He unwrapped the wound and covered it with honey and wrapped it up. He then told the students that the wound will not be inspected for seven days. We were incredulous. However seven days later when we inspected the wound. All the infection was gone and it was just healthy granulation tissue ready for a skin graft. All of us students were thoroughly impressed.


On another day, we had a young lady who had sustained significant burns. The burns were not deep but she was in considerable pain. Dr. Odigie looked at her and said we need some placental lining. Even though we students were used to his unconventional approach, we were very confused. The lining of a human placenta he explained is very effective in treating these kinds of relatively superficial burns. He taught us that a dressing made of the placental lining of a human embryo helps ease pain and promotes healing of the skin.


Where are we going to get this placental lining one student asked? The labor and delivery ward he said. It was late in the evening, but Dr. Odigie was a very dedicated physician. He marched the students to the labor and delivery ward and asked the rather surprised charge nurse there if she had a discarded placenta we could have. The nurse was used to Dr. Odigie and did not bat an eyelid. She said the Gynecologists were just doing a C-section and she would get us that placenta instead of discarding it. Dr. Odigie beamed a smile.


She soon brought out a placenta for us. Dr. Odigie then proceeded to cut out the placental linings. He then rigorously washed the tissue and then put it in a disinfectant and proceeded to the burn patient. The sun had set and we students were tired, but we had to see this.


The young lady was in considerable pain. Dr. Odigie carefully undressed her wounds and then proceeded to place the placental lining tissue over the wounds. He then wrapped the wounds with a regular dressing. Once he was done, our patient did look more comfortable.


Our patient did quite well and within a week her wounds had healed enough for her to be discharged. I saw a recent study done that showed placental dressings reduce pain and allow for faster healing.


We students learnt a lot from Dr. Odigie. He may not remember me or these lessons he taught us, but I will never forget them. Today he is Professor Vincent Odigie of Surgery at my old teaching hospital.

Sometimes unconventional approaches can be very effective and just imagine my delight to see all this talk of using honey for wounds today in the more developed countries. I can say confidently that this approach is effective as I have seen this myself thirty years ago!

Manuka Honey

The American Indians

The American Indians

Today I read about the untimely death of Indian actor Tom Alter at age 67. He had died of skin cancer. He likely developed this skin cancer in part due to the abundant sun exposure in India. You see, he was a fair skinned Caucasian.

Mr. Alter was the grandson of a missionary who had come to British India in 1916 from Ohio in the United States. Mr. Alter's grandfather had a son who was born in the city of Sialkot which is in present day Pakistan. When the Indian sub- continent was partitioned in 1947, the elder Alter remained in what is now Pakistan, but his son (Tom's father) had become a missionary in the city of Mussorie in India.

The partition of the Indian sub-continent by the British split many families including those of my parents. I however never imagined that it also would affect an American family living in India.

Mr. Tom Alter was born to his missionary father in Mussorie in India in 1950. His grandfather remained a missionary in Pakistan, and the young Tom Alter grew up in the Indian state of Uttar Pardesh. He was fluent in Hindi and Urdu. When it was time to go to college, he was sent to Yale university in the United States.

He however did not like Yale, and left after a year and came back to India. After trying a few different things, he fell in love with an Indian movie starring the Indian super hero of those days, Rajesh Khanna and decided to become a movie actor.

I can imagine that it must have been difficult for a Caucasian man to make it into Indian movies in the 1970’s, but Tom Alter did. Some of his roles portrayed him as a British man speaking poor and broken Hindi. Interestingly he himself was very fluent in both Hindi and Urdu, and even well versed in Urdu poetry.

He did succeed and eventually worked in over 300 movies including a movie with his idol Rajesh Khanna. Also, incongruously for a man of American origins, he became a great fan of the game of cricket and even became a correspondent for a cricketing news organization. He was eventually given the fourth highest civilian national award of India, the Padma Shri and was much loved in India. He once said in an interview that he hates being called an ‘angrez’ (white man). He said he was Hindustani (Indian) and proud of it.

In this day and age, it is more common to see immigrants to the United States rather than the other way around. I myself am an immigrant. While growing up in Nigeria, two of my closest friends were American brothers. Their father had moved to West Africa in the 1960's, but it is generally rare to see an American who has made another country home. However, recently I met another.

I work as a doctor in a small town in North Carolina. On one recent day in the clinic, a man in his late sixties came in as a new patient. He had just moved to our small town to live close to one of his daughters who lives here.

As part of my history, I asked what he did for a living? He had been a teacher, he told me and he had just retired. Where did you teach I ask? ‘India’, he replies. I was taken aback. You mean the country of India? Yes indeed, he replied.

This made me very interested and I asked him for more details. He told me that as a young couple both him and his wife had been interested in missionary work. They left America in the 1980’s and first lived in North Africa for a few years. Their first child was born there. They then moved to India. They moved between different cities in India. Their second child was born in the Indian city of Patna.

I found this very interesting as my parents were originally from the Patna area of North Eastern India. He lived with his family in India for 28 years. His daughters grew up there. He came back to America to take care of his elderly father. The family was initially split as his wife tried to stay on in India with his children.

After four years, his wife also moved back. One daughter had gotten married and moved to my small town. My patient moved here after his father died. He found a job here and became my patient. Both him and his wife are some of the most humble and nicest people I have ever met.

When I decided to write this essay, I titled it ‘The American Indians’, even though this has nothing to do with Native Americans who are also called by that name. I think it is the people above who more accurately fit this title

Tom Alter

Sabo

Sabo

This is a memorial for my dear friend Sabo Saleh who died a few years ago. Sabo Saleh was my classmate in medical school and we also started out residency together. We had many memorable times with each other. Here is one incident that I remember distinctly.

Sabo was the son of a farmer from a small village in Bauchi State in Northern Nigeria. His family was of modest means and most people in his village became farmers. Sabo was different. He excelled in his elementary school and got a scholarship to secondary school. Over there, he excelled again and was eventually admitted to medical school at the Ahmadu Bello University in Zaria, Northern Nigeria. I was his classmate.

Sabo was muscular, stocky and a picture of strength. He was characteristically bold and feared no one. He never hesitated to speak his mind and could be quite blunt. This attitude would sometimes get him into trouble, but he was much liked by his classmates. We all respected his fearless attitude and we knew that he had a great heart underneath that gruff exterior.  

After graduation and an internship year, Sabo eventually started a residency in General Surgery. By that time, I had started a residency in Orthopedics. We would meet often in the hospital.

One particular day in early 1993, we were both working in Operation Theater two. I was with the Orthopedics team and Sabo was with the General Surgery team. The other resident in Surgery was our mutual friend Ahmed. Like Sabo, he was also from Bauchi state. On that day, for some reason, Sabo was mercilessly teasing and taunting him in his characteristic style. However, it was all in good fun and all of us were laughing.

I went in for a case, and then when I came out, Sabo was scrubbed in another Surgery case. In the physicians lounge I come across Ahmed. He was sneaking out Sabo’s clothes from the changing room. What are you doing I asked? He put a finger to his lips and said to me, “Quiet, I am getting back at Sabo, don’t say anything”. He explained that he was only going to hide the clothes for a little bit as a prank.

It appeared a harmless prank, and I thought nothing of it. I went back in for another case. When I got out, there was pandemonium in the physician’s lounge. Sabo had come out and noticed his missing clothes. He became upset as his home keys were in his pockets and he thought somebody might use them to break into his house. He got another resident to drive him home immediately while still in scrubs. The theater staff was busy trying to find the missing clothes and keys.

I ran back in and grabbed Ahmed who was just coming out of another case and told him. A look of fear came over Ahmed. He looks at me and says Sabo will kill us. Us, I say? Why us? I have nothing to do with this I protested! You knew about it he replied, that makes you an accomplice. Now take me to him so I can return his stuff to him. Ahmed later told me that he wanted me along as he thought Sabo will then go easier on us, since he was my good friend.

So, we changed and I drove Ahmed to Sabo’s apartment. Sabo was standing outside his locked door, not looking happy. We ran up to him, both pleading for forgiveness even though I was not sure what I was apologizing for. A surprising thing then happened. Sabo started laughing. I think he saw the fear on our faces and found it very funny. In the end, there were no hard feelings.

Some months later I was leaving for America and both Ahmed and Sabo were at my farewell reception. The very macho Sabo had tears in his eyes as he hugged me and bade me farewell. I never realized at that time that it would be the last time I ever saw him.

A few years ago, Sabo was diagnosed with cancer. This cancer took the life of my strong and tough friend leaving behind a wife and three small children. I will never forget the fun times with him and pray that his soul rests in perfect peace.

As students with Sabo in 1989

With Ahmed in 1993

In Operating theater two in 1992

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.