Mysterious Ways

Dube, Mark

Rhonda, the charge nurse in the emergency department came up to me.

"You're just the man to answer this call." She said and handed me the phone.

"It's constable ----. I have this guy we picked up who is on methadone. He says he's having belly pain.

Does he need to see a doctor?" I was taken aback by the question. I guess he was hoping I would say no and he would take the detainee directly to the station. I couldn't imagine anyone ever doing this. Rhonda had passed me the phone because she knew that I had been the sole methadone prescriber in the city for eight years and was very familiar with the therapy and clients.

My answer was the standard: I-don't-practice-medicine-over-the-phone.

The police eventually brought him, and I was called to assess him. We recognized each other immediately.

"Hi, Ralph." I said. I hadn't seen him in years. He had been one of my first clients for the methadone program. We had had a demanding doctor-patient relationship. He had had difficulty with all the program rules. I had had to do a lot of enforcing of consequences. His opiate use had persisted. After about a year or so I got a call from a pharmacist asking if I had prescribed narcotics to Ralph. Our demanding relationship came to an abrupt end as I discovered that he had stolen one of my prescriptions and forged my signature.

So, there he was looking at me, scared about his current legal situation, his health, and me. I ignored our previous dealings and proceeded with the task at hand. He was febrile, tachycardic, and normotensive. He complained of abdominal pain and demonstrated massive splenomegaly that could be detected simply by visual inspection of the left middle and lower quadrants. There was a mass that moved with respiration. There was no hepatomegaly, no murmur, none of findings of endocarditis, the lungs were clear. He had needle tracks.

I had blood cultures drawn, did routine blood work, CXR, etc. and discussed his case with the internal medicine service. CT of the abdomen, HIV, HCV, Echo were all ordered for the next morning. Broad spectrum IV antibiotics were started. It was Thursday around midnight. My involvement with Ralph's care was now over.

On Monday, I received a copy of the CT report. He had two splenic abscesses, one of them 10 cm in diameter with an air fluid level. The echocardiogram showed vegetations on the aortic valve with incompetence. The echocardiographer recommended an urgent surgical consult. I was a little surprised that the results came to my office as he was admitted under internal medicine five days earlier, none the less I thought I had better confirm that indeed medicine had received these results. I was informed that he had signed himself against medical advice on the Sunday. At that time the attending did not have the Echocardiogram result and thus the patient himself was unaware of the endocarditis. I called his methadone prescriber. He didn't have privileges at the hospital. We decided together that if he showed up looking for a dose of methadone on Monday, that his prescriber would refuse to give it to him unless he returned the hospital and was re admitted, this time under me. We didn't think we could insist that medicine take him back. We didn't think that telling him to return to the emergency department to be readmitted would work. The idea of stepping up to the plate for this patient whom I should have had charged years ago didn't really go over well with me, but, given his personality and his disease, if I didn't do this he might actually die from a treatable disease.

Around 4 pm he showed up at the methadone prescriber's office. He was 3 hrs late for his appointment. The prescriber explained his critical cardiac infection and the refusal to administer the methadone. Ralph didn't have much strength to refuse our tactics and was admitted under my care.

Infectious disease was consulted. Radiology drained the splenic abscesses one of which grew clostridium perfringens. Cardiac surgery looked at him and thought he was not suitable for surgery until after six weeks of intravenous antibiotic therapy.

Ralph and I established a new relationship in the context of his life threatening illness and we got along fine. He declined steadily as his aortic incompetence worsened.

One day, about ten days into the admission I found him in severe heart failure. We couldn't get his Oxygen saturation up over 80% no matter what we did. He was in severe distress and he was going to die. I called the cardiac surgeon and the ICU service. We discussed the case. The surgeon wanted to know about the patient's IVDU after a possible aortic valve replacement. He couldn't see the value in doing the surgery. I couldn't guarantee he wouldn't inject illicit drugs postoperatively; in fact, it was quite likely given the success he had had with the methadone to date. On the other hand he was going to die right there on the ward if nothing was done.

He was 38 years old.

I think it was the intensivist who convinced the surgeon of the need to act, and Ralph was taken to the OR that night. He received a tissue valve.

He survived the operation, and was transferred out of CCU on post op day 4. I saw him on rounds and he told me he wanted to leave the hospital that day. I had a long discussion with him going over his recent brush with the grim reaper, and how stupid it would be to leave against medical advice. His significant other was there with me trying to reason with him. But he was back to his old argumentative self, and we had no power over him. So he signed himself out against medical advice.

I learned from his methadone prescriber that he had continued to inject narcotics for a short period. Thereafter he seemed to have "cleaned up" and has only used opiates intranasally. He had regained his weight and earned no carries. This is 2 years since his valve replacement. He has had no recurrence of endocarditis.

So often life hangs by a thread and all our medical heroics are futile. So often patients make incredible efforts to give medicine's efforts every possible chance of success and still we fail. In Ralph's case it was exactly the opposite. It makes you wonder.

Theme: Health Care Delivery | Prestation des soins de santé

Theme: Patients | Patients
Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --. 




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