The Joy of Medical Practice

iUniverse, Inc.

Contents

Preface..............................................................................iiiIntroduction to Eye Anatomy and Physiology...........................................xi1. Worms in Her Eyes.................................................................52. The Belly Dancer..................................................................73. Man with a Heart Attack Man.......................................................104. The Coach.........................................................................135. Dr. Bricker.......................................................................166. A Mentally Challenged Pregnant Woman..............................................207. The Jaundiced Woman...............................................................248. Hiccups...........................................................................289. The Cataract Matriarch............................................................3210. My First Cataract Operation......................................................3411. My First Corneal Transplant......................................................3912. The Lady from San Antonio........................................................4313. Results of a Hunting Accident....................................................4614. Bad Trifocals....................................................................5915. The Shakespearian Actor..........................................................6216. A Conflict of Interest...........................................................6517. The Miraculous Unveiling.........................................................6818. The Little Cross-Eyed Girl.......................................................7719. The Baby with a Congenital Orbital Teratoma......................................8120. An Infant with Aniridia..........................................................8821. The Swimmer......................................................................9222. The Girl with the Bulging Eye....................................................9523. The Five-Year-Old Surfer.........................................................9924. Bottle Rocket....................................................................10225. Boys Will Be Boys................................................................10526. Running with Scissors............................................................10827. Boy with Peters Anomaly..........................................................11128. The Snuff Dipper.................................................................11429. The Nun Who Could Not Wear Black.................................................12330. The Lady Who Sat in the Dark.....................................................13231. A Special-Needs Woman with a Corneal Transplant..................................13632. A Melanoma Survivor..............................................................13933. The Texas Bowler.................................................................14434. The Lady with Arthritic Contractures.............................................15035. The Deer Hunter..................................................................15636. The Eighty-Year-Old Tennis Pro...................................................15937. An Intraocular Lens for a Handball Player........................................16238. Paper-Thin Cornea................................................................16639. The Newsstand Operator...........................................................16940. Unusual Results from an Alkali Burn of the Eye...................................17241. The Big Thicket Thorn............................................................17742. Man-o-War Sting..................................................................18043. Daddy Is Going to Die............................................................18344. Bushy Eyebrows...................................................................18945. A Stubborn Keratoconus Patient...................................................19246. The Rock Musician................................................................19547. The Golf Pro.....................................................................19748. A Corneal Transplant Patient Who Did Drugs.......................................20049. Disingenuous Patient with a Melanoma.............................................20250. A City League Baseball Player....................................................20951. The Bottle of Jack Daniels.......................................................21352. The Fixed Cornea Episode.........................................................21653. The Vision Needs of a Preacher...................................................21954. The Ungrateful Expulsive Hemorrhage Patient......................................22355. Vision after Twenty Years of Blindness...........................................22656. The Myopic Librarian.............................................................22957. A Nun with a Sexually Transmitted Disease........................................23258. A Small Epidemic.................................................................23559. The Recreational Vehicle Driver..................................................23860. A Dislocated Lens in a Myasthenia Patient........................................24261. The Lions Club President.........................................................24562. A Strange Reaction after Cataract Surgery........................................24963. An Unusual Steroid Complication..................................................25464. Radial Keratotomy with Complications.............................................25865. Spontaneous Transplant Rejection Reversal........................................26166. Medication Confusion.............................................................26367. Herpes Simplex after Cardiac Catheterization.....................................26668. The Danger of DMSO...............................................................26969. A Grateful Patient Turned Benefactor.............................................27270. A Leading Lady of Galveston......................................................27971. The Man Who Survived Guadalcanal.................................................28272. A Nervous Resident...............................................................28573. A Shy Resident...................................................................28874. Someone Must Care for the Prisoners..............................................29575. The Snake in the Alley...........................................................29976. A Partially Blind Prisoner.......................................................30177. The Lady from New Jersey.........................................................30978. A Hydrogen Fluoride Burn.........................................................31379. The Blind Computer Science Student...............................................31780. The Irish Lady with Pemphigoid...................................................32281. One in a Million.................................................................32682. The Stevens-Johnson Syndrome Lady................................................32983. The Eye and Sex..................................................................33384. A Corneal Melting Problem........................................................33685. Missions to Montserrat...........................................................34186. The Blast Injury.................................................................34687. Complication of Contact Lens Wear................................................35088. A Lady with a Recurrent Cornea Problem...........................................35489. A Nun with Glaucoma and a Red Eye................................................35790. An Unusual Shingles Treatment....................................................361Epilogue.............................................................................365

Chapter One

In medical school, we were encouraged to read widely about diseases and not to limit ourselves to diagnosing only common diseases. I did some extra reading, but being a slow reader, I did not read too far afield. I did, however, get into a funny situation from reading about a rare disease.

As a junior student I was rotating on the orthopedic service and was assigned to the arthritis clinic one afternoon. As students, we would see the patient and take the history and perform an examination. We would then present the patient to the resident or an attending physician, who would check our findings and then determine what treatment was appropriate.

A small, elderly black woman came into the clinic for treatment of her rheumatoid arthritis. Her fingers were stiff and distorted and her feet bothered her when she walked. Sometimes her other joints would flare up with pain and swelling. After we talked about her joints, she told me that she had another problem. She had been bothered by little white worms in her eyes. Sometimes she felt the worms crawl from one eye to the other across her nose, although she had never seen one on her nose.

She produced a small glass vial from her purse and proceeded to show me the worms. These were little round balls of grey-white material which were adherent to the sides of the vial. She said that she would see these in the corner of her eyes and pull them out. Sometimes they stretched to as much as an inch long as she pulled them from her eye. As soon as they came loose, they would curl up in a ball, which she would put into the vial. All of the things in the vial were round in shape, not elongated.

I remembered reading about a disease that is most often found in the South Pacific Islands, called Loa Loa. In this disease, thin white worms are found in the conjunctiva (the mucous membrane that covers the scleral portion of the front surface of the eye). The worms are known to migrate from one eye to the other across the nose, especially during sleep. When I presented this lady to the attending physician and the other students, I included my diagnosis of Loa Loa. I was almost laughed out of the clinic.

They were sure that Loa Loa never occurred in the United States and that this was a true medical student diagnosis. Word of my bizarre diagnosis spread all over campus, and it took awhile to live it down. I learned that the worms were probably just mucous strands that collect in the corners of the eye in patients with dry eyes and that dry eyes were common in arthritis patients. We sent her to the ophthalmology clinic for treatment of her dry eyes to get rid of the "worms."

I now know that people with rheumatoid arthritis often have dry eyes. The disease attacks the tear glands, and the watery part of tear production decreases. There are three layers of the tear film. A mucous layer coats the eye surface, a watery layer keeps the eye wet, and an oily top layer holds the tears by surface tension and retards evaporation of the watery layer. When there is not enough watery layer to separate the top layer of oil from the bottom layer of mucus, the oil and mucus mix, creating a gummy film. Blinking rolls up the film into strands, which are carried by tears to the nasal corner of the eye, where they accumulate.

This patient had rheumatoid arthritis with dry eyes and developed mucous strands that she thought were worms. She did not have Loa Loa or any other kind of worms. I have since had many patients with dry eyes who have told me about the worms in their eyes. I now know that they are not Loa Loa worms or any worms at all, but mucus strands.

This patient taught me not to believe everything that the patient told me and to reserve judgment on such stories. She also taught me that rare diseases occur rarely, so I must think carefully before diagnosing a rare disease that does not fit the circumstances. This case also illustrates the desire of patients to explain diseases to themselves so that they can understand their signs and symptoms.

Chapter Two

The outcomes of some medical care can be very ironic. I had one such patient encounter while I was an intern, rotating through the obstetrics and gynecology hospital service.

A woman came to the free clinic that was operated by St. Luke's Hospital. She was performing as a belly dancer in St. Louis, at the same club where the Smothers Brothers and Phyllis Diller performed when they made their first breaks. She was not a resident of St. Louis, but she had continued to perform in St. Louis, so she came to the clinic.

Her complaint was that she felt a dragging sensation in her lower abdomen and pelvis while she was belly dancing. She felt that something was bouncing around inside of her. She already had two children who were being cared for by her mother back home while she was on the road. She said that she did not really need any more children, so if we had to take something out of her reproductive tract, it was all right with her.

On examination, we found that she had two masses, each about five centimeters, two inches, in diameter, in her pelvis. They were in the location where her ovaries should be and were nodular in character. This was in the days before diagnostic ultrasound and CT scans were in use to obtain a more definitive diagnosis. Our tentative diagnosis was polycystic ovaries, which could be cancerous or precancerous. She wanted to have them removed, but was concerned about the effects of a large abdominal scar on her career as a belly dancer.

The chief resident, who would be doing the surgery, was a woman from Turkey. She had commented that belly dancing is considered low class in Turkey, at least by the higher class women. She understood the patient's need for a scar-free abdomen, so she suggested a Pfannenstiel incision. This incision is also called the bikini incision because it follows the upper edge of the pelvic bones and can be hidden by a bikini, or a belly dancer's costume.

There are two ways to do a bikini incision, and both require a horizontal skin incision along the pelvic rim. The skin incision is spread upward to expose the vertical muscles of the abdominal wall. These muscles are then split vertically, between the muscles, to enter the lower abdomen and pelvis. The other approach involves the same skin incision, but the muscles are cut free from the bone horizontally and retracted to allow entry to the lower abdomen and pelvis. This latter approach is said to give better surgical exposure, allowing the surgeon to see better and providing more room for surgical instruments.

One of the gynecologists on the teaching staff was known for doing this incision on the society women who could still wear bikinis (it was a more expensive operation). He agreed to help the chief resident do the procedure. Because this was the resident's first Pfannenstiel procedure, she chose the horizontal muscle cutting approach because of the better exposure.

The surgery went well, and we removed two large polycystic ovaries. The incision was closed nicely, with sutures holding the severed muscles to the pelvic bones and a good plastic surgery skin closure. The patient was in the hospital for about one week after the surgery.

On the day of discharge, the chief resident went over the discharge instructions with the patient while we were on rounds. She told the patient that she could walk around, drive a car, carry one bag of groceries, and do light housework. She went on to say that she should not do any belly dancing, not even practice, for at least six months, because this activity might tear open the wound. I could feel a sense of righteousness coming from the chief resident. I learned later that the other incision would have caused disability from belly dancing for only six weeks to two months, but the chief resident did not tell her that.

The patient asked, "Can I walk around and do light exercise?"

The resident answered, "As much as you like."

The patient replied, "Good, then I can strip, and that pays only five dollars less a performance than belly dancing."

The resident was stunned. Instead of keeping her from belly dancing with her costume on, she had forced her to strip and take it all off. No great moral victory!

This patient was discussed long after she left the hospital and our care. When I learned in those discussions that the chief resident had intentionally chosen the incision she did, because it would have a longer healing time and not because it gave the best pelvic exposure, I thought that it was wrong. The doctor had let her own feelings and prejudices interfere with the proper treatment of the patient. She had inflicted her own moral values onto the patient, which was inappropriate. By choosing a procedure for moral reasons instead of the one that was best for her patient, she did not serve her patient well.

Chapter Three

During the mid-sixties, when I was doing my internship, new drugs and therapies were becoming available every week. Off-label uses for older medications were being discovered and disseminated through journal articles, often with little more that anecdotal justification and very little good research. Today many doctors accept only evidence-based medical conclusions founded on quality research.

We had a patient who had suffered a major heart attack and was admitted to the intensive care unit (ICU). He was alive, but he had developed severe heart failure. His cardiac rhythm was ventricular tachycardia, which meant that his heart did not beat from top to bottom as it should, but simply quivered. He was not moving his blood through his lungs and to his body very efficiently.

He was restless and semiconscious. His circulatory system had collapsed so much that it was difficult to find a vein through which to give him fluids or medications. We had done a "cut down" incision on his right ankle to establish an intravenous access. His level of consciousness and blue color told us that his circulation was very poor.

The resident on the case told all of the doctors in the ICU that he had just read a medical journal article in which Valium was used intravenously on several patients to stabilize the cardiac muscle to control cardiac arrhythmias. He had written down the dose that the journal article recommended. The house staff in the ICU agreed that the patient would not live very long in his present condition and elected to try the Valium.

The senior resident on the case gave the man the recommended dose of Valium by injecting it into his intravenous cut down port in his ankle. We waited and watched the electrocardiogram (ECG) for any changes, realizing that it might take awhile for the Valium to travel from his ankle to his heart. After five minutes, nothing had happened, so the resident repeated the dose of Valium into the intravenous port.

We continued to watch the electrocardiogram. After a few minutes, the ventricular pattern changed to a normal configuration, with a very rapid heart beat. After a few minutes of this electrocardiogram rhythm, he began to develop a better color-less blue, more pink. He also started to slow his heart rate. The rate decreased from about one hundred forty beats per minute to one hundred beats. His color continued to improve, which was an indication of the improvement in his circulation. As we watched, his heart rate slowed to seventy beats per minute, and his rhythm was regular and without abnormal beats.

The Valium was stabilizing his cardiac muscle membranes and controlling his heartbeat. The more regular his heartbeat, the better his circulation became. The Valium that had been injected in his ankle had taken ten minutes to arrive at his heart and start to work. The better the heart worked, the faster the Valium moved from his ankle toward his heart. As we watched, the Valium had more and more effect on his heart. The electrical heartbeats became further and further apart. Over the next few minutes, his heart rate slowed to forty, then thirty, and then twenty beats per minute. The ECG configuration looked good, except for the evidence of his massive heart attack. As we continued to watch, the heart rate slowly decreased to an occasional beat and then a straight line. His cardiac muscle membranes had been completely stabilized, stopping his heart all together.

Because he had not been in the hospital for more than twenty-four hours, Missouri state law required that an autopsy be performed. The results of the autopsy showed that the heart attack had killed about 80 percent of his heart muscle. People with this extent of myocardial infarction do not survive more than a few hours. Our therapy may have hastened his demise, but he would have died within hours if we had not intervened. The pathologist thought that the damage to the heart was too extensive for anything to have saved the life of this patient for more than a few hours.

This was a case of applied science. Valium was known to stabilize cell membranes, so it was used on several patients to stop cardiac arrhythmias. Damaged cardiac cell membranes do not conduct the signal that causes the heart to beat. Our patient had damage to his cardiac cells, resulting in an arrhythmia.

Valium did stabilize the patient's cardiac cell membranes and stop his arrhythmia, but it was delayed in reaching the heart because his circulation was so poor. This resulted in a second dose by the impatient resident. The second dose stabilized the membranes even more and stopped his heart. The theory worked too well because of the overdose. However, as noted earlier, the autopsy revealed that this patient would have died anyway.

The patient taught me that acting on theories involved risk. This case is a good argument for fact-based medicine, which is the current standard. As a rule, treatments that have been used on only one or a few patients without further study are no longer considered appropriate unless other therapies are not available and a last-ditch effort is required to try to save the patient from certain death. That was essentially what we were doing that night in 1965. Unfortunately for the patient, the Valium treatment would not have worked even if we had done it correctly.

As I gained more experience, I sometimes broke this rule with some success.

Chapter Four

I was on my neurosurgery rotation during my rotating internship when a high school basketball coach was brought in after complaining of a severe headache that had come on very suddenly while he was arguing with a referee. Shortly after his headache began, he passed out and collapsed.

At the hospital, a lumbar puncture showed blood in the spinal fluid, so a cerebral angiogram was performed that demonstrated a ruptured aneurysm at the base of his brain. The aneurysm was actually located at the junction of the frontal artery and the anterior communicating artery that connects the two frontal arteries as part of the circle of Willis, a ring of connected blood vessels that surrounds the base of the brain. It allows for blood flow to all parts of the brain when one of the major arteries is blocked below the ring. The circle is supplied by all of the major arteries to the head, making it hard to stop bleeding from a hole anywhere on the circle. This aneurysm was at the exact center of the skull, beneath the brain, making it very difficult to approach surgically.

The neurosurgeons planned surgery to clip this leaking aneurysm where it budded off the frontal artery. The approach was to enter the skull from the side while the patient was positioned lying on his other side. The bone plate was removed from the skull, and the dura mater, the tough, fibrous membrane that envelopes the brain, was opened, exposing the brain. The brain was retracted toward the top of the skull to expose the vessels lying in an area beneath the brain.

The aneurysm was visible between the two frontal arteries where the short anterior communicating artery connected the frontal arteries. The neurosurgeon took a clip loaded in a clip holder and attempted to clamp off the base of the aneurysm. As he applied the clip, it sheared off the aneurysm where it attached to the frontal artery. This left a hole in the side of the frontal artery, which immediately started spewing blood. The blood immediately filled the area and obscured the view of the artery.

(Continues...)

Excerpted from The Joy of Medical Practiceby John C. Barber Copyright © 2009 by John C. Barber. Excerpted by permission.
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