Reaching Down the Rabbit Hole by Allan H. Ropper Read Free Book Online Page A

delivered the patient history with a curious mixture of arcane medical nomenclature and L.A. street slang.
    “She’s a forty-nine-year-old woman with a history of basilar predominant severe lepto-meningial inflammatory syndrome that’s been worked up up the wazoo. At baseline, she can kind of shuffle. She has some intermittent diplopia and dysarthria, and she’s presenting with increased difficulty with walking, and also a gnarly occipital headache. She can’t walk without two people assisting her. For the last six days she’s had to concentrate a lot more than usual. Of note, in addition to this lepto-meningial inflammatory syndrome, she’s had chronic hydrocephalus.”
    More plainly put, Mrs. G had serious problems, had been in and out of the hospital, and was nearing a kind of crisis. Her scans, when Hannah put them up on the flat screen, looked so unusual as to be alarming.
    “What’s going on there?” I asked. Clearly, we were coming into the middle of a very complicated case. I was immediately bothered by the pear shape of the ventricles, the fluid-filled cavities in the middle of the brain. I had seen this before in brains in which the spinal fluid was under very high pressure. The team seemed to appreciate that the ventricles were enlarged, but did not pick up on the fact that they were also under substantial tension. I took this as a cue to look for worrisome signs when we finally got around to the bedside.
    “She shouldn’t be here on the ward, the ICU would be better,” I said. “She has massive hydrocephalus. She’s not going to able to walk soon.”
    “So we essentially cut right to the chase?”
    “Right. There’s no time to make this diagnosis. She needs a shunt ASAP.” A shunt is an internal one-way drainage valve that relieves and controls the internal pressure of cerebrospinal fluid.
    “Neurosurg needed a place to put her while they figured this out,” Callie said.
    “Well I can figure it out for them: send her back to the ICU, have them do a temporary, external shunt, get some cerebrospinal fluid to test, get her walking, make a diagnosis, and then do a permanent shunt. We need to prevent her from getting demented and being wheelchair-bound. I know this is meta-level stuff, but we should keep our eye on the ball here.”
    I once had a professor who used to say you should never joke with your patients, and you should never return their jocularities. He said it was a bad, bad mistake. I have never followed that advice, although it might be a good rule to apply with the residents. In hindsight, I should have stayed on message. Instead, I asked if Mrs. G had any unusual exposures. “She has a Greek name. Does she work any place special? The last case of this I saw was a guard at the Egyptian room at the Museum of Fine Arts. He got Nocardia from the mummy.” Nocardia is a bacterium, typically found in soil that, if inhaled, can cause a slowly progressing pneumonia. In rare cases, it can cause an inflammation of the meninges, the brain’s protective sac, and lead to hydrocephalus. The museum is just down the street from the hospital. It was an interesting case, but didn’t shed any light on the matter at hand.
    “Oh, that’s awesome,” Callie said. “Actually, I don’t know what her exposures are, her mummy exposures.”
    As entertaining as this was, my little anecdote diverted the team’s attention from the very point I wanted to drive home: that this woman should be sent back to the ICU or even straight to the operating room.We needed to keep a close eye on her to make sure that the pressure in her brain did not cause her to crash. But in a setting in which thirty cases are discussed within two hours, no patient gets more than fifteen minutes of fame, making it doubly imperative that we stick to relevant facts. Instead, I took my eye off the ball, and the rest of the team did, too.
    When we finally got to see Mrs. G on rounds that morning, I was impressed by her odd combination of