Thursday, October 6, 2011
I Was Still The Apprentice
The residents actively searched for cases to stump Dr. G. We connived to present to him at case conference, something he had never seen before. But mostly we sat back and enjoyed watching the mind of a master clinician at work.
He taught us lessons about being a physician. He hammered us on deductive reasoning. I can still here his raspy voice scolding me in the exam room when I'm struggling to put the pieces together:
Be the detective.
While Dr. G could expound on almost any topic, he was known as an expert in one disease in particular: Hereditary Hemorrhagic Telangectasia (HHT). An autosomal dominant disease, HHT was widely recognized among our residents. Patients came from far and wide to see Dr. G in his clinic. By the time I finished training, I treated at least ten patients with this rare problem.
Although years later my mind is fuzzy on the details, every time I see a person with chronic nose bleeds I think of HHT. Often when I hear hoof beats I think of this zebra.
I watched in the ER as my patient rolled back from xray. She was thirty five years old and plagued by anemia. She had been admitted to the hospital five times over the last decade for transfusions. She showed up at our door when fatigue and shortness of breath had become unbearable.
The laboratory values confirmed it. She lost quite a bit of blood. Given her good pressure and pulse rate it was likely that this occurred over several months. I introduced myself and started to question her.
As the details unfolded I became excited. Apparently she had nose bleeds since childhood. There was no other cause of blood loss. I examined her. When she opened her mouth I saw a few small red dots on her tongue. Telangectasias! The hallmark of HHT.
As I explained the diagnosis, I informed her that I knew one of the world's experts on this disease. We would transfuse her blood. Have her see an ENT to help with the nose bleeds. If she was willing to travel the few hours to St. Louis, she could even see Dr. G. himself.
As the phone rang I felt like I was in residency again. I was calling Dr. G to tell him about another patient. Could I stump him?
After exchanging pleasantries, I informed him that this was not a social call. I had a patient to discuss. I was about to begin with the details when he interrupted me.
What's the patients name?
I stammered. Epi...Mrs Epi Staxis
He laughed a deep belly laugh. I felt small. Like I was a student again.
Another HHT case!
I was taken by surprise.
How...how did you know?
He paused. Well I take care of at least ten different people from the Staxis family! Didn't she tell you she comes from St. Louis?
I felt a growing sense of embarrassment. Dr. G. made the diagnosis without even hearing a single detail of the patient presentation. He was still the Jedi Master. I was still the apprentice.
Didn't we teach you anything hear in St. Louis?
You gotta take a thorough Family History!
Posted by Jordan Grumet at 5:16 AM