Revenge. Sheldon Cohen
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his right hand still stroking his forehead. He sat down and looked at the students, their eyes burning a hole in his forehead. He said, “We don’t often start our day with such a bang. If you noted surprise registered on my face it was because I happen to know this patient. He is a physician and a member of the Medical Executive Committee. He paused. “But let’s get on with what you could learn.”
They spent five minutes discussing the various types of meningitis: bacterial, viral, fungal. They reviewed the typical symptoms and signs, the confirmatory tests, the treatment, and the prognosis.
Then Pollard said, “But I have a bigger question for you to ponder. Why the heck did he get meningitis in the first place? Before I came back to the office I spoke to his physician who said that he was a very healthy man and enjoyed good health.”
“Will we ever know?” asked Amanda.
“I hope we find out by means other than autopsy, but we may not. Believe me at this point it’s very confusing. You saw me examine his ears nose and throat because I was looking for a source of infection. You saw me checking the whole length of his vertebrae as well for the same reason. There are two ways that bacteria can reach the meninges: first by extension from nearby infections, such as from sinuses, nose, throat or ears, or along the vertebrae such as an epidural abscess; second by hematogenous spread, that is by reaching the meninges through the blood stream from some distant site. I couldn’t find any obvious source from either route. Granted I was in a hurry to examine him and so I didn’t do a thorough detailed exam. It’s a mystery, but we can’t let pondering about a source stop us from starting a full course of treatment. This man’s life is at stake.”
At this point, the phone rang in his office. He picked it up. “Hello. Oh good. Let’s hear.” His right hand again stroked his forehead. “Staph? How much? Okay thanks. His wife not here yet? Bring her in the minute she gets here. Yes, call Baehler now. He should be in Intensive Care. Bye.” He leaned back on his swivel chair.
“That was Mrs. Cowan. The gram stain is back. The bacteria are staph. Could you believe it? Staph aureus. That’s very unusual and at the same time very bad. We’ve discussed the more common organisms. Also, his complete blood count is back, and it’s normal except for a four thousand white blood cell count. You remember the normal? What is it?
“Five to ten thousand.”
“Correct.”
“It should be high because of the infection,” said Amanda.
“Yes, that’s right,” he said. “So what does a reduced white blood count tell you?”
“Could it be a lab error?” asked Barry.
“Not much chance. These tests are all automated and it’s near impossible to make a mistake.”
“If it’s accurate then I would think that for some reason he’s unable to launch a white blood cell response. Is something wrong with his bone marrow?” said Amanda.
“Probably not,” replied Pollard. The blood count and the platelets are within normal limits, so that tells us that the bone marrow is capable of manufacturing those cells. But you’re on to it. He has a reduced white blood cell count in the face of a severe infection. One would expect a count of twenty, thirty thousand or more in a case like this. The bone marrow is working overtime launching white cells to attack the invading bacteria. This has been such a massive effort that the bone marrow can’t release any more white blood cells, and when that happens it is a very poor prognostic sign. It means that he is no longer able to utilize his first line of defense: his white cells. Without those, it wouldn’t surprise me if the bacteria take over and this patient is now in septic shock. Without white cells you can replace his blood with antibiotics and it won’t make a difference.” He sighed and got up from his chair.
As the students stared wide-eyed at Pollard he said, “In the Emergency Department things don’t grind to a halt after a gut wrenching experience. Let’s get back to work.”
CHAPTER 7
They followed him out like the Pied Piper and he stopped at the nurse’s station where Gail told him, “Room three, doctor.”
“Get me as soon as Spann’s wife comes in please.”
A mother with her three-year-old son sitting on her lap occupied room three. The nurse had cleansed a forehead laceration on the child and covered it with sterile gauze. As soon as the mother saw this impressive looking doctor, upright, confident, smiling, and warm walk into the room, she relaxed.
“Good morning, Mrs. Williams. I’m Dr. Pollard. What happened to Jimmy?”
“He fell down outside and cut his forehead.”
“Let’s get him up here on the table and we’ll take a good look,” said Pollard. “Do you mind if these doctors watch, Mrs. Williams?”
“Oh no, doctor.”
“Was Jimmy knocked out?”
“Oh, no, he cried right away.”
“He turned to the students, “Why did I ask if Jimmy was knocked out?”
Amanda answered, “Just to gauge the extent of the head injury. If someone is knocked out the head injury might be more severe?”
“Yes, and that would mandate a more careful neurological examination, which I’ll still do anyhow, just to be certain. Got it? You can’t be too careful in this business.”
He stood in front of the young man who looked up at him with bulging eyes. He reached down to hold the youngster’s hands in his. “Hi, Jimmy. We’re going to fix that head of yours. Would you lay Jimmy down on the table, Mrs. Williams? Stay there and hold his hand, please.”
He donned sterile gloves, while demonstrating proper technique for doing so to the medical students. He had the nurse take off the loose gauze covering the wound. He then showed them Jimmy’s one-inch laceration. “It’s certainly deep enough to warrant some sutures,” he told them. “Mrs. Williams, has Jimmy had all his childhood shots including tetanus?”
“Oh yes, doctor.”
The nurses had already set up a suture set, cleansed, and draped the wound. He applied a local anesthetic and in three minutes placed five sutures. At the same time, he lectured to the medical students about sterile and suture technique. He then removed his gloves, did his neurological examination, reassured the mother, gave her follow up instructions and was about to take his entourage into the next patient room when Gail told him that Mrs. Spann had just arrived and was waiting in his office.
When they arrived, they saw a somewhat disheveled appearing middle-aged woman sitting on the couch. She was leaning forward with her hands clasped under her chin, her body rocking back and forth. Her brown, highlighted hair suggested that it had not seen a comb or brush for some time. Her face was pale and gaunt. Her lips were quivering and her dark eyes were moist with tears. She had the appearance of a woman who lacked sleep and was paying no attention to her appearance. When she saw Pollard and the two students, she rose from the couch.
“Hello Mrs. Spann. Please sit down.” He sat next to her, turned to face her and said, “I saw your husband a few minutes ago. The paramedics brought him in. I was able to make a definite diagnosis.”
Mrs. Spann interrupted and said, “What doctor, what?”
“He has somehow developed meningitis. I did a spinal tap that confirmed the diagnosis.”
“Meningitis? What does it mean? Will he be all right?”
“I don’t know, Mrs. Spann. Meningitis is an infection of the meninges, or covering of the brain. He was in coma and that’s a cause for concern. He’s in Intensive Care now and on therapy. I got hold of Dr. Baehler and told him what happened. He was on his way to the hospital and may be in Intensive Care as we speak. Has your husband been ill lately?”
“No. He’s always been in great health. Why he can