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Most Memorable Case

This is a transcript of a brief talk I gave at the end of my fellowship in 2007. All graduating chiefs and fellows were to speak about their “most memorable case.” Some gave academic presentations, mine was more personal. If you’d rather watch me present it, the video is here. It is also embedded at […]

This is a transcript of a brief talk I gave at the end of my fellowship in 2007. All graduating chiefs and fellows were to speak about their “most memorable case.” Some gave academic presentations, mine was more personal. If you’d rather watch me present it, the video is here. It is also embedded at the end of this piece.

I saw a corpse for the first time 30 [40 now] years ago this summer. I had arrived in Lagos Nigeria with my family to begin a one-year stay as our driver navigated north to the the university where my father would assume a teaching post for the year. It was by the side of the road bloated and covered with flies. My mother tried to divert my attention but she must have failed since I can now recall the incident three decades later. Sixteen years later I saw a corpse for the second time [As I wrote this ten years ago, I neglected to remember or acknowledge the cadavers we had in medical school]. 

My medical school, an enthusiastic supporter of the push in the late twentieth century to encourage medical students to go into primary care, had every student spend a week with a community doctor. My assignment was to the rural office of a solo practitioner in the Northern Neck of Virginia. This lovely peninsula on the Chesapeake Bay between the Potomac and Rappahannock rivers was dominated by farmers and waterman and it was to an elderly farmer’s house we were called one evening. The farmer’s wife was cooking supper while the farmer napped in the sitting room and he now wouldn’t wake up. She feared he was dead. We drove to their house on our way home from the office. 

The classic four over four looked upon the bay where the sun illuminated it as it set. After greeting the farmer’s wife, we proceeded to the parlor where the farmer was spotlighted by the sun streaming through the blinds. His feet rested on an ottoman and his hands were folded on his belly. Dr. Lewis [my mentor for the week] had me listen to the farmer’s chest and feel for a pulse. It was absent. The farmer was dead.

While I comforted his wife, Dr. Lewis called the undertaker to take the farmer away. The three of us settled into the kitchen where fresh baked bread lay cooling and rabbit stew simmered on the stove. The farmer’s wife looked at the food and said, “it would be such a shame for all this good food to go to waste.” We quickly agreed and the three of us sat down to eat while we waited for the undertaker.Not all of my memories deal with death. 

I remember the first time I saw a wound explored and closed. In an effort to conform to the mold of the ideal applicant to medical school, I was volunteering in our local emergency room the summer after my freshman year in college. A two-year-old had a complex laceration of the forehead and the local plastic surgeon came by the ER to close the wound. He seemed to have been on a date since he had a dressed-up woman in tow who waited for him at the nurse’s station. I watched with fascination as he soothed  the child, helped the nurses papoose the baby, and commenced numbing the wound. When he began running his finger under the flush of the child’s forehead my parasympathetic system kicked in. Breaking out in a cold sweat and feeling dizzy, I rapidly found a chair and watched the rest of the procedure from its safety; albeit with some embarrassment. How would I ever be able to do this myself? 

I remember the first time I cut living human flesh. I started my third year of medical school in late June on the neurosurgery service. My clerkship was in the era where it was rare for an attending surgeon to come to the operating room. The residents performed most cases with supervision from afar. Since it was very close to the end of the medical year, the residents were generous to eager students like me. For example, I would assist the neurosurgery intern on simpler cases like shunts. On craniotomies the residents would allow me and other students to make burr holes into skulls and sew skin. On my first weekend on call, a young woman came to the ER with severe back pain. She was two weeks postpartum and it turned out that she had a large lumbar abscess from the epidural catheter that had comforted her during her delivery. Since there was a possibility of extension of the abscess into her epidural space, even though she had no neurologic deficit, the case fell to us. I helped the intern take her to the OR. When she was positioned, prepped, and draped, he handed me the scalpel. With a pronounced tremor due to fear (or perhaps a little from an enjoyable night at the bars on the Charlottesville corner the night before), I grasped the blade and timidly scratched at her skin. Egged on by the intern, I gained some confidence and plunged the blade into her angry flesh. The warm, creamy pus that exuded from the wound gave me a satisfaction that rapidly started me thinking about a career as a surgeon. My first night of call on the medical service six months later, however, was what finalized that decision.

I think there are several things that make a case memorable: an unusual presentation of a common disease a; common presentation of an uncommon disease; tragedy, of course, lends itself to memory. For me, though, I think the relationship you have with the patient is what really makes a case unforgettable. It is difficult with the constant changing of services as a resident to develop these long-term relationships, but practice as a primary care doctor and fellowship have allowed me to have such contacts with patients.

While working as a flight surgeon in the 28th Bomb squadron — the B-1 schoolhouse for the Air Force — I met a young B-1 navigator student named Ed. I continued to take care of him as he finished his training and moved across base to the 9th Bomb Squadron, the operational squadron. One day, he came to me to say that he had just found out that his mother at hepatitis B. Unfortunately, when I tested him, he proved to be a chronic carrier of the disease. This would be tragic and scary for anyone diagnosed with it but for someone in military aviation it can be career-ending. By this point in my Air Force career, I was very familiar with the waiver process and with a few phone calls and the right paperwork I was able to get Ed returned to flying status. In consultation with a hepatologist, we put Ed on a screening program to watch him for liver cancer. 

Several months later, a bottle of wine and a framed photograph showed up in my office. Ed called me to explain. “All my life, Colin, I’ve wanted to see the White Cliffs of Dover. Thanks to the work you did to give me a waiver and return me to flying status, I deployed with my squadron to England this summer. The picture on your desk is a picture I took of those cliffs from the window of the B-1. Without your help, I would have never been able to take it. Thank you.”

That December Ed’s AFP took a jump and a liver ultrasound showed a mass that had not been there before. Amazingly he had developed hepatocellular carcinoma less than a year before we had found out he was a carrier of hepatitis B. Despite a clean resection, Ed developed a recurrence after I left active duty and died soon after. I still have the photo on my desk. 

My first weekend of call as a fellow was going well until the phone rang early Sunday morning. The NICU charge nurse apologized for waking me. “We have a kid here,” she said, “who we are really worried about. She’s had increasing abdominal distension. She’s vomiting and she’s becoming more tachycardic and tachypneic. We’ve been calling the senior resident all night long and he won’t come to see her.” I thanked her for calling me and asked her to give the patient a fluid bolus, start antibiotics, and obtain X-rays. I was scared as I drove to the hospital. Taking care of neonates was foreign to me and as a new fellow I really did not want to screw up. After examining the patient and the X-rays, I called the attending.  We soon took her to the operating room and found that she had a single adhesive band across the SMA; her entire small bowel was dead. After the resection, she was sick in the ICU for months. We were finally able to send her home on TPN. I watched her grow into a cute toddler. Over the time I’ve known her mother, a Mexican immigrant, she has gone from knowing no English to be conversant in it.

These long relationships with patients are one of the most rewarding aspects of pediatric surgery.

As we focus today on what is memorable I think it’s important to note that for most of our patients well what to us may be minor is to them memorable. In fact, it may be the most important event of their lives.

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