Wednesday, March 16, 2016

The Winged Victories fly Elsewhere

Medicine is not all technology you know.  There is still room for that curious mix of mental organization, inquisitiveness, diligence and insight that collectively make you "smart".  The straightforward plow horses of the Healing Arts certainly get the job done, albeit in dull and unimaginative ways.  They order lots of CAT scans and consults and broad spectrum antibiotics.

I would like to think that three plus decades and a still lively mind allow me to work with more....elegance.

Of course most of what I see on any given day is routine.  But recently I had for one brief, shining moment a clinical challenge that made me stop in my tracks.  If I was right....well, it would be a diagnosis so clever; a diagnosis arrived at entirely with Old School methods; a diagnosis so obscure and esoteric that there would simply be nothing for it but to retire on the spot because clearly I would never be that smart ever again.

(I actually made a call like that two weeks into my first job after residency but that's another story, another day).

Yes I had a vision.  A vision in which clinicians now young and fresh of face would look back years and years from now nodding heads silvered by years and gravitas and say "Ah, Tacitus, now there was a clinician!"

On my schedule the complaint was "golf ball sized lump".  In a fifty something person that strikes an ominous note.  And remarkably the patient spontaneously served up a most unusual clue: "When I drink alcohol I get this weird, sudden pain".

That sent my internal search engines on a furious hunt.  It was a familiar bit of trivia.  Back I went decade by decade through Lord knows how many thousand patient encounters.  I had chased this lead a couple of times in the past.....Eventually I came full stop to a lecture hall in Minneapolis circa 1983. Medical students scribbling notes as a lecturer mentions in passing some of the unusual ways in which Hodgkin's disease can present itself.

Like a birder tiptoeing up for a photo of an avia most rara I gently inquire.  "Itching?"  No.  "Other lumps?" No.  "Weight loss?" Yes, but she felt it was related to her psychiatric meds.  Now, you may think a psychiatric history would lessen my zeal for pursuing an exotic diagnosis.  But in reality it only makes the Great Catch even greater.  To find something fascinating, rare and very treatable to boot in a patient whose issues would generally be dismissed as nonsense just makes the entire endevour all the more Glorious.

As I sometimes am wont to say, "when all else fails examine the patient".  Hmmm.  Well, now.  That lump really is rather difficult to feel.  Golf ball seems a bit over stating things.  I see that several other physicians, good clinicians all, have checked this complaint out and found nothing.  With those minor notes of discouragement creeping in around the edges I waited for a couple of basic but telling lab tests to return.

You can learn a lot by asking a few more questions.  And as it happens that peculiar sudden pain with alcohol - the clue most hidden to a medical mystery - was also happening with stress.  And certain foods.  And when she over slept.

The tests were going to come back entirely normal.

The Winged Victories that were supposed to crown my noble brow with laurels and bear me aloft in triumph flew past.  I could metaphorically feel the flutter of their wings and see one of them look back, wink, and say "Nice try Old Timer".

So today at least I do not ascend to those Olympian Heights - or more likely just the foot hills of same - where dwell Galen, Hippocrates and The Brothers Mayo.  But at least until I retire again I can take comfort in the fact that tomorrow is another day.  The schedule is full.

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