Lisa Sanders - Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis

B arbara Lessing stared out the window at the snowy field behind the hospital. The afternoon sky was dark with yet more snow to come. She looked at the slender figure in the bed. Her daughter, Crystal, barely twenty-two years old and healthy her entire life, was nowsomehowdying. The young woman had been in the Nassau University Medical Center ICU for two days; shed been seen by a dozen doctors and had scores of tests, yet no one seemed to have the slightest idea of just what was killing her.

It all started at the dentists office. Crystal had had a couple of impacted wisdom teeth taken out the month before. But even after the teeth were gone, the pain persisted. Shed called her mother halfway across the state just about every day to complain. Call your dentist, shed urged her daughter. And she had. Finally.

The dentist gave her a weeks worth of antibiotics and then another. After that her mouth felt betterbut she didnt. She was tired. Achy. For the next week shed felt like she was coming down with something. Then the bloody diarrhea started. And then the fevers. Why didnt you go to the doctor sooner? the trim middle-aged woman scolded her daughter silently.

Barbara had gotten a call from a doctor in the emergency room of this suburban hospital the night before. Her daughter was ill, he told her. Deathly ill. She drove to Syracuse, caught the next flight to New York City, and drove to the sprawling academic medical center on Long Island. In the ICU, Dr. Daniel Wagoner, a resident in his second year of training, ushered her in to see her daughter. Crystal was asleep, her dark curly hair a tangled mat on the pillow. And she looked very thin. But most terrifying of allshe was yellow. Highlighter yellow.

Wagoner could feel his heart racing as he stood looking at this jaundiced wisp of a girl lying motionless on the bed. The bright unnatural yellow of her skin was shiny with sweat. She had a fever of nearly 103. Her pulse was rapid but barely palpable and she was breathing much faster than normal despite the oxygen piped into her nose. She slept most of the time now and when awake she was often confused about where she was and how she had gotten there.

To a doctor, nothing is more terrifying than a patient who is dying before your eyes. Death is part of the regular routine of the ICU. It can be a welcome relief to the patient, or to his family. Even a doctor may accept it for a patient whose life can be prolonged no longer. But not for a young girl who was healthy just weeks ago. These doctors had done everything they could think of but still there was a feara reasonable fearthat theyd missed some clue that could mean the difference between life and death for this young woman. She shouldnt die, but the young resident and all the doctors caring for her knew that she might.

Crystals thin chart was filled with numbers that testified to how very ill she was. Wagoner had been through the chart a dozen times. Virtually every test theyd run was abnormal. Her white blood cell count was very high, suggesting an infection. And her red blood cell count was lowshe had barely half the amount of blood she should have. Shed gotten a transfusion in the emergency room and another after she was moved to the ICU, but her blood count never budged. Her kidneys werent working. Her clotting system wasnt either. Her yellow skin was covered in bruises and her urine was stained deep red.

Sometimes, if you just work hard enough to keep a patient aliveto keep the blood circulating, the lungs oxygenating, the blood pressure high enoughthe body will be able to survive even a vicious illness. These are the miracles brought by technological advances. Sometimes, but not this time. The ICU team gave Crystal bag after bag of blood; they did their best to shore up her damaged clotting system; she got pressers (medications designed to increase blood pressure) and fluids to help her kidneys. She was on several broad-spectrum antibiotics. And yet none of that was enough. She needed a diagnosis. Indeed, she was dying for a diagnosis.

This book is about the process of making that diagnosis, making any diagnosis. So often this crucial linchpin of medicine goes unnoticed and undescribed, yet it is often the most difficult and most important component of what physicians do. As pervasive as medicine has become in modern life, this process remains mostly hidden, often misunderstood, and sometimes mistrusted. In movies and novels its usually the one-liner that separates the fascinating symptoms from the initiation of the life-saving therapy. On television its the contemporary version of Dr. McCoys (Star Trek) magic diagnostic device (his tricorder) that sees all, tells all. But in real life, the story of making a diagnosis is the most complex and exciting story that doctors tell. And these are stories that doctors tell. Just as Sherlock Holmes or Nick Charles (the hero of the Thin Man mysteries) or Gil Grissom (CSI) delights in explaining the crime to victims and colleagues, doctors take pleasure in recounting the completed story of their complex diagnoses, stories where every strange symptom and unexpected finding, every mystifying twist and nearly overlooked clue, finally fit together just right and the diagnosis is revealed. In this book Ill take you into those conversations and onto the front lines where these modern medical mysteries are solvedor sometimes not.

Just a hundred years ago, journalist and acerbic social critic Ambrose Bierce defined the word diagnosis in his Devils Dictionary as A physicians forecast of disease by [taking] the patients pulse and purse. And that was true for most of human history. Until very recently, diagnosis was much more art than science.

But since Ambrose Bierce wielded his rapier pen, there has been a revolution in our ability to identify the cause of symptoms and understand the pathology behind them. In the era in which Bierce wrote, Sir William Osler, considered by many to be the father of American medicine, was able to write a comprehensive summary of all the known diseases in his 1,100-page masterwork, The Principles and Practice of Medicine. These days each tiny sub-branch of medicine could provide as many pages on its super-specialized knowledge alone.

At the birth of medicine, millennia ago, diagnosis (the identification of the patients disease) and prognosis (the understanding of the diseases likely course and outcome) were the most effective tools a doctor brought to the patients bedside. But beyond that, little could be done to either confirm a diagnosis or alter the course of the disease. Because of this impotence in the face of illness, the consequences of an incorrect diagnosis were minimal. The true cause of the illness was often buried with the patient.