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Did you see that anemia patient in the ICU?
‘In Practice’ columnist says a physician and his patient can sometimes get lucky.
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“Did you see that anemia patient in the ICU yet?” the resident asked as I breezed through the ICU on my way to another floor.
“No, who are you referring to?” I asked.
“Room 312, right here.”
How could I leave at that point — it was an ICU case and you never know what that could mean. The patient’s chart was relatively thick and not very helpful. A man in his mid-70s, the patient was on a respirator and had pretty severe anemia. The staff was convinced it was due to a drug, and there were some suggestions for hemolysis, including an elevated LDH. But when I ran through the list of his drugs, nothing stood out as being causative. I figured it was just another case of chronic, not-so-simple anemia in an intubated ICU patient.
When I walked into the patient’s room, a relative asked, “Who are you, and why are you here?”
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Three very angry family members were guarding the patient and watching the respirator breathe for him.
“I’m Dr. Topilow and I’ve been asked to review Mr. X’s anemia problem,” I replied.
“Well listen, doc. This guy was well until six weeks ago when he had a heart attack. After that episode, they gave him all sorts of cardiac medications and look what has happened to him! He just kept getting worse until he went into a coma. What are you going to do about it?” they asked.
I had no idea what I was going to do about it, but I felt I had to defuse the situation in some way.
“What did he do for a living? What line of work was he in?” I asked his family.
“He was a physics and biology teacher, and he’s been working on our family tree farm since he retired.”
It did not seem like much of lead, and one of the patient’s relatives questioned where I was going as I turned to leave the room.
“I’m going to study his chart and check his blood,” I said quite sheepishly. I could not wait to get out of the room, of course. The chart was little help, so I called the lab and asked them to pull out the blood smear so that I could look at it.
At this point, I decided to go to the tumor conference that I was running, rather than go directly to the lab. I figured the smear could wait until after the conference, plus I needed some comic relief. I had no sooner settled into my chair when the pathologist came to me and whispered in my ear.
“Your patient has malaria,” he said.
“What? No, he hasn’t been out of the country. He must have babesiosis.”
I went right to the lab. Sure enough, those little intracellular parasites were all over the place. I called the I.D. team who had already seen the patient. “You’d better get to the ICU and treat this guy for babesiosis.”
I called the family and told them that their father had babesiosis, explaining that it probably came from his exposure to ticks while working on the tree farm.
The family members returned that afternoon and were much more civil this time.
The I.D. team wrote the medications, and the staff withdrew the endotracheal tube within two days. Two days later the patient left the hospital.
Four weeks later I was out racing my sailboat with my regular crew. “I heard you treated my old professor,” said Roy, one of my younger crew members. “It’s all over the neighborhood how you diagnosed him and saved him.”
I didn’t mind the compliment but didn’t say much. Sometimes both you and your patient get lucky.
Arthur Topilow, MD, is in practice at Atlantic Hematology & Oncology in Manasquan, New Jersey.