Error in Diagnosis

by Mason Lucas M. D.

  “I’ll take you up to the ICU. We can talk on the way,” Helen said to Jack gesturing toward the elevators. “As of nine this morning, we’ve admitted thirty-five women with GNS. All indications are that we can expect more . . . a lot more. Our facilities are already stressed. From what I hear, the same scenario’s being played out in hospitals from here to California.” The elevator doors rolled open and they stepped aboard. “The frustration amongst our physicians is soaring. We really need a fresh pair of eyes. I can assure you, Jack, that everyone on staff is excited about collaborating with you.”

  Jack smiled politely. He hoped his expression didn’t betray his anxiety. He wondered if Helen Morales’s expectations of him were even remotely realistic. He was a well-trained and experienced neurologist; but he wasn’t bestowed with divine diagnostic or healing powers. It wasn’t that he lacked confidence, but his gut feeling was that figuring out the cause of GNS and how to treat it would be the greatest challenge of his career.

  11

  The entire sixth floor of Southeastern State University Hospital was a designated critical care area consisting of four separate intensive care units. After walking down a wide corridor, Helen and Jack arrived at ICU 3. She tapped on a metal plate and the two frosted glass doors swung open.

  The unit was laid out in a circular configuration with the nursing station and all of its monitoring equipment in the middle. The patient rooms ran the entire circumference of the spacious unit like the spokes of a wheel. Similar to the lobby, it was obvious to Jack no money had been spared on its design and construction. It was always amazing to him that irrespective of what state he was in, all intensive care units had the same mineral scent.

  “Tomorrow night we’ve arranged a dinner at your hotel,” Helen said. “It will be mostly social but we’d like to spend some time discussing the GNS cases if you’re amenable.”

  “Of course,” Jack said. “I understand Dr. Sanchez recently stepped down as your chief of neurology. Have you named his successor?”

  “Not yet, but our search committee has already interviewed a few promising candidates. In the meantime, Hollis Sinclair is serving as interim chief. He’s an excellent clinician and teacher.” She paused briefly. From her expression, Jack got the feeling she was collecting her thoughts and had something to add. “At times, Hollis can seem a little proud and single-minded, but I assure you he always has the best interests of his patients at heart. I’m sure you two will work well together.”

  Helen’s comments struck an immediate cautionary note in Jack’s mind. He assumed in the interest of diplomacy, they had been understated. He’d never met Sinclair, nor did he know of him by reputation, but when somebody was easy to work with, it generally wasn’t necessary to point it out.

  “I fully understand your close friendship with Mike may complicate matters,” Helen mentioned. “If there’s anything I can do to help, please don’t hesitate to ask.”

  “Thank you,” he said, thinking to himself it was nice to hear Helen acknowledge that she was keenly aware of his predicament.

  Helen motioned to a young man working on a laptop. He returned the wave, stood up and walked over. Appearing sleep deprived and skeletal, his Brillo-y black hair and Ringo Starr mustache were both screaming for a grooming. An iPod was hitched to his frayed brown belt right next to a standard-issue hospital phone. The pockets of his white coat overflowed with an assortment of folded papers and medical manuals.

  “I’d like you to meet Marc Jaylind,” Helen said. “He’s our senior fellow in perinatology. He’s been working very closely with our division chief, Madison Shaw, on these cases. He’ll get you acquainted and answer any questions you may have.”

  Marc extended his hand, “Welcome to Southeastern State, Dr. Wyatt.”

  “I appreciate the invitation. It’s a pleasure to be here.”

  “I have a meeting so I’ll let you two get started,” she said above the shrill alarm of one of the cardiac monitors.

  “Dr. Morales mentioned you’d probably want to begin by being briefed on Tess Ryan before we discussed the other patients.” Marc pointed toward the nursing station. “There’s a physician’s conference room over there.”

  “How did you get interested in perinatology?” he asked Marc as they made their way past a portable X-ray machine.

  “I saw a lot of high-risk pregnancies at Northwestern during my OB residency. Most of the other residents hated complicated obstetrics. I really liked it.”

  “Well, if Southeastern State’s perinatology fellowship’s anything like Ohio State’s, I’m sure you’ve been working your tail off.”

  “It hasn’t exactly been a pajama party, I’ll give you that. I was an optometrist for five years before I decided to go to med school, so I’m a little older than most of the other residents and fellows.” He grinned and held up a hand. “I know. It sounds kind of strange.”

  “Not really. I did a year of vet school before switching into medicine.”

  “Any regrets?” Marc inquired with a sidelong glance.

  “From time to time, I guess,” he answered. “Are you coming to dinner tomorrow night?”

  “I’m afraid not. No bottom-feeders. Only the elite are invited.”

  Jack chuckled. “Well, at least you can take comfort in the fact that you’re only a few months from the promised land. If it makes you feel any better, we all had to pay our dues.”

  The main part of the ICU was visible from the physician conference room through a large glass window. In the center of the room was a table with six chairs around it. Marc sat down, extending his legs and crossing them at the ankles. Jack took the seat directly across from him.

  “I heard you’ve spent quite a bit of time with these patients. I guess that makes you the GNS expert.”

  “I’m afraid GNS expert would be a strong contender for the oxymoron of the month.”

  Jack smiled. “How are the babies doing?”

  “They seem to be holding their own—at least to this point. Two quad screens have been done on each of them, which have all been normal. The other hospitals are reporting the same thing. We are planning on—”

  Jack held up his hand. “Quad screen? My perinatology’s a little rusty. You’ll have to refresh my memory.”

  “Beginning at eighteen or nineteen weeks, we measure four hormones levels in the mother’s blood. If any of them is abnormal, it can be an indication of fetal distress or the development of a serious malformation. We’ve also done ultrasounds and amniocenteses on almost all of the patients, and they’ve all been normal.”

  Jack would be the first to admit he suffered from his fair share of professional shortcomings, but being completely clueless regarding a medical case had never been one of them. But at the moment, that’s exactly how he felt. Just then, the door opened and the unit secretary poked her head in.

  “Everybody’s looking for you, Marc. They’re ready to start rounds.”

  He stood up, removed his stethoscope from around his neck and shoved it into his back pocket.

  “C’mon, I’ll introduce you to Dr. Shaw. I’m sure she’s looking forward to meeting you.”

  Jack followed Marc out of the room. He had always relied heavily on first impressions. Marc struck him as bright, personable and mature. Spending a great deal of time with the residents and fellows at Ohio State, he often wondered how a particular one would fare in the real world after his or her training was over. In the case of Marc Jaylind, he had little doubt a promising career awaited him.

  12

  Poised to begin rounds, an anxious group of residents and students congregated in front of the nursing station. As a frequent visiting professor, Jack had seen the same scene play out at a dozen different medical schools. While some of the aspiring doctors feverishly paged through pocket-size manuals, others shuffled index cards packed with medical information, preparing to present their
assigned patients to the group.

  Marc raised his hand, signaling to a petite-framed woman in a knee-length white coat who was talking on her cell phone. She gestured back and a few seconds later, she slipped her phone into her coat and walked over.

  “Dr. Wyatt. This is Madison Shaw.”

  “Dr. Wyatt,” she said.

  “Please call me Jack.” He smiled, extending his hand. Even though his social life was in the doldrums, it would have been difficult for him not to notice she was an attractive woman. She had willowy fingers, a thinly pointed nose and the neck of a ballet dancer. “It’s nice to meet you. Dr. Morales had a lot of nice things to say about you.”

  “That was kind of her,” she responded, stone-faced with a clipped handshake. “If you need anything, please let Marc know.” She looked at the assembled group and then motioned to one of the residents who walked over. “Go ahead and get started with rounds. Have J. C. present the first case. I’ll join you in a couple of minutes.” Madison turned back to Jack. “As I said, if there’s anything you need, just let Marc know. Please excuse me. I have to get back to rounds.”

  “Of . . . Of course,” he answered.

  With a stiffened posture, he watched Madison start to walk away. Just at that moment, Helen Morales approached. She motioned for Madison to return.

  “I’m glad to see you two have had a chance to meet. I just got off the phone with the Office of the Surgeon General. There’s an emergency meeting tomorrow in Atlanta at the CDC. I think it would be an excellent idea for the both of you to attend.” Her gaze turned to Jack. “Do you think you can make the trip?”

  “Of course.”

  “It’s a three-hour meeting. It’s scheduled to begin at eleven. I’ll have my assistant make the travel arrangements and e-mail you the information. You should make it back in plenty of time for our dinner.” She looked down at her watch. “Just once I’d like to be on time for a meeting. I’ll speak with you both later.”

  “Will you be attending the dinner tomorrow evening?” Jack asked Madison.

  “It’s not voluntary, Dr. Wyatt. Dean Morales expects all of us to be there.”

  Madison returned to the group, leaving Jack’s head nodding like the Woody Hayes bobblehead doll that sat on his desk in Columbus. After an awkward few seconds, he had the sudden urge to feel his checks to make sure the flesh hadn’t completely melted from his face. So much for the warm greeting and heartfelt expression of gratitude for agreeing to serve as a guest professor, he thought to himself. He chanced a look in Marc’s direction.

  “Did I miss something here?” he inquired, scratching the back of his head, unable to remember the last time somebody had taken such an instant disliking to him.

  “I’m not sure. Do you frequently have this effect on women?”

  “From time to time, but it usually takes a little longer. Is she always like that?”

  Marc couldn’t contain a short laugh. “Actually, she’s one of the most easygoing, pleasant people I’ve ever worked with.”

  “All evidence to the contrary,” Jack said with a huff.

  “You probably just caught her at a bad moment. Things have been pretty tense around here the past couple of days. I’m sure she’ll be in a better mood the next time you meet.”

  “Well, you’ve certainly honed your diplomatic skills,” Jack responded as if Marc were somebody trying to sell him enough life insurance for three people. Jack was still wondering what he’d done to deserve such an ungracious welcome when one of the interns rushed up.

  Between clipped breaths, she said, “Marc, Dr. Shaw wants you stat. Tess Ryan’s crashing.”

  13

  Tess’s room was generous in size but not designed to accommodate twelve crane-necked medical students and residents, all struggling to see what was going on.

  Jack followed Marc as he cut a path through the group. When he reached the head of Tess’s bed, his gaze instantly fixed on her face. Her eyes were hollow, glazed and frozen open. Her skin was the color of a clamshell, and at the corners of her mouth, filmy puddles of saliva lightly bubbled.

  “What’s going on?” Marc asked John Fuller, the ICU physician on duty.

  “About half an hour ago, she developed sudden bursts of non-purposeful movement and arching of her back. Her pulse went crazy but it’s slowing down now.” He then gestured toward her upper body. “At about the same time, a facial rash appeared.” Jack took a moment to study the brightly speckled crimson rash on Tess’s cheeks.

  “Does she have a fever?” Madison asked.

  “No, which surprises me a little because this disease is starting to look more and more like a virus every hour.”

  “Do any of the other patients have similar findings?” she inquired.

  “Not yet,” he answered, unfastening the top button of his white coat. “But Tess was one of our first patients, and since they’ve all had identical symptoms to this point, I suspect the others will follow suit soon enough.”

  “Has she had a recurrence of dancing eye syndrome?” Jack asked.

  Fuller gazed over at him. A curious look crossed his face.

  “I’m sorry,” Marc said. “This is Dr. Jack Wyatt. He’s chief of neurology at Ohio State. Because of his special expertise in elusive diagnoses, he’s serving as a guest professor and consultant on the GNS cases.”

  Fuller took a couple of steps forward and shook Jack’s hand. “Welcome. I think we’ve got her dancing eye syndrome under control, but she’s becoming less responsive with each passing hour. I’ve ordered another MRI but I’m not sending her up to radiology until I’m sure she’s stable.”

  “Has Dr. Sinclair been informed?” Madison inquired.

  “I spoke with him a little while ago. He’s in a lengthy budget meeting, but he agreed with ordering an MRI. He also wanted to repeat an EEG to see if there’s been any change in her brain wave pattern. He said he’d be down to see her as soon as the meeting was over.” From the tone of his voice, Jack suspected Fuller was miffed that Sinclair didn’t share his sense of urgency regarding the abrupt change in Tess’s condition. Jack was in agreement: No budget meeting should take priority over a patient in trouble. Fuller continued, “Her blood pressure and pulse are okay for now. So, apart from an assessment of the baby’s condition, which I’ll leave to you and Marc, I can’t think of anything else to do at the moment except keep a close eye on things.”

  “Have we notified her husband?” Madison asked.

  “No, but I was just about to do that. I’ll give him a call in the next few minutes.”

  Madison stepped up to Tess’s bed and slowly began an examination of her abdomen. While she was still feeling her lower belly, she turned to Marc. “Find an ultrasound machine and get it in here stat. When you’re ready to go, come and get me. I want to have another look at the baby.” She pulled the covers back up and then led the group out of the room. Jack and Marc were a few steps behind them.

  “As soon as we’re done with the ultrasound, I’ll give you a ride over to your hotel,” Marc said.

  “That won’t be necessary. I’ll be happy to take him,” came a voice from behind them. Jack recognized it instantly. It was Mike Ryan.

  14

  “What’s all the excitement about?” Mike asked, peering into Tess’s room. The forced calmness in his tone did little to mask his anxiety.

  “We were just about to call you,” Marc said. “There’s been a change in Tess’s condition. She’s developed some new neurologic symptoms and a facial rash.”

  Mike took a hard look at Jack before turning back to Marc. “What does all that mean?”

  “We can’t be completely sure. There are several possibilities we’re looking into.”

  “It sounds like you’re saying Tess is getting worse, and you don’t know why.”

  “Dr. Shaw and I are looking after the baby, so it would pr
obably be better if you spoke with Dr. Fuller directly.”

  With his eyebrows drawn together, Mike said, “If Tess had suddenly improved, I suspect you’d be more than happy to share the news with me.” Mike was not one to become easily unhinged or forget his manners. Jack suspected the pure weight of the stress he was under was to blame.

  “Take it easy, Mike,” Jack said in a calming voice. “The new symptoms don’t necessarily mean things are worse. It may just be the natural course of the disease. Marc and Dr. Shaw are going to do an ultrasound of the baby to make sure she’s okay.”

  “I don’t think you’re as convinced as you’re trying to sound.”

  Before Jack could respond, Mike turned and walked toward the nursing station. With his back to them, he shook his head slowly. Jack was tempted to join him but thought better of the idea and decided to give him a few moments alone to regain his composure.

  As Jack suspected, after a minute or so, Mike walked back down the hall.

  His words were measured. “Ever since Tess was admitted I’ve listened to one learned medical opinion after another. The only thing I know for sure is that none of the doctors has the first damn clue of what to do to help Tess or our baby. I’m not naïve and I don’t believe in miracles, so I wasn’t expecting you to breeze in here and instantly tell me what’s wrong with her, but I was hoping you’d . . . you’d at least have some—”

  “We’re only a few days into this illness. The only thing I can tell you for certain is this will be an hour-to-hour process. Right now, nobody can say when the pieces will start coming together.”

  “Or if they ever will,” Mike stated.

  “I’m not going to paint a rosy picture for you. Figuring out what’s wrong with Tess isn’t going to be easy. I understand that right now you’re a little frantic, but every disease leaves footprints. We need more time to find them, and then see where they take us.”