“I have two possibilities,” said Barry, “either a vascular accident like a cerebral hemorrhage or thrombosis, or a meningitis.”
“Both good thoughts,” said Pollard. “One could have a fever with a cerebral hemorrhage, but you wouldn’t expect it to be that high again, so your second suggestion would be the better one. We see very little meningitis in the Emergency Department. It’s logical to think of the brain as the etiology of these symptoms, so you’re wise to zero in on this source, but you need to know there are plenty of other non-cerebral problems that could cause coma, seizures, and an elevated temperature. So we’re dealing with many possibilities, and we’ll try and sort them out when we see the patient. We’ll use our powers of observation, if we have any, and we’ll see what a physical exam can add to defining the problem. Any other questions while we wait?”
The students shook their heads. “No, sir.”
“Okay, when we’re together and in front of patients I’ll call you Dr. Galinski and Dr. Johnson. You’ll call me Dr. Pollard.”
The students nodded.
“One more question,” said Pollard. “What have you got to work with here?”
Both students stood silent. There was no answer forthcoming as they turned and looked at each other.
Pollard laughed. “Silence…That’s what I always get and that’s what I expected,” he said, “so don’t feel bad…you passed, and that brings me to the answer, but first a little lecture. This is your chance to polish your physical diagnostic ability. We make initial diagnoses here using four things: our sense of sight, hearing, touch and smell, aided by our hand held medical equipment and our brain. We use high tech when we have to. If you do a good history and listen to the patient, and do a good physical examination you will make a diagnosis at least 80 percent of the time. That’s not me talking, that’s Sir William Osler, and there were never any truer words describing the practice of medicine. That’s one way I’m going to judge you in these three months. So expect two questions from me after you see a patient: what is the medical history and what are the physical examination findings. After that I’ll want to know your diagnostic impression and then all the treatment options. Simple. It’s a ritual…and that’s how we learn. There will be no shortage of clinical material. Am I clear?
“Yes, they both answered.
“One more thing,” said Pollard, “we have a tremendous volume of patients here. So what I just told you is ideal, but when you get to be an emergency medicine physician, you’ll discover that you may not have the time it takes to do a thorough examination. In my case, there’s where you students come in. You may see a patient first. You’ll tell them Dr. Pollard, or whoever will see you soon. You’ll introduce yourself, tell them that you’re a medical student and you’ll see them, take as good a history as you can, do the best exam you can, and then when I come in we’ll work together. Now, all that assumes that the patient is conscious and rational and can give a history. There will be plenty who won’t be able to. Understand?” he said without looking up.
Before the students could answer, Gail entered. “The paramedics are pulling in with your patient, Dr. Pollard.”
He shook his head in acknowledgement. “Mrs. Cowan, this is Amanda Galinski and Barry Johnson. They’ll be working with us for three months as part of their junior clinical clerkship.” Getting up from his desk and turning to his students he said, “Now you two listen up. Mrs. Cowan will also be orienting you, and if I’m not around and you have any questions you’re free to ask any doctor on duty, but if you want my advice you’ll ask Mrs. Cowan. She knows more than all of the doctors put together and that includes me.”
“He says that about all the nurses,” laughed Cowan.
“Okay let’s go see our first patient.”
CHAPTER 6
It was a ten-yard walk to the Emergency Department from his office. As they walked in, they could see the paramedics wheeling a cart into the main trauma room near the ambulance entrance. The medical students had to speed walk to keep pace with Pollard’s flying coat tails. Cowan matched him stride for stride. As they entered the room, the patient was on the examining table. Betty, the paramedic, was transferring the plastic intravenous fluid bottle to the table’s IV stand.
“Hi, Betty. Anything happen since we last spoke?”
“No change,” she reported. “The seizures stayed under control with the Diazepam 20. His pulse rate increased to 128, regular, and his last blood pressure was 114 over 60. He hasn’t regained consciousness.”
“Good description.” Pollard turned to the medical students and told them, “They found this man after he was missing for two days. Most unusual.”
He was about to speak again, but he glanced at the patient lying unconscious on the table and froze. He shook his head. He seemed unsure of what to do next, an unusual state of mind for this self-assured physician. He took Cowan by the arm, took her to a corner of the examining room and whispered something in her ear. As he did so, she turned to look at the patient and the same type of startled look crossed her features.
Pollard took a position on the patient’s right side. The medical students stood next to the patient’s cart on his left side. Pollard took his thumb and placed it on the patient’s bony ridge above his right eye. He pressed hard, but there was no response from the patient. Without looking up at the students he said, “Do you know what I’m doing?”
“Testing the patient’s response to pain stimulation,” said Amanda.
“Right. Am I getting a response?”
The students observed the patient while the pain stimulus continued. He did not move or wince. “No,” they said together.
“Right. What does that tell you?”
“The coma is deep.”
“Good. We have the history of seizures and high fever. That’s all the history we have, except for the fact that he was missing for two days, plus we just learned he’s in deep coma by his failure to respond to intense pain. What should I do next?”
Before his students could answer, he placed his hand under the patient’s head and tried to flex the neck. The unconscious patient’s hips and knees flexed. “What do you call that sign?” asked Pollard.
The students looked at each other and remained silent.
“Brudzinski’s sign,” said Pollard, and in a non-deprecating manner he added, “Did you forget all your physical diagnosis already?”
He then flexed the patient’s right leg at the hip and then attempted to flex the patient’s right knee, but had difficulty as he met considerable resistance.
“And what do you call this sign?” Hearing nothing he added, “Kernig’s. You’ll never forget these signs now. What we read about we easily forget. What we witness or perform ourselves we never forget. What are these two classical signs indicative of?”
“Meningitis,” said Barry.
“What causes those signs you just witnessed?” Pollard asked.
“Meningeal irritation?” asked Barry.
“Close enough. It’s thought to represent irritation of motor nerve roots as they are put under tension and pass through inflamed meninges. At this point, I have to confirm this strong index of suspicion of meningitis because we need to identify the organism causing this disease. We have made a clinical diagnosis, and that diagnosis is important and serious enough that we have to confirm it and start therapy. We have no time to lose. How will I confirm it?” he said.
Pollard continued his