The Ballad of Mr. Blue - part 2

Sometimes things aren't as they appear

This is a change of pace from my usual writing here on “Building Docs.” What follows is the second part of a series involving one of my first, and most memorable, patients - Mr. Blue. I hope you enjoy the story and learn something in the process! If you haven’t read part 1 - click the link below…

Part 1

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Medical students are doctors in the same way that a new puppy is a well-trained guard dog. You wouldn’t expect a new puppy to understand how to sit, stay, or heel; just like you wouldn’t expect a med student to lead a team or know what treatments are available for a patient’s diagnosis, or know offhand what tests to order. They are first and foremost students, placed in the position of learning medicine while simultaneously being asked to do it.

This doesn’t mean, however, that medical students can’t add value to a medical team. They will eventually become competent doctors. Additionally, just because they don’t have the reps, knowledge, and experience in medicine to be deemed competent doctors now, they can still become competent students by performing tasks suited to their skill level. In other words, they add value to the team by leveraging what they have an excess amount of – that which is time (compared to the residents and attendings) and manual labor.

What do you mean by manual labor?

The case of Mr. Blue required a lot of digging; excavating. It’s unskilled but can be time- and effort-intensive. With time and effort at my disposal, I set out to unearth as much information as possible regarding Mr. Blue. Taking my lead from the detective novels I love (from Raymond Chandler to Robert Galbraith) I first went about canvassing.

Canvassing

Going up to Mr. Blue’s floor, I didn’t have a specific plan of attack other than to see if the nursing staff had any relevant information on him. Getting out of the elevator, I took a right onto his ward and asked the nurses at the station who was caring for Mr. Blue. “Oh that’s Steve, he’s down the hall” was the reply. I walked down the hall and spotted Steve, 6’5” bushy beard with thick-rimmed glasses.

“Hey man, I’m a student on the medicine team caring for Mr. Blue. How is he doing? Have you noticed anything out of the ordinary?”

Steve goes on to tell me that Mr. Blue is a difficult patient. Regarding his nurses, he either loves them or hates them. He verbally accosted his night nurse to the point where she had to switch patients. Throughout the week, there were other difficult situations, too. In fact, a nurse from the opposite ward recognized him from a previous job at a different hospital. She had told Steve that Mr. Blue had exhibited drug-seeking behavior during that encounter and was well-known to that hospital’s staff. To lend credence to her story, Mr. Blue had asked me for Dilaudid earlier in the week for his pain, though he exhibited no outwardly signs of pain and anguish (e.g. he was sitting quietly and politely asked for it). I told Steve that I was going to speak with Mr. Blue, and his reply was to “set a timer” because he will talk my ear off.

And with that, I entered Mr. Blue’s room. I found him lying quietly, half-draped in blankets and staring off into space. My goal was to discern if there was an actual physical medical problem going on, or if something else was happening. I quickly realized that Steve had a point - for an hour, Mr. Blue told me his life story seemingly without stopping to breathe. I had inadvertently stepped onto a train with no stops.

I learned he had family, but he no longer spoke with them. I learned he hated his night nurse but loved his day nurse. And I learned that his best friend in the world was his mother. She, unfortunately, passed away about a decade earlier. She had had a stroke, and Mr. Blue cared for her in her final days. He himself stated, “I never got over that - her death.”

I left Mr. Blue, getting more suspicious that something other than physical was going on with him. To parse this out, I came up with a plan.

Observe, Observe, Observe

As Dr. Meador says with Rule 28 “There is no substitute for direct observation” …

There is a questionnaire that can be used in Parkinson-plus disorders, like Multiple System Atrophy – the disease I had first suspected. It is called SCOPA-AUT. My plan was this – ask him to fill out the questionnaire and then observe him. If he had difficulty filling it out, as in trouble gripping the pen or writing legibly, it would be reasonable to still consider a neurological origin for his problem. However, if filled out the sheet without error or issue, then it would be time to focus more on a psychogenic origin.

I entered his room with the questionnaire. “Hi Mr. Blue, we’re trying to get more information on your symptoms, can you fill this out?” I asked as I handed him the sheet and pen. He took both with ease and proceeded to circle and write without issue. The tremor in his hand disappeared. In distracting Mr. Blue, I was able to “cure” him of the tremor, something that residents on the team noticed and were able to reproduce. Distractibility, as in a tremor that goes away when being distracted, is a sign pointing towards a psychogenic tremor.

Excavating

With this newfound information, I set out to sift through his entire electronic medical record, which went back more than a decade, looking for information that could give context to Mr. Blue’s presentation. Starting from the most recent…

The first thing that struck me was the number of emergency room visits within the last few years. I opened his most recent one, from a different hospital, to get some information. It described the following scenario: Mr. Blue was at the mall, going down the escalator. He felt faint and fell down the last few steps of the escalator. The security guard helped him and offered to call an ambulance, but Mr. Blue opted to call a taxi instead. Findings in the emergency room were benign other than difficulty walking. He wanted to be admitted to the hospital but was ultimately declined, so he later left the emergency room.

The next entry came a month before (from yet a different hospital) – Mr. Blue was at the mall. While going down the escalator he felt faint and fell the last few steps. Those around helped him and offered to call an ambulance, but he declined and grabbed a taxi to the emergency department. Exam findings were benign other than a new-onset difficulty walking. Mr. Blue was admitted to the hospital, and after observation, was recommended rehabilitation at a subacute nursing facility instead of an inpatient rehab ward. After hearing this he left the hospital against medical advice.

Two months before this entry, it was the exact same story – Mr. Blue was at the mall, got lightheaded on the escalator and fell the last few steps, and took a cab to the hospital. All three of these entries were essentially word-for-word, the same story over and over. Now I suppose it is possible that this same event happened three times over within 4-5 months, but EXTREMELY unlikely. Pressing forward…

A few years go by where nothing of relevance happens, no emergency room visits or doctor’s appointments. But eventually, more notes pop up regarding stroke-like symptoms where Mr. Blue either fell or couldn’t walk and went to the ED (emergency department) for diagnosis and treatment. These notes are a bit unclear as it’s unclear whether Mr. Blue suffered a stroke or a TIA (transient ischemic attack…essentially a mini-stroke without lasting damage). There was one entry in particular that, in a nursing note, described a dramatic scene in which Mr. Blue fell out of his bed in the ED yelling “I’m having a stroke!”

Each of these entries, under his medical history, lists “history of stroke.” I knew, eventually, I would get to that note.

The Trouble with Labels

And I did. It occurred 8-9 years before his current admission. He presented to the ED for stroke-like symptoms, they did a CT scan and started the appropriate workup on Mr. Blue because of the high suspicion of stroke. However, Mr. Blue chose to leave AMA (against medical advice) from the emergency room before they could confirm the diagnosis. It was from this note that his “history of stroke” had been carried onward…a diagnosis not technically made or confirmed at this encounter.

I paused here to look at every MRI and CT scan of his brain in our hospital database. None of them showed any evidence of Mr. Blue having experienced a stroke, past or present. This does not mean Mr. Blue did not have a stroke…but it certainly clouds his medical history and puts “history of stroke” into serious question. As Dr. Meador says in Rule 65 – Be careful with labels; they can be very difficult to remove.

Just a few other medical notes predated this one, and they added what I felt to be context to Mr. Blue’s story. One note described an event where Mr. Blue had fallen downstairs and suffered a TBI (Traumatic Brain Injury). A few years before this he was cared for in a psychiatric hospital for an unknown amount of time. From the brief note available in his chart, it seemed he had experienced something like a psychotic break and had suffered a great deal. The exact timeline was fuzzy, but these two things happened around the time his mother passed away.

With Mr. Blue, nothing was what it seemed to be. We knew for sure that he suffered a psychotic break, has a history of TBI and substance use and had recurring visits to the emergency room. We discovered that though he said he had a history of stroke, and that was in his chart, there was serious evidence to the contrary including no evidence on imaging (CT or MRI).

I presented this information to my team, yet the question remained…

What to do about Mr. Blue?

The third and final part of this series comes out next Wednesday. See you then!

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Thank you for reading Building Docs! Check back next Wednesday for the conclusion of Mr. Blue’s story. If you enjoyed reading this - consider sharing it with friends and family who have yet to subscribe!

As always, thank you to Dr. Meador who wrote the wonderful book that influences much of my articles and philosophy on “doctoring.” Also, a heartfelt thanks to those members of the medical team I worked with while caring for Mr. Blue. It was some of the greatest training I received during medical school, with the absolute best professionals and teammates.