History is important.
“The farther back you look, the farther forward you will see,” Winston
Churchill once said. Particular to our
profession as doctors, William Osler’s famous adage, “Listen to your patient,
he is telling you the diagnosis,” rings true even to this day. But there is another, often forgotten edict,
created long before these two figures came into being, handed down from
generation to generation. And that is:
“Listen to your mother.”
I am living proof of the power of this statement.
Years ago in my early days as a otolaryngologist I saw a
patient who was referred by one of the emergency rooms for dysphagia
(difficulty swallowing). The E.R. had
not called me but rather instructed the patient to call my office to schedule
an appointment within a week. He was an
elderly gentleman accompanied by his son who provided much of the all-important
history, for I could barely understand what the patient was saying.
Since he was not having pain or fevers, I figured the ER
concluded this was not a severe infection such as a peritonsillar or deep neck
abscess—two potentially life-threatening emergencies. His dysphagia was not from a mechanical
obstruction since he could actually swallow, but rather he appeared to have an
oro-motor problem, meaning he had problems with the muscles in and around his
mouth, causing difficulty chewing and operating his mouth properly, which was
also causing dysarthria (difficulty speaking and forming words) and the reason
for his unintelligible speech. He was
otherwise in no acute distress and was actually laughing at times. Naturally, I wondered if he had a stroke.
“Nope, the doc at the ER said he didn’t,” his son
replied. “They said they didn’t know
what’s causing his problem, that it was an ear, nose and throat problem and
that you’d figure it out.”
As a young doc barely out of residency, those were words I
didn’t want to hear. Sure, I like
challenges from time to time, but I was rather swamped, seeing other patients
with urgent needs as I was still on-call for the ERs.
We talked a bit more.
I examined him and found he had severe trismus (inability to open his
mouth). There were no areas of
tenderness but mainly a sense of tightness of the master muscles. “Lock-jaw?” spontaneously popped into my head
without a deliberate thought process to put it there. “Lock-jaw” was a term my mom used when I was
a kid, a term some of you may have heard growing up as well. “Don’t play with that rusty nail!” Mom cried
out one day as I was about to do something really stupid, like play with a rusty
nail protruding from a fence. “You’ll
get lock-jaw!” came immediately after.
I didn’t know what she meant by “lock-jaw.” Mom said it was from tetanus, a nebulous
thing found in rusting metal and I’d be sorry if I ever got it. Fast forward to medical school and I better
understood the nature of tetanus.
Through med school and residency however, I had never seen a case of
tetanus, ever.
 |
| Mom, front and center, surrounded by some of her grandkids. |
So there I was sitting in front of this patient with the
words “lock-jaw” in my brain, much like a comic strip character with those very
words alighting in a cartoon bubble floating over my head. Reflecting not on my accumulated medical
knowledge but more on Mom’s lesson, I asked if he recently cut himself with
anything rusty.
“You know, he did,” replied his son. “He cut his hand on an old chain-link fence
about two weeks ago. He’s always outside working on things. He went to an urgent care for that. That’s why his hand is still bandaged.” I hadn’t noticed that detail before, perhaps
it was the sleeve of his jacket partially covering it, but more likely I wasn’t
being a complete doctor and instead focused too much on the head and neck as
per my profession.
“When was his last tetanus shot?” I asked, which happened to
be the day he was at the urgent care.
Having immigrated into the U.S. some time ago, he never had a
vaccination before, so that tetanus shot was his very first. I put two and two together and told them what
I was thinking.
“You know, I’m not completely sure, but I think he has
tetanus.”
His son looked at me blankly for a few seconds, then a
sudden realization came. “Hey doc, that
makes sense!” His father, hampered by
the tight muscles, tried to smile but was able to laugh through clenched teeth. I immediately admitted him to the hospital
(this was before hospitalists were available), consulted an Infectious Disease
specialist who confirmed he had tetanus and started treatment. Unfortunately, he soon went into acute
respiratory failure needing emergent intubation and mechanical ventilation, and
sadly passed away not too long after. He
kept his sense of humor to the very end, and I was surprised his family was
very grateful for the care he received from us and everyone at the hospital. He was 97 years old and had a very happy
life. The local newspaper had the story
and his picture on the front page, as tetanus is indeed a rare disease.
I have not seen another case of tetanus since. From time to time the memory of this pleasant
gentleman comes to me, as a reminder that the importance of obtaining history
lies not so much in the medical catch-phrases or the algorithms we often
mechanically use, but in the personal dialogue we have, and that much of our
learning comes not only from formal study and our experiences as physicians,
but from the most unlikely of circumstances, such as the memory of a silly kid
playing in the yard and recalling many years later the wisdom of his mom.
©Randall S. Fong, M.D.
Comments
Post a Comment