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Once Upon a Tenens


Having finished my family practice residency, and not being tied down by friends or family, I thought a round of working locum tenens would be a good way to see some different styles of practice.

I contacted a company called Locum-motion, filled out my paper work and was on my way. I had graduated from the University of Hamlin a few weeks earlier, armed with stethoscope and hammer. Dr. Claudio Prince (that’s me) was ready to stamp out disease and save lives.

There were several practice options available, but I chose a small hospital in Bremen. The three doctors who ran the hospital were going on a musical cruise for a week, and I would cover the entire facility for that time—ED and floor. I met with Drs. Baker, Butcher, and Maker briefly before they left for a trip. There were only a few inpatients, and one patient in the ICU. Then they were gone, and I was on my own.

“Miss White” had choked on fruit and was unresponsive in the ICU. She had a living will and didn’t want prolonged life support.

My First Patient: I thought I’d start with the inpatients. The first was a Mr. B.B. Wolfe. He had been admitted for myalgia.

I was shocked when I walked into the room. He had severe hypertrichosis, prominent dentition, and proptosis. I briefly considered porphyria. I noted his history of muscle aches, high fever, facial swelling, and visual disturbance. His admit lab had showed a high CPK and LDH.

It sounded like an infestation of Trichinella to me. I questioned him about the ingestion of raw pork. He looked me in the eye and asked if his answer would be part of his medical record. I told him he needed to tell the truth for me to help him. Finally, he admitted he had eaten several portions of uncooked pig. I began to explain to him about the workup, the need for a muscle biopsy, and treatment options like mebendazole or steroids. I described the intestinal stage, which occurs between two and seven days after ingestion, when encysted larvae are liberated from the meat by gastric juices. I told him how the larvae mature into adult worms that burrow into the intestinal mucosa. I described the muscle stage, which develops after the first week and represents the period when adult-derived larvae in the intestines enter the bloodstream and disseminate hematogenously, then enter skeletal muscle causing pain.

He jumped out of bed and said he was leaving AMA; he had an appointment with a red-hooded girl. Whatever. I let him go; not much I could do to prevent his departure.

In the ED: I got a call from the ED about an old lady who had come in, having nearly choked on a bug. She looked fine to me, and I let her go. While down there, another older woman came in—in active labor. She admitted to having taken her friend’s Clomid, and had had little antepartum care secondary to a dearth of health insurance. Before I knew it, we were in the labor suite. First came one boy, then another, then another. I thought I was done, then two girls, another boy, then another girl. Seven babies—incredible! She moaned, not knowing what she was going to do with all these children.

I headed back to the floor to see more patients. The second one for the day was simple: a scrotal burn on a Mr. J.B. Nimble, who had been injured jumping over a flame. He was ready for discharge. The third patient was interesting, a Mrs. Spratt. I had been called by the lab with word that her serum looked like mayonnaise. She had abdominal pain, hepatosplenomegaly, memory loss, dyspnea and eruptive xanthomas. It sounded like type V hyperlipoproteinemia with chylomicronemia syndrome. What an interesting case, probably worse secondary to her very high-fat diet.

I walked down the hall to see my last inpatient, billed as a young man with psychotic depression pending psychiatric placement. I heard him yelling about burning witches and eating the walls. It sounded pretty psychotic. (I learned that his sister had been arraigned on manslaughter charges.) I entered the room and was struck by the smell of his breath, like cherries. A fruity smell, could he be ketotic? I instantly thought about ethylene glycol toxicity, maybe he had been sipping antifreeze, but there were no oxalate crystals in his urine. Was it delirium? I checked an O2 saturation; 95%, that wasn’t it. His blood pressure was 120/60. How about checking his finger-stick glucose? It read >400. This boy was in DKA! I started an insulin drip and hydration. It was only later I learned he had been on a starvation diet for weeks, then had binged on candy. His story about burning an old woman in a stove was unfortunately true. I called child protective services.

The ED pager went off again. That old lady who had swallowed a bug had ingested another, possibly a spider. I was worried about brown recluse or black widow envenomation, but it seemed to have been a simple barn spider, as she was now feeling OK. Again I discharged her with stern warnings to limit her invertebrate consumption. I stopped by the multiparous patient. She was happy to have the children and that they were all healthy, but what was she going to do? Where would she go? I called a social work consult.

ICU Time: I headed to the ICU. A sad story: a 24-year-old woman was unresponsive. She had a living will and did not want prolonged life support. She had choked on a piece of fruit. I walked into a room crowded with her family; it looked like seven very short uncles—one of whom was a doctor. They watched sadly as I pulled the endotracheal tube and the IVs. I told them I’d give them some time with her alone and would be back in an hour. It was a somber and tearful affair. She was so young and so beautiful. What a tragic end.

Another ED call; this bug-swallowing lady was driving them nuts. Now she was claiming she had swallowed a thrush, or maybe had thrush. Either way, she was gone before I got down there to see her.

I met with the social worker. She was dressed in a fancy gown and said she had just been at a party. She heard the story of the lady who had had so many children. She thought for a moment then said she had a few leads to check and would get back to me later that day.

We had a rush in the ED: a boy I thought might have rhinophyma and stiff-man syndrome, a girl with warts on her lips she attributed to kissing a frog, another with a glass splinter in her foot. There was a Mr. W.W. Winkee with hypothermia, and a young girl named Mary who thought she had contracted anthrax from a sheep. There was a boy named Jackie Horner with a tenosynovitis of the thumb.

The old lady came back in again. Now she was complaining of abdominal distention. When I finally laid eyes on her, I noted she certainly had a large abdomen. I grabbed a quick X-ray. Apparently she had taken my warnings against consuming avian and invertebrate entities, as now she had radiographic evidence of a feline skeleton. I planned to send her to a tertiary-care facility; perhaps they could do an endoscopic cat removal. Whatever they did, I was afraid if she kept this up she was bound to die.

I headed back to the ICU. They had dressed the girl, Miss White, in her street clothes and done her hair and makeup, but nothing could hide her severe pallor. She looked so peaceful.

Her “uncles” expectantly greeted me. They said in unison, “Welcome, Dr. Prince.” They were all inappropriately smiling. What was going on here? I went to declare her dead. I held a mirror up to her face, no signs of breathing, no lung sounds with auscultation. I laid my fingers gently across her throat. No pulse, but her skin was strangely pliant and warm.

I stared at her lovely face and the rest of the world suddenly shut itself off from me. I felt like singing. I could not stop myself … how unprofessional. But I bent over and gently kissed her goodbye. Suddenly there was music playing and—even more strangely—woodland animals frolicking at my feet. The uncles, who turned out to be roommates not relatives (had I known that I would never have stopped life support!), danced merrily. I looked back at her, and her eyes were open. She was smiling and gazing at her future husband, me.

Epilogue: The masticatory old lady eventually died from eating tainted horse meat. Mrs. Sprat improved with a low-fat diet. Mr. Wolfe died in a tragic logging accident, killed by the swing of an ax. The housing issues of the old lady with so many kids she did not know what to do was settled by the social worker, who became the septuplets’ godmother and found them housing in a refurbished, oversize shoe. As for Snow and me, we plan on living happily ever after. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

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