Every Patient Tells A Story Part 3

As I stepped up to the exam table I could feel my discomfort reemerging. I rubbed my suddenly cold hands together, trying to coax blood into icy fingers, then placed them on her chest. Her skin was warm and I could smell the fragrance from the soap or deodorant she'd used that morning. Her professional but casual tone kept me focused on the medicine at play here and not the intimate zone that she and I had suddenly entered.

"Follow the clavicle over to where it meets the sternum," she instructed me. Her voice was patient, comfortable, completely relaxed. I moved my fingers self-consciously, in an awkward circle over the skin, bone, and cartilage. Next to the sternum a thin film of fat overlies smooth, tough muscle and ribs. Further down the chest the layer of fat gets thicker at the outer region of the prominence we recognize as breast. It wasn't until I started the second stripe that I encountered the fingerlike irregular densities of the glands themselves, pointing inward to the nipple like the spokes of a wheel. As I made my way across the breast, images from my anatomy book depicting these structures I could only feel flooded my mind, like aerial photographs providing landmarks and explanations of the terrain beneath my fingers. The area directly under the nipple dips like a soft well into this dense tissue; I could picture the ducts, too fine to be felt. Below that, I felt a saucer, a hockey puck of thick consolidated gland too closely packed to be individually distinguished.

As I worked my way across her b.r.e.a.s.t.s, she offered advice and encouragement.

"You can use more pressure than that if you need to. It doesn't hurt me. Use your other hand to stabilize the breast."

I covered her chest with the lines of circles, working to make sure I could feel every structure below the skin from as many angles as possible. I thanked the instructor and gratefully stepped back from the exam table as the next student stepped forward. I watched as she coaxed and encouraged my three cla.s.smates through the exam and reviewed the process in my head from the safety of my chair.

A couple of years ago I moved my practice from one office to another. As I reviewed the charts of my relocated patients, transferring data from old to new, I noticed that although I had done a pretty good job in making sure that my patients got their recommended screening tests, I hadn't done nearly as well on the hands-on component. Women should have a breast and pelvic exam performed annually, I was taught. Men over fifty should have a yearly rectal exam to look for prostate cancer. I saw that my adherence to those guidelines was pretty spotty. I was surprised by this oversight, but the trend was too strong to deny.

I puzzled over this. How could this happen? Some of it was a systems problem. In my old office there was no simple way to keep track of routine exams. To find the last exam I'd have to page through the last year's worth of visits to see where I'd doc.u.mented the results. And yet regular cholesterol tests were there. My patients over fifty had colonoscopies ordered or at least discussed. No, it was the breast exams, pelvic exams, and prostate exams that were missing. And I realized that despite the years of practice and the mastery of technique, I still found these exams uncomfortable to perform. On some level, I was still that medical student, reluctant to touch another person's private places.

I'm not alone in this. There's not a lot of data on this issue, but what's there suggests that more of us are sending our patients for the screening test and dispensing with the hands-on component. In a study published in 2002, of the 1,100 women who went for annual mammograms in one facility over the course of a year, only half reported having had a breast exam done by their physician-ever. And while rates of mammography have increased over the past twenty years, rates of physician breast exam have declined.

Is that all due to the awkward intimacy of the exam? Probably not, though research has shown that it plays a role. Instead, the development of newer and better technologies-the mammogram, ultrasound, most recently the MRI-has caused doctors to doubt the value of what their hands can tell them. Why deal with your own embarra.s.sment, the possibility of patient embarra.s.sment, and the difficulty of interpreting the fuzzy pictures generated by touch when a study can show you the inner structures of the body with more precision and accuracy?

Why indeed? I'll explore some of the answers to this increasingly urgent question in the next chapter.

CHAPTER FOUR.

What Only the Exam Can Show.

As the skills required for an expert physical exam have become more and more rare, both among medical students and among practicing physicians, what has been lost? Among doctors, this is a topic of pa.s.sionate debate.

On one side are those who argue that the demise of the physical exam is a natural consequence of progress. They say that the exam is just a charming remnant of a bygone era-like cupping (attaching warmed cups to the skin until blisters are formed) or bleeding or mustard plasters for colds-now replaced by an ever enlarging menu of technologies that provide better information with greater efficiency and accuracy. Affection for this discredited practice is characterized as pointless and sentimental.

On the other side are the romantics: doctors who see the physical exam as part of the long tradition of caring in medicine and cherish the profound connection between doctor and patient when linked by a well-placed hand and a warm heart. They see those who think otherwise as soulless technicians.

In the middle are the rest of us who simply want to understand what's been lost. How large a role did the physical exam once play in making a diagnosis? What are we missing in the modern version of medicine that somehow seeks to manage without it?

Steven McGee, a mild-mannered man with a serious face, an FM radio voice, and a scholarly pa.s.sion for the physical exam, has blazed a rational trail deep into that middle ground. As an internist and a professor of medicine at the University of Was.h.i.+ngton, he embraces technology but also believes that the physical exam has uses that machines cannot replicate. McGee's research is an outgrowth of his own experiences in medicine, and his book, Evidence Based Physical Diagnosis Evidence Based Physical Diagnosis, outlines the evidence for the utility of the physical exam in the age of high technology.

When I spoke with McGee about his work, he was eager to tell me about examples from his own experience of medicine that proved to him the fundamental importance of examining the patient. He recalled a particularly dramatic case that had occurred just a few weeks before we spoke.

McGee and his team of residents and medical students were called to see a patient on a surgical floor. The patient had come to the hospital for the excision of a skin cancer on his ear. That morning he'd developed severe abdominal pain, and the plastic surgeons had asked them to help figure out what was going on.

Michael Killian, a thin elderly man, lay on the bed with his eyes wide open, moving restlessly as if he couldn't find a comfortable position. He muttered incoherently as he s.h.i.+fted awkwardly across the bed.

The resident introduced himself to the distraught patient and immediately began asking questions. "I don't know. I don't know. I don't know," was his only answer. It quickly became clear that the elderly man was too confused to provide any details about his pain. He could tell them his name. But he didn't seem to know that he was in the hospital or why. All he could say was that he hurt. When the resident asked if he had pain in his belly, he started his litany once more: I don't know, I don't know.

His skin was pale and littered with scaly patches of red, evidence that he'd spent too many hours in the sun. The ear that had brought him to the hospital in the first place was enlarged and distorted by a raised red and scaly lesion at the tip. His unshaved cheeks were gaunt, his cheekbones sharply defined, his eyes seemed focused on something in the room no one else could see. A fringe of white hair was well cut but uncombed. His skin was cool and damp with sweat. It was difficult to examine him because of the constant restless movement. His heart was fast but regular. So was his breathing. When the resident moved to examine the patient's abdomen, he jerked away. "No. No. No. Don't touch me." The distant eyes were now back in the room, glaring at the young doctor. The patient waved his arms in a way that suggested that no means no. The doctor quickly pulled back.

"No. No. No."

The resident leaned down and began to speak in a quiet voice to the distressed man. "I know you are in pain and I want to help you. But in order to help you I need to touch your stomach. I won't hurt you." The soothing tone eventually quieted the suffering man, though he continued to s.h.i.+ft his position on the bed, as if the soft mattress had been replaced by a bed of nails.

As the resident rea.s.sured the confused and frightened man, McGee gently placed his hand on the upper left side of the man's abdomen. He felt an unexpected resistance in the normally soft region of the belly and quiet steady pulsations. He placed his other hand over the man's navel. A soft ma.s.s throbbed beneath his fingers, pus.h.i.+ng his fingers away to the right. And that told him everything he needed to know.

"Call the surgeons," McGee told the resident. "This man needs to go to the OR. He's got a rupturing aortic aneurysm."

The aorta is the vessel that carries blood from the heart to the rest of the body. Patients with hardening of the arteries and high blood pressure-like this man-can develop areas of weakness in the normally thick muscular tubing, and the stress of this high-pressure system can cause these weak spots to balloon outward, forming a pulsating bulge in the abdomen. When the balloon gets large enough, the muscle wall becomes dangerously thin and it's at risk for bursting. The excruciating pain and the restless movement were cla.s.sic for a tear in the now delicate muscle wall, and the huge pulsating ma.s.s clinched the diagnosis. Three quarters of all patients who suffer this dire event die either on the operating table or on their way there.

The vascular surgeons were paged and the patient was taken to the OR, stopping only briefly at the CT scanner to verify the diagnosis. Defying the odds, Mr. Killian survived the surgery, his life saved by a simple touch.

As compelling as any individual case may be, in medicine, if you want proof you need studies. And McGee has spent his career investigating and tabulating the accuracy of individual components of that endangered art, the physical exam. His results have managed to anger folks on both sides of the debate. Some well-known, frequently taught parts of the physical exam have turned out to be virtually worthless-listening to the lungs will rarely help a physician decide if a patient has pneumonia. Others, when done well, have shown themselves to be as solid and reliable as the tests we use to confirm our diagnoses. In the hands of experts, a cardiac exam can identify problems in the valves of the heart almost as well as the echocardiogram. It's essential to know how well each of these individual tests performs.

But this research still leaves the big question unanswered: is there any evidence that this old-fas.h.i.+oned practice really makes a difference difference in how patients do? There is surprisingly little research on this. Several now cla.s.sic studies done in the 1960s and 1970s tried to a.s.sess which tools are most useful in helping doctors make a diagnosis. In these studies the most important tool was the simplest-doctors were able to correctly diagnose patients' illnesses in most cases just by talking. The patient's story contained the diagnostic tip-off up to 70 percent of the time. Doctors are told repeatedly in medical school to listen to patients and they will tell you what they have. These studies prove the wisdom of this advice. in how patients do? There is surprisingly little research on this. Several now cla.s.sic studies done in the 1960s and 1970s tried to a.s.sess which tools are most useful in helping doctors make a diagnosis. In these studies the most important tool was the simplest-doctors were able to correctly diagnose patients' illnesses in most cases just by talking. The patient's story contained the diagnostic tip-off up to 70 percent of the time. Doctors are told repeatedly in medical school to listen to patients and they will tell you what they have. These studies prove the wisdom of this advice.

But what about the physical exam? In these same studies, when you looked at just those patients whose story didn't provide the answer, the physical exam led to the right diagnosis about half the time. High-tech testing showed the way in the remaining cases.

Of course, testing has changed a lot since those studies were done. A more recent study, done by Brendan Reilly, a head of clinical medicine at Weill Cornell Medical Center, looked at this question in a different way. Reilly was asked by one of the residents he teaches how important the physical exam was in making a diagnosis. Reilly searched the medical literature for an answer. When he couldn't find a good answer, he designed his own study.

In a teaching service like his, patients are seen first by the internal medicine residents and then are examined and evaluated separately by the attending physician. The residents and the attending swap the information they collected independently to figure out a diagnosis and care plan. Reilly reviewed the charts of all the patients he had admitted to the hospital with his team over the previous six weeks, looking for any case where something he found on the physical exam had changed the diagnosis and the treatment of patients under his team's care.

The findings were pretty impressive. A careful physical exam changed the patient's diagnosis and treatment in twenty-six out of one hundred cases-one in four patients. And in almost half of these cases, had Reilly not discovered the correct diagnosis on exam, it would not have been found by "reasonable testing"-that is, testing that would have been ordered if these physical findings had not been discovered. In those cases, the correct diagnosis would have only become apparent when the disease progressed and the patient worsened.

These were important discoveries. In one striking case, a patient who was admitted to the hospital for difficulty breathing was thought to have a tumor in his chest, picked up on his admission X-ray. He had been scheduled for a biopsy of the ma.s.s. When Reilly examined the patient, he found a loud heart murmur. Based on the location and timing of the abnormal sound, he realized the noise was caused by an obstruction in one of the valves of the heart. The blockage was causing the vessels leading up to the valve to enlarge with the excess blood-the way traffic backs up when construction or an accident narrows a busy highway. The "ma.s.s" seen in the chest X-ray was actually the blood-engorged vessels. The biopsy was canceled and the patient was referred for the surgical repair of his valve.

Another patient had a fever, but no source of infection had been found. He was being treated with intravenous antibiotics. Reilly noticed that one of the patient's toes was discolored in a way that suggested the toe had been cut off from the body's blood supply and had become infected. Surgery was consulted and the toe was amputated. The fever disappeared along with the toe.

This handful of studies suggests that a thorough physical examination can play a critical role in making a timely diagnosis-a role that cannot be duplicated by even the sophisticated tests we now have available.

One of the ironies of our technology-laden age is that many of the time-and labor-saving devices that have crept into our daily lives often save neither. Most computer desktops include a virtual notepad. Is it any better than the actual notepad kept in your pocket? A calculator can be essential for performing complex functions, but does it save time when all you really need to do is add, subtract, or multiply a few numbers?

In the same way, medical testing is one way to come up with a diagnosis, but sometimes-and if Brendan Reilly is right, up to 25 percent of the time-you can get the right answer by simply examining the patient.

This is not to say that a physical exam can subst.i.tute for testing. With the tests we now have at our disposal, we can diagnose diseases that in another era, not so long ago, could be identified only at autopsy. But the physical examination can direct the doctor's thinking and narrow the choice of tests to those most likely to provide useful answers-saving time, saving money, and sometimes even saving lives.

The Language the Body Speaks The experience of being ill can be like waking up in a foreign country. Life, as you formerly knew it, is put on hold while you travel through this other world as unknown as it is unexpected. When I see patients in the hospital or in my office who are suddenly, surprisingly ill, what they really want to know is "What is wrong with me?" They want a road map that will help them manage their new surroundings. The ability to give this unnerving and unfamiliar place a name, to know it-on some level-restores a measure of control, independent of whether that diagnosis comes attached to a cure. Because, even today, a diagnosis is frequently all a good doctor has to offer.

That was certainly the case with Gayle Delacroix, a fifty-eight-year-old retired soccer coach and gym teacher who came to the small community hospital in Connecticut I work in with a puzzling illness.

It was in the late summer of 2003 and Gayle and her longtime partner, Kathy James, were on their way home from a two-month camping trek across the country-driving, biking, and hiking from northern Connecticut as far west as the mountains of Colorado. They'd planned to end up in their own beds by the weekend. It had been a great summer, until one night, when Gayle was awakened by an excruciating pain across her lower back. The pain was sharp. Stabbing. Unbearable.

Gayle woke her partner: "Something's wrong with me," she told her. In the flickering glare of the flashlight Kathy saw that Gayle's face was slick with sweat, tense with pain. Though the summer night was cool in the mountains, her skin was hot and Kathy didn't need a thermometer to know that her partner had a fever.

Her head hurt, Gayle told her. And she felt hot and cold at the same time. But worst of all, she had this intense pain across the lowest part of her back. It had that precise yet elusive quality of an ice cream headache. Sharp needles of electricity flashed down the back of her legs every now and then, but the back pain was persistent, gnawing. Her teeth chattered as she spoke. Her body shook with wracking chills.

Kathy realized that Gayle needed a doctor. She dressed and quickly stuffed her sleeping bag into a sack. Helping Gayle out of the tent and onto the stump they'd used that evening for a table, she packed up their gear and hurried down the trail to the car. Then she returned to help her partner down the rough track.

They drove an hour through the back roads of West Virginia to Maryland. Another hour to an exit marked with the white H promising a hospital ahead. The ER doctor was practically a kid. Tall, wiry, with stylish gla.s.ses and a rumpled scrub s.h.i.+rt over blue jeans, he looked like he'd just crawled out of bed. He helped Gayle sit up and quickly examined her back.

He offered a diagnosis and some rea.s.surance.

"I don't think the fever and the back pain are related," he told them. "I think the back and leg pain is sciatica. And the fever-who knows? Some virus, probably." He gave Gayle some ibuprofen and a muscle relaxer for her back. When Kathy-angered at the breezy exam and unconvinced by his diagnosis-brought up the possibility of Lyme disease ("We've been camping, for G.o.d's sake"), he dutifully wrote out a prescription for doxycycline, the antibiotic of choice for this disease.

Kathy was worried-she was a physical therapist. She had seen lots of sciatica but none this bad. And this fever? Hard to believe they weren't related. Gayle, on the other hand, was relieved by the rea.s.suring diagnoses. She had never been sick and wasn't ready to start now. After leaving the hospital they drove until dawn, then checked into a roadside motel and caught up on the sleep they'd missed. They slept soundly-Gayle with the help of the ibuprofen, the muscle relaxer, and, at Kathy's insistence, the doxycycline. When they awoke it was late afternoon.

Gayle sat up. She felt a little better, though her legs were strangely heavy as she swung them to the floor. When she tried to stand, they buckled beneath her and she fell back, helpless, onto the bed.

"My legs aren't working, Kathy. I can't walk." Gayle's voice was high-pitched and terrified. "I can't walk," she repeated.

Kathy's heart began to race. She knew it. There really was something wrong. They weren't far from Baltimore-maybe there? No, Gayle insisted. She wanted to go home.

They were at least five or six hours from the small Connecticut city they lived in. Kathy drove as fast as she could directly to their local hospital. "It was the longest five hours of my life," she told me later.

"Stay here," she instructed her partner and disappeared into the emergency room. She returned a few minutes later with a couple of EMTs-emergency medical technicians-and a wheelchair. The three of them helped the now crippled woman out of the car and hurried her into the ER.

Dr. Parvin Zawahir, a first-year resident, was the doctor on call that night. She quickly reviewed the thin chart that doc.u.mented the patient's time in the ER. A fever of 101. Weakness. The blood work already done didn't show much-the white blood cell count wasn't elevated. Chemistry was normal. Liver-normal.

She found the patient's curtained-off cubicle, introduced herself, and began the familiar process of taking a history. It had started five days ago, Gayle told her. She had a stomachache and some diarrhea. She figured it was a touch of food poisoning and didn't think much of it. Two days later she'd developed a rash on her neck. It didn't itch or hurt and she hadn't even noticed it until Kathy pointed it out. She thought at first it might have been a spot rubbed raw by the strap of her bicycling helmet, but the next day it had spread to her legs and stomach. Then yesterday, she'd felt tired after shooting a few baskets-not her normal stamina. But she hadn't actually felt sick until that pain woke her up almost twenty-four hours ago.

Any bites? Zawahir asked. Gayle nodded. Lots. She'd gotten plenty of mosquito bites. Didn't recall any tick bites. She hadn't been around anyone who was sick. No pets. She didn't smoke-never had. She didn't drink or use drugs.

The young doctor looked closely at the rash. It was faint but covered much of her body. It was made up of dozens of small, slightly raised, slightly red b.u.mps.

Her back looked normal enough and had no tenderness. The rest of the exam was unremarkable until she got to the patient's legs. Gayle was able to wiggle her toes and move her feet forward and backward. But she couldn't lift her legs-at least not the left one. Zawahir sat down at the desk and started on her admission note. How was she to put all this together? Was this a problem of the muscles? That was the only part of the exam that was abnormal. Or was it the nerves that empowered the muscles? The kind of pain the patient described-with the electric charges down her leg-certainly sounded a lot like the sciatica the Maryland ER doctor had thought it was. But Zawahir couldn't believe that the fever and pain were separate problems. That didn't make sense. They started at the same time. No, they had to be linked.

Infection seemed most likely. Being outdoors for all that time, she was a perfect candidate for Lyme disease. On the other hand, the patient had been in Colorado and West Virginia and a dozen points between-was there Lyme disease in these places? What about Rocky Mountain spotted fever? That was also carried by ticks and characterized by a fever and a rash. And it could be deadly.

Could it be a mosquito-borne illness? In Connecticut, every summer there was a big scare for Eastern equine encephalitis. Though she didn't know how many cases of this disease there were in a year, she'd read that it was frequently fatal. What other viruses could do this? Could this be West Nile virus? Herpes encephalitis? She wasn't sure. She'd never seen any of these illnesses.

She would need to do a spinal tap to see if the lab could find any bacteria or evidence of infection in the fluid. And she would send off for more blood tests as well. An MRI would show if there was an infection in or near the spinal cord. She would start her on high-dose antibiotics-one that would cover both Lyme and Rocky Mountain spotted fever. And she'd like to get an infectious disease consult. Maybe a specialist could help her figure this case out.

Although she'd taken care of sicker patients, the intern was worried about the near paralysis of the patient's legs. If you catch a neurological injury early enough you can sometimes reverse the damage. If not, this youthful, active woman could be crippled for life.

After rounds the next morning, Zawahir sought out Dr. Majid Sadigh, an infectious disease expert in the hospital and one of the smartest doctors she knew. Every doctor knows someone like this-the guy you go to when you're stumped. Or worried. Or scared. In every hospital or community of physicians, there is always that one doctor whose clinical ac.u.men and breadth of knowledge seem far greater than anyone else's. There is no list of such names or awards given for this honor. It's simply word of mouth among physicians. In central Connecticut, Sadigh was one of those doctors.

Majid Sadigh had trained in infectious disease in his homeland of Iran. In 1979, not long after Sadigh had completed his training, Mohammed Reza Pahlavi, the U.S.-supported monarch (known here as the Shah of Iran), was overthrown in a religious revolution and Sadigh and his family were forced to flee. He ended up in Waterbury, Connecticut. In order to practice medicine in this country, all foreign-trained physicians have to complete a residency here, regardless of their previous experience. The program Sadigh was accepted into was small but widely respected for the high quality of its teaching. Sadigh's skills were so impressive that by the end of the first year of what is normally a three-year program, he was made chief resident. The following year, he joined the faculty at Yale Medical School and has been there ever since.

From the first days of his residency, Sadigh realized that he had a skill almost unknown in this country: he understood the techniques and the value of the physical examination. In Iran even simple tests are often unavailable. In this setting a physician must rely on the patient's story and physical exam to make a diagnosis. "The body is there, filled with so much, so much to tell you. But if you do not speak the language, you will be deaf to its secrets. My job," he told me, "is to teach our residents this important language."

Zawahir briefly laid out the case for Sadigh, then took him to the patient. The young doctor watched with interest as Sadigh spoke to Gayle and Kathy. He sat down next to the bed and began to question the two women about what had happened. Then he carefully examined Gayle, paying special attention to the affected left leg. He elevated both heels, cupping them in his palms a couple of inches above the sheets.

"Lift your right leg," he instructed. As she struggled to raise the weakened right leg, the paralyzed left leg sank a bit, but not low enough to touch the sheets.

"Now lift the left." Gayle bit her lip as she strained to elevate the partially paralyzed leg. As she worked, the right heel sank down to the bed as she recruited the strength in her hips to raise the leg. The left leg never budged. Replacing her legs on the bed, he tested the strength in her lower legs.

"Push against my hand with your feet like you are stepping on the gas." The right foot flexed forward; the left barely moved. He touched her gently on both legs.

"Can you feel this?" She nodded. "Is it the same on both legs?" Again she nodded. He worked his way up her legs. Sensation was normal. He lifted her left knee with one hand and struck it with a rubber arrowhead hammer. Nothing. He repeated the move on the right. The leg jerked and swung upward. He tried again on the left and again there was no response at all.

He stared at the left leg, then called Zawahir over. "Look at this," he said, pointing to the patient's leg. Tiny patches of skin on Gayle's leg appeared to be moving, jerking, twisting. There was no movement of the leg itself-just the skin and the muscles of the thigh. Small groups of muscles were contracting spontaneously, independently. It looked as if there were little worms inching along under the skin.

"Fasciculations," said Sadigh in his soft accented voice; little uncoordinated bursts of activity from a group of muscle fibers powered by a single nerve fiber. He knew he had found an important clue.

Outside the room, Sadigh reviewed what he thought were the important characteristics of the patient and her illness: First, she had been very healthy until now and had spent a lot of time outdoors. She had a profound weakness that affected both legs, but one much more than the other. It was only the thigh and hip muscles that were involved-the muscles of the lower leg and upper body were spared. Only the nerves that power the muscles were affected. Sensation, which is carried on different nerve fibers and connects to a different part of the spinal cord, was normal. And she had fasciculations. Those little muscle jerks were the clincher. The fasciculations and the sparing of sensation suggested that a single type of cell in the spinal cord was affected: the cells that control the muscles of the body, known as the anterior horn cells-a description based on where they are located in the spinal cord.

"I've seen this before-but not so much in this country. This is what polio looks like," he said-then added: "But I do not think this is polio." There is another disease, he explained, a disease new to this country. A disease that can look just like polio. A disease that can cause the same devastating paralysis. He paused. "I think she has the West Nile virus."

West Nile had burst into the news four years earlier in the summer of 1999, when it ravaged a small community in Queens, New York. It was a disease well known in Africa, where it originated, and localized epidemics had been reported throughout Europe and parts of Russia, but until that summer, it had never been seen in the United States. The distinctive presentation of the disease-with its polio-like paralysis and its preference for those over fifty-had helped the Health Department doctors in New York recognize it as a new ent.i.ty and move rapidly and aggressively to contain the epidemic. Nevertheless, sixty-two people were hospitalized with the virus that summer; seven of them-all over fifty-had died. Despite aggressive measures to wipe out the mosquitoes that spread the disease, by 2003 cases had been reported in every state in the continental United States.

Sadigh remembered the events of the summer of 1999 clearly. The poliolike quality of the disease had been much discussed at the time. Seeing Delacroix, Sadigh was certain this is what she had. A sample of Gayle Delacroix's spinal fluid had to be sent to the state lab in Hartford to confirm the diagnosis. It would be days-maybe weeks-before the results would be available. In the meantime they would make sure that it wasn't some other ent.i.ty that they would need to treat.

After discussing the likelihood of West Nile virus with Dr. Sadigh, Zawahir returned to the patient's bedside to tell her the news. Gayle and Kathy had heard about West Nile virus. Who in Connecticut had not? But they didn't know much about it. Zawahir made the parallel to polio that Sadigh had made. When she heard that, the patient's eyes filled with tears. The very word brought up images of children in iron lungs or walking with metal braces and crutches. Was that her future? Zawahir tried to rea.s.sure her but she didn't know. This was one of the first cases seen in the state. They'd simply have to wait and see what happened.

"The hardest part was not knowing what was going on or where this would take me," Gayle told me. The diagnosis of West Nile virus wasn't rea.s.suring, but for someone relatively young and exceptionally healthy it was survivable. She and her partner found themselves in a whole new world. It wasn't where they wanted to be, but it was where they were, and so they threw themselves into the work of learning a new language, mastering a new landscape.

Kathy read up on West Nile virus and polio, hungry for strategies to help her partner fight back. By her third day in the hospital, though still febrile and weak, Gayle insisted on trying to get out of bed and stand. She did it, though she needed help. By the end of the week she had taken a few unsteady steps braced with a walker and monitored by the physical therapist. Meanwhile, the test results slowly trickled in. It wasn't Lyme; it wasn't Rocky Mountain spotted fever. It wasn't tuberculosis, sarcoidosis, syphilis, or HIV. Antibiotics given in the hope of a treatable infection were stopped. Finally they received the confirmation of what they already knew. She had been infected with the West Nile virus.

"We hoped against hope that it wasn't West Nile, but the doctors seemed pretty sure right from the start," Gayle told me. Just knowing what she was up against-as scary as it was-was unexpectedly comforting and gave her a direction to focus her considerable energy to get well.

No Time for a Physical In the case of Gayle Delacroix and the West Nile virus, the physical exam led directly to an extraordinary diagnosis. More commonly, the physical exam can provide not a diagnosis but an essential clue to direct further testing-a shortcut to the right answer. Ordering a slew of studies to evaluate a patient might get you the answer eventually, but time is often short in the care of a very sick patient. In many cases a careful exam can focus the search and help the physician find the problem faster. Where such an advantage would be most helpful, naturally, is among those patients who are critically ill. But even here-maybe especially here-the physical exam is becoming as obsolete as the doctor's black bag.

The sicker the patient, the greater the temptation to skip the fundamentals-like the physical examination-and to rely on the available technology to provide us with answers. It's a temptation that can sometimes prove fatal-as Charlie Jackson almost discovered.

For most of his adult life Charlie Jackson didn't go to doctors. That changed when he had a ma.s.sive stroke at age sixty-two. The stroke rendered his right leg and arm nearly motionless, his face crooked, and his speech slurred. Still, his beautiful c.o.c.keyed smile and gallant manner-he frequently showed up for his appointments toting a basket of peaches or a bag of pecans from back home in his native Carolina-made him a favorite at our office. He had been doing well, so I was shocked when I got a call from the staff saying that Charlie was dying.

He'd come to the office for a regular follow-up appointment with Sue, our nurse-pract.i.tioner. As soon as she saw him that morning, she knew that there was something very wrong. His walk, always a little ungainly after his stroke, was barely a shuffle. His slender frame was bent over his walker as if he couldn't hold himself up.

"What's the matter, Charlie?" she asked as she hurried to his side. "I ... can't ... walk." He choked out the words. His voice was strange in a new way, too-as if he were speaking in slow motion. She reached down and felt his pulse. It was slow-very slow. Too slow to keep even this slender reed of a man alive. She didn't do any more of an examination. She knew he needed to be in a hospital.

The EMT team burst through the emergency room doors, pus.h.i.+ng Charlie into the throng of the crowded room. The triage nurse directed them straight into an empty cubicle as they barked out what they knew. "Sixty-four-year-old man ... history of a stroke ... complaints of weakness and belly pain." His heart was slow, they reported; his blood pressure too low to be measured. The monitor showed a heart rate in the twenties-normal is over sixty. Dr. Ralph Warner strode in and quickly a.s.sessed the situation. "Get me an amp of atropine," he snapped, calling for the medicine used to speed up the heart.

After injecting the medicine, he watched as the monitor continued its flat yellow line, broken far too rarely by the spike indicating another heartbeat. But slowly the patient's heart rate and blood pressure began to rise.

With the usual chaos of the emergency room boiling around them, Warner forced himself to sit and focus as Charlie described his symptoms. It had started the night before, he told the doctor in his new, strange slur. He felt weak, could barely move. That morning his stomach began to ache. Any chest pain? Warner broke in. Shortness of breath? Fever or chills? Vomiting? The patient shook his head no. He was taking medications to lower his blood pressure and cholesterol. He had not smoked or drunk alcohol since his stroke. A brief exam showed Warner the results of the stroke but he saw nothing else.

Why was his heart beating so slowly? the doctor wondered. Had he taken too much of one of his medications? Had he suffered a heart attack that affected the natural pacemaker in his heart? The EKG, although abnormal, didn't suggest a heart attack. Warner called the cardiologist, who rushed in to place a temporary pacemaker. Charlie was being prepped for this potentially life-saving treatment when the lab called with part of the answer.

Blood work done in the emergency room showed that the patient's kidneys weren't working. And his pota.s.sium-an essential element in body chemistry, regulated by the kidneys-was dangerously high. Pota.s.sium controls how easily a cell responds to the body's commands. Too little pota.s.sium, and the cells overreact to any stimulation; too much, and the body slows down. If the elevated pota.s.sium was slowing his heart, then getting rid of the mineral would allow his heart to pump at a normal rate. The patient was given a medicine to get the pota.s.sium out of his system and then transferred to the ICU for monitoring.

If the pota.s.sium was high because of his kidney failure, what had caused his kidneys to fail? Dr. Peter Sands, the intern on call in the ICU, gnawed at this question as he reviewed the chart and results of all the tests that had been done. It wasn't a drug error. The patient's medication box showed the correct number of pills. And it hadn't been a heart attack; a blood test proved that. Sands looked for the results of the urinalysis to see if there was any clue there but he couldn't find it. Somehow no one had sent any urine to the lab. Were his kidneys too damaged to produce urine? That would be critical to know.

Sands asked the nurse to get some urine from the patient. She returned empty-handed. The patient couldn't urinate; he told her he hadn't been able to since the night before. The nurse hadn't been able to insert a Foley catheter, a rubber tube that is pa.s.sed through the urethra into the bladder to collect urine. Was something blocking the urethra? A urology resident finally managed to get a catheter into the bladder and immediately urine gushed out of the tube-nearly half a gallon of it. A full bladder comfortably holds a little over a cup of urine. Charlie's bladder had held just under eight. The urology resident looked at the intern: "I guess now we know why his kidneys weren't working."

The urethra was was blocked-by the prostate gland. The prostate surrounds the urethra, and when it enlarges, as it often does with age, it can impinge on the narrow outlet, obstructing and ultimately blocking it so that no urine can pa.s.s. As the trapped liquid filled the bladder, stretching it far beyond its normal capacity, the pressure shut down the patient's kidneys. Just hours after the obstruction was relieved, Charlie's pota.s.sium began to drop as the kidneys went back to work. Four hours later, his heart rate was up over sixty. By the next morning, the abdominal pain, probably caused by his hugely distended bladder, had eased. When he left the hospital three days later, his pota.s.sium and heart rate were normal and his kidneys nearly so. He would have to keep the tube in his bladder until the obstructed tube could be opened. blocked-by the prostate gland. The prostate surrounds the urethra, and when it enlarges, as it often does with age, it can impinge on the narrow outlet, obstructing and ultimately blocking it so that no urine can pa.s.s. As the trapped liquid filled the bladder, stretching it far beyond its normal capacity, the pressure shut down the patient's kidneys. Just hours after the obstruction was relieved, Charlie's pota.s.sium began to drop as the kidneys went back to work. Four hours later, his heart rate was up over sixty. By the next morning, the abdominal pain, probably caused by his hugely distended bladder, had eased. When he left the hospital three days later, his pota.s.sium and heart rate were normal and his kidneys nearly so. He would have to keep the tube in his bladder until the obstructed tube could be opened.

In the hours before his diagnosis, Charlie was seen by at least two nurses and three doctors. He had complained of abdominal pain. How is it possible that none of these doctors or nurses noticed that his bladder, normally the size of a hockey puck, was the size of a football? Charlie's a slender man, over six feet tall and weighing only 140 pounds. His belly is normally flat. I didn't see him that day, but I'm guessing it was distended and tender. No one noticed, I suspect, because no one looked.