COLD CASE FILES

1. COLD CASE FILES REFLECTIONS ON TWENTY FIVE YEARS AS A GENERAL INTERNIST

2. A WALK IN THE WOODS

3. MUSE • To become absorbed in thought • To wonder, marvel • Something to do with your head between Middleton and EastTowne five days a week for the last twelve years • Works better with coffee • May result in speeding tickets

4. There are no rules for musing • You can muse backwards and forward • Sometimes it helps to have a vague idea where you are headed • Everything mused upon for this talk has to do with medical cases I have known • The real meaning of a case may not bubble into your head immediately. Sometimes things happen in medicine that don’t make any sense at all. Sometimes they start to make more sense as time goes by. • A case is always in some way about a person and another person who just happens to be a doctor

5. WHY AM I A DOCTOR ? • This is an important question to ask yourself. Frequently. The answers will sustain you when you are mired in concerns about RVU’s and whether ‘tis nobler to prescribe Flonase or Flomax or the formulary drug du jour • There are times when we all wonder as David Byrne from Talking Heads wonders “This is not my beautiful house, this is not my beautiful wife. How did I get here?” • The answer most often lies in the cases we’ve seen and the situations we find ourselves in. • Find time to muse about them. This has been an interesting exercise

6. MY FIRST CASE The first case is full of meaning. It is special. Every time it turns over in our mind it reveals something new. I wasn’t a doctor – in fact I had no idea I’d become one

7. ABDOMINAL PAIN Amar was a twenty seven year old school teacher in Dolakha Nepal. He became ill with nausea and diffuse abdominal pain. Within 24 hours he was critically ill with gross abdominal distention and excruciating pain. The doctor was called.

9. ON THE HORNS OF A DILEMMA The Peace Corps had a fairly explicit policy regarding medical evacuations I decided to send a message to Kathmandu- a short wave telegram

10. THE MESSAGE VERY SICK STOP DYING STOP SEND HELICOPTER

11. THE AFTERMATH As Ricky often said to Lucy on the old “I Love Lucy” “YOU GOT SOME SPLAININ’ TO DO”

12. LIKE PEELING AN ONION • Belief vs Knowledge • Rich vs Poor • What is a healer? • What happens when cultures clash? • What if? • Would I do now what I did then? I returned home knowing what I wanted.

13. TIME MARCHES ON Kaiser Foundation Hospital San Francisco, 1979 JF was a twenty seven year old man who presented to the ER in respiratory distress. He was diagnosed with pneumocystis pneumonia. He recovered and followed up with me in the continuity clinic. Four months later he returned to the hospital in respiratory failure and died. We never knew why.

14. FAST FORWARD-THE TURNING POINT Meriter Hospital 1994 Madison JK was a 29 yo grad student with AIDS. I had followed him in the primary care clinic since moving here in 1992. In spite of treatment with AZT and ddI his CD4 counts declined and he was admitted to the hospital with jaundice. A liver biopsy demonstrated extensive infiltration with histoplasmosis. In a last ditch effort to save him we started amphotericin and a new drug saquinivir obtained on a compassionate use petition. In 1996 JK moved to Florida to start a business with a friend.

15. AIDS TIMELINE

16. AIDS TIMELINE • 1978 1st signs in US, Sweden, Haiti of the disease which is to become AIDS • 1981 June, 5 gay men die in LA of Pneumocystis pneumonia. On July 4th 26 cases of Kaposi Sarcoma reported. In 24 months 8 had died • 1982 CDC links disease to blood, press secretary to President Reagan joked about AIDS, and President Reagan hadn’t yet mentioned AIDS in public. 853 deaths attributed to AIDS. • 1983 HIV Virus isolated. 2304 deaths attributed to AIDS. President Reagan hasn’t mentioned the word AIDS in public. • 1985 HIV antibody test. 5636 deaths. President Reagan mentions AIDS for the 1st time-when asked about it at a press conference. • 1986 President Reagan mentions AIDS in a message to Congress. Surgeon General Koop released a report on AIDS calling for sex education • 1989 AZT released. Ronald Reagan in an address to the ACP finally calls AIDS “Public Enemy #1”

17. TIMELINE • 1990 Ronald Reagan apologizes for his neglect of the epidemic during his Presidency. • 1991 ddi introduced. FDA starts accelerated approval process for new drugs in the pipeline. AIDS deaths in the US 20,454. • 1992 ddc. • 1993 d4T. • 1995 Saquinavir 1st Protease inhibitor released. • 1996 Nevirapine, Ritonavir • 1997 Annual AIDS deaths dropped in the US. By this time AIDS is a global epidemic with AIDS deaths at 6.4 million and over 22 million with known HIV infection. • 2002 Cumulative deaths in the US. • 2005 World AIDS Day. 40 million infected worldwide. In US 14000 die each year. Worldwide 3 million people die each year- almost 6 people every minute.

18. A CASE OF CRUEL IRONY Kaiser Foundation Hospital San Francisco 1979 Chan was a 32 yo Chinese immigrant diagnosed with promyelocytic leukemia who practically lived in the hospital during my internship year. I spent hours with him when things were slow or when he was undergoing yet another transfusion or fever crisis. What I’ll never forget is his stoicism in the face of pain and more importantly in the face of death which was inevitable and cruel given all that he had endured to be there.

19. Remembering Chan Chan was orphaned as a young boy. He had been born a peasant in mainland China. He lived by his wits and made his way to Kowloon by the time he was fourteen. He describes staring over the strait between Kowloon and Hong Kong, marveling at the lights and dreaming of freedom and prosperity. One night he couldn’t stand it any more-he dove in and swam over a mile to arrive in Hong Kong. A few years later he started to dream again and paid all his savings to stowaway in a container destined for America. All alone he worked and worked and finally opened a small tourist shop in the city. He met a girl and married. He got a green card and dreamed of becoming a citizen. In 1979 he became ill and in less than a year he was dead

20. Greg 1985 • 18 yo boy presented to my office with a cough and weight loss. CXR revealed hundreds of pulmonary nodules. Physical exam revealed a small tender nodule in the testicle.He received a platinum based regimen and would have miraculous brief remissions but finally died after a difficult year. I was invited into his home and was there when he died.

21. Testicular Cancer • In 1970, 90% of patients with metastatic disease died of their cancer • By 1990, 90% are cured

22. GA 1987 • 76 yo had retired to Tucson after a life as a petroleum attorney in Oklahoma City. He had grown up on a poor ranch in Oklahoma, worked on wildcat rigs, fought in WWII, and studied under the GI Bill. In his spare time he wrote pulp fiction and was looking forward to this in retirement. At our 1st meeting I noticed mild jaundice. Workup revealed a hepatoma which turned out to be wildly anaplastic. He died in three months. I still treasure an autographed copy of “Ambush at Cibecue Creek.”

23. Mabel 1982- A Curious Case of Chest Pain Mabel was a jolly 60 yo obese street person who used to show up in my resident’s clinic at the old County Hospital in Milwaukee. She was in remarkably good health but every now and then her social worker would drag her in for a “check up” On this particular day she actually had a complaint- a sharp intermittent pain on the right side of her chest.

24. A CASE OF SYNCOPE 32 yo burly construction worker presented to my office with a complaint of mild urinary urgency.

25. An Unusual Presentation OP was a 52 yo man who was brought into the Milwaukee County ER by a bus driver who noticed him never getting off the bus. He found him with a sign hanging from his neck.

26. THIS MAN CAN’T TALK OR NOTHIN

27. CULTURE SHOCK? 78 yo Vietnamese woman presented to my office on referral from a friend. She was confused and lethargic and was admitted to the hospital where we found her to be quite hyponatremic. We did a fairly standard workup and suspected SIADH due to recent infection. Her serum sodium responded to treatment but she wouldn’t wake up. She developed some peculiar signs that suggested catatonia and ultimately responded to antidepressants and Seroquel.

28. A CAUTIONARY TALE 67yo physician was admitted to Meriter Neurology service with a complaint of dizziness. MRI revealed a solitary lesion at the right occiput. He asked me to assume his internal medicine care. Metabolic workup was negative, alk phos minimally elevated, and PSA normal.

29. The Case of the Sleepy Artist CM was a 60 yo water color instructor from the University of Arizona. When I first met her she made it known that she didn’t care much for doctors. They had never treated her well and never helped her much anyway. She fell asleep right in my office. Her TSH was 180 and her polysomnogram revealed severe OSA and desats into the 60% range much of the night. I was to learn the power of CPAP and thyroxine.

30. WHY BECOME A GENERAL INTERNIST 10. There are a million stories in the Naked City and these are some of them. 9. What could possibly be more interesting? 8. You will be privy to the innermost thoughts, hopes, and concerns of those patients you engage with. 7. Every day you will work with wonderful colleagues who share your devotion to the care of patients and the teaching of students. 6. You’ll meet and come to know people from all walks of life and every corner of the globe. 5. As a generalist you can learn something new and different every day. For as they say about subspecialization, the more you know about less and less the less you know. 4. You can take care of more than you think you can and can resist having that caregiving taken away from you. You can reclaim being the primary care giver. 3. The more you give the more you get. You can become very rich in the most important ways. 2. The essential part of the job doesn’t change. You begin to work when the exam room door closes and you greet your patient. You never know where that conversation will take you.

31. You will always have something to muse about

32. 25 years was spent preparing this talk and at least half of it was (a)musing Level 4