LITMIR.BIZ

Скачать книгу

do a spinal tap,” said Amanda.

      “Perfect,” he said.

      Gail entered the room at that point and Pollard, out of the corner of his eye, saw her coming. “Gail, I’m going to need a spinal tap tray stat.”

      “Here it is.”

      Again, without looking up, he said, “You see. Now do you believe what I said about her before?” He winked at Gail. “She knows what I’m going to need before I know it. I’ll need the usual blood work up. A complete cbc, and full profile stat plus an immediate blood culture times two.”

      “Yes, doctor. The lab’s on the way.”

      Then he reached for an ophthalmoscope and looked into the eyes of his patient. “Why am I doing this?” he asked.

      There was no answer.

      “I’m trying to rule out evidence of a mass lesion that would cause severe enough increased intracranial pressure making a spinal tap hazardous. It could cause a cerebellar herniation if I relieve some pressure doing the tap. I get a rough estimate of the pressure by looking at the optic disc.” Examining as he talked he continued, “No. There is no papilledema, or swelling of the optic nerve disc. Does that rule out a brain tumor?”

      Both students looked at each other, but no answer came forth.

      “The answer is no,” said Pollard. We don’t have time for a CT scan. We’ve got to act fast.”

      The students felt the tension. It was clear that Pollard was dealing with life or death.

      With the patient positioned on his left side with hips and knees and chest and neck flexed as much as possible, Pollard asked Barry to hold the patient in that position. Pollard sat down facing the patient’s lumbar area. Before he performed the tap, he noted a half-inch superficial abrasion exactly at the insertion site. It appeared recent. There was a spot of dried blood present.

      I wonder what that’s doing there? Has he seen a physician? Could he have hurt himself? I’m sure that’s it. I have to go in close to the abrasion, he thought. There’s enough viable and healthy skin that will enable me to miss it. Good enough. I’ll use plenty of antiseptic.

      He took the long spinal needle and inserted it between the spinous processes. Normally the cerebrospinal fluid is crystal clear, but when he took the trochar out of the hollow spinal needle he noted that the emerging fluid was very cloudy and the pressure by manometer was 280 (normal 100-200). He collected the fluid in several test tubes and said, “We’ve just confirmed our clinical diagnosis: meningitis it is.” He held one of the test tubes of fluid up to the light and shook it so the students could see the marked cloudiness. “If I did a spinal tap on either of you right now, the fluid would be crystal clear. What does the cloudiness represent?” He asked.

      “Bacteria,” said Amanda.

      “Or fungus, perhaps, or malignant cells. I’m sure you’re right, but the lab will confirm this soon. Gail, take these tubes and send them to the lab. We need a culture for bacteria, Tb, and fungus. Do a gram stain for bacteria, and an acid-fast stain for Tb, and an india ink for cryptococcosis. Get a cell count, glucose, and protein. Read it back please.”

      Satisfied, he said, “Okay, we’re done. Let’s go write treatment orders and call his personal physician if he’s got one. If not, we’ll get hold of the internist on call. We need to keep the patient on his side now and put up the guardrails. He’ll have to be admitted to Intensive Care stat. His situation is urgent. Let’s move.”

      When they arrived at the nurse’s station, he told the two medical students to go to his office and wait there for him. When he was sure they left, he turned to Gail and said, “Do you believe what just happened? Are we being cursed?”

      “What a shock,” she said shaking her head. “Why the heck would Dr. Spann get meningitis?”

      Pollard shrugged his shoulders. “You’re guess is as good as mine. Most of the time we see meningitis in college epidemics, or in ill patients with some underlying disease process and/or a compromised immune system. We both know this man. He was in great shape as far as I knew. But that’s what medicine is all about…one surprise after the other. And the truth of the matter is that with his depth of coma we’re dealing with a very poor prognosis. Now we’re confronted with the second physician from the Medical Executive Committee; the first one, Harrison, dead, and Dr. Spann in extremis. What the hell’s going on?”

      “My God, you’re right. This has been a terrible few days,” said Gail. “Two Medical Executive Committee members; one dead and one dying. I can’t believe it.”

      Pollard stared down at the floor and rubbed his forehead with his right hand. After a short while he said, “Were you able to get hold of his wife?”

      “Yes, I did, and what a story I got. She told me he went out to the pharmacy two nights ago, and he never returned home. When he didn’t return the first night, she called the police and they told her they couldn’t do anything until someone was missing for twenty-four hours. I suppose they figured another wayward husband out on a fling. But she called again after an hour had passed, and the police interviewed her and put out a search for him. This morning a motorist saw a car parked on an off ramp with a man slumped over the wheel. He called the police and they called the paramedics and that’s when we came in.”

      “So the wife will be here soon?” asked Pollard.

      “Yes, in about thirty minutes.”

      “Did she tell you who his doctor was?”

      Gail responded, “She said he had a complete physical from Doctor Baehler not too long ago. I called his home and his wife says he’s on the way to the hospital. I was just about to call his cell.”

      “Go ahead. See if we can get him. Let me talk to him,” said Pollard.

      As it turned out, he was only a few minutes from the hospital when he received the call. “John?”

      “Jason? If I’m hearing from you first thing in the morning I’ve got a feeling I’m in for a bad day.”

      “Your patient, Arnold Spann, was just here.”

      “Arnold? Was just there…in the emergency room?”

      “Yes, he’s on his way to Intensive Care and I’ve put him in isolation.”

      “Oh boy, give me the bad news.”

      “Oh boy is right. He’s got a fulminating meningitis and is in extremis.”

      “You’re kidding.”

      “I wish I was.”

      “Why the hell?” said Dr. Baehler.

      “That’s the big question. Has he been sick? Is he immunosuppressed?””

      “No. I only saw him for a general physical not too long ago. He was in great shape. This is unbelievable.”

      “You haven’t done a spinal tap lately?” said Pollard thinking of the abrasion he identified.

      “No way.”

      “Did you refer him to a neurologist?”

      “No. Why do you ask?”

      “He had an abrasion on his back by L4 and for a moment I thought it might have been from a recent tap, but I’m sure he just injured himself.” Pollard continued, “His spinal fluid was confirmatory. It looked like pure pus. The pressure was elevated. He had seizures and is in deep coma. This is a bad prognosis. I would call infectious disease stat.”

      “Okay, I’m pulling in to the parking lot. Thanks, Jason.”

      “You’re welcome. All the lab work is pending. His wife is on the way to the hospital. After I speak with her, I’ll send her up to Intensive Care. Good luck. Keep me posted, please.”

      Pollard hung up the phone

Скачать книгу