Montreal is a very hot city. Maybe not in absolute terms, because 32 celsius would not impress most people south of here, but when you get there from the -20 of winter, it feels very hot. It's humid too, Montreal being trapped in a river valley. Those summer temperatures are also much worse when experienced in Montreal's Royal Victoria hospital, especially a few years back. This hospital is over a hundred years old, and it is still awaiting it's first cooling system upgrade. The ventilation plans are reported to be included in Leonardo's sketchings. There's a second peak of influenza during Montreal summers as Royal Vic staff all huddle uncomfortably close around the rare on-floor fan. Nobody investigates fever-of-unknown-origin because we just assume it's the oven we work in.
And it was at the Royal Vic in July that we were rounding with Dr. Cherry. Dr. Cherry was a great clinical teacher. I'm sure he'd seen a million patients with a million med students, yet he still seemed honestly excited demonstrating clinical exam to second year students. So we were happy to be with him visiting the 6th floor. The patient he presented was in not-great shape, breathless and leaning over his wobbly food tray. I immediately tried to classify him; pink puffer or blue bloater. Grey seemed more appropriate. We began discussing the case and I was already loosening my tie from the heat. Dr. Cherry was explaining that the man had COPD, and was admitted with a pneumonia of the left lower lobe. The offending bacteria was still unidentified because he had yet to produce any sputum and blood cultures were negative. Just as this point was made, we were drawn to the patient by a deep, very deep rumble. A rolling choking hacking cough from the deepest of alveoli was finally summoning some of this microbial gold. The cough was never-ending. He continued with such effort that I thought he may well hark up the entire left lower lobe of his lung, the spleen perhaps caught up in the draft. As it looked like success was forthcoming, Dr. Cherry sprung into action. Like only a clinician with a teaching moment can, he grabbed a specimen jar from the side table and presented the patient a target. I almost laughed at the specimen jar which clearly could not hold an adrenal gland let alone the train of organs I was sure was forthcoming. But no, as I stepped far back the patient produced only a finger sized blob of viscous green sputum. Clearly spent, the patient was unable to expectorate. The blob hung tenuously to his lower lip, swinging like a pendulum while Dr. Cherry followed with his sterile cup, coaxing the tenacious phlegm to fall. While he patiently tracked the Hemophilus laden metronome I noticed that the room itself was starting to sway and wobble. The lights at the periphery started to fade and the heating system seemed to have kicked in. Just as Dr. Cherry pounced on the finally cooperative mucus I exited the room in a pre-syncopal stumble, unable to join in his moment of triumph. As my senses slowly returned and Dr. Cherry proudly capped his frothy prize I finally fully appreciated his teaching point. Chest medicine- forget it.