Rheumination

Phlegm, or Why I became a Rheumatologist

 

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.

Google Comes to the Aid of S3 Challenged

Not a day goes by that somebody doesn't check out one of my S3 Denialism posts (1, 2, or 3).  Some come by it through an old  Grand Rounds and others are browsing through my blog,  but lately the majority are coming via google searches.  It seems that because of blog traffic magic, my blog posts show up on the first google page for any search including 'S3' and 'heart failure'.  I imagine medical students are the major searchers, but it may well be residents hoping to finally find a way to hear that elusive third heart sound.  Well, fortunately they find the truth within the first few search results, undoubtedly putting their minds, and perhaps their stethoscopes, to rest.

S3 Denialism: Part 3

Stubby is in the house.  I believe his real name was Dr. Stubblethorn or something similar.  Old english stock with a highly expressed eccentricity gene.  His main preoccupation was heart sounds and there was nothing more interesting in his world than a rheumatic heart.  It was a shame, in his view, that there were only four valves to muck up.  It was said that his stethescope had three heads, and if you were to cut off one of them, two more would grow in it's place.  Generations of med students were entertained by his imitation of heart sounds.  In fine form,  he could simulate more snaps, pops and clicks than a flock of  starlings in a feeding frenzy. And he was now on the cardiology consultation service.

   Generally that was cause for celebration because not only was he highly entertaining, he was so genuinely fascinated by anything noisy that pointing him towards any heart that could still produce a beat or two would send him off into an ausculatory revery that would distract from any shortcomings the service might want to hide. But this time it was different because he came armed.  He had now in his possession something called a phonocardiogram.  Apparently it was an apparatus of sorts that could amplify and record heart sounds.  This would make sorting out the many different murmurs and thrills so much easier.Debate over such matters would come to an end.  But what about the S3?  Surely he didn't want to surrender his absolute power over the S3, for after all, Stubby was the supreme judge of the matter. If he said an S3 was present, there wasn't a sole on the continent who could say otherwise. More importantly, how could housestaff discipline be maintained without the hierarchy preserving ambiguity of the S3?  Did he expect us to return to spleen tip palpation?

This was a clear and present danger that required swift action.  Though there was no meeting, no collusion amongst residents, a consensus evolved and a simple, precise response.  We never ordered the test.  Though the technology apparently existed, nobody seemed interested in finding out if the S3 was out there.  Nobody seemed to think it's importance warranted confirming it's presence or absence.  I never once heard "phono stat, might be an S3!"  The world could apparently continue to thrive in uncertainty because the phonocardiogram subsequently slipped into oblivion.  I sometimes suspect that even Dr. Stubblethorn was glad to see it go.

S3 Denialism Part 2

S3 Denialism Part 1

S3 Denialism. Part 2

In my third year of internal medicine residency I discovered that I had magical powers.  I discovered that I could create or destroy the third heart sound, the S3, at will.  On rounds I would listen to the heart of a patient and if I wanted the S3 to be there I said so.  Magically it would appear so in the chart thereafter, even if three med students, two interns and an R2 had missed it.  It was equally easy to make them disappear.  It was a power I used selectively and wisely.  An S3 could be produced to encourage a medical student, but could be disappeared for an over-reaching intern.  Near absolute S3 power.  I say near because there were, however, some dark wizards in the hospital with some seriously black magic who could reverse my S3 conjuring.  The cardiology fellows would flaunt their magic cruelly.  I once saw them transform my loud S3 into an atrial plop after an echo confirmed an atrial myxoma.  One week it's S1S2S3 every day, and the next it's S1S2 plop. Mercifully, surgery put an end to it all.

The S3; Or Why I Became a Rheumatologist

I was an R2 doing a mock oral exam with my senior, a third year resident who I knew was going into gastroenterology at the end of the month.  The patient was a sweet elderly lady who had difficulty giving her complete history because she was very short of breath.  The exam was fairly simple, an obvious case of congestive heart failure.  A snap right?  Should have been, but there was always the tricky question of that third heart sound, the S3.  I had heard of the mythical entity, since the earliest days of medical school.  During our first bedside lessons in second year we had a cardiologist who patiently let us all listen to the 'best' S3 he had heard in ages.  We all listened intently, trying our hardest to parcel out that little lub or dub or whatever was supposed to be there.  After we had all had a turn he asked me if I had heard it.  Perhaps foolishly, I was after all only in second year, I admitted that I had not, even though it was the best he had heard in ages.  Perhaps stiffened by my admission, every one of the six students admitted the same.  The cardiologist looked at us with something between contempt and disgust and said, "what are you all bloody deaf?"  He told us to listen again and promptly left as we fiddled with our stethoscopes.   I then knew that the S3 must exist.

Over the next few years I learned the the S3 was a sign of congestive heart failure, appeared in almost all charts of CHF patients.  Apparently everybody could hear the damn thing, on an amazingly regular basis.  Everybody, that is, except me.  I had never, ever, ever, heard an S3.  Sure I wrote it in the chart.  Almost any patient with heart failure got a big S1S2S3 for heart sounds, but only because I knew it had to be there.    I never sought help for my S3 handicap, though psychologically  my stethescope became an instrument of shame.  Oddly though,  it didn't seem to have much impact on my day-to-day functioning. Occasionally a more senior resident would disagree with my assessment, but I was never given a hard time about it.  As I got more experience though, I started to see signs that maybe I was not alone.  My dirty little secret seemed to be shared by more than a few of the housestaff.  I noticed that my juniors would often mention the S3 during discussion of the case with the same learned assurance I gave, but when I would ask them how sure they were, or if we examined the patients together, they would often add qualifiers.  "Well at least I heard it this morning when she was worse, I'm not sure about this afternoon."  Soon it seemed that rather than  being a dirty secret, it was more like a secret society.  A society of S3 deniers.  With time, it began to seem like a rather large secret society, but with no membership list to prove it. 

 So back to my oral exam.  My R3 came in with a real seriousness that took the mock out of mock exam.  I rolled through the history and physical right up to the heart sounds where there must have been a just-discernable pause where I might have hesitated a fraction before lying with conviction about the presence of the CHF-related S3.  I then demonstrated all the signs I could think of  to prove that the patient was in fact in heart failure, a heart failure so classical that surely the S3 was a given. The senior resident raised an eyebrow and slowly pulled off her stethescope that had been draped over her neck.  She leaned over the patient and listened for what must have been a half-hour or so, flipping from bell to diaphragm a couple of times.  Then she straightened, looked me in the eye, and said, " yup, a loud S3".  A tiny smile then formed in the corners of her mouth as she wandered out of the room and into the saner world of gastroenterology where borborygmi are borborygmi, loud and clear.  No secret handshake, no codewords exchanged, but no doubt either that I had just met a fellow member of the society of S3 deniers.

Why I Became A Rheumatologist I

In the mid-eighties I was a fourth year med student and took rheumatology as an elective. At the time, I had no clue about the field and took it at the recommendation of my brother. This was odd in itself as my brother, who has since become an intensivist, has never since shown even the slightest residual interest. I was initially underwhelmed, seeing numerous burned-out rheumatoids as pre-op courtesy consults and acute osteoporotic fractures with an attending who seemed to long for his lab. In the second week my attending and my luck changed as I rounded with the chief of the department. He was an imposing figure, six foot four or more and rather austere, but I soon discovered that though he had an active lab and admininstrative duties, his curiosity for clinical medicine had never been expunged. No case, even the most mundane at first glance, seemed to go past without some comment. Not for teaching purposes, not to look clever, but simply because the world was still full of mysteries, large and small. Even today, whenever I palpate a small tender peri-lumbar lipoma I remember our discussion about fibrositic nodules and whether they in fact existed. I still wonder, as he did, why shoulder bursitis hurts so much at night.
At our first service rounds I remember that a junior staff presented a case of pulmonary sarcoidosis that was on the floor. I don't recall the details, but it included pulmonary and neurological symptoms. After the case presentation there was a review of the latest literature which showed, at that time, that there was no value in giving corticosteroids. After a lively round table discussion which thoroughly impressed me, all seemed to agree, and they then asked the junior attending what he was doing for the patient. To my surprise, he answered with- prednisone! The chief, with everybody uncomfortably silent, asked how he decided upon that course, given the just-discussed literature. He responded with "well, what'ya gonna do". That seemed to satisfy everybody present and we moved along to the next case.
That one service rounds said a lot about rheumatology. Odd, debilitating diseases with mysterious origins and uncertain treatments. Intelligent clinicians sometimes forced into seat-of-the-pants treatments. A world of mysteries, large and small.

As a last note, the junior staff just mentioned has been exonerated, of course. In the may 2007 issue of the American Journal of Medicine, a review of the treatment of sarcoidosis lists corticosteroids as the preferred medication for all manifestations except arthritis and E. Nodosum, where they were second to nsaids.