Five Patients

The proliferation of tests and techniques in this century is staggering. Consider the following list of tests performed on Mr. O'Co

X ray: chest and abdomen (1905-15)

White cell count (about 1895)

Serum acetone (1928)

Amylase (1948)

Calcium (1931)

Phosphorus (1925)

SCOT (1955)

LDH (1956)

CPK (1961) 

John O'Co

Aldolase (1949)

Lipase (1934)

CSF protein (1931)

CSF sugar (1932)

Blood sugar (1932)

Bilirubin (1937)

Serum albumin/globulin (1923-38)

Electrolytes (1941-6)

Electrocardiogram (about 1915)

Prothrombin time (1940)

Blood pH (1924-57)

Blood gases (1957)

Protein-bound iodine (1948)

Alkaline phosphatase (1933)

Watson-Schwartz (1941)

Creatinine (1933)

Uric acid (1933)

If one were to graph these tests, and others commonly used, against the total time course of medical history, one would see a flat line for more than two thousand years, followed by a slight rise begi

That is the meaning of technological i

What makes the case of Mr. O'Co

Presumably, Mr. O'Co

In this light, consider Mr. O'Co

The use of antibiotics is more sophisticated now than it was twenty years ago, corresponding to a better appraisal of the benefits and limitations of the drugs. Generally speaking, the antibiotic cocktail, a mixture of drugs given before one has diagnosed the nature of the infection, is frowned upon. The arguments against it are simple enough. For Mr. O'Co

The arguments in favor of the cocktail are equally simple: that Mr. O'Co

It all comes back to Hippocrates: Does one treat with a grave remedy, or a specific one? The MGH chose a grave remedy, a strong antibiotic cocktail. The residents did so with the full knowledge that it might impair further work.

Let us now see what happened to Mr. O'Co

Mr. O'Co

At eight in the morning the genito-urinary consult saw him and felt that he had peritonitis of the right abdomen, or infection of the sac-like membrane which surrounds the abdominal contents. Evidence included tenderness and muscle spasm on the right side, and tenderness when his liver was tapped. Bowel sounds were decreased, suggestive of intra-abdominal infection. There was tenderness to rectal examination, also suggestive of such infection.

At nine, Dr. Mi

At noon, the gastrointestinal consult reviewed the barium enema, which was normal. They concluded that "we remain in the dark regarding diagnosis but would agree that bacterial sepsis secondary to a right abdominal lesion is the best bet." They suggested, however, that perforated small bowel, duodenal lesion, pancreatitis, and a number of other possibilities remained, and advised an upper GI series of X rays.

At approximately the same time, the attending physician on the wards, Dr. Kurt Bloch, noted that Mr. O'Co

Later in the day the surgeons again saw Mr. O'Co

At eight in the evening, the neuromedical consult again evaluated Mr. O'Co

That same evening, more abnormal laboratory values came back from the labs. They had been taken the day of admission, and included an elevated uric acid level of 17.1 and an elevated alkaline phosphatase level of 37.6. The alkaline phosphatase test was repeated, and was found to be still higher, at 61.0. Two other enzymes were also slightly high: the serum glutamic oxalocetic transaminase, or SGOT, was 123, and the lactic dehydrogenase, or LDH, was 540. Blood samples were immediately drawn for repeat determinations.

These two enzymes, SGOT and LDH, are measured as indexes of cell destruction. Cells normally contain them; if the cells die, they rupture and release their enzymes to the bloodstream. A rise in enzyme levels is thought to correspond moderately well with the degree of cellular damage, particularly when examined over several days. However, these enzymes are found in many kinds of cells, and thus an enzyme rise does not pinpoint precisely the area of destruction. For example, heart, skeletal muscle, brain, liver, and kidneys all contain SGOT; damage to any of them will produce an SGOT rise. In recent years, there has been a search for enzymes specific to certain tissues. Cre-atinine phosphokinase, or CPK, is usually considered more specific for heart damage.

At 3:30 a.m., Michael Soper, a medical resident, got back the new set of enzyme values. Everything was further increased: SGOT was now 640, LDH 1250, and CPK very high, at 320. He wrote: "I've never seen a CPK this high and don't know where it is coming from. Doubt it is solely of cardiac origin. Electrocardiogram tonight is unchanged."

At 7 a.m., on morning rounds, Mr. O'Co

Later in the morning, the patient was seen by the infectious-disease consult, which concluded that the agitation and unresponsiveness were almost certainly secondary to gastrointestinal disorders and metabolic problems. The elevated enzymes could be the consequence of insufficient oxygen and shock, present at admission. However, they noted that the elevated alkaline phosphatase and elevated uric acid were unexplained. They suggested the possibility, previously unconsidered, of staphylococcal food poisoning.

Since no information could be obtained directly from the patient, his wife was closely requestioned about symptoms of thyroid disease, or longstanding diarrhea or other GI problems. The paregoric that the patient had taken on the day of admission was brought into the hospital and checked; it was, indeed, paregoric.

During this period the patient was examined by Dr. Alexander Leaf, the chief of medicine, and Dr. Daniel Federman, the assistant chief, as well as by a large number of other physicians, in an informal brainstorming session. Every conceivable diagnosis, including mushroom poisoning and cholera, was considered at this time.

The patient's condition remained unchanged.

Continued problems with oxygenating the patient's bloodstream produced a consultation by the respiratory unit, which advised drying the lungs as much as possible, naso-tracheal suctioning, encouraging coughing, and close monitoring by arterial blood gases. The patient improved somewhat during the day, becoming less wild. That evening, for the first time, he responded to his name.

The patient was more alert. He was seen again by the surgeons, who noted his abdomen was still soft, without any indications for surgery. His dose of Valium, to contain his agitation, was reduced.