Tagged Emergency Medical Treatment

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

During the pandemic, suicidal thinking is up. And families find that hospitals can’t handle adolescents in crisis.

Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”
Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”Credit…Jacob Biba for The New York Times
Benedict Carey

  • Published Feb. 23, 2021Updated Feb. 24, 2021, 5:00 a.m. ET

When the pandemic first hit the Bay Area last spring, Ann thought that her son, a 17-year-old senior, was finally on track to finish high school. He had kicked a heavy marijuana habit and was studying in virtual classes while school was closed.

The first wave of stay-at-home orders shut down his usual routines — sports, playing music with friends. But the stability didn’t last.

“The social isolation since then, over all this time, it just got to him,” said Ann, a consultant living in suburban San Francisco. She, like the other parents in this article, asked that her last name be omitted for privacy and to protect her child. “This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

“We called 911, and he was taken to the emergency room,” his mother said. “But there they just stitched him up and released him.” The doctors sent him home, she said, “with no support, no therapy, nothing.”

Ann and her son are like many families over the last year. Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink. Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn. They need help, but it’s hard to come up with a psychiatric diagnosis. They are trying to manage a surprise interruption in their lives, a vague loss. And without a diagnosis, reimbursement for therapy is hard to come by. And that is assuming parents know what kind of help is appropriate, and where to find it.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

Many E.R. departments across the country are now seeing a surge in such cases. Through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year, according to a recent report by the Centers for Disease Control and Prevention.

And the local emergency department is frequently unprepared for the added burden. Workers often are not specially trained to manage behavioral problems, and families don’t have many options for where to go next, leaving many of these pandemic-insecure adolescents in limbo at the E.R.

“This is a national crisis we’re facing,” Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C. “Kids are having to board in the E.R. for days on end, because there are no psychiatric beds available in their entire state, never mind the hospital. And of course, the child or adolescent is lying there and doesn’t understand what’s happening in the E.R., why they’re having to wait there or where they’re going.”

What Adolescents Are Feeling

Most teenagers and young adults have done fine through this pandemic year, provided that their families have stayed healthy and economically stable. They may be irritable or missing their friends, but their support networks have been enough to get them through the pandemic.

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say. Most are temperamentally sensitive and after months of being socially cut off from friends and activities, they have much less control over their moods.

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,” said Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine. It is this prolonged stress, Dr. Spinks-Franklin said, that in time blunts the brain’s ability to manage emotions.

Jean, an artist and mother of two living in Hendersonville, N.C., said that her 17-year-old son was doing fine through last spring. But the months of virtual classes and loss of simple social pleasures — hanging out with friends, playing chess — changed him through the fall months.

“Now, he’s become very reclusive, he has mood swings, he cries a lot,” Jean said. “This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.
Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.Credit…Brett Deering for The New York Times

Lisa, a mother of three in Asheville, said that the months of virtual classes and relative social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”

His grades slipped badly, and he began to withdraw. “Next, he was telling us he couldn’t make himself do the work, that he didn’t want to disappoint us all the time, that he was worthless. Worthless.”

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one.) Rather, they are trying to manage an interruption in their normal development, child psychologists say: a sudden and indefinite suspension of almost every routine and social connection, leaving a deep yet vague sense of loss with no single, distinct source.

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.” The concept is usually reserved to describe the experience of immigrants, displaced from everything familiar, who shut down emotionally in a new and strange country. Or to describe disaster survivors, who return to neighborhoods that are hollowed out, transformed.

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

System Overload

The resulting changes in behavior can seem sudden: A bright sixth-grader is found cutting herself; a sweet-natured sophomore takes a swing at a parent or sibling. Parents, frightened, often don’t know where to go for appropriate help. Many don’t have the resources or knowledge to hire a therapist.

Families that land in the emergency departments of their local hospitals often find that the clinics are poorly equipped to handle these incoming cases. The staff is better trained to manage physical trauma than the mental variety, and patients are often sent right back home, without proper evaluation or support. In severe cases, they may linger in the emergency department for days before a bed can be found elsewhere.

In a recent report, a research team led by the C.D.C. found that less than half of the emergency departments in U.S. hospitals had clear policies in place to handle children with behavior problems. Getting to the bottom of any complex behavior issue can takes days of patient observation, at minimum, psychiatrists say. And many emergency departments do not have the on-hand specialists, dedicated space or off-site resources to help do the job well.

For Jean, diagnosing her son has been complicated. He has since developed irritable bowel syndrome. “He has been losing weight, and started smoking pot due to the boredom,” Jean said. “This is all due to the anxiety.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents. But well before the arrival of the coronavirus, the department was straining to handle increasing numbers of patients with behavior problems.

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

Last March, to address the crowding, Nationwide Children’s opened a new pavilion, a nine-story facility with 54 dedicated beds for observation and for longer-term stays for those with mental challenges. It has taken the pressure off the hospital’s regular emergency department and greatly improved care, Dr. Axelson said.

Over this pandemic year, with the number of admissions for mental health problems up by some 15 percent over previous years, it is hard to imagine what it would have been like without the additional, devoted behavioral clinic, Dr. Axelson said.

Other hospitals from out of state often call, hoping to place a patient in crisis, but there is simply not enough space. “We have to say no,” Dr. Axelson said.

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it,” said  Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C.Credit…Jacob Biba for The New York Times

Dr. Rachel Stanley, the chief of emergency medicine at Nationwide, said that most hospitals have far fewer resources. “I worked at a hospital in Michigan for years, and when these kinds of kids come in, everyone dreaded seeing them, because we didn’t feel like we had the tools to help,” she said. “They have to go into a safe room; they can’t be in a shared area. You have to provide a sitter for the child, a staff person to stay with them all the time to make sure they’re not suicidal or homicidal. It could take hours and hours to get social workers involved, and all this time they’re getting worse.”

Anne, the consultant in the Bay Area, said that her son’s visit to the emergency room this month was his third in the past 18 months, each time for issues related to drug withdrawal. On one visit, he was misdiagnosed with psychosis and sent to a locked county psychiatric ward. “That experience itself — locked for days in a ward, with no one telling him why, or how long he’d be there — was the most traumatic thing he’s experienced,” she said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

Lisa has hired a therapist for her son, a Zoom session every other week. That seems to have helped, she said, but it is too early to tell. And Jean, for the moment, is hoping the infection risk will diminish soon, so her son can get a safe job.

All three parents have become keen observers of their children, more aware of shifting moods. Listening by itself usually helps relieve distress, therapists say. “Trying to educate parents is a routine part of the job,” said Dr. Robert Duffey, a pediatrician in Hendersonville. “And of course we need these kids back in school, so badly.”

But medical professional say that until the health care system finds a way to equip and support emergency departments for what they have become — the first and sometimes last resort — parents will be left to navigate mostly on their own, leaning on others who have managed similar problems.

“Covid has put our system under a microscope in terms of the things that don’t work,” said Dr. Baum, the pediatrician in Asheville. “We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

During the pandemic, suicidal thinking is up. And families find that hospitals can’t handle adolescents in crisis.

Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”
Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”Credit…Jacob Biba for The New York Times
Benedict Carey

  • Feb. 23, 2021, 3:48 p.m. ET

When the pandemic first hit the Bay Area last spring, Ann thought that her son, a 17-year-old senior, was finally on track to finish high school. He had kicked a heavy marijuana habit and was studying in virtual classes while school was closed.

The first wave of stay-at-home orders shut down his usual routines — sports, playing music with friends. But the stability didn’t last.

“The social isolation since then, over all this time, it just got to him,” said Ann, a consultant living in suburban San Francisco. She, like the other parents in this article, asked that her last name be omitted for privacy and to protect her child. “This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

“We called 911, and he was taken to the emergency room,” his mother said. “But there they just stitched him up and released him.” The doctors sent him home, she said, “with no support, no therapy, nothing.”

Ann and her son are like many families over the last year. Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink. Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn. They need help, but it’s hard to come up with a psychiatric diagnosis. They are trying to manage a surprise interruption in their lives, a vague loss. And without a diagnosis, reimbursement for therapy is hard to come by. And that is assuming parents know what kind of help is appropriate, and where to find it.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

Many E.R. departments across the country are now seeing a surge in such cases. Through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year, according to a recent report by the Centers for Disease Control and Prevention.

And the local emergency department is frequently unprepared for the added burden. Workers often are not specially trained to manage behavioral problems, and families don’t have many options for where to go next, leaving many of these pandemic-insecure adolescents in limbo at the E.R.

“This is a national crisis we’re facing,” Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C. “Kids are having to board in the E.R. for days on end, because there are no psychiatric beds available in their entire state, never mind the hospital. And of course, the child or adolescent is lying there and doesn’t understand what’s happening in the E.R., why they’re having to wait there or where they’re going.”

What Adolescents Are Feeling

Most teenagers and young adults have done fine through this pandemic year, provided that their families have stayed healthy and economically stable. They may be irritable or missing their friends, but their support networks have been enough to get them through the pandemic.

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say. Most are temperamentally sensitive and after months of being socially cut off from friends and activities, they have much less control over their moods.

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,” said Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine. It is this prolonged stress, Dr. Spinks-Franklin said, that in time blunts the brain’s ability to manage emotions.

Jean, an artist and mother of two living in Hendersonville, N.C., said that her 17-year-old son was doing fine through last spring. But the months of virtual classes and loss of simple social pleasures — hanging out with friends, playing chess — changed him through the fall months.

“Now, he’s become very reclusive, he has mood swings, he cries a lot,” Jean said. “This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.
Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.Credit…Brett Deering for The New York Times

Lisa, a mother of three in Asheville, said that the months of virtual classes and relative social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”

His grades slipped badly, and he began to withdraw. “Next, he was telling us he couldn’t make himself do the work, that he didn’t want to disappoint us all the time, that he was worthless. Worthless.”

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one.) Rather, they are trying to manage an interruption in their normal development, child psychologists say: a sudden and indefinite suspension of almost every routine and social connection, leaving a deep yet vague sense of loss with no single, distinct source.

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.” The concept is usually reserved to describe the experience of immigrants, displaced from everything familiar, who shut down emotionally in a new and strange country. Or to describe disaster survivors, who return to neighborhoods that are hollowed out, transformed.

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

System Overload

The resulting changes in behavior can seem sudden: A bright sixth-grader is found cutting herself; a sweet-natured sophomore takes a swing at a parent or sibling. Parents, frightened, often don’t know where to go for appropriate help. Many don’t have the resources or knowledge to hire a therapist.

Families that land in the emergency departments of their local hospitals often find that the clinics are poorly equipped to handle these incoming cases. The staff is better trained to manage physical trauma than the mental variety, and patients are often sent right back home, without proper evaluation or support. In severe cases, they may linger in the emergency department for days before a bed can be found elsewhere.

In a recent report, a research team led by the C.D.C. found that less than half of the emergency departments in U.S. hospitals had clear policies in place to handle children with behavior problems. Getting to the bottom of any complex behavior issue can takes days of patient observation, at minimum, psychiatrists say. And many emergency departments do not have the on-hand specialists, dedicated space or off-site resources to help do the job well.

For Jean, diagnosing her son has been complicated. He has since developed irritable bowel syndrome. “He has been losing weight, and started smoking pot due to the boredom,” Jean said. “This is all due to the anxiety.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents. But well before the arrival of the coronavirus, the department was straining to handle increasing numbers of patients with behavior problems.

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

Last March, to address the crowding, Nationwide Children’s opened a new pavilion, a nine-story facility with 54 dedicated beds for observation and for longer-term stays for those with mental challenges. It has taken the pressure off the hospital’s regular emergency department and greatly improved care, Dr. Axelson said.

Over this pandemic year, with the number of admissions for mental health problems up by some 15 percent over previous years, it is hard to imagine what it would have been like without the additional, devoted behavioral clinic, Dr. Axelson said.

Other hospitals from out of state often call, hoping to place a patient in crisis, but there is simply not enough space. “We have to say no,” Dr. Axelson said.

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it,” said  Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C.Credit…Jacob Biba for The New York Times

Dr. Rachel Stanley, the chief of emergency medicine at Nationwide, said that most hospitals have far fewer resources. “I worked at a hospital in Michigan for years, and when these kinds of kids come in, everyone dreaded seeing them, because we didn’t feel like we had the tools to help,” she said. “They have to go into a safe room; they can’t be in a shared area. You have to provide a sitter for the child, a staff person to stay with them all the time to make sure they’re not suicidal or homicidal. It could take hours and hours to get social workers involved, and all this time they’re getting worse.”

Anne, the consultant in the Bay Area, said that her son’s visit to the emergency room this month was his third in the past 18 months, each time for issues related to drug withdrawal. On one visit, he was misdiagnosed with psychosis and sent to a locked county psychiatric ward. “That experience itself — locked for days in a ward, with no one telling him why, or how long he’d be there — was the most traumatic thing he’s experienced,” she said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

Lisa has hired a therapist for her son, a Zoom session every other week. That seems to have helped, she said, but it is too early to tell. And Jean, for the moment, is hoping the infection risk will diminish soon, so her son can get a safe job.

All three parents have become keen observers of their children, more aware of shifting moods. Listening by itself usually helps relieve distress, therapists say. “Trying to educate parents is a routine part of the job,” said Dr. Robert Duffey, a pediatrician in Hendersonville. “And of course we need these kids back in school, so badly.”

But medical professional say that until the health care system finds a way to equip and support emergency departments for what they have become — the first and sometimes last resort — parents will be left to navigate mostly on their own, leaning on others who have managed similar problems.

“Covid has put our system under a microscope in terms of the things that don’t work,” said Dr. Baum, the pediatrician in Asheville. “We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.

Got a Pandemic Puppy? Learn How to Prevent Dog Bites

The Checkup

Got a Pandemic Puppy? Learn How to Prevent Dog Bites

With new puppies and kids at home, doctors are worried about treating more children for dog bites.

Credit…Manon Cezaro

  • Feb. 23, 2021, 2:33 p.m. ET

The surge in pet adoptions during the pandemic brought much-needed joy to many families, but doctors are worrying about a downside as well: more dog bites.

A commentary published in October in The Journal of Pediatrics noted an almost threefold increase in children with dog bites coming into the pediatric emergency room at Children’s Hospital Colorado after the stay-at-home order went into effect.

The lead author, Dr. Cinnamon Dixon, a medical officer in the Pediatric Trauma and Critical Illness Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, said: “If someone were to tell me they were going to get a new dog during Covid, I would first and foremost want to make sure that family is prepared to have a new entity in their household, a new family member.”

Dr. Dixon said that as a pediatric emergency room doctor, taking care of children who get bitten had been a priority for her. Still, she said, from the stories she heard, she often felt “that dogs are victims in this as well.”

Brooke Goff, a partner in the personal-injury law firm the Goff Law Group in Hartford, Conn., said, “We’re definitely seeing a huge uptick in dog bite cases.”

Ms. Goff said that dog bites harm children in ways that go well beyond the physical damage. “It creates major emotional issues and PTSD,” she said. “If you’ve ever spoken to a dog bite victim as an adult that was bitten as a child, they are deathly afraid of dogs.”

Dog bites are “an underrepresented public health problem” in the United States, said Dr. Dixon, the daughter of a veterinarian who grew up around animals. The Centers for Disease Control and Prevention’s best estimates from old research put the number of dog bites at 4.5 million a year. There are over 300,000 nonfatal emergency department visits a year related to dog bites, and among children, the greatest incidence is in school age children, aged 5 to 9, but the most severe injuries are among infants and young children, presumably because they are less mobile, and lower to the ground, with their heads and faces closer to the dogs.

Dr. Robert McLoughlin, a general surgery resident at the University of Massachusetts Medical School in Worcester, was the first author on a 2020 study of hospitalizations for pediatric dog bite injuries in the United States. He said that his research grew out of an interest in pediatric surgery and pediatric injury prevention. “I had seen a lot of cases of toddlers with head and neck injuries,” he said.

The study showed that younger children, ages 1 to 4 and 5 to 10, were much more likely to need hospitalization than those over 11. In the youngest children, most injuries are to the head and neck, and beyond the age of 6, extremity wounds (arms, legs, hands) become increasingly prevalent and predominate after the age of 11, Dr. McLoughlin said.

The bites that require hospitalization and surgical repair are the most serious injuries, such as toddlers bitten in the face and neck, where many critical structures can be damaged, including eyes and ears, and there can be devastating cosmetic damage done as well. But hand injuries can also have a very lasting impact and need expert repair.

For dog bite prevention, Dr. Dixon said, “the No. 1 strategy remains supervision.” Children should learn to leave dogs alone when they are eating, when they are sleeping with a favorite toy, when they are caring for their puppies. They should not reach out to unfamiliar dogs. And dog owners should keep their dogs healthy and should socialize and train them from an early age.

“It’s important we take responsibility for our animals,” said Ms. Goff, who has a dog named Daisy that she brings with her to the office. “Most dogs don’t bite to attack, they bite because they’re scared or provoked.”

Ms. Goff also emphasized that from the point of view of liability, anyone who owns a dog should have insurance coverage. In her state, Connecticut, a strict liability state, “I don’t have to prove anybody was at fault,” she said, and the dog owner is responsible for the damages. “If you can afford the dog, you can afford the insurance,” she said.

She said that it’s important as well that dog bites be reported because of the need to track dogs who bite multiple times, but reassured those who were worried that a dog might be destroyed that, at least in Connecticut, unless there is a catastrophic or fatal injury, “our forgiveness about animals extends quite heavily.”

When dogs do show aggressive behavior, Dr. Dixon said, owners should seek expert help from a veterinarian or “a behavioral expert in canine aggression — ideally before something bad happens.”

Dr. Judy Schaechter, a professor of pediatrics and public health at the University of Miami, said that given the increase in puppy buying during the Covid epidemic, “We’re now a year into this; puppies may be big, strong dogs at this point.” And with many parents juggling work from home with their children’s school issues, it can be difficult for them to supervise all the children (and pets) all the time.

Bites often occur, Dr. Schaechter said, “around playing and feeding behaviors.” Small children are particularly at risk, in part because they may be close to the dog’s food dish, or on the ground when food falls, and the dog may see the child as competition. “Any dog can bite, any breed can bite, and that can be horrific,” she said, but a medium or large dog, or a dog with a very strong jaw, “can quickly do a lot more damage.”

When Dr. Dixon saw children who had been bitten in the emergency room, “the most common story I would hear over and over,” she said, involved “resource guarding,” in which the child seemed to be encroaching on something that belonged to the dog. “The child was next to the dog’s food or had gone next to a dog’s toy or was playing with the dog and the dog jumped up and grabbed the arm instead of the bone,” she said.

Dr. McLoughlin sees opportunities for programs to address dog bite prevention, perhaps drawing lessons from programs that discuss “stranger danger.” It’s important to teach children not to approach strange dogs, he said, but also to help them interpret dogs’ behavior, “to identify when a dog is saying leave me alone, give me some space.” He is interested in the possibility of taking dogs into schools in order to educate children about dogs they may encounter outside their homes, but emphasized that parents should be teaching even very young children about how to approach a dog — including that they should always ask the owner first.

Dr. Schaechter pointed to research on the benefits of having a dog in the family, from the joys of companionship and the lessons children learn from caring for a pet to the medical evidence that children may be at lower risk of allergy and asthma if they are exposed early to animals. The bond between children and their pets is the substance of so many books and movies, Dr. Schaechter said. “It’s real — but don’t let that be so romantic that a child ends up being hurt or scarred.”

[Get the C.D.C.’s advice on dogs, the A.A.P.’s advice on dog bite prevention, and more tips from the American Veterinary Medical Association]

A Night in the Hospital, From Both Ends of the Stethoscope

Doctors

A Night in the Hospital, From Both Ends of the Stethoscope

As a doctor writing about medical errors, I saw potential risks lurking everywhere when my daughter was hospitalized with appendicitis.

Credit…Xiao Hua Yang

  • Jan. 5, 2021, 5:00 a.m. ET

Just as the first coronavirus reports were emerging from China in late 2019, the medical world was observing the 20th anniversary of “To Err is Human,” the seminal report from the Institute of Medicine that opened our eyes to the extent of medical error. The news media jumped on the popular aviation metaphor, that the number of Americans dying each year as a result of medical error was the equivalent of a jumbo jet crashing every day. Those numbers remain difficult to accurately quantitate, but we know that they are not small.

The conversation has now been broadened to include all preventable harms to patients, even ones that are not errors per se. As I set about writing a book on medical error, I wanted to see both sides of the story. I drew upon my own experiences as a physician but also interviewed patients and families to get the view from the other side. But I soon realized that the distinction between those two “sides” was rather fluid.

Midway through writing the book, my teenage daughter experienced a stomachache. My kids know that fevers, colds, coughs and sprained ankles do not get my pulse up, and that “if you’re not bleeding out or in cardiac arrest” they should seek medical sympathy from their computer programmer father. They often accuse me of ignoring their medical complaints altogether, but as a primary care doctor I know that most aches and pains of daily life get better on their own and are best left unobsessed about.

But this time I became suspicious of my daughter’s inability to find a comfortable position and so pulled out my stethoscope. When I heard complete silence instead of gurgling bowel sounds, I shuttled us straight to my hospital’s E.R. My correct diagnosis of appendicitis modestly redeemed me in my daughter’s eyes, though she was mortified that I chatted it up with colleagues.

Surgery was planned for the next morning, so I stayed in her hospital room overnight, reading the stack of journal articles I’d been reviewing for my book. Hospitals have always been a comfortable setting for me, but the familiar ward suddenly felt apocalyptic, with medical errors and harms lurking everywhere. The population of a midsize city traipsed in and out of my daughter’s room that night, each armed with potentially dangerous things to administer or extricate. And even if they were all batting 99 percent, the denominator of “things” was so enormous that some amount of error was all but guaranteed.

When the pediatric resident arrived at 3 a.m. to assess my daughter — after she’d been evaluated by the triage nurse, the E.R. resident, the E.R. attending, the surgery resident, the surgery chief, and then the surgery attending — I put my foot down.

“She’s on pain meds now,” I hissed, “so you won’t find any abdominal tenderness. And the ultrasound already showed an inflamed appendix.” The resident eyed me warily, clearly calculating the risk/benefit ratio of pressing her case with an ornery, sleep-deprived parent.

“But if you are going to wake her up, jab on her belly, and then come to the grand conclusion that she has appendicitis and needs surgery, forget about it,” I snapped. The resident backed off, and I flopped back into my chair to read yet another cheery article about medical calamities.

The surgery team came by with another option: giving just IV antibiotics, with no operation. With antibiotics alone, they said, there was a 50 percent chance of appendicitis recurring. Which meant that for half the patients, surgery could be avoided altogether. But we had to decide right away so they could know whether to book the O.R.

I asked the surgery resident how strong the data were. I wasn’t going to make a half-baked decision just because he was time-pressed to set the O.R. schedule. He groaned mightily but stood by while I searched up some studies. The data were preliminary but seemed encouraging.

Just getting a flu shot reduces my daughter to a sobbing mess huddled in my lap even though she’s a head taller than me. So I was sure she’d jump at the chance to avoid surgery.

It turned out that she had an utterly different take. The experience of getting an IV in the E.R. was so miserable that she never wanted to repeat it. The definitiveness of surgery was much more appealing than the possibility — however small — of going through this again in the future.

The next morning, that dangly tail of residual colon was successfully snipped. When my daughter was coming out of anesthesia, I asked her if she’d like some Toradol, the pain medication that the nurse was offering. “Tortellini?” she mumbled foggily. “Are we having tortellini?”

I was impressed, yet again, by the marvels of modern medicine, knowing full well that had this taken place a century earlier I might have been digging a grave for my child that evening instead of digging through the freezer for tortellini.

As a physician, I’m stunningly proud of the medical care our hospitals can provide. But during our stay as civilians, every aspect felt like harm waiting to happen. I’m sure I ruffled a few feathers with all of my questions, but addressing family members’ worries is part of the job — even if the family member isn’t a physician, and isn’t on the faculty of that institution, and doesn’t coincidentally happen to be writing a book about medical error while sitting at the bedside.

It’s not comfortable being the squeaky wheel. Being on guard for my daughter 24/7 was frankly exhausting. But once you are on the patient side of the stethoscope, everything looks like a minefield.

Of course, the burden should not have to be on the patient or family for ensuring safe medical care. That is the job of the health care system. But as we well know, the system has not yet achieved pristine perfection, so it behooves patients and families to stay engaged as much as possible.

The Covid-19 pandemic has surely demonstrated the professionalism of health care workers. But even the most dedicated staff need extra sets of eyes on the ground.

My advice to patients is to be polite but persistent. Don’t let unspoken annoyance deter you. Offer appreciation for the things that are going well — and acknowledge that everyone is working hard! — but plow forward. At the very least, ask what each medication is and why you are getting it.

And if you are too nauseated or too sleepy or too feverish, don’t rack yourself with guilt because you are not interrogating every staff member. Get the rest you need. Before you doze off, though, use some leftover surgical tape to affix a sign across your chest that says “Wash your hands!”

The onus is on the medical system to make health care as safe as possible. But patients and families shouldn’t feel shy about taking a forthright role. Keeping those jumbo jets from falling out of the sky is a team effort, and the team includes the folks on both ends of the stethoscope.

Dr. Danielle Ofri practices at Bellevue Hospital in New York City and is a clinical professor of medicine at New York University. Her newest book is “When We Do Harm: A Doctor Confronts Medical Error.”

Think Like a Doctor: A Cough That Won’t Stop

Photo

Credit Andreas Samuelsson

The Challenge: A 43-year-old man starts to cough every time he takes a deep breath. Can you help him figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a healthy middle-aged man who starts coughing and just can’t stop. He can’t exercise. He can’t laugh. Sometimes he can’t even talk without interrupting himself with deep, awful-sounding hacks.

Below I provide much of the information available to the doctors who examined him. It took 18 months before a doctor figured out what was wrong. Can you do it any faster? The first reader to offer the correct diagnosis will receive a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a real-life case.

An Emergency 18 Months in the Making

“You should probably have that checked out in the E.R.,” the nurse suggested to the middle-aged man on the other end of the phone. “And sooner rather than later.” In the next few days? he asked. In the next few hours, the nurse replied.

The 43-year-old man hung up the phone more surprised than worried. He had been dealing with an annoying and persistent cough for a year and a half and none of the doctors or nurses he’d seen in that time seemed to think it was a big deal. Until now – since he started coughing up blood.

He called his wife to tell her what the nurse suggested. After work he was going to drive himself to the emergency room at the veterans’ hospital in downtown Denver. He could hear the relief in her voice when she asked if he wanted her to come with him. No, she had enough on her hands looking after their four children. He’d let her know what they said.

An Abnormal X-ray

In the E.R., the man’s complaint got him seen right away. His chest X-ray was normal, they told him. (The X-ray is shown here)

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Credit

But when they came back into his cubby wearing masks over their noses and mouths he suspected that the CT scan was not. The scan had shown some kind of hole in his lungs, the E.R. doctor told him. That’s why he was coughing up blood. One of the diseases that can cause those kinds of cavities was tuberculosis. Had he ever been exposed to TB? Not that he knew of. (The CT scan images are shown here.)

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Credit

Because TB was such a dangerous disease – and extremely contagious — they would have to find out if he had it. If he did, he would certainly need to be treated. And to make sure he didn’t infect anyone while he was being tested, he needed to be in a specialized room – a room where the air he breathed wouldn’t be breathed by anyone else. None of the hospital’s negative pressure rooms were available so they were going to transfer him to Presbyterian/St. Luke’s Medical Center, the big regional hospital just a couple of miles away. They had an available room and would be able to care for him.

You can read the patient’s history and physical from the E.R. here:

Admission Notes

The patient’s notes from the hospital.

The Patient’s Long Story

Dr. Karen Schmitz was the second-year resident assigned to care for the new guy sent over to be tested for TB. She could see the patient sitting up in bed talking on the phone as she secured the mask over her nose and mouth and entered the double-door room that would prevent any air-borne infectives from spreading. As she entered, the patient looked at her, smiled a warm smile, and held up a finger as if to say, “I’ll be with you in a minute.” As he finished up his phone call, the doctor looked at him carefully. He was a robust guy – youthful and healthy looking. He certainly didn’t look like any of the people she’d cared for with active TB. When he hung up, he apologized and the doctor introduced herself. She pulled up a chair and settled in. She knew from what she’d read in the chart that it was going to be a long story.

The bloody cough was pretty new, he told her. It started two weeks earlier. But the cough itself had been around for 18 months. He’d caught it a couple of summers ago, and it just never went away. At first he thought it was bronchitis – he’d had that a lot when he was a kid — but when it lasted for more than a couple of weeks, he went to see his primary care doctor. He’d never had a fever or any other sign of being sick. He had some runny nose and itchy eye symptoms that started weeks before the cough and so he and his doctors thought it was allergies. Or asthma. His doctor prescribed an antihistamine and later an inhaler. They fixed his runny nose, and eased up the chest tightness, but the hacking never slowed down.

He went to an ear, nose and throat specialist who scoped his nose and throat. Completely normal. He had a chest X-ray – also normal.

He saw a pulmonologist who, hearing that he had a little heartburn, started him on a powerful antacid medication. That pill completely fixed the heartburn but didn’t touch the cough.

That first year he’d seen three doctors in a half-dozen appointments, and had a scope, a chest X-ray and a slew of blood tests and still no one could tell him why he was coughing or how to make it stop. So he figured he’d just have to learn to live with it.

Not that he wanted that. Every time he took a deep breath he would cough. In the middle of telling a good story he’d have to stop to cough. Whenever he laughed, he coughed. Dozens of times a day, he coughed. He even had to give up exercising. Any time he exerted himself, even just a little, the cough would kick in with a shocking fierceness. Recently he’d tried riding his bike and just 15 minutes in he had to stop. Even though he was taking it easy, as soon as he started to breathe just a little harder than usual, he nearly keeled over. He had to get off his bike. He was doubled over with the ferocious hacking. Sweat and tears poured down his cheeks. He could hear the rasping sound of his breath between the deep jagged coughs. He wondered if he could even make it home. That was the last time he tried to exert himself. And that had been weeks earlier.

You can see the pulmonologist’s notes here:

Pulmonary Consult Note

The notes from the lung specialist.

The Doctor’s Visit

But eventually, he started to cough up blood. That happened the morning after he’d had another terrible blast of coughing. He’d gone with his wife and four children to Vail for Thanksgiving. As he was packing the car to come home he started coughing and felt as if it would never stop, as if he’d never be able to breathe again. But he recovered, until the next morning when he started to cough up blood. It scared him. And terrified his wife. When it didn’t get better after a couple of weeks, he’d decided to call the hospital, and the nurse on the phone sent him to the E.R.

Now, talking to Dr. Schmitz, he told her he never smoked and rarely drank. And even though it was legal, he never smoked pot either. He had been an officer in the Air Force and now was a real estate agent. He had spent a few months in Kuwait and another few in Saudi Arabia, but that was in the 1990s. He’d traveled a bit – mostly out west, but nothing recent. He took medicine for high cholesterol, the antihistamine and the antacid medicine, but that was it. His exam was unremarkable. Dr. Schmitz listened hard through her stethoscope as she placed it on his chest where she knew the hole in his lung was, but heard nothing abnormal.

She didn’t start him on antibiotics, because she didn’t yet know what she was treating, she told him. Tuberculosis seemed unlikely so she was going to test him for other infections as well. To make sure the team didn’t miss anything, they consulted an infectious diseases specialist and a pulmonologist.

You can see their notes here.

Infectious Disease Consult

Notes from the infectious disease specialist.

Dr. Schmitz checked on her patient throughout the day. He was always on the phone, his computer open, hard at work. So far they were doing nothing for the guy – just watching and waiting for answers. When the TB test came back negative, Dr. Schmitz thought he might very well be the healthiest patient in the entire hospital. Was she right? The patient got his diagnosis the very next day.

Solve the Mystery

What do you think is making this patient cough?

Post your answers in the comment section. I’ll tell you the answer tomorrow.

Think Like a Doctor: The Tired Gardener

The Challenge: Can you figure out what is wrong with a lively 67-year-old gardener who develops a daily fever and shaking chills along with chest pain and a dry cough?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to solve a real-life diagnostic mystery. Below you will find the details of a case involving a retired maker of surgical supplies who starts having daily fevers along with chills, chest pain and a dry cough.

I’ll give you the same information the doctor was given before he made this diagnosis. Will you be able to figure out what’s wrong?

As usual, the first reader to submit the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the pleasure of puzzling out a tough but fascinating case.

The Patient’s Story

“NoNo says he doesn’t feel good,” the 9-year-old girl said of her grandfather, handing her mother the thermometer. The woman dried her hands on her apron and took the device. She squinted at the little electronic numbers. Just under 102 degrees.

Her father had been sick for weeks. Feverish, weak, not eating. It was late summer and the tomatoes and eggplants in the garden were ripe, but he hadn’t even walked through his garden for days, so she knew he wasn’t feeling well. But this was the first time he’d admitted that something more serious might be going on.

It was about time. She’d taken her 67-year-old father to several doctors over the past two months. They’d looked him over and given him antibiotics, but it hadn’t helped.

“Tell NoNo that if he’s feeling sick he’s got to go to the hospital,” she told the little girl. She darted back to her grandfather’s room then quickly returned. “He says he’s ready to go.”

The woman wasn’t sure exactly when her father had started to get sick, but six or seven weeks earlier she had noticed that he was no longer the first one out of bed. Instead of being up and out before 7 a.m., he wouldn’t get up until late morning. And he started to have strange shaking chills each afternoon and evening, followed by a fever — regular as clockwork.

He looked sweaty and pale. She asked him what was wrong, but he said he was fine. Or sometimes he’d say he felt a little tired. After an hour or two the fever would pass and he’d just look tired, but the next day, or sometimes the day after, the fever would be back.

The First Diagnosis

The woman first took her father to his regular doctor. Knowing how much he loved to work in his garden, the doctor figured he probably had Lyme disease. It was summertime, and Lyme was common in the area of Connecticut where they lived. Plus, he practically took root in the half-acre garden back behind the house where he lived with his wife and their children and grandchildren.

This was the first summer the woman could remember where her father wasn’t out in his garden every single day. This year it seemed that whole weeks would go by when he did nothing but look out the window at his beautiful handiwork.

Her father took antibiotics for the presumed Lyme. It didn’t help.

A Second Diagnosis

When the patient went for a follow-up visit, he told his doctor that his stomach was bothering him a bit. So he was referred to a gastroenterologist. That doctor diagnosed Helicobacter pylori – a bacterium tough enough to survive the acid environment of the stomach that can cause pain and ulcers.

He took two weeks of treatment for that — three medications to kill the bug, and one to neutralize the acid they thrive in. That didn’t stop the daily fevers, either.

Recently the man’s wife noticed that he’d developed a dry cough. Was this a pneumonia? His doctor gave him yet another antibiotic. And he was still taking that pill when he agreed to go to the emergency room.

Pneumonia?

So three generations — wife, daughter and granddaughter — got in the car with the man they loved and drove to the hospital where the daughter worked.

The emergency room was quiet when they arrived, and after explaining that the patient had been having fevers for weeks, the patient and his entourage were taken into the back so he could be seen right away.

He did have a fever but otherwise looked pretty healthy. The doctors there seemed to focus on the cough and fever. They figured he had a pneumonia that wasn’t responding to the antibiotics he was taking. And when a chest X-ray failed to show any sign of pneumonia at all, the doctors sent him home.

You can see the note from that first visit to the Emergency Department here.

First ER Visit

If Not Pneumonia, Then What?

The next day, the man felt no better. His daughter was distressed. Her father was sick. Antibiotics weren’t working. And he was getting worse.

She called his primary care doctor again. He was also worried, he told her. But he didn’t know what to suggest.

What if she tried a different emergency room?, she suggested. They had gone to Yale-New Haven Hospital initially because that’s where she worked, but what if they went to the smaller branch of the hospital, St. Raphael’s Hospital, less than a mile away. They had different doctors there, and the hospital had a different feel — local and friendly rather than big and academic. Maybe they would find a doctor there who could help them figure out what was going wrong. It was unorthodox, the doctor told her, to shop around emergency rooms. And it wasn’t clear what another E.R. visit might do. But he was also worried about the patient, and it was certainly worth a try.

Another E.R. Visit

So early that evening they all got back into the car and drove to the St. Raphael campus. The E.R. was bustling when the family came in. Once again he had a fever – 101.6 degrees. His family explained how sick he’d been, how tired. And yet when the doctor examined him, he seemed well enough. He couldn’t find anything abnormal beyond the fever.

The labs told a slightly different story. His red blood cell count was low. So were his platelets – a type of blood cell that helps blood to clot. What was particularly strange was that these two findings had been checked the day before at the other E.R. and had been fine. And there was some evidence that he had some liver damage.

And when tested for viral hepatitis — a common causes of abnormal liver tests — he tested positive for hepatitis A and possibly hepatitis B as well.

He was admitted to St. Raphael’s Hospital because of his worsening anemia and viral hepatitis.

You can see the note from this second emergency room visit, and the admission note from the night team here.

The Second ER Note

Admission Note

Fitting the Pattern

The next morning, Dr. Neil Gupta saw the patient. Hearing the patient’s story, and the diagnosis of hepatitis A infection, was a little puzzling. Patients with hepatitis usually have mild flu-like symptoms, with a loss of appetite, nausea and vomiting, plus fatigue, low-grade fever and a generalized sense of being unwell. Certainly this patient didn’t feel well, but he had no nausea, no vomiting. And his fever came in spikes. The pattern didn’t really match.

Dr. Gupta sat down with the patient’s family and reviewed all the symptoms and the timeline. Then he reviewed all the labs. He sent off a bunch of tests.

You can see Dr. Gupta’s note here.

The Doctor’s Note

Solving the Mystery

Dr. Gupta was finally able to figure out what was wrong with this man. Can you?

The first person to figure out what is really going on with this 67-year-old gardener gets a copy of my book and that lovely sense of satisfaction that comes from making a tough diagnosis.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Picking Up an Infection in the Hospital

Photo

Credit Stuart Bradford

When the emergency room doctor pulled the blanket aside, looked at my elephant-size inflamed leg and said, “Whoa!” I knew that wasn’t a good sign.

Nor was the reaction of the emergency room nurse, who glanced down at my bizarrely swollen extremity, then started nervously backing away.

Health care practitioners are trained not to show their feelings, but there are clearly times when things look so bad that even they can’t hide their reactions.

I was in the emergency room at Los Robles Hospital in Thousand Oaks, Calif., because a few days earlier I had undergone what was supposed to be a relatively straightforward outpatient procedure to remove a skin growth on my leg. A couple of days after the surgery I felt fine. The surgeon told me I could drive whenever I was up for it, so we took our grandchildren to the Magic Castle in Hollywood. Running from room to room to see the different sleight-of-hand acts, I no longer felt fine. Now I felt a searing knife-like pain in my leg, which soon began to swell in size.

I went back to see my surgeon, who looked a little concerned. You have an infection, she said. Take these two antibiotic pills, schedule a Doppler scan for the next day, and all should be well.

That night, my leg got even bigger; from the waist down one side of me looked like I weighed 350 pounds (I’m not even half that.) My wife and I spoke to the surgeon, who was vague. “You could go to the E.R. if you want,” she said. “Or wait.”

I went and was admitted immediately. That night, a Doppler study showed no life-threatening blood clots. With no beds available, I was kept in the emergency department overnight, taking catnaps while trying to blot out the screams and moans from down the hall, before being given a room, and intravenous antibiotics, the next morning.

“This is very serious,” said Dr. Barry Statner, the infectious disease specialist who came to see me the next day in my hospital room. “We’ll cure you,” he said while firing questions at me about my medical history. “But you need to know, this is very serious.” I wondered if I was going to lose my leg.

For the first time in my life, I had entered the world of the powerless sick. Like most people, I had long heard about the dangers of contracting infections in hospitals or surgical centers, but I never took them seriously. I assumed that, except for the worst cases, such as those caused by improperly disinfected scopes and other instruments, they were little more than a minor annoyance.

In fact, infections kill, and they do so regularly, even to people who are otherwise healthy.

“There are diseases that can take a regular healthy person and destroy them within hours,” Dr. Statner told me. “You don’t get a second chance. People don’t realize how rapid and lethal infections can be.”

In the United States in 2014, one in 25 patients contracted a hospital-borne infection on any given day, according to the Centers for Disease Control and Prevention. Some 722,000 Americans developed such infections in hospitals in 2011, and about 75,000 died during their hospital stay.

I count myself as somewhat lucky. My wound was infected with a relatively run-of-the-mill strain of Staphylococcus aureus, and after a week in the hospital, followed by two weeks hobbling around the house, where a nurse visited daily to pack my wound with prodigious amounts of gauze, I was on the road to recovery. I was fortunate it wasn’t one of the more serious infections that lurk around hospitals, like MRSA, a “super bug” strain of Staph that is resistant to most antibiotics, or C. difficile, which can cause months of relapsing and severe diarrhea.

No one knows how my infection happened. It was the first, and only, case of this type of infection at the surgical center that year, I was told by Dr. Richard Hoberman, the medical director and the anesthesiologist who had put me under general sedation during my surgery. Clearly shaken by what happened to me, he unexpectedly popped in to my hospital room early in my stay to apologize.

My infection resulted in my being “the subject of several very uncomfortable meetings with the hospital administration” and a five-page written report, Dr. Hoberman said. (They passed on sharing a copy of that report with me.)

Hospitals are anxious to reduce hospital-borne infections, to reduce deaths and improve their reputations. There are also immediate financial incentives: Medicare may penalize hospitals for infections acquired in the facility.

The medical center I’d gone to for my surgery, associated with Los Robles Hospital, practices all the well-known standard forms of infection prevention: constant washing of hands; sterilizing equipment; giving patients preoperative antibiotics; cleaning operating room surfaces and thorough cleaning at night. In addition doctors are not allowed to enter the operating room wearing the same scrubs they wear in the street. To prevent the spread of microbes, cellphones and jewelry are banned, as well as ties.

But infections still happen. While most infections happen at the time of surgery, according to Dr. Statner, they can occur in the hospital room as well. A break in the skin, a lapse in the handling of a paper surgical cover, lackluster cleaning, intravenous lines or catheters that remain in too long — all can result in infection.

In the end, stamping out infections depends on the vagaries of human behavior. “Medical care is done by people. There can be gaps in quality. People must remember to do certain things,” said Dr. Arjun Srinivasan, the associate director for health care associated infection prevention programs at the C.D.C.

“Far too many Americans get sick in the hospital,” said Dr. Thomas R. Frieden, director of the C.D.C. “The importance of making care safer cannot be overstated.” One limitation is that the C.D.C. can only recommend, not mandate, practices to reduce infection, he said. And because hospitals are owned by various corporations, it can be a challenge to know how effectively patients are being protected in any one hospital. If a patient is moved from one hospital to another across town, he said, it “can cause problems,” given that one hospital may have less rigorous infection-reduction policies than another.

Hospitals are experimenting with new disinfection techniques. For example, some disinfecting machines using ultraviolet light are so powerful that no one is allowed in the room when they are in operation. And routine measures like thorough hand washing, and having patients thoroughly shower using chlorhexidine before surgery is helping bring infection rates down in the United States in recent years. In the three to six years before 2014, depending on the type of infection, the rate of surgical-site infections has dropped by 17 percent, C. diff by 8 percent and hospital-borne MRSA by 13 percent, according to the C.D.C. However, there was no change in the rate of urinary tract infections caused by catheters between 2009 and 2014.

Infection rates have dropped even more steeply in Britain, where total MRSA reduction from 2004 is now 80 percent, according to Dr. Mark Wilcox, the head of medical microbiology at Leeds Teaching Hospitals and the head of the C. difficile task force for Public Health England. Leeds Hospital used to see 15 to 25 MRSA infections per month; now it gets five per year, he said.

Dr. Wilcox attributes their success in part to having a coordinated, single health system for the entire country. To encourage hygiene, National Health Service hospitals post current infection rates on boards that can be seen by doctors, patients and visitors. Hospitals are “obsessional” about hand hygiene, Dr. Wilcox said. To do the best cleaning job, health workers must be “bare below the elbows,” with no watches on the wrist. Lab coats, while making a doctor look professional, are also banned, as they can brush up against patients and transfer bacteria from one patient to the next.

Hospitals that fail to meet infection reduction targets are visited by a “hit squad improvement team” that demands a new plan, Dr. Wilcox said. Those that fail lose the right to decide how to spend some of their annual budget.

“A decade ago, people would say that only a small proportion of infections are preventable,” said the C.D.C.’s Dr. Srinivasan. “Now we know that a large proportion are preventable. We’ve turned that paradigm on its head.”

Think Like a Doctor: Sick at the Wedding Solved!

Photo

Credit Anna Parini

On Thursday, we asked Well readers to take on a challenging case. A 38-year-old man who traveled to the mountains of Colorado for his brother’s wedding suddenly became ill. He had fevers and chills, chest pain, a severe headache and a sore throat. There was so much going on that it was really tough to see what might be underlying it all. More than 400 of you offered your diagnoses, but no one got it completely right. I had to choose two winners, each of whom was the first to get at least part of it right.

The correct diagnosis was:

Lemierre’s disease caused by an invasive strep infection

One of the winning answers came from Dr. Hediyeh Baradaran, a chief resident in the radiology department of Weill Cornell Medical Center. She recognized that an invasive strep infection could cause both the inflamed heart muscle diagnosed at one hospital and the abscess found at the other. She didn’t mention the Lemierre’s. That diagnosis was offered by Dr. Ariaratnam Gobikrishna, a cardiologist with Montefiore Medical Center in the Bronx.

The Diagnosis

In 1932, Dr. André Lemierre reported on 20 patients he’d seen who became ill with a sore throat and then went on to develop a clot in their jugular vein. The clot was infected with bacteria, and the disease spread from the jugular to the lungs, bones, brain and other organs when tiny pieces broke off, seeding the infection throughout the body. The illness came to be known as Lemierre’s disease, or syndrome.

Lemierre’s is rare, most commonly seen in teenagers and young adults. And it is frequently misdiagnosed, at least initially. In one study of hospitalized patients, a correct diagnosis of Lemierre’s was made, on average, five days after admission.

Most of the time the infection is caused by an unusual bacterium called Fusobacterium necrophorum, but it has been associated with other bugs as well. And no matter which bacterium caused it, in the era before antibiotics, Lemierre’s was practically a death sentence, with 90 percent of patients dying. Even now, it’s not a disease to be taken lightly. Up to 18 percent of patients will die of the infection.

However, it wasn’t some rare infection behind this man’s illness. Blood cultures drawn at Anna Jaques Hospital in Newburyport, Mass., where the patient went after returning home, revealed an underlying disorder that is much more common and much less feared: strep throat. There are millions of cases of streptococcal infections in this country every year, usually in the throat or on the skin. But in a tiny fraction of these cases, the bacterium will invade the surrounding tissues and cause a life-threatening illness, as it did with this man.

Both the Lemierre’s and the myocarditis were caused by this strep throat gone wild. This kind of invasive infection must be treated with antibiotics. This patient was taking an antibiotic, doxycycline, because the doctors were worried initially that he might be suffering from some kind of tick-borne infection, but that antibiotic is ineffective against most types of strep.

How the Diagnosis Was Made

After the patient’s flight back from Colorado to Boston, he had ended up in Massachusetts General Hospital, where he’d been diagnosed with myocarditis, or inflamed heart muscle. He began to feel a little better and returned home, but after a day he began to feel worse again. He was pale and sweaty, the way he’d been in the mountains. And the shaking and fevers were back. His headache was terrible, almost as bad as it had been in the hospital, where it had brought the man to tears — something his wife had never seen before.

The patient’s wife called Mass General several times with her concerns; the doctor who’d cared for the patient there suggested she take him to a local hospital. And that’s when she turned to her husband and gave him a choice: She could drive him to the hospital or she could call an ambulance, but he was going to go to the hospital – and he was going to go now.

At the Anna Jaques emergency room, the couple met Dr. Domenic Martinello. He heard their complicated story of traveling to Colorado and feeling sick, then returning to Boston and feeling sicker; then going to Mass General and getting a diagnosis of myocarditis, but not getting better. After a quick exam, Dr. Martinello decided to focus on the most prominent symptoms at that moment: the headache, the neck and throat pain, and the fever.

Scanning the Head and Neck

He would start with a CT scan of the head, he told the patient and his wife. And if that didn’t provide an answer, he would get a CT scan of the neck. And if he still had no answer, he would get a lumbar puncture, or spinal tap. One of those tests, he was certain, would provide the answer.

The head scan was completely normal. There was no tumor, no blood clot and no sign of increased pressure. That was important because Dr. Martinello suspected that the patient had some kind of meningitis, and if the scan had shown increased pressure, he wouldn’t be able to do a spinal tap. But as it turned out, a spinal tap wasn’t needed.

The emergency room doctor wanted the CT of the patient’s neck because it was swollen and tender. The patient had told him he had a sore throat, yet when the doctor looked in his throat he saw nothing. Could there be an abscess seeded deep in his oral pharynx from some earlier infection? Is that what was causing his throat and neck pain?

Photo

The arrow is pointing to a clot (darker gray) within the jugular vein (lighter gray).

The arrow is pointing to a clot (darker gray) within the jugular vein (lighter gray).Credit

It was the right question, though the result was not what Dr. Martinello expected. There was a small abscess. More worrisome, there was a blood clot in the patient’s jugular vein, on the patient’s right side. He had Lemierre’s disease, a rare infection that Dr. Martinello had seen only once before. You can see the clot in the CT image shown here.

Transferring to a Bigger Hospital

Now that Dr. Martinello knew what was making this man so sick, he was worried that his small community hospital was not prepared to care for him. They didn’t have the kind of specialists he needed on call 24/7. It seemed clear that the patient needed a hospital with more resources. So Dr. Martinello arranged for the patient to be transferred to a sister hospital, Beth Israel Deaconess Medical Center in Boston.

Identifying the Bug

Dr. Andrew Hale was the infectious disease specialist on duty the night the patient arrived at Beth Israel. When the patient and his wife arrived at the B.I. emergency department, Dr. Hale hurried to meet them. He spoke to husband and wife and reviewed their complicated history of the past week or so. But he also learned that both children had come down with strep throat while their father was at Mass General. It was an important discovery since, although unusual, it was well known that strep could cause Lemierre’s, He ordered another set of blood cultures and started the patient on broad-spectrum antibiotics.

Because the patient had been started on intravenous antibiotics while at Anna Jaques, there was a good chance that these cultures wouldn’t grow anything, but he needed to try. He also knew that Dr. Martinello had drawn blood cultures from the patient before he had started on the intravenous antibiotics, and was optimistic that these cultures would show what the bugs were. Identifying the bacteria that were causing the infection was important so that the antibiotics could be more narrowly targeted.

The cultures from Anna Jaques grew out Strep pyogenes, the most common cause of strep throat. The patient continued on antibiotics for six weeks and started a three-month course of a blood thinner to keep the clot from growing or spreading.

How the Patient Fared

That was a year ago. The patient is completely recovered. It was kind of funny, he told me recently. Even though his throat was painful, the sore throat seemed insignificant compared to the shaking chills, the fever, the headache. “I thought of it as kind of a sidebar, when in fact it was the main event,” he said.

Both he and his wife have read up on the illness and come up with a new family motto: Take strep seriously.

Think Like a Doctor: Sick at the Wedding

Photo

Credit Anna Parini

The Challenge: Can you figure out what is wrong with a 38-year-old man who suffers from fevers, insomnia and night sweats after traveling to the mountains of Colorado to be his brother’s best man?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a real-life medical mystery. Below you will find the story of a 38-year-old marketing executive from the Boston area who suddenly becomes sick when he takes his family to his brother’s destination wedding in the Rockies. Within a day of their arrival, the man begins to feel sick, though the rest of his family feels fine.

As usual, the first reader to offer the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” along with that feeling of satisfaction that comes from solving a difficult but really cool case.

The Patient’s Story

“Either you are getting in the car with me to go back to the hospital, or I’m calling an ambulance,” the woman announced. “It’s totally up to you.”

Her husband, 38 and never sick a day in his life, had been desperately ill for more than a week. He’d just gotten out of the hospital that morning, and after being home for less than 12 hours he was worse than ever. Though she couldn’t bring herself to say it out loud, she was worried he might be dying. And though he didn’t say anything, so was he.

It had started at his brother’s wedding, one of those destination events in the mountains of Colorado. And almost from the moment he stepped off the plane, he’d started to feel awful. His head ached. So did his body. His eyes were puffy, and his whole face looked swollen. He couldn’t eat, and he couldn’t sleep. When he went to bed that first night, he tossed and turned, though he felt exhausted. In the morning, when he dragged himself out of bed, the sheets were soaked with sweat.

Just the Altitude?

At first he wrote it off as altitude sickness. The resort was 11,000 feet above sea level, and he’d never been this high up. Though his wife and the kids felt fine, there were others in the wedding party who were feeling the effects of the altitude as badly as he did. One of the bridesmaids fainted at the rehearsal dinner. And an elderly aunt had to leave before the wedding.

The day of the wedding it snowed – in May. The kids were thrilled. His wife took them sledding. He’d spent the day in bed, trying – mostly unsuccessfully — to get some sleep. That afternoon the wedding service seemed to last forever. The tuxedo felt like a straitjacket. There was a pressure in his chest that made it hard to breathe. But he’d stood at the front of the church, proud to be best man to his younger brother.

After the service, the photographer led them outside, trying to capture the spring blossoms covered with snow that made the setting so extraordinary, and he worked hard to exhibit an enthusiasm he was too sick to feel.

By the time he made it to the dinner reception, his whole body shook with violent chills, and his head was pounding. His collar felt so tight he could hardly swallow. He’d been working on his toast for days, so his wife talked to the D.J. and changed the order of the toasts so that he could give his toast early. After completing it, he made his apologies, went back to the hotel and climbed into bed.

Feeling Worse and Worse

He figured he’d feel better when they got to the lower altitudes of Denver, where they’d arranged to spend their last night. But he didn’t. Even when he traveled back to Boston, down at sea level, he didn’t feel any better. He had some business in the city so was staying at a hotel while his wife took the two kids back to their home, an hour away. She was worried but he reassured her he’d be O.K.

But that night, alone in his hotel room, he felt so bad he began to get scared. If this was altitude sickness, he should be better by now. Everything he read on the Internet said so.

Finally he could take it no more. He went to the front desk and asked for a taxi and went to the closest emergency room, at Massachusetts General Hospital.

An Inflamed Heart

Because of his chest tightness, the doctors at Mass General ordered an EKG. To his surprise, it was abnormal, and he was rushed to the cardiac care unit. He hadn’t had a heart attack; they were sure of that. But something had damaged his heart.

After dozens of tests, the doctors told him he had something called myocarditis, an inflamed heart muscle, though they couldn’t tell him why. For three days they searched for the cause of injured muscle. Myocarditis is often due to a viral infection, but the doctors wanted to make sure they didn’t miss anything treatable.

At the top of their list, they worried that he had picked up some kind of tick-borne infection while in rural Colorado. None of the tests came back positive, but they sent him home to finish up a week of the antibiotic doxycycline, just in case.

You can read the notes from Mass General and the infectious disease specialist here.

Admission Note

Infectious Disease Notes

A Short Trip Home

In the hospital he felt a little better. His chest didn’t hurt, and his heart wasn’t racing. His fever went down. On his way home he felt like he was on the mend. His wife wasn’t so sure. And a couple of hours later, when she looked in on him again, she was frightened by how sick he looked.

He was pale and sweaty – the way he’d been in the mountains. And the shaking and fevers were back. His headache was so bad that he was crying with pain, something she’d never seen before. She called Mass General. The doctor there said that if she was worried she should bring him right back. But the prospect of an hour-long drive seemed daunting. She decided to take him to the local hospital one town over.

So, did he want her to call an ambulance, or should they go by car?

Back to the Hospital

The patient’s wife dropped off the kids at a friend’s house, then drove him to Anna Jaques Hospital in Newburyport, Mass. It was late by the time they arrived and the emergency room was quiet.

Dr. Domenic Martinello knocked at the entrance to their hospital cubicle. The patient’s wife looked up expectantly, her face tight with exhaustion. The patient lay motionless on the stretcher; his eyes were sunken, and his skin hung off his face as if he hadn’t eaten much recently. His voice was soft but raspy, and every time he swallowed, his lips tightened in a grimace of pain.

Together, husband and wife recounted the events of the past few days: the wedding, the fevers, headaches, pain in his chest, in his neck and in his throat, the four days in the hospital in Boston.

It was certainly a confusing picture, and Dr. Martinello wasn’t sure what to make of the diagnosis of myocarditis. But the patient had no chest pain now, only the headache, sore neck and painful throat.

He quickly examined him. The patient’s skin was warm and sweaty, and his neck was stiff and tender, especially on the right. He was going to approach this systematically, he told the couple. First he would get a head CT, then a scan of the neck, and then he would do a lumbar puncture – a spinal tap. He felt optimistic that one of those tests would give him an answer.

You can see Dr. Martinello’s note here.

Hospital Note

Solving the Mystery

Dr. Martinello did get an answer. But it wasn’t the one he was expecting.

The first reader to identify the cause of this man’s illness gets a copy of my book and the pleasure of making a difficult diagnosis. The answer will be posted Friday afternoon on Well.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Letting Patients Tell Their Stories

Photo

Credit Lehel Kovacs

Photo

Credit Earl Wilson/The New York Times

Friday night in the emergency department is about what you’d think.

It starts off slow: a middle-aged man with a middling pneumonia; an older nursing home resident with a urinary tract infection that is making her delirious. Then come two heart attacks at the same time, followed by a drunken driver with a head bleed and half his rib cage fractured. At midnight, in roll the inebriated members of a bachelorette party that has not gone, one assumes, according to plan.

Amid the chaos, I break off to greet a thin, older man, quietly bundled up on a hallway stretcher. I look over his chart and prior scans. His prostate cancer has grown through several chemotherapy regimens. His spine is full of tumor and he’s been vomiting everything he eats or drinks for weeks. He can’t move the left side of his body after a recent stroke.

He smiles a charming, crooked smile. “It hasn’t been the best month of my life.”

“I’m sorry to hear that.”

I ask him about his symptoms, when they started, how bad they’ve gotten. He asks me where I went to medical school and if I have a girlfriend. I ask him if he’s dizzy and whether there’s blood in his stool. He tells me he emigrated from Greece 50 years ago, almost to the day. He won a scholarship to M.I.T. and studied electrical engineering. There he met his wife — “a fantastic cook” — and started his first company.

Now, decades later, he’s alone — in a crowded emergency room, on a Friday night, his wife dead, his two sons overseas, a nurse visiting him once a week at home to help him with some medicines and make sure the various tubes coming out of his body aren’t infected.

I ask him when he last moved his bowels.

“Son, I’m dying. I’m alone. One day you’ll learn there’s more to a good death than how often I move my bowels.”

I pause.

I am better at many things than I was when I started my journey to become a physician more than a decade ago. But I am not sure that understanding patients as people — and placing them in the context of their long, messy, beautiful lives — is one of them.

Doctors are trained first to diagnose, treat and fix — and second, to comfort, palliate and soothe. The result is a slow loss of vision, an inability to see who and what people are outside the patient we see in the hospital.

As we acquire new and more technical skills, we begin to devalue what we had before we started: understanding, empathy, imagination. We see patients dressed in hospital gowns and non-skid socks — not jeans and baseball caps — and train our eyes to see asymmetries, rashes and blood vessels, while un-training them to see insecurities, joys and frustrations. As big data, consensus statements and treatment algorithms pervade medicine, small gestures of kindness and spontaneity — the caregiving equivalents of holding open doors and pulling out chairs — fall by the wayside.

But all care is ultimately delivered at the level of an individual. And while we might learn more about a particular patient’s preferences or tolerance for risk while explaining the pros and cons of a specific procedure or test, a more robust, more holistic understanding requires a deeper appreciation of “Who is this person I’m speaking with?”

In Britain, a small but growing body of research has found that allowing patients to tell their life stories has benefits for both patients and caregivers. Research — focused mostly on older patients and other residents of long-term care facilities — suggests that providing a biographical account of one’s past can help patients gain insight into their current needs and priorities, and allow doctors to develop closer relationships with patients by more clearly seeing “the person behind the patient.”

In the United States, Medicare recently began paying doctors to talk with their patients about end-of-life planning. These conversations allow patients to discuss and explore their preferences about a slew of complex medical interventions, including clinical trials, transfers to the intensive care unit, use of mechanical ventilation or feeding tubes, and the desire to die at home or in the hospital. These discussions, too, may benefit from a biographical approach, in which patients are able to elaborate on what is and has been most important in their lives. To better serve patients, we need to see not only who they are, but also who they were, and ultimately, who they hope to become even at the end of life.

How much more effective would we be as diagnosticians, prognosticators and healers if we had a more longitudinal understanding of the patient in front of us? If we saw not just the shrunken, elderly Greek man on the emergency room stretcher in front of us, but also the proud teenager flying across the Atlantic to start a new life half a century ago?

The emergency room is, by its nature, an arena designed for quick thinking and swift action. There are certainly other places, times and circumstances more conducive to probing goals-of-care discussions and lengthy forays into the internal lives of patients.

Still, there is always some moment of grace and meaning we can help patients find in the time they have left, a moment that recalls a time when they felt most alive — even if it’s just a fleeting conversation about gyros and electrical circuits in a busy emergency room, late on a Friday night.

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Dhruv Khullar, M.D., M.P.P. is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.

Think Like a Doctor: Drowning on Dry Land

The Challenge: A healthy 67-year-old man develops an annoying little cough that, over the course of a week, worsens and nearly takes his breath away. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine challenges Well readers with a real-life diagnostic question. In this case, a retired Air Force officer shows up in an emergency room with chest pain so severe he can barely breathe.

I will provide you with the history, data and imaging available to the doctor who made the diagnosis. It’s up to you to make it all make sense.

The first person to identify the cause for these symptoms will win a copy of my book, “Every Patient Tells a Story.”

The Patient’s Story

“I think you’re dying,” the anxious wife told her husband of 38 years. Her 67-year-old spouse sat propped up at the head of the bed. His chin rested on his chest and his face bobbed up and down with each rapid fire breath. He gazed up at her from beneath his shaggy gray eyebrows.

“I’m going … to be … O.K.,” he panted in a whisper.

She didn’t think so, and she wasn’t alone. She had just spoken to one of his oldest friends, and he was worried too, she told her husband. The friend thought they should go to the hospital.

“Now?” the man breathed.

She nodded. He finally nodded in return. He would go.

A Knife in the Back

It all happened so fast. An annoying little tickle that started maybe a week before was now a great wracking cough. Every breath felt like a knife cutting through to his back. The pain was so severe he couldn’t take a deep breath, and he felt like there was so much stuff in his lungs that the little breaths he could take didn’t bring in enough air.

As he sat on his bed struggling to breathe, he suddenly flashed back to a morning many years ago when, as a small child, he’d fallen into the deep end of the pool. He sank to the bottom, arms and legs flailing, the need for breath overwhelming. Suddenly he saw an explosion of bubbles, then felt strong hands lift him up, back into the air. Back where he could breathe.

Now more than 60 years later he felt like he was struggling the same way. This time without the water, but still in need of rescue.

The 30-mile drive from their home to Huntsville Hospital in Huntsville, Ala., was mostly on the interstate, but every tiny bump or dip brought a soft grunt of pain. The man held onto the strap above the window, willing himself motionless.

His wife walked him into the emergency room, then hurried to park the car. By the time she got back he was already in a bed and, with oxygen piped into his nose, a little more comfortable.

Downhill at the Fishing Camp

Dr. Robert Centor, the attending physician on call at the hospital, had heard about the patient the night before and was eager to see him the next morning on rounds.

He’d started off with a little nothing of a cough, the man told Dr. Centor. He mentioned it to his own doctor just before he went out to his fishing camp with some pals. After listening to his lungs, his doctor had pronounced him “just fine.”

But the cough kept getting worse, going from occasional to constant practically overnight. He couldn’t read or eat or sleep. Lying down made it even harder to breathe, so he spent two nights in a recliner. And the friends who’d come to the camp with him got absolutely no sleep because of his persistent hacking.

The third day of their trip, his chest began to hurt. Every breath felt like a dagger. Moving made it worse. So did breathing. He got out of breath just walking to the kitchen. His friends were worried. And, finally, so was he.

As soon has he got home his wife took him to the local emergency room. A chest X-ray showed cloudy white patches over both lungs. He had no fever nor any sign of infection, and so the E.R. doctor figured it was probably his heart. The patient could stay in the hospital and see his doctor there or go home and see her in her office the next day.

It was an easy decision: He’d much rather go home. The E.R. doctor admonished the patient to see his doctor as soon as he could and let him leave.

A Problem Heart?

The patient saw his doctor a couple of days later, and a brief exam convinced her that the E.R. doctor was right: It probably was his heart. It was hard to imagine any other reason for there to be clouds all over both of his lungs. Not too many things could do that. You could see it with a whopping pneumonia – but he had no fever or other signs of infection. Or you could see it with something known as congestive heart failure, which is what the emergency room doc thought he had.

Congestive heart failure reflects a problem not with the lungs but with the muscle of the heart, the doctor explained. It gets injured somehow – maybe because of a heart attack or infection – and suddenly it can’t beat as strongly as it had. Fluid from the blood, which should have been pumped out into the body, was instead backing up into his lungs.

She sent him home on a powerful diuretic to help draw the water out of his chest and arranged for him to have an echocardiogram, an ultrasound of his heart, to confirm her diagnosis.

The diuretic kept him in the bathroom for much of the next two days, but it didn’t seem to help at all. And so his wife, with the support of his friends, finally convinced the breathless man not to wait for the “echo” but to go right then to the big university hospital in Huntsville.

A Healthy Guy, Until Now

As the man and his wife told their story, Dr. Centor took a good look at his new patient. He was tanned and trim – clearly not someone who spent much time being sick. But he coughed frequently, and every paroxysm brought a grimace of pain to his face.

Before this, the man told him, he’d been pretty healthy. He took a medication for high blood pressure and another for his heartburn. A month earlier, he’d had knee surgery, an operation that left him with a big pus-filled wound – red, hot and incredibly painful. So, for the past few weeks his wife had been injecting a syringe full of an antibiotic, called Cubicin, into an intravenous line he had snaking up through his left arm. It was clearly doing its job because, although his knee was still pretty sore, there was no more pus and it looked a whole lot better.

He quit smoking five years ago. He drank sometimes with his pals on special occasions but hadn’t had anything since he started taking the antibiotic. He exercised regularly, at least before the surgery.

The couple had a dog, but no birds or other pets. He had retired five years earlier, but during his career he had been assigned to bases all over the world – especially the Middle East. He spent a lot of time in Afghanistan. And he’d done some time as a pilot in Vietnam, where he’d been exposed to Agent Orange, the herbicide used there that had been associated with many health problems later in life.

Working to Breathe

On exam, the patient’s breathing and heart rate were high and his oxygen level was low – a bad combination.

Dr. Centor gently placed a hand on each side of the patient’s neck and could feel the strap muscles there tense with every breath. These muscles are recruited to help breathing when needed; they pull the rib cage up to help the patient suck in more air. And when Dr. Centor listened to the patient’s lungs he heard a cacophony of tiny snaps with every breath, as if inside his ribs a sheet of bubble wrap was exploding. His knee revealed a well healing surgical scar.

Dr. Centor had already seen the X-ray and CT scan done the day before. You can see the chest X-ray and the CT report here.

Photo

The chest X-ray showed cloudy white patches over both lungs.

The chest X-ray showed cloudy white patches over both lungs.Credit

The CT Report

Reviewing the Notes

The radiologist thought it was an infection, and so the patient had been started on the usual antibiotic combination for pneumonia. But why had this healthy retiree developed a whopping pneumonia – not in part of one lung, which is usually what occurs with pneumonia, but all over, and in both lungs?

Dr. Centor reviewed the notes from the E.R. and from his resident, and the data from the labs. You can see those notes and labs here.

Emergency Room Note

The Resident’s Note

The Lab Reports

Solving the Mystery

What was he missing? Dr. Centor asked himself.

He figured it out. Can you?

Submit your responses in the Comments section. As usual, the first person to figure out the diagnosis gets a copy of my book. And that warm satisfaction that comes from solving a mystery.


Rules and Regulations: Post your questions and diagnosis in the comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.