the patient’s response to pain stimulation,” said Amanda.
“Right. Am I getting a response?”
The students observed the patient while the pain stimulus continued. He did not move or wince. “No,” they said together.
“Right. What does that tell you?”
“The coma is deep.”
“Good. We have the history of seizures and high fever. That’s all the history we have, except for the fact that he was missing for two days, plus we just learned he’s in deep coma by his failure to respond to intense pain. What should I do next?”
Before his students could answer, he placed his hand under the patient’s head and tried to flex the neck. The unconscious patient’s hips and knees flexed. “What do you call that sign?” asked Pollard.
The students looked at each other and remained silent.
“Brudzinski’s sign,” said Pollard, and in a non-deprecating manner he added, “Did you forget all your physical diagnosis already?”
He then flexed the patient’s right leg at the hip and then attempted to flex the patient’s right knee, but had difficulty as he met considerable resistance.
“And what do you call this sign?” Hearing nothing he added, “Kernig’s. You’ll never forget these signs now. What we read about we easily forget. What we witness or perform ourselves we never forget. What are these two classical signs indicative of?”
“Meningitis,” said Barry.
“What causes those signs you just witnessed?” Pollard asked.
“Meningeal irritation?” asked Barry.
“Close enough. It’s thought to represent irritation of motor nerve roots as they are put under tension and pass through inflamed meninges. At this point, I have to confirm this strong index of suspicion of meningitis because we need to identify the organism causing this disease. We have made a clinical diagnosis, and that diagnosis is important and serious enough that we have to confirm it and start therapy. We have no time to lose. How will I confirm it?” he said.
Pollard continued his methodical way of examining the patient while talking to the students without looking in their direction. Here was a man focused on the task at hand. All other thoughts suppressed as his mind and hands worked in close collaboration like the first violinist in a symphony orchestra.
“You do a spinal tap,” said Amanda.
“Perfect,” he said.
Gail entered the room at that point and Pollard, out of the corner of his eye, saw her coming. “Gail, I’m going to need a spinal tap tray stat.”
“Here it is.”
Again, without looking up, he said, “You see. Now do you believe what I said about her before?” He winked at Gail. “She knows what I’m going to need before I know it. I’ll need the usual blood work up. A complete cbc, and full profile stat plus an immediate blood culture times two.”
“Yes, doctor. The lab’s on the way.”
Then he reached for an ophthalmoscope and looked into the eyes of his patient. “Why am I doing this?” he asked.
There was no answer.
“I’m trying to rule out evidence of a mass lesion that would cause severe enough increased intracranial pressure making a spinal tap hazardous. It could cause a cerebellar herniation if I relieve some pressure doing the tap. I get a rough estimate of the pressure by looking at the optic disc.” Examining as he talked he continued, “No. There is no papilledema, or swelling of the optic nerve disc. Does that rule out a brain tumor?”
Both students looked at each other, but no answer came forth.
“The answer is no,” said Pollard. We don’t have time for a CT scan. We’ve got to act fast.”
The students felt the tension. It was clear that Pollard was dealing with life or death.
With the patient positioned on his left side with hips and knees and chest and neck flexed as much as possible, Pollard asked Barry to hold the patient in that position. Pollard sat down facing the patient’s lumbar area. Before he performed the tap, he noted a half-inch superficial abrasion exactly at the insertion site. It appeared recent. There was a spot of dried blood present.
I wonder what that’s doing there? Has he seen a physician? Could he have hurt himself? I’m sure that’s it. I have to go in close to the abrasion, he thought. There’s enough viable and healthy skin that will enable me to miss it. Good enough. I’ll use plenty of antiseptic.
He took the long spinal needle and inserted it between the spinous processes. Normally the cerebrospinal fluid is crystal clear, but when he took the trochar out of the hollow spinal needle he noted that the emerging fluid was very cloudy and the pressure by manometer was 280 (normal 100-200). He collected the fluid in several test tubes and said, “We’ve just confirmed our clinical diagnosis: meningitis it is.” He held one of the test tubes of fluid up to the light and shook it so the students could see the marked cloudiness. “If I did a spinal tap on either of you right now, the fluid would be crystal clear. What does the cloudiness represent?” He asked.
“Bacteria,” said Amanda.
“Or fungus, perhaps, or malignant cells. I’m sure you’re right, but the lab will confirm this soon. Gail, take these tubes and send them to the lab. We need a culture for bacteria, Tb, and fungus. Do a gram stain for bacteria, and an acid-fast stain for Tb, and an india ink for cryptococcosis. Get a cell count, glucose, and protein. Read it back please.”
Satisfied, he said, “Okay, we’re done. Let’s go write treatment orders and call his personal physician if he’s got one. If not, we’ll get hold of the internist on call. We need to keep the patient on his side now and put up the guardrails. He’ll have to be admitted to Intensive Care stat. His situation is urgent. Let’s move.”
When they arrived at the nurse’s station, he told the two medical students to go to his office and wait there for him. When he was sure they left, he turned to Gail and said, “Do you believe what just happened? Are we being cursed?”
“What a shock,” she said shaking her head. “Why the heck would Dr. Spann get meningitis?”
Pollard shrugged his shoulders. “You’re guess is as good as mine. Most of the time we see meningitis in college epidemics, or in ill patients with some underlying disease process and/or a compromised immune system. We both know this man. He was in great shape as far as I knew. But that’s what medicine is all about…one surprise after the other. And the truth of the matter is that with his depth of coma we’re dealing with a very poor prognosis. Now we’re confronted with the second physician from the Medical Executive Committee; the first one, Harrison, dead, and Dr. Spann in extremis. What the hell’s going on?”
“My God, you’re right. This has been a terrible few days,” said Gail. “Two Medical Executive Committee members; one dead and one dying. I can’t believe it.”
Pollard stared down at the floor and rubbed his forehead with his right hand. After a short while he said, “Were you able to get hold of his
