and they told her they couldn’t do anything until someone was missing for twenty-four hours. I suppose they figured another wayward husband out on a fling. But she called again after an hour had passed, and the police interviewed her and put out a search for him. This morning a motorist saw a car parked on an off ramp with a man slumped over the wheel. He called the police and they called the paramedics and that’s when we came in.”
“So the wife will be here soon?” asked Pollard.
“Yes, in about thirty minutes.”
“Did she tell you who his doctor was?”
Gail responded, “She said he had a complete physical from Doctor Baehler not too long ago. I called his home and his wife says he’s on the way to the hospital. I was just about to call his cell.”
“Go ahead. See if we can get him. Let me talk to him,” said Pollard.
As it turned out, he was only a few minutes from the hospital when he received the call. “John?”
“Jason? If I’m hearing from you first thing in the morning I’ve got a feeling I’m in for a bad day.”
“Your patient, Arnold Spann, was just here.”
“Arnold? Was just there…in the emergency room?”
“Yes, he’s on his way to Intensive Care and I’ve put him in isolation.”
“Oh boy, give me the bad news.”
“Oh boy is right. He’s got a fulminating meningitis and is in extremis.”
“You’re kidding.”
“I wish I was.”
“Why the hell?” said Dr. Baehler.
“That’s the big question. Has he been sick? Is he immunosuppressed?””
“No. I only saw him for a general physical not too long ago. He was in great shape. This is unbelievable.”
“You haven’t done a spinal tap lately?” said Pollard thinking of the abrasion he identified.
“No way.”
“Did you refer him to a neurologist?”
“No. Why do you ask?”
“He had an abrasion on his back by L4 and for a moment I thought it might have been from a recent tap, but I’m sure he just injured himself.” Pollard continued, “His spinal fluid was confirmatory. It looked like pure pus. The pressure was elevated. He had seizures and is in deep coma. This is a bad prognosis. I would call infectious disease stat.”
“Okay, I’m pulling in to the parking lot. Thanks, Jason.”
“You’re welcome. All the lab work is pending. His wife is on the way to the hospital. After I speak with her, I’ll send her up to Intensive Care. Good luck. Keep me posted, please.”
Pollard hung up the phone and drew a big sigh. “Gail, I’m going to the office to talk to the students for a few minutes. Bring Mrs. Spann to me when she gets here, please.”
He entered his office, his head down and his right hand still stroking his forehead. He sat down and looked at the students, their eyes burning a hole in his forehead. He said, “We don’t often start our day with such a bang. If you noted surprise registered on my face it was because I happen to know this patient. He is a physician and a member of the Medical Executive Committee. He paused. “But let’s get on with what you could learn.”
They spent five minutes discussing the various types of meningitis: bacterial, viral, fungal. They reviewed the typical symptoms and signs, the confirmatory tests, the treatment, and the prognosis.
Then Pollard said, “But I have a bigger question for you to ponder. Why the heck did he get meningitis in the first place? Before I came back to the office I spoke to his physician who said that he was a very healthy man and enjoyed good health.”
“Will we ever know?” asked Amanda.
“I hope we find out by means other than autopsy, but we may not. Believe me at this point it’s very confusing. You saw me examine his ears nose and throat because I was looking for a source of infection. You saw me checking the whole length of his vertebrae as well for the same reason. There are two ways that bacteria can reach the meninges: first by extension from nearby infections, such as from sinuses, nose, throat or ears, or along the vertebrae such as an epidural abscess; second by hematogenous spread, that is by reaching the meninges through the blood stream from some distant site. I couldn’t find any obvious source from either route. Granted I was in a hurry to examine him and so I didn’t do a thorough detailed exam. It’s a mystery, but we can’t let pondering about a source stop us from starting a full course of treatment. This man’s life is at stake.”
At this point, the phone rang in his office. He picked it up. “Hello. Oh good. Let’s hear.” His right hand again stroked his forehead. “Staph? How much? Okay thanks. His wife not here yet? Bring her in the minute she gets here. Yes, call Baehler now. He should be in Intensive Care. Bye.” He leaned back on his swivel chair.
“That was Mrs. Cowan. The gram stain is back. The bacteria are staph. Could you believe it? Staph aureus. That’s very unusual and at the same time very bad. We’ve discussed the more common organisms. Also, his complete blood count is back, and it’s normal except for a four thousand white blood cell count. You remember the normal? What is it?
“Five to ten thousand.”
“Correct.”
“It should be high because of the infection,” said Amanda.
“Yes, that’s right,” he said. “So what does a reduced white blood count tell you?”
“Could it be a lab error?” asked Barry.
“Not much chance. These tests are all automated and it’s near impossible to make a mistake.”
“If it’s accurate then I would think that for some reason he’s unable to launch a white blood cell response. Is something wrong with his bone marrow?” said Amanda.
“Probably not,” replied Pollard. The blood count and the platelets are within normal limits, so that tells us that the bone marrow is capable of manufacturing those cells. But you’re on to it. He has a reduced white blood cell count in the face of a severe infection. One would expect a count of twenty, thirty thousand or more in a case like this. The bone marrow is working overtime launching white cells to attack the invading bacteria. This has been such a massive effort that the bone marrow can’t release any more white blood cells, and when that happens it is a very poor prognostic sign. It means that he is no longer able to utilize his first line of defense: his white cells. Without those, it wouldn’t surprise me if the bacteria take over and this patient is now in septic shock. Without white cells you can replace his blood with antibiotics and it won’t make a difference.” He sighed and got up from his chair.
As the students stared wide-eyed at Pollard he said, “In the Emergency Department things don’t grind to a halt after a gut wrenching experience. Let’s get back to work.”
CHAPTER
