March 21, 2014

things rarely present like they do in the textbook

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     I came home from working at the pediatrics clinic all day and told my wife, "If you get syphilis, this is why.  But don't worry.  It's really easy to treat."

     Needless to say, she was not amused.  A rather precocious teenaged patient had come with a rash that was rather widespread.  And the rash didn't look like anything I'd seen before.  Common sense says to wear gloves, which I fortunately I remembered to do.  I went out and presented to my attending.  When he asked me what I wanted to do, I honestly replied, "I've got nothing."

     We both walked in and he looked at the rash in a similar fashion.  I could tell he was just as perplexed as I was.  We went and got the Nurse Practioner.  The NP came in, shrugged her shoulders in uncertainty and thought it might, maybe, just possibly, I don't know be an atypical case of a staph infection, emphasis on the word 'might'.  So the patient got amoxicillin and sent on their way with a follow up in three days because honestly, we were anything but sure.  In the back of everyone's mind lingered the thought, "is this syphilis?"

     Sir William Osler, the founding father of modern 20th century of medicine said, "He who knows syphilis, knows medicine."  The rationale of that statement is because syphilis can pretty much do whatever it damned well wants to do - rash, fever, muscle aches, joint pain, heart disease, brain disease, psychiatric symptoms, etc.  But we rarely see it anymore because it's highly susceptible to antibiotics.  Most people in the western world have had a dose of penicillin or a z-pack for a respiratory infection or sinusitis.  That antibiotic would've knocked out any syphilis hanging around.  So much like rheumatic fever, it's becoming a thing of the past, which is a good thing.

     The patient returns three days later.  I walk in and it's clear the rash hasn't improved at all.  In fact, it's gotten worse.  Again, I smartly put on gloves but now notice that the rash has spread to the palms of the patient's hands.  In the immortal words of Scooby Doo, "Ruh-roh".  There are only a handful of rashes that go to the palms, syphilis being one of them.  It also means that at that stage of syphilis, the lesions are teaming with the parasites.  Even a simple handshake can spread millions of the little buggers.  I've never washed my hands so thoroughly as after that visit. 

     But the patient was already on antibiotics.  Was this a resistant form of syphilis?  Gonorrhea is making a strong comeback with resistance to our usual armamentarium.  So why not syphilis?  We ran the blood tests of syphilis but in the meantime, tried another approach.  We kept her on the antibiotics but treated her as if it might be scabies.  Or, bed bugs.  Hell, it really didn't matter in the end.  It didn't look like either but hey, this is the art of educated guesses.  Again, another three days pass and the patient returns.  This time the rash is subsiding so it must have been an atypical presentation of scabies rather than an atypical case of syphilis.  Who knows?  My wife was only mildly relieved.  She threatened to have me start stripping in the garage before coming home and heading straight to the shower.

     So the next time you hear some politician talking about how medicine can be just algorithms and essentially a cookbook, please, please, please don't vote for that person if you want to help me.  Sure, the algorithm will help about 80% of the patients but removing any concept of actually thinking and relying on our decade of training is going to hurt the other 20%.  It is MUCH more subtle and complex.  There's a reason our training is so long and education continues lifelong.

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