It was during the final leg of the 10K that Amanda started to feel dizzy. Perhaps her boyfriend Dean was right, and she had overdone it. With a triathlon and an Iron Man contest in the last month, it might have been better to sit this one out. But her favorite charity has sponsored this event and she had promised her self she would make it this year. It wasn’t a timed event, so she would walk it out the rest of the way. It was another runner who stopped ask her if she was OK? When she said she was fine, just tired, she began coughing, and she covered her mouth with her hand. When she whipped her hand on her shorts she saw the red streak. She had started to cough up blood.
After she walked across the finish line, she met with the ladies at the First Aid tent, and she was advised to go immediately to the clinic. At the clinic, she told the nurse her training schedule, that she had recently done a triathlon and an Iron man contest and was just a little fatigued. She coughed again into a Kleenex that she pulled from a box on the table. It was soaked with blood. The nurse called for the doctor.
Peter James Smyth, MD, or “Pete” as he preferred was new at the clinic. Having emigrated with his wife Amelia, an American who had studied marketing in Edinburgh. Pete was in final year of studies, and during a bank holiday break had attended a soirée with his sister Eileen. Eileen introduced Pete to her classmate Amelia. She was captivated by his smooth charm and boyish good looks, he by the way she laughed and, of course, that crazy American accent. Amelia had gone up in Boston, the only child of Hungarian immigrants. Her father had commented, good naturedly, that he had sent her to England to get an education not a husband. He was glad to see she had returned with both.
After taking Amanda’s history, the Peter Smyth ordered blood work, and soon a young lady dressed in white and pushing a red cart appeared at the door. Blood was taken, and the doctor came back in to continue his questions. Had she any drug use? “No” she replied. Any falls, accidents, or anything that might produce trauma? Again she responded no. Her temperature was normal; oxygen saturation was perfect, tendon responses normal. Palpitation of her abdomen revealed acute pain response; Psoas and Rovsing’s were negative, ruling out appendicitis. Further examination revealed negative Murphy’s, ruling out cholecystitis. Dr. Smyth was perplexed.
When lab tests came back as normal Pete Smyth ordered a bronchoscopy, and she was taken to the X-Ray department for the procedure. One probable cause of coughing up blood is a problem with the lungs. The doctor received a phone call from the x-ray department explaining that Amanda’s lungs were clean. She was being brought back to the ER. Next to be considered was gastric ulcer. Gastric cancer can also cause coughing or vomiting of blood. Soon Amanda found herself back in x-ray department undergoing endoscopy. Endoscopy uses a thin, lighted tube that is inserted through the mouth and into the stomach to look for the presence of an ulcer.
The report from endoscopy was both predictable, and odd. There was a presence of blood, as the physician expected, but no sign of an ulcer. In fact, the stomach lining looked perfectly normal. Reviewing the report, Dr. Smyth though, what was going on with this woman who seemed to be in perfect health, but was clearly not. It simply didn’t make sense. She had no obvious infection; there were no lung issues that he could see, and no ulcer. She reported no trauma and she claimed no drug use. It all added up, but the sum made no sense. Amanda was kept for observation, and her boyfriend had arrived with her nightgown and slippers.
The next morning Amanda awoke, requested breakfast, and was pacing the hall by the time Pete Smyth made his rounds. When she asked when she could go home, Dr. Smyth could think of no reason to keep her. She checked out by 11 AM, and Dean took her home.
“What is wrong with me,” Amanda asked the ER physician on duty. She had felt great for the last few days, and this afternoon while walking to her car she doubled over in pain. Dr. Smyth, currently off duty, was paged. When Pete Smyth came to the examination room and saw Amanda, he was visibly surprised. When she told him the symptoms have returned, he was even more so.
The questions and answers began again. Nothing had changed so far as she knew. She took the rest of the day off when she left the hospital earlier in the week, and felt so good that she had some did up to just being tired, having done too much. But almost immediately she began to feel odd. And then, after a night of tossing and turning with a stomachache, she went to work exhausted. Walking to her car this afternoon she had doubled over in pain. A coworker had called 911 and the ambulance had brought her here. She looked at Pete Smyth, and through tears asked, “Why is this happening?”
Now, back in an observation room, Amanda underwent the routine again. More blood was being drawn, lab work completed, and Pete Smyth was even more perplexed. This time the tests included an MRI of her chest and abdomen. The next morning during rounds, Pete spoke with a colleague about his unusual case. Aside from suggesting that his patient had an ulcer, or possibly an underlying chronic condition, he was a little help. Dr. Smyth new that whatever it was that was affecting his patient it was occurring outside of the hospital. He ran down to the list of usual culprits.
There didn’t seem to be an infection. Amanda reported having no allergies. What was left? “Toxin” came a response from the man standing next to him in the elevator. Suddenly, Dr. Smyth realized he had been talking to himself out loud. Pete Smyth, feeling a bit embarrassed, apologized. The man smiled and said, “If you have ruled out infection and allergy you need to look at toxins. Quickly Pete Smyth searched for the man’s nametag. It read “Dr. William Harford.” “Are you a physician here?” Dr. Smyth asked. “I am a Clinical Epidemiologist. My office is on the 3rd floor. Most people never even know I am here,” he said as he smiled.
Pete Smyth introduced himself, and asked if he might have a few minutes to talk with someone? “Do I have time to get a cup of coffee?” He asked, and the elevator doors opened to the lobby, across from the coffee shop. Dr. Smyth had been headed to the lab and had stopped one floor short. He looked at Bill Harford and said, “I’ll join you.”
The two men emerged from the elevator on the second floor, turned left past the nurse’s desk, and went into the room where Amanda was resting. As they entered, she opened her eyes and looked at the two men. “Wow. I must really be sick if you’ve had to recruit help,” she said, half smiling. Pete Smyth saw that the chart had been updated, and looked quickly at the lab results. Again, very odd. Turning to Amanda, Pete Smith said, “you’re a fine specimen. At least according to these test results.” Then he introduced Bill Harford. She smiled at both men, and the corners of her mouth were stained red.
In Bill Harford’s office on the 3rd floor, both men sat in front of a round coffee table and considered the odd presentation of Amanda’s condition. All tests that would indicate anything out of the ordinary have revealed nothing abnormal. Abdominal pain, coughing blood, yet no cause can be found. “Well, what do we know as of right now” the epidemiologist asked. Getting up and walking across to a whiteboard hanging on a wall, he made two lists: Symptoms and Causes.
Under symptoms, he passed the blue marker to Pete Smyth and sat down. Dr. Smyth walked to the board and began writing. Abdominal pain, Bloody sputum, Fatigue, Abdominal tenderness, and Insomnia. Under Causes he wrote: Myocardial infarction, diabetic ketoacidosis, Ulcer, Cholecystitis, Hypercalcaemia, Angioadema, Lower lobe pneumonia, Dug Use, Ectopic pregnancy, Severe UTI, Placental abruption, ovarian hyperstimulation, Idiopathic inflammation.
This process, known as differential diagnosis, or murderboarding, allows medical and clinical practitioners to work out the most likely cause of a condition or symptom. The presenting symptoms were acute abdominal pain and coughing blood.
As the MRI and bronchoscope found no inflammation in the lungs, Smyth crossed out Pneumonia. “Hematocrit?” asked Bill Harford. Smyth responded “44,” and drew a line through Inflammation. “Vomiting?” asked Bill Harford? Shaking his head, Dr. Smyth drew a line through “Cholecystitis.” Looking at the list, it was decided that due to her activity, Amanda was most likely not diabetic, nor was it likely she had suffered a heart attack, and these were lined out. As no ulcer was discovered on examination, a line was drawn through Ulcer. “Pregnant?” asked Harford. Dr. Smyth looked through the lab results. “Nope” he said, and drew a line through Ectopic pregnancy.” “Fever?” asked Harford. “None” responded Smyth and he drew a line through Severe UTI. Stepping back, both looked over the board, now crisscrossed with lines. “Hormone levels normal?” asked Harford. “Glancing again at the lab results, Smyth walked to the board and crossed out Ovarian hyperstimulation. As both looked at the board they could agree on what was left: “Placental abruption would have shown up on the imaging tests,” Smyth said, so it too was crossed out.
One possible cause was left: Drug use.
Thinking back to the few moments he had spent with Amanda, Bill Harford was hardly convinced that she was suffering the effects of drug use, which was echoed by Pete Smyth. “If not that, what?” asked Smyth. I still think we need to consider toxins, the epidemiologist said, “at the very least you need to ask her some direct questions about what drugs she may be taking, prescription or otherwise.”
It was about 9:30 am the following day when Bill Harford’s phone rang. It was Pete Smyth. He called to say that Amanda was being discharged. Just as the last time, her symptoms had cleared up and, while Dr. Smyth had encouraged her to stay until they had figured out what was going on, she had said she felt great. Dean was here and she asked if she could leave.
Aside from the usual traffic accidents, coughing children, cuts, scrapes, and contusions, life was back to normal in the ER, and soon Pete Smyth had forgotten all about Amanda and her odd symptoms. The reality was that some illnesses remain idiopathic and resolve themselves over time. He didn’t know it yet, but Amanda’s would not be one.
It had been six weeks since her last visit to the ER. She had followed up with her family doctor, and seemed to be back to normal. She woke up today in excruciating pain. She made it to the bathroom just in time to vomit blood before passing out. Her boyfriend Dean had called the ambulance and she was back in the ER. This time, the intake nurse recognized her and immediately called Dr. Smyth.
Pete Smyth was in the cafeteria having an early breakfast with Bill Harford. Since meeting last month the two had become friends, and they discovered many common interests, including sailing, and Irish Football. When he heard his pager, he took his cell phone and dialed the ER. After a few seconds he turned to his colleague and said, “You’re not going to believe this.”
Standing in the exam room the two colleagues spoke with Dean. The symptoms were the same as before. She felt great, got back into her fitness routine, everything seem to be going great.
Dr. Smyth looked over his previous notes. He had run all the tests, he had run the labs, and everything appeared normal. Yet clearly something was very wrong. But what was it? Had she lied about drug use? He needed to start from square one. He had to start fresh and forget her previous visits to the ER. He needed a fresh look, and he needed help.
As Drs. Smyth and Harford stood in Harford’s office, Pete Smyth turned to Bill Harford and asked, “What was it you said about toxins?” Bill Harford thought back to their first conversation. “I simply commented that for an acute attack they were very limited causal agents, one being exposure to a toxin.” Pete Smyth nodded his head. “Must be”, he said, “But what?” Bill Harford walked to the dry erase board and said, “What do we really know?”
Pete Smyth shook his head, “not a lot.” “We know that she has been in the ER three times for the same symptoms. We know that the symptoms clear up within 36 hours and she goes home.” “What was the time differential between her first and second visits?” asked Bill Harford. “Just a couple of days” came the response. “And how long since her second visit?” Harford asked. Looking at the discharge sheet from Amanda’s second visit, Pete Smyth though for a moment and said “Over 6 weeks.” Dr. Harford thought for a moment before asking “Was she this ill before?” Dr. Smyth responded that she was not nearly this ill at either of the last two ER visits.
Dr. Harford thought for a moment before suggesting “If it’s a toxin, she must’ve had significantly higher exposure this time. But why a time delay? What was different?”
Dr. Smyth asked if there had been any changes recently? Had she change jobs? Was there a new apartment? Could he think of anything that was different? Dean thought for a moment and then shook his head, he could not think of anything that had changed. He did say that she seemed much worse this time.
Amanda had been transferred directly from the ER to the ICU, and was still unconscious. Looking at the nurse’s notes, Pete Smyth turned to Bill Harford. “There is a new symptom,” he said, low blood pressure.” Bill Harford asked, “Is there anything from the list of conditions from before that would suggest hypotension?”
“Only drug use” was the response.
Jen Barlow, MD was the hospitalist attending to Amanda now that she was in the ICU. Meeting with Pete Smyth, she asked if he had any idea what was happening with Amanda? He explained that he had been discussing the case with Bill Harford and they were drawing a blank. “The epidemiologist?” she asked. Pete Smyth replied that he had been helpful in narrowing down the possible causes. So far, the only thing that fit was drug ingestion. Dr. Barlow said that she had ordered blood work to test for the known street drugs, but that she did not seem to fit the profile. “Athletic, professional people tend to be overly concerned with their health” she said. Still, she knew Dr. Harford and she knew he was more than thorough.
When his beeper sounded, Pete Smyth reached for the wall phone in the ER. It was Dr. Barlow. Amanda was awake. The ER was quiet, and there were two residents on duty. He called Bill Harford and the two met at the nurse’s station in the ICU. Dr. Barlow joined them, and the three walked to Amanda’s room. Upon seeing Dr. Smyth Amanda began to cry. “What is wrong with me? Why does this keep happening?” Pete Smyth walked to her bedside and held her hand. “That is what we are trying to figure out”, he said. He had not noticed that Dean was seated nearby and immediately arose to go to Amanda’s bedside. He seemed annoyed, but perhaps this was due to her deteriorating illness. She had said that she felt better, and asked when she might go home. Pete Smyth turned to Dr. Barlow saying “we would prefer to keep you here until we can piece this together.” She nodded, and forced a smile.
Over the next 48 hours Amanda’s condition steadily improved. Her blood pressure has returned to normal, her abdominal pain had subsided, and she began to feel impatient about staying in the hospital. Dr. Barlow explained there was little need for the ICU at this point, and Amanda was transferred to the medical/surgical wing for another 48 hours of observation. She was scheduled for discharge the following morning when her symptoms returned with a vengeance. A nurse taking vital signs came into Amanda’s room and noticed her doubled over in pain. Her symptoms were returning. Both Pete Smyth and Jen Barlow were called. Pete Smyth paged Bill Harford.
Dr. Harford stopped at the nurse’s station and asked if Amanda had any visitors? He was told that her boyfriend had come back last night for a visit. Has there been anyone else? “No” came the response. Bill Harford asked the nurse if she could quietly ask Dr. Smyth to join him in the hallway. Pete Smyth exited Amanda’s room, seeming puzzled by the request.
Bill Harford began, “What is the one constant for Amanda in all her visits?” Pete Smyth responded that her symptoms seemed to go away when she was in the hospital and soon cleared up. But then she came back as the symptoms returned. “I bet the labs found no indication of drug use, prescription or otherwise did they?” Pete Smyth responded “No, nothing. How did you know?” “The one constant,” Bill Harford replied, “is Dean.” He continued, “I spoke with the nurses and it appears that Dean was not here yesterday at all, and only came in for a short visit last night.”
Pete Smyth seemed to recoil. “Do you think it’s possible that he’s poisoning her?” He asked. Bill Harford responded there was only one way to find out. Returning to the room, Dr. Smyth asked Amanda if she had taken anything since last night? Amanda responded annoyingly “for the last time, I do not take drugs.” Dr. Smyth Apologized and said that was not what he meant; had she taken anything that was brought in from home? “Only my supplements,” she responded. I didn’t have them last time because I came from work. Dean brought them in for me last night, and she reached into her purse and pulled out a small pill container marked AM PM. Bill Harford, who had been standing in the doorway, noticed that Dean seemed annoyed at the questions. He was now standing next to her bed. “Would you mind if I had these tested by our lab?” Dr. Smyth asked, to which Amanda shook her head, saying, “no, I don’t mind.” “Is that really necessary?” asked Dean. They are just vitamins that she needs for her running and other events” he added.
Dr. Smyth responded with a smile, “We just want to be sure that these supplements are not causing some of the symptoms. This is why it is generally not allowed to bring anything from home in regards to medications or supplements. We need to know everything in order to formulate an effective treatment.” Dean seemed concerned at this, and told Amanda that it was really unnecessary, and that the vitamins came from the bottles on their kitchen counter, and she has been taking them for months. Dr. Smyth placed a pill container into a plastic bag, sealed it, and handed it to the nurse. “Please ask the lab to do a chemical analysis on these capsules,” he added. When the lab called to inquire as to specific tests, Dr. Smyth turned to Bill Harford. Harford said, “I have no idea. Start with household cleaners.”
The lab tech put on the latex gloves and started to pull apart the first capsule. She noticed some markings in tiny white text. “00VegCap” it read. She twisted the capsule but it refused to budge. Using a small set of forceps she managed to pull the capsule apart and immediately met with a strong odor. When the lab technician opened the first capsule she noticed it had a strong odor that reminded her of window cleaner.
When Dr. Smyth received a call to come down to the lab, he called Bill Harford to join him. When they got to the lab they were met at the door by the lab technician. She held up a cotton swab and asked, “What does this smell like?” Both caught the smell of window clean. She stated, “This is what the capsules are filled with. They are not vitamins, they are solvents.” Bill Harford looked at the other capsules, and remarked, “Why didn’t in the solvent would dissolve the capsule material?” The lab technician showed him a capsule, and handed him a magnifying glass. “What’s a Veg Cap?” he asked. She showed him a web search she had done. It was a capsule for homemade medicines and herbs, but rather than breaking down in the stomach, it was made from plant cellulose that would survive stomach acid. “And apparently solvents too”, Dr. Smyth added. The next call was to security and two security officers met them at the nurse’s station. There was a small chance that Dean was innocent and that Amanda had made the capsules. The security offices were asked to wait at the nurse’s station. This may all be a mistake.
When Dr. Smyth asked Amanda about her supplements, she stated they were liquid B-12 that she had purchased at the drugstore across the street from where she worked. He then took one from the pill container that she had given him and opened it up for her. Immediately the smell of cleaner filled the room. Amanda said, “this is what was in the capsules?” She looked a Dean who had sat back down. “Did you do this to me?” she asked.
At first Dean consider denying it. He thought he would blame the drugstore. But looking at the doctors present, he knew it would not work.
“You left me behind” he said, suddenly very angry, glaring at her. Since you lost all the weight you’ve forgotten all about me. You’re always off with your fitness friends, and your workout partner Luke. It’s like I don’t exist anymore.” Pete Smyth left the room and asked the nurse at the desk to call the police and request an officer. The two security officers follow him down to the room, and escorted Dean to the lobby to wait. Amanda, sobbing, kept repeating “How could he do this to me?”
It had been nearly 8 weeks Amanda returned to the ER. Seeing her in the waiting room, Dr. Smyth felt his stomach fall. When he opened the door, she stood smiling.
Amanda said she wanted to thank him and “that other doctor” for helping her and figuring out what was making her so sick. She said that she was now living with her sister, and that she had a new job and will be moving soon. She turned toward the door, and then turned back and smiled.
And then she was gone.