Recently, I was asked what a disease detective did. While I considered my response, a situation came to mind from a few years back that captured the process perfectly. The following events are true, the names of been changed to protect the innocent, namely me.
Shifu: This can’t be right, it must be a coincidence.
Oogway: There are NO coincidences.
Shifu: Yes, you said that before.
Oogway: That was no coincidence either. (Kung Fu Panda)
My wife developed a nasty cough one October. Listening to her breath sounds through a stethoscope, I could hear a distinct rattle, indicated fluid of some sort. Her chief complaint was feeling tired, and having a headache. This was just a week after we had completed an outdoor endurance event that involved a great deal of mud, freezing water, and military-style obstacles. It felt fine the day after the event, but by the middle of the next week, started to experience the symptoms. At my urging, she made an appointment with her nurse practitioner. In retrospect, I should have accompanied her to her appointment.
The practitioner explained that she had a cold. She prescribed Tylenol, fluids, and bed rest. Two weeks later, the symptoms had worsened, and she made another appointment. This time the clinician ordered a cardiac stress test. I am uncertain as to her reasoning, however, I believe in being thorough. My wife mentioned having participated in an event that involved mud and water just a few days before the onset of symptoms but was told it had nothing to do with her illness. When I heard this, I was shocked and any respect I had for this practitioner, albeit slight, disappeared. Any good disease detective understands that foundationally, there simply are no coincidences.
Two weeks passed, and the appointment for the cardiac stress test came and went. My wife continued working, but looked and felt run down. Her breathing continued to be labored, and she lacked energy. When the practitioner called and explained that the test had revealed no abnormalities, my wife asked the logical question, “What will they do now?” The response (and I still have difficulty believing this had I not heard it myself) was “What do you mean?”
My wife said, “I still have the symptoms, what are you going to try next?” The nurse said that the practitioner had not made any follow ups or recommendations. At this point, although I knew it might annoy my wife, I called the office back and demanded to speak to the practitioner. Trying to remain calm, I explained that my wife’s symptoms were intensifying, and that I felt fairly strongly that she had a lung infection, most probably Campylobacter, and that she had most probably been infected during the event she had described, now over two months prior. Again, I was told that this was merely a coincidence, and that frankly she did not feel comfortable being questioned by the spouse of a patient. At this point, my patience evaporated. I explained to her that I was not just the spouse of a patent; I was a clinical epidemiologist and an environmental health scientist. Further, I said, I believed allowing a patient suffer for over two months while proffering no answers was ridiculous, and furthermore, to have a patient have to repeatedly ask “What do we do next” for some course of treatment bordered on incompetence. Her demeanor softened, and she then asked what I would recommend. I suggested that, as the primary symptom was breathing related, I would want to see a pulmonologist as soon as possible.
I accompanied her to the pulmonologist office, which conducted a thorough history. When I mentioned the event in October, and explained what we had done for nearly 9 hours, she put a pen down and looked at us. “That is most likely the cause,” she remarked. My wife then repeated what her practitioner had said, that it was just a coincidence. The pulmonologist smiled and said, “There are no coincidences.”
I could not help but smile as I had been saying this for almost three months.
After the pulmonologist conducted a few tests (Peak flow, Diffusion gas), and my wife was given an inhaler, after which peak flow was tested again. Finally, she stepped away from the room while my wife redressed, she asked me what I thought the pulmonologist would say. I said that I thought perhaps she would diagnose a lung infection, probably Campylobacter, which was picked up during the event, which had taken place on a farm that once raised swine. I said that she would most probably be given an antibiotic, most likely Zpac, a corticosteroid dilatator, and a rescue inhaler. The pulmonologist returned and, told us that she believed my wife had picked up a Campylobacter infection from the mud and water during the event. She was surprised that this was not diagnosed months ago, but that it should be relatively easy to treat. She handed my wife three scripts, explaining that the first one was for a medicine called “Azithromycin, or Zpac.” There were also scripts for a corticosteroid, and a rescue inhaler, which could be used as needed.
My wife turned to me and said, “you think you’re so smart don’t you?” My wife now sees a board-certified internist that I vetted. It never ceases to amaze me why people would not keep going to a mechanic who could not fix their car but will continue to see a healthcare provider who cannot seem to properly diagnose their illness. Especially when you give them the answer, not just once, but several times.
As Oogway said, “There are no coincidences.”