Budd Gets Better

Remember Budd-Chiari? Here’s what I love about family medicine: I get to be part of the story.

Here’s what I hate about family medicine: the hospitalist thinks I’m stupid.

A couple of months ago Budd-Chiari was sick, no doubt about it. After I called several specialists and read everything I could on Up-to-Date, I ordered some tests.  And the tests showed he was marginally sicker. His sedimentation rate, a marker of inflammation, was climbing to 100. His white blood cell count, while not outlandish, was high. Higher than before. And he was still having fevers, with hallucinations.

This is not normal in a 35 year old.

And I had it on good authority that it wasn’t explained by the clot in his liver, either. And by good authority I mean the jovial gastroenterologist I managed to reach by phone. I don’t know what the hell I’m doing.

So I sent him that evening to the emergency room, for further work-up on his spiking fevers to 103, with delirium and worsening lab values.

The dictation for his admission goes something like this:  “35 year old male sent over by primary care doctor for abnormal lab values, including elevated sedimentation rate. There is really nothing wrong with him and so I don’t know what the big deal is and why I had to waste my time on this admission. Obviously he has a clot in his liver and that is why he feels sick. Stupid family doctors who freak out about the Erythrocyte Sedimentation Rate. Temp 101.5. Whatever, dude. I’m going back to bed.”

I may be paraphrasing a bit. Not much.

Sure enough, they sent him home the next day. No antibiotics. Still spiking fevers. Still delirious.

I was disheartened to say the least. Now the enigma was back in my lap, and I had even less confidence than before.

A week later the blood cultures from his overnight admission came back growing gram-negative rods. At the same time the blood cultures I had drawn with the ESR and CBC came up positive as well.

It was my day off. They called the residents, for reasons I don’t understand. The residents called me. I called the family. They weren’t keen on going back to the hospital, understandably. We talked about options. They felt he was better and might be able to take oral antibiotics.

Then he spiked a fever again and they called the answering service, who connected them to Leafy.

Leafy is just like me, fresh out, 6 months younger than I am if that’s possible. She told him to go to the ER. Leafy has an asset I don’t: her husband is an ER doctor who may also be a Linebacker. He took the case.

She called me. “Yeah, I read that history and physical from his earlier admission. A little passive-aggressive, I thought.”

“Me too! I knew something was wrong with that guy. And they totally didn’t take me seriously.”

“And they implied as much in their dictation. But you were right – he was sick. Not cool, hospitalist.”

I was right. –ish. I mean, I didn’t know what was wrong with him, just that he was SICK. And none of us could ever have guessed, nor spelled, the cause of his illness:

Erysipelothrix rhusiopathiae.

He got lots of attention in the hospital. IV antibiotics, ID consult, the works.

And then he got better. I saw him 2 weeks out, smiling, laughing, a quick wit. He told me about his heavy metal band, and the impending birth of his daughter.

What a difference a few antibiotics make. 

It’s pretty great to see the end of the story, to see him get better. I kind of want to call that first hospitalist to let him know. But I don’t think I’ll allow him that gratification.