“If It Isn’t Fun.” – A Fair-Haired Boy
(Or, How to Coast Through Internship by Snowing Everyone the First Week)
It looked for a while that “Dr. Fritz” was going to die.
He was my senior resident in medicine on the first service of my internship at Wesley Memorial Hospital in Chicago. His given name suggested that he was German; his last name, not to be disclosed here, indicated he might be southern European. Whatever he was, Fritz didn’t talk much; in fact, he was taciturn to the point of being unfriendly. I suppose he was no more skeptical about me than he was about life in general, but it seemed that he had real reservations about a small-town boy from down South who had just arrived in the Windy City.
Dr. Fritz was no more voluble on ward rounds than in private conversation. He tossed us swine few “pearls,” the much sought-after, real wages of an academic internship. But he did make his orders clear, and always recommended specific courses of action. For this, an intern in the first week on service could be very grateful. At least, I always knew my assignment and responsibility, as well as my “place,” and in time I came to regard my chief resident as competent and fair, if not jovial or inspiring. It was going to be all right on his service, just not much fun.
Ward rounds and social evenings with Gil Marquardt, chief of service, gave pleasant relief from the hospital routine. Marquardt was quite a role model for a young person interested in academic medicine. In his late forties, he was tall, tanned, and chiseled, worldly, wealthy, and wise. Dr. Fritz, his chief resident, was almost grubby by comparison. But Fritz was honest and earnest, and, as I said, it was going to be all right on his service.
My second day on service, at the end of evening rounds, Dr. Fritz looked a little wan but he wasn’t the sort you would ask about his feelings. He didn’t show up for the late night staff meal, but also didn’t sign out of the hospital, so I knew he was in quarters. I didn’t worry, knowing he was available as I entered the responsibilities of my first all-night duty as intern.
Things were quiet on the ward that night. I went to bed directly following late rounds and a quick supper, and, happily, wasn’t wakened until my 6 a.m. call. Then I quickly showered and dressed and ran up for pre-breakfast, “get-things-started” rounds. To my surprise, a new patient chart on the rack was for Dr. Fritz, himself. I glanced at the folder long enough to see that he had entered after midnight with a fever of 104° and symptoms of weakness and achiness. His first morning temp hadn’t yet been charted.
I should not have been put off, of course. If I were chief resident I would likely not have called to my bedside a fresh new intern in his first days of service, but rather, as Dr. Fritz had done, I would have summoned my attending colleagues. They, in turn, had not felt it necessary to notify me, the new intern, of this late-night admission. I felt bad being left out of the loop. But never mind!
Dr. Fritz’s temperature on the afternoon of the second day was again 104°, and still there were no specific symptoms or signs. The usual laboratory tests were back and showed nothing remarkable in the blood work besides an elevated neutrophil count, with nothing on chest X-ray or cardiogram; routine blood and urine cultures for infection were underway.
On the third morning, the Chief of Infectious Disease of Northwestern University visited Dr. Fritz and went through an impressive display of bedside history-taking and physical examination. As I had already recorded, nothing was notable in that history: no known exposures, no eating out, no recent travel outside Chicago, no patients with exotic diseases on our service, and so on down the line. Similarly, there were few signs: no rash, only mild epigastric tenderness, no jaundice. All was negative, negative, normal. The diagnosis by exclusion was “FUO,” the dread “fever of unknown origin.”
On the fourth morning Dr. Fritz was difficult to rouse. When awakened he was intelligible but volunteered little and indicated he didn’t want to be bothered. By afternoon his temperature had climbed to 105° and he had developed a tachycardia with S-T segment elevations on the electrocardiogram. Still there was only mild epigastric tenderness and discomfort on tipping the liver edge, but otherwise no localizing signs and nothing new in the laboratory findings.
I still don’t know what led me to do it, but as I saw the nurse leaving his room in the late evening carrying a covered bedpan, I asked her to bring it into the ward workroom. There I grabbed a tube of sterile broth, took a swab sample of the soft but unremarkable stool specimen and put the tube in my breast pocket to keep it warm. By this time it was 11 p.m. Before going to late evening dinner, I went by the laboratory and asked the technician to let me borrow a microscope and lamp, and then I set up a wet preparation of the stool. I had not specifically entertained a diagnosis; for a Tulane graduate the procedure was simply routine. I just did it. The warm wet drop was swarming with active trophozoites of Entamoeba Histolytica. Dr. Fritz had a severe, disseminated amebiasis.
I had been taught the routine as a junior med student, to do a warm wet- drop stool prep in any patient with a fever of unknown origin. Training routine, plus luck, added up to my being able to announce, at midnight of the fifth day of Dr. Fritz’s now critical illness, that he was literally “alive” with ameba. An acutely toxic systemic infestation now involved his liver, heart, and brain. This active amebic state could be diagnosed positively only by a warm, wet-stool preparation, because ova and encysted forms aren’t yet there to show up in an ordinary stool specimen stained for ova and parasites.
The small-town boy from the deep South had made the unheard-of diagnosis (in Chicago) of acute amebiasis. Moreover, I had lucked out in the first week of my internship, in a strange hospital and new environment, and with my chief medical resident who was actually dying of the severe infestation.
I ordered parenteral Emetine, after telephonic approval by the Chief of Service, and the first dose was given at 1:00 a.m. That day the afternoon temp rose only to 102°. The following morning, after 36 hours of therapy, Dr. Fritz was afebrile, weak but bright-eyed, and wore a wan but perceptible smile as I came in on pre-breakfast rounds. He sat up in bed and, in typically clipped tones, said, “Thanks, Blackburn. You and I know what you did. But you won’t let it go to your head, now, will you?”
In two subsequent months on the service, now the “fair-haired boy,” I got treated with a certain deference by staff and colleagues, and, in fact, probably continued to do a decent job as intern. But it was all pretty anti-climactic after that one dramatic diagnosis. My last day on service, the elegant internist-cardiologist and chief of service, Gilbert Marquardt, the one with the beautifully chiseled features and the touch of grey at the temples, called me into his mahogany-paneled office at Wesley for an exit interview. We chatted about my future plans. He casually mentioned his “nice set of offices down Michigan Avenue” that I might want to visit and look over. “My colleague, Dr. Cummings would be happy to bring you by,” he invited.
I thanked him for his attentions and for the excellent learning period on his service (even though it involved 20 hours a day, seven days a week, for two months, for the noble wages of room, board, and hospitalization insurance). Closing off our exit interview, he rose from his desk and walked around it toward me wearing the most gracious smile. Then he put his arm around my shoulders and gently escorted me to the door. There he looked directly into my eyes and said warmly, sincerely, “Happy to have had you on the service, Osborn!”