A MEDICAL MYSTERY UNHAPPILY SOLVED

I've always had a faculty for diagnosis; that is, putting two and two together to make a right conclusion. In fact, while I was at Yale, all the pre-medical students took the Medical Aptitude Test prior to application to medical schools. I had the highest score among all my class. In fact, my score was among the best in the country, and my professor commended me for that publicly. I used this talent in my practice with good results.

But in December 1998, I developed symptoms that I had never seen in any of my patients, and I was stumped. For no apparent reason, I had a couple of episodes of rather severe pain in my left shoulder, rather posterior for a heart attack or angina pectoris, but, on the other hand, it went down into my left upper arm. The pain felt like ischemia, that is, lack of blood supply, the sort of pain one gets in the thighs when bicycling fast up hill. It came on quickly like a muscle cramp and left as abruptly ten or fifteen minutes later. Walking around or holding my breath didn't help, nor did stretching, the things that usually help a cramp.

I went to our local cardiologist who got an ECG and a thallium stress test. Aside from a murmur due to calcification in my aortic valve, he found nothing abnormal in my heart. He had no idea what was causing my "weird pains" as I called them. A trial of nitroglycerine under my tongue didn't help. Shortly after, I developed the same weird pain in my right scapula and shoulder, and then even in my low back or hips, so the heart was not the cause, obviously. At the same time I began having scintillating scotomata--flickering spots in both eyes, usually in symmetrical crescents, that came once or twice a day and would last half an hour or so. At first I wasn't worried about those; I had had them occurring two or three times a year for thirty years, always diagnosed by ophthalmologists as a migraine, but without headache or vomiting. Why were they now happening daily?

I got some chemistry tests to check my calcium level and other things, and a chest x-ray to see about any tumors, etc. The chest x-ray showed a small round spot in the right lung thought to be a benign tumor such as a hamartoma (first noted in 1991).

When I had a few minutes of seeing double one day in February 1999, I went to an internist friend, Mark Howard, who I knew was pretty sharp and well informed. A repeat of the chest x-ray still looked benign, but he noted a trace of blood on stool exam and so he ordered a colon x-ray which was negative except for diverticulosis--tiny out-pouchings that may or may not cause abdominal symptoms. Other tests were normal. He had no idea of the cause of my weird pains.

In March with the weird pains and scotomata continuing, I again had a short bout of seeing double, and then I had numbness and tingling in one arm that was unexplained. When I had my right eye go blind except for the lower-most part, I saw the local ophthalmologist, who thought it was a migraine equivalent, but he suggested a neurology consultation anyway. I saw a neurologist, whose examination was rather negative. We got a MRI scan of the brain which showed a spot of ischemia, likely a very small stroke, in the left posterior cerebrum. The neurologist said that this was not at all uncommon in a man of 77 and he wasn't impressed, but he did say to increase the aspirin I was taking, just in case there were any transient ischemic attacks going on, and to prevent strokes. He didn't explain the weird pains, but felt the scotomata were due to migraine. Anyway, we had ruled out a brain tumor and I felt better about the whole thing. Maybe the weird pains were a spastic vessel phenomenon, too, like a migraine. Or were they due to emboli (traveling blood clots) actually cutting off the circulation to the muscles for a few minutes? I thought of sub-acute endocarditis, which could send off showers of tiny infected clots from an infected heart valve, but no tests had supported that idea. The heart had shown no clots either on echocardiogram.

In late May Teresa and I flew to Albany, New York, to see my daughter-in law, JoAnne, graduate from medical school. We had a great time there and then we drove to the Pocono Mountains in Pennsylvania to visit my sister, Marian. I was tired from the drive and Teresa noted I had a little fever and a fast pulse and respiration. I was having some chest pain, too, not steady and crushing like a heart attack, but more like pleurisy because it hurt just when I breathed. When I still had the symptoms in the morning and my pulse became irregular, I consented to go to the hospital. The nearest was the Wilkes-Barre branch of the Geisinger Medical Center. I had done my internship and some surgical residency at the original Geisinger in Danville, so I had confidence that they might solve all my questions. Surprise, surprise! They found I had had a small heart attack, though my heart had been declared in good shape just five months before. The attack apparently had been "silent," and only because it later caused inflammation in the pericardial sac, and the pain on breathing, did they suspect a heart problem. They couldn't tell just how old the attack was so they didn't give me any "clot-buster" (tPA). They gave me a nitroglycerine infusion drip, and other medicines which made me a bit dopey. They said I had to go to the Danville main hospital for heart catheterization to visualize the coronary arteries. The ambulance driver for the Memorial Day weekend could not be reached, so they flew me by helicopter the fifty miles or so. This cost me $5,000, or about $50 per mile! It was good that I didn't know of this extravagance at the time or I would have had a second attack.

Anyway, the coronaries all looked excellent except for an abrupt cut-off in the left anterior descending artery of the heart, so they rightly suspected that this blockage might be from an embolus rather than just the usual clot forming in an artery full of cholesterol. They rammed an umbrella (so it felt) down my esophagus and did another echocardiogram to see if I had a hole in my heart that might allow clots to flow from my legs to the left side of the heart, and thus to the coronaries. That was negative, so we had no idea of why I had the attack or the weird pains.

I did so well that they let me go back to my sister's home, and we even attended my Hill School 60th reunion in Pottstown, Pennsylvania, where I got to show off my pretty young wife, dance, and eat Pennsylvania scrapple. I even sang in the chapel choir that Sunday. We returned home, but I was still having the weird pains and scotomata nearly daily. I noted that where I had had intravenous lines were cord-like thromboses, and there was soreness and swelling in my right leg. Dr. Howard ordered a sonogram of my left leg that showed some superficial phlebitis. Shortly afterwards this got worse, and I had another ten minute bout of blindness, which Dr. Howard suspected was amaurosis fugax, due to spontaneous clotting in the vessels.

Sonograms of my carotid arteries were quite clean, suggesting that there were no emboli from there. Sonograms of my leg were worse on a second exam, so we decided to go to the Mayo Clinic, Scottsdale branch, as soon as possible. I had a blood work-up in Carlsbad to test for clotting disorders, and started low dose heparin and Coumadin to prevent further clotting, another heart attack or even a stroke. Dr. Howard spoke of familial clotting disorders, and I recalled that my brother, Tommy, had had unexplained lung clots in the past. That was what we hoped would be the case, though Dr. Howard and I knew that there was a far more sinister possibility.

We had our first visit at Mayo with Dr. Lee, who agreed that this was a clotting disorder (coagulopathy). He doubted it was of a familial sort, but rather Trousseau's syndrome, where clotting here and there is secondary to a malignancy, often of the pancreas. He changed my medication to low dose heparin (Lovenox) instead of the Coumadin, as it is safer and more effective in these cases, but expensive and requiring shots twice a day. A sonogram of the abdomen and a CT scan were negative for pancreatic cancer and other abdominal tumors, but in the upper chest were suspiciously enlarged lymph nodes, and the nodule in the right lung was more definite. We saw a rheumatologist to rule out vasculitis, a neurologist to see if he could contribute anything (he couldn't), and a hematologist who said I had a low grade DIC (disseminated intravascular coagulopathy), where clots actually form inside blood vessels and then are broken down. That could finally explain why I felt those weird pains, as though the blood supply was cut off for a short time.

Though this confirmed what I had been guessing at for a long time, somehow it didn't give me much comfort. It appeared I had lung cancer, spread to the nodes, and therefore inoperable. The next step was to get a biopsy of one of these nodes, and an appointment to see a surgeon was made for four days later. Dr. Lanza found an enlarged node in the right supraclavicular area, so he didn't have to go down into my chest, but he removed it under local anesthesia in the new Mayo hospital. The diagnosis was poorly differentiated adenocarcinoma, compatible with a lung origin. We later saw an oncologist, Dr. Braich, who suggested I try chemotherapy and radiation treatment to try to delay the progression of the cancer and perhaps shrink it so I would stop this DIC and the need for the heparin. He didn't outline any specific regimen for either treatment but said that must be supervised by an oncologist near home. After twelve worrisome days in Scottsdale, helped by the arrival of my son, George, the three of us flew to El Paso and drove home from there.

It was all hard to believe. I was looking well, I felt rather well except for some loss of appetite and a bit of fatigue. We arranged for chemotherapy from Dr. Khorsand in Roswell, and radiation therapy from Dr. Hadzic in Carlsbad. So far, as I write these last few pages, things are going rather well, considering. I tolerate the treatments so far, and don't mind if I lose my hair because I don't have much on my head anyway, but I have formidable eyebrows and a dapper moustache I don't want to lose. All this time we were receiving calls from family and from friends, and we continued to appreciate their support and prayers.

It is tough, but I am philosophic and know that I've been blessed beyond most mortals. I think I am leaving the World a better place for my having lived. I've touched millions of people around the World through the Voice Of America and other radio work, I've treated many patients successfully, I've helped others through my books, and I hope I've entertained some through my novels. I think I have had some influence for the good on the Medical Profession, and I've been a good citizen. I believe I was a good husband to two fine ladies, and I tried hard to be a good father.

And you know, something like this is never bad--except when one thinks about it. So I take my own philosophy and try to keep busy, helpful and as cheerful as possible. I've learned to carry a spare Kleenex tissue for when Teresa just can't contain her sorrow, and it is really sad to see her cry, but generally, she is being brave, realistic and comforting to me and I know she will bear it all well.

The End