King of Organs (3)
As always, you never know if a treatment has truly succeeded until you see it for yourself. There are cases where everything seems fine, only for the patient to suddenly collapse and end up back in the hospital.
"We'll know when we see it."
Creak. Alice opened the door to the patient's room. The guardian, predictably owl-eyed from pulling an all-nighter, looked exhausted. The patient was in a state of depressed consciousness—no, probably just sleeping.
"He's sleeping, right?"
The guardian rubbed his eyes and nodded. I glanced at the patient briefly. Is he really okay? I nearly jumped—thought he was passed out. I shook him awake right away.
"How's your body feeling?"
The patient looked up at me with eyes that said, Why wake a sick man?
"Pardon? Ah... everything hurts..."
I let out a sigh of relief. So the steroid injection had worked, after all. You could tell just from the fact that he was speaking. His language function had returned in just a few hours! Of course, we still didn't know how much function would recover overall, but progress was progress—thank goodness.
"How does it compare to before?"
"A bit better, maybe. My whole body still aches—is this treatment even working?"
I nodded. Compared to earlier, when he couldn't even open his eyes or speak properly, this was a huge improvement, wasn't it? He might not feel it himself yet.
"Your dulled sensations are coming back, so it might feel worse temporarily. We'll consider painkillers, though I'm hesitant because of the depressed consciousness."
Poor guy went through hell. But now that we'd confirmed the steroids were effective, I could finally get some rest. All that was left was figuring out the scientific mechanism.
"What? He's improved with steroids?"
"The patient's up and walking around."
The nurse replied casually, leaving a stunned Henry Kaplan deep in thought behind her.
Henry Kaplan. The renowned veteran scholar who had transformed Hodgkin's lymphoma from a death sentence in one's thirties into a fully curable disease. One of the most famous doctors in America.
But even a genius who conquered such a disease could still be shocked sometimes—by how unpredictable illnesses are, and by how brilliant humans can be.
This can't be real.
Kaplan pressed his temples. He'd considered the possibility of improvement, but this? It was absurd.
How had that resident come up with this? No matter how he thought about it, it was shocking.
I'm getting surprised every damn day.
Morning rounds on the ward. Professor Kaplan approached me with a troubled expression after checking the patient's condition himself. I bowed my head in greeting.
"Good morning, Professor."
"Does this make any sense? Lung cancer symptoms improving in a single day with steroids?"
Precisely six hours, actually—for his language function to return. As always, it did make sense.
"You're right."
"Even the idea that lung cancer causes autoimmune encephalitis is baffling enough. And that autoimmune encephalitis responds to steroids..."
What can you do? That's what the disease wanted. Baffling, sure.
Small cell lung cancer is a specific subtype of lung cancer, a neuroendocrine tumor. In these cases, the tumor can produce hormones directly, leading to all sorts of bizarre symptoms. Like what we'd seen yesterday.
"The symptoms have improved dramatically. It seems the brain edema from the inflammatory response resolved quickly."
"Indeed. It's a real mystery."
I looked at Professor Kaplan. Why do you think it's a mystery? You're the one who discovered the treatment for Hodgkin's lymphoma. No one knows better than you that research can change the world.
"Couldn't we elucidate the mechanism? We have the problematic serum, and we've seen the process."
"A nonstop parade of shock and awe. What's next?"
"If the patient's serum contains antibodies specifically targeting nerve cells, this is a case we absolutely need to study."
"Fine. Get the consent form."
I returned to the patient's bedside with the consent form. He was sitting up, and a few family members had come back. I looked at the patient, and the three kids sitting beside the bed stared right back at me.
"Feeling a bit better?"
"Much better than yesterday. Just a few hours ago, my head felt like it was splitting open."
"That's great to hear."
"Thank you so much... Yesterday, I really thought I was going to die. After the injection, it feels like my head's been stitched back together."
Time to get to the point of why I was here.
"I know you're in pain and disoriented, but I'd like to make a proposal."
"What is it?"
The patient looked at me, and I paused for a moment.
"I'd like you to participate in a Stanford Hospital research study. It could help uncover the brain's mechanisms and benefit future patients."
"Do I have to do anything?"
"No... nothing special. The hospital will cover your medical bills instead. I hear it's around $30,000 before insurance?"
The patient stared at me.
"This is insane."
Tell me about it. $30,000 for lung cancer treatment. No average person could afford that. Insurance would cover some, but still.
Pay $30,000, or participate in research?
Paying patients for clinical trial participation is illegal, but covering costs for research participants is allowed. It felt almost coercive. But that's how the law worked—no arguing.
I sighed softly.
"Yes... The hospital will handle the bills, so no worries there. I'd just ask that you participate in the study."
"Aigoo, alright."
"Thank you."
The patient signed the consent form hastily, as if someone might snatch it away. Understandable. It was a $30,000 signature.
"Really, thank you... I heard you're the one who tried the new treatment. Participating in research—and surviving—is all thanks to you. If we'd had to pay the bills ourselves, we'd be in deep trouble."
Trouble already happened. You have cancer. The bills on top would have been worse, though.
"Then rest well."
I headed back to the station with the signed consent form. Now for the experiment.
I made my way to the hospital lab. What the experiment would reveal...
Small cell lung cancer and its paraneoplastic syndrome are rare, but academically important for a different reason. They provide clues to the question: What are nerve cells' mechanisms?
The theory goes like this: Starting in the 1980s or so, doctors noticed that autoimmune encephalitis causes specific neuropsychiatric symptoms. Autoantibodies attack particular receptors, impairing their function. This later helped reveal what those receptors do in the brain and how neurons work.
What does that even mean? Complicated stuff. Treatment wasn't the only issue.
Anyway, time to prove the hypothesis experimentally. I checked the culture dish with rat neural tissue. Still alive.
Sitting there waiting for the centrifuge, Alice walked into the lab.
"Whatcha doing?"
"Neural tissue culture. For that encephalitis patient."
"Human brain tissue!?"
I scratched my head. What kind of nonsense is that? As if.
"Rat."
Obviously. We'd sliced rat brain tissue thin and plated it on the dish. Where would we get live human brain tissue?
"Oh, right."
Alice scratched her head sheepishly.
"Checking if the serum from that steroid-responsive patient has neuron-specific autoantibodies. Planning to bring it up at the internal medicine conference."
She clearly had no idea what I was talking about. Alice blinked blankly.
"Uh... yeah. No clue what that means, but I'm off for an ice cream sandwich."
Sounds delicious. Ice cream sandwich. I should go with her after the experiment—once I finished the immunofluorescence staining.
Stanford Hospital, Internal Medicine Conference Room.
The day of the presentation had arrived. Nothing groundbreaking.
Stanford residents take turns presenting topics to the other internists. Usually everyday stuff—sharing new treatments or medical knowledge. Sometimes hospital case studies, like my autoimmune encephalitis patient.
But today's presentation would be more interesting than usual, at least I thought so.
I began.
"Good morning. Today's presentation is on a case of small cell lung cancer paraneoplastic syndrome and autoimmune encephalitis."
Professor Kaplan, the Neurology Professor, and Dean Rich sat with arms crossed, watching me. Like, go on, impress us.
The elder statesmen of America's top hospital. Naturally, they wouldn't buy it easily.
In some ways, the medical community is the slowest to change in the world. If I could convince them...