The Angel's Insight
I pointed to the medical record. “One month ago, dental treatment. Senior James didn’t seem to have noticed yet, but once you gather the information, it becomes quite clear.”
“Looks like infective endocarditis, doesn’t it?”
To put it simply, it’s a disease where bacteria grow inside the heart’s great vessels. Bacterial clusters attach to and proliferate on the heart valves. In severe cases, the valves can be destroyed or cardiac function can be compromised. In this patient, the resulting thrombus had stopped the heart. It had been a close call.
At the same time, it’s a condition internists love. It’s significant, has a clear treatment protocol, and presents with unmistakable causes and physical signs.
Senior James glanced at me again with that familiar look of mild awe, as if wondering how I had figured it out so quickly.
“What’s your reasoning?”
He had probably already suspected the same diagnosis. After all, I had written it in the chart before leaving.
“This patient mentioned a few days ago that a tooth had broken. I couldn’t hear it myself because the patient was barely conscious when I saw him……”
“Why does a broken tooth matter?”
“Because he must have received dental treatment, right?”
Senior James nodded. “Ah……?”
“When someone drills into your mouth, the veins in the mouth and head connect directly to the heart through the superior vena cava. That can be a direct cause of infective endocarditis.”
It was a common occurrence. The most frequent trigger for infective endocarditis is dental work. Senior James pondered for a moment, then let out a sigh.
“I’m not even surprised anymore. You hear the words ‘dental treatment’ and immediately connect it to this?”
“But they usually give prophylactic ampicillin during dental procedures. So it’s probably a gram-negative organism that doesn’t respond to ampicillin.”
Infective endocarditis is most often caused by gram-positive bacteria, but not always. There are cases where treatment is delayed because physicians assume gram-positive organisms and prescribe antibiotics accordingly. When cultures take too long, gram-positive antibiotics fail, and the endocarditis is caused by one of five gram-negative organisms—collectively known as HACEK infections. These are the five oral commensal bacteria capable of causing endocarditis. I won’t go into the full acronym here; it’s complicated.
This patient was probably only receiving gram-positive coverage. Look—sure enough, only vancomycin is listed. That’s the drug for gram-positive infections. I’ll have to adjust the orders later.
Senior James gave me a helpless little laugh and shot me a sidelong glance.
“I told you to take at least a day off. Looks like you spent the whole time thinking about patients.”
Well, what could I do when I could already see the treatment and diagnostic direction drifting off course? Days off were rare for me.
“Ah…… I suppose so.”
“You work too hard.”
Anyway, even while waiting for culture results, we would prescribe an antibiotic effective against gram-negative organisms—gentamicin, for example.
Even in the 1970s, the medical community already knew what infective endocarditis was and how to treat it. The differences lay in the details: exactly which organisms were responsible, which empiric antibiotics to use, what to do when cultures failed, and which agents to employ for preventing thrombi. The concept of HACEK organisms in endocarditis was only just beginning to be used around this time. In short, standardized protocols had not yet been established. The finer points differed. Between me and them, after all, lay decades of accumulated experience and research.
I needed to observe as much as I could firsthand.
While I was handling ward duties, the cardiology professor who had initially treated this patient entered the nursing station. The patient had been admitted under Professor Alderman’s name. The professor flipped through the chart.
“Look at this. The patient’s almost back to normal. Still doing rehab because of the microemboli, but…… you did a tremendous job. You couldn’t even go home that day.”
I nodded. “Thank you.”
“It’s a miracle the patient met you and was able to receive coronary intervention.”
That was certainly true. If I hadn’t been there, the patient would likely have died or suffered permanent sequelae.
The professor looked puzzled. “Now that I think about it, at the time I just assumed it was standard, but this patient was receiving aspirin as an antipyretic. Isn’t that a rather old-fashioned prescription?”
Ah, that. I had known the question would come up. In modern hospitals, aspirin is no longer used as an antipyretic-analgesic. Even in the 1970s there were plenty of alternatives, and high-dose regimens like this one were almost never employed. It was an anachronistic choice for this era.
The reason this patient needed aspirin wasn’t for pain or fever control, but for its antiplatelet effect. Aspirin-based antiplatelet therapy was only beginning to be introduced in American hospitals around the 1970s—right about now.
I met the professor’s gaze. “I judged that high-dose aspirin was necessary because of the risk of thrombosis.”
“Interesting. A good point. As you say, aspirin may have an antithrombotic effect in addition to its antipyretic and analgesic properties.”
The cardiology professor scratched his head. It would—because the research had already been done in the future.
I looked back at Professor Alderman. “Should we include this patient as a research case? Catheter-based coronary intervention is still considered experimental, so we could cover it with research funds.”
“That would be good.”
Things were gradually settling into place. I should go check on how the patient’s rehabilitation was progressing. I gathered the chart and headed to the hospital’s rehabilitation unit. Senior Christine was already there—the physiatrist.
“Hello.”
“Oh, you’re that Asian resident.”
Senior Christine nodded. The patient’s condition looked reasonably good considering the cardiac arrest and microemboli, though functional recovery was not yet complete.
“How’s the patient doing? I suspect gram-negative organisms from the infective endocarditis.”
“Internists love their tests. What really matters is how much function remains, how much recovery is possible—that sort of thing.”
I smiled inwardly. Internists only care about numbers. They never ask the truly important questions—like whether the patient still collects butterflies. What was that book again? The Little Prince. Tests were important, of course. But physiatrists usually saw stable patients who needed rehabilitation, so I could understand why she thought that way.
Senior Christine blinked slowly, like an owl. I scratched my head.
“Right. What about on your end?”
“We’ll do hospital-based rehab for about a month, with the long-term goal of full recovery. It seems possible, but……”
It was the usual caveat. Probabilities had been studied, but until you actually tried, there was no way to be certain. How much function would return was ultimately in God’s hands—even if we expected most of it to come back.
“Understood.”
“He’ll be back soon. There’s already improvement.”
While rehabilitation continued, the patient’s father waited at his son’s bedside, his face still etched with worry. I walked over to the guardian.
“Hello.”
“Ah, you’re the doctor we saw on Christmas Day. My daughter said an angel pulled her down during the surgery.”
“That’s an exaggeration……”
An angel, really. I scratched my head awkwardly.
“How is he? Do you think he’s improving?”
“Patients in their twenties have better than a fifty percent chance of returning close to normal. It’s still too early to worry. I believe he’ll be fine.”
“That’s a relief. Everyone was so worried—wondering what kind of disaster this was on Christmas.”
I thought the same. It must have been chaos. Still, things had turned out well.
“Once again…… thank you so much. I heard you tried a new treatment that day. I don’t know if I should bring a gift or……”
The guardian bowed his head again. Since the topic of gifts had come up, I decided to speak.
“Yes. This patient was treated with a machine that only arrived at our hospital this year.”
He looked at me, still not understanding.
“So, if it’s all right with you, I was thinking of processing this as an experimental treatment for research funding purposes.”
“Is there something we need to do?”
He still didn’t seem to grasp what I meant. I shook my head.
“No, nothing like that. If you consent, Stanford will cover the hospital bill.”
The man grabbed my shoulder. I jumped.
“I don’t know how to thank you enough…… You really must be an angel. I wasn’t mistaken.”
His reaction was a little exaggerated. I nodded sheepishly.
“Yes…… Take care.”
“I could cry.”
The patient’s father went on at length praising me. Something about how Japanese people were truly diligent, and whether they believed in Buddha or Jesus, they were surely headed for a good place, and how grateful he was…… I was just glad he didn’t seem too distraught.