Newbie Assignment (3): Accepting the Rookie
Most patients who come to the emergency room with headaches are riddled with worry. Hardly anyone fails to grasp that the brain is the most vital organ. Fortunately, I didn’t have to deliver the worst possible news. It wasn’t a fatal disease—just occasional headaches and discomfort. I returned to the patient’s bedside. As I approached, the patient’s mother looked up at me with anxious eyes.
“It’s nothing serious, right?”
I nodded. It seemed safe enough to say so. Far better than a stroke or some other brain malformation, at least. “The patient has Type 1 Arnold-Chiari malformation. The symptoms are dizziness and headaches, but they don’t appear severe.”
She still looked unconvinced. Understandable, given the sudden fainting. “Then what about the collapse?”
“That was from excessive vomiting. We don’t believe it’s a problem with the brain itself.”
Both patient and guardian looked visibly relieved, though traces of worry lingered. “How does someone get this condition?”
“It’s a congenital malformation.”
“Ah. Is there any treatment?”
“We’ll manage it like migraines. I’ll prescribe daily medication to reduce symptoms and something stronger for acute episodes.”
Luna nodded beside me. In truth, Chiari Type 1 wasn’t particularly dangerous. In the 1970s, most physicians didn’t even recognize its existence. Arnold-Chiari syndrome was the term of the era; what we now call Chiari Type 2 was closer to the original description—a neurological disorder accompanied by multiple malformations. Chiari Type 1, by contrast, remained largely unknown. Unless a hospital possessed both a CT scanner and a specialist familiar with the condition, it simply went undiagnosed.
The patient met my gaze again. “So it can be managed?”
“That’s the expectation for now.”
“I see……”
Both nodded. The explanation was finished. We left the bedside, Luna trailing close behind while scribbling furiously on her clipboard. We returned to the ward station.
Upon checking, I realized migraine medications in the 1970s hadn’t been studied as thoroughly as I’d hoped. This would require some thought. Triptans—the cornerstone of modern headache management—hadn’t been invented yet. There was no helping it. For maintenance, I’d use low-dose propranolol to ease anxiety; for acute pain…… I glanced at Luna. “What would you prescribe for the headache?”
“Uh, something with codeine?”
I shook my head. That was an opioid analgesic. No need to risk turning the patient into an addict, even if it would work. “For acute treatment we’ll use ergotamine and metoclopramide. Ergotamine constricts blood vessels; metoclopramide controls nausea.”
“Ah.” Luna nodded, clearly lost. Neurology drugs could be daunting without dedicated study. “Learn slowly. Try to remember as much as you can.”
“Yes!”
After all, today was her first day on the job. She was doing well enough. A short while later, Professor Aird returned. He studied the prescription I’d written—the migraine regimen covering both prevention and acute attacks. “You’ve covered the medications as thoroughly as possible.”
“There aren’t many options for headaches. Still, this should be adequate for management. Where did you learn migraine treatment, son?”
Professor Aird looked at me. “I read a paper recently.”
“Why don’t we have more residents like you in neurology? If only they’d handle tasks the way you do—figuring things out on their own.”
I simply nodded. “They probably would, if given the chance.”
“Perhaps. I should try assigning them more.”
I could already imagine the groans from the neurology residents in the near future, but that wasn’t my fault. Professor Aird took a seat at the station. “There’s something I’ve been mulling over. What do you think? Arnold-Chiari syndrome is usually a fairly severe hereditary condition.”
“It is.”
“Should we consider this patient’s case a mild presentation of the same disease, or something distinct?”
“I believe it’s the same condition. The degree of brain herniation differs, but the underlying mechanism appears shared.”
“I see…… Would you consider writing a paper on this case? Check the literature for similar presentations.”
“Ah, I’ll look into it.”
Professor Aird muttered something and left the emergency station, already contemplating his next research project. The patient with Arnold-Chiari malformation was transferred from the ER to the neurology ward.
***
With that, this case was closed. Luna followed me like a shadow while I returned to the internal medicine ward and resumed my usual duties. Routine work, though at America’s premier university hospital even routine tasks often involved life-or-death stakes. We moved briskly through the ward, charts and clipboards in hand. There were plenty of patients to see; internal medicine residents were everyone’s go-to.
I prescribed antiemetics for nausea, laxatives for constipation, and then—wait. Why was there fluid in the lungs? Ah, that patient. The one recently diagnosed with multiple myeloma. Treatment was possible, but it was far too early to relax. Multiple myeloma was a form of blood cancer. An intriguing disease, certainly. I frowned at the patient’s chest X-ray. The situation wasn’t good. Pulmonary edema was present. Was the IV fluid running too aggressively? I turned to Luna. “Pulmonary edema. You know what to order?”
“Oh, furosemide!”
Simply put, a water pill. A potent diuretic and one of the most commonly used medications on the ward. “Correct.”
If the edema didn’t improve by tomorrow despite the diuretic, we’d have a serious problem. “This patient has multiple myeloma, so the kidneys are compromised. Still, we can’t withhold fluids entirely.”
“Understood. Is this another new disease?”
“No.” I shook my head. Quite the opposite. Multiple myeloma had first been described in the 1840s…… The name itself appeared in the 1870s. When one considered it, the timeline was absurd. Western physicians had been examining bone marrow under microscopes and diagnosing blood cancers since the 1870s, all while hoping someone in the distant future might find a cure. And by the 1970s, treatment for multiple myeloma had indeed begun. In any case, I handed the final prescription to the nurses’ station. Today’s tasks were complete. “Whew……”
The day, which had passed like a storm, finally wound down. I sank into a chair with a sigh. “It wasn’t as busy as I expected.”
Luna tilted her head beside me. An absurd statement. She must have remarkable stamina. “Not a chance. There were simply fewer patients dying on the ward than usual……”
Far from quiet. And voicing such thoughts aloud rarely brought good fortune. Luna scratched her head sheepishly. “Ah, sorry.”
Having a rookie in tow had slowed me down, yet today had gone smoothly enough. Maybe I could push her a little harder tomorrow. “Let’s call it a day.”
Lucky that nothing catastrophic had occurred on the new resident’s first shift. She might still run away otherwise.
***
On the opposite side of the globe, at Royal Perth Hospital in Australia, pathologist Robin Warren spent his days examining gastric cancer specimens. A few years earlier, the advent of fiber-optic endoscopy had made gastric biopsies routine, and now he reviewed stomach tissue slides from morning until night. Most patients referred for suspected gastric cancer did not, in fact, have cancer.
They had something that merely resembled it—usually peptic ulcers or gastritis. Still, Warren couldn’t shake the feeling that something else was at work. Gastritis seemed to progress to cancer, and more specifically…… something felt off.
When he gathered cases together, a new pattern emerged. The suspicion could be summed up in a single question: Was peptic ulcer disease contagious? Clusters of gastritis appeared frequently among family members or people living in close quarters—military barracks, for instance.
Moreover, the mechanism behind chronic gastritis, the condition that led to ulcers, seemed far too complex to attribute solely to stress. It was only a hypothesis, but clearly something remained scientifically unexplained. Perhaps a pathogen capable of causing ulcers, or an autoimmune process that had yet to be identified.