Doctor Whimsy

There is a disorder, myasthenia gravis, that I used to think was a zebra. In this area, in fact, it is quite common. It is a classic "fascinating" disease because it we know a lot about it and typically presents with such reproducible findings that it can be diagnosed in 30 seconds. In myasthenia, patients develop auto-antibodies that keep their nerves from telling their muscles what to do. As such, myasthenics have significant weakness and it typically increases as the day progresses. In a classic case, the patient will complain first of double or blurry vision, which would seem odd (that's a brain problem, right?) until you remember that the eye muscles are the most used muscles in the entire body. They are always contracting. Over time, myasthenics will have lower face weakness, such that their smiles are characteristically lop-sided. And the weakness continues to march down the body, capturing the mouth and throat until it finally vanquishes the diaphragm. All of us have been taught to fear the mighty "myasthenic crisis" which occurs when the patient is no longer able to swallow their oral secretions and, coupled with a weakened diaphragm that cannot cough, they begin to drown.

This morning I could have prattled off the previous paragraph and not thought much of it. We have three myasthenic patients on the floor these days (a topic for another post are the patterns life throws at you until you learn them, the true definition of "karma"). We've been fussing over one in particular, a newly-diagnosed patient who's on their third admission in a month, largely because they seemed to be having some difficulties coping with their diagnosis. We noted some anxiety yesterday during their initial plasma exchange treatment (like dialysis, in which the patient's blood is removed from their body, cleaned of antibodies, and returned), but we chalked it up to coping difficulties. And in the back of our minds we silently wondered...Anxiety is a sentinel symptom for respiratory distress. When you cannot oxygenate, you will do anything and everything to keep from dying, and it is often-forgotten fact that in the acutely ill, violence in the setting of confusion can often be explained by poor breathing. We should have known better, been more vigilant, and this morning our patient decompensated. The ICU team was called emergently to bedside, the patient was intubated, and sent up "to the unit" with a tube in his throat for the next week. But thanks to skilled nurses who rang the bells quickly, the patient will survive and recover.

How quickly bad goes to worse...it was one of the scariest half-hours of my life. I wrote once before about the hierarchy of the organs: first lungs, then heart, then brain. Truly the lungs, truly they matter.