Polite Dissent

Episode Title: In Which Sam Receives an Unexpected Visitor

Two significant cases this week: one was medically wrong and ethically murky, and the second was medically correct (if incredibly fast) but ethically wrong. I’m not going to say much about the stripper other than the rash appeared to be a resolving case of shingles (herpes zoster) from what little was shown. As for Violet, well the bicyclist in me was pained by her destruction of such a nice bicycle.

Dr. Cooper Freedman (with assistance from Dr. Addison Montgomery and Dr. Naomi Bennet)
Cooper has a patient, 9-month Emily O’Brien who is has been sick since birth and not growing well. She also has some poorly defined neurological symptoms. He runs some tests on her, including genetic testing, and determines that she is suffering from a severe form of the rare neurological disorder Pelizeaus Merzbacher. He runs tests on her parents and discovers that they are not carriers for the mutation responsible for Pelizeaus Merzbacher, and this makes him realize that Emily cannot be their child.
Looking through the hospital records, the team is eventually discovers that while Emily was in the nursery after birth, her real father switched his sick child with another couple’s healthy baby. Much pathos ensues when this is announced.

• Pelizeaus Merzbacher is an often fatal x-linked gene. This means that it is a disease that shows up in males, not females. Females are carriers for the condition, and can very rarely show mild symptoms, but full Pelizeaus Merzbacher cases (as Emily is said to be) are always males. This is a major mistake — there is no way that Emily can have Pelizeaus Merzbacher in that they’re describing.
• Any real infertility expert would cringe at Naomi’s line: “I didn’t promise you perfection, I promised you a baby.” The first part is true enough with any pregnancy, but no fertility doctor would ever “promise” any couple a baby. Even with all of modern science, the odds of an infertile couple conceiving is roughly 50%, and drops with each subsequent attempt. Promising success is inviting angry bitter couples and lawsuits.

Dr. Sam Bennet
Sam is making a house call on Dave Walker, a patient who is a known alcoholic. Dave is recently divorced and living with his teenage son and elderly mother. Arriving at the house, Sam finds him very sick with nausea and vomiting. An ambulance is called and Dave transported to the hospital. He improves after a short amount of time and is sent home, much to Sam’s dismay, with a diagnosis of viral gastroenteritis (the “stomach flu”).
Later in the same day his teenage son shows up at the clinic with identical symptoms. A check of his blood reveals coprine (scroll down to the bottom of the page), a toxin found is certain mushrooms. Coprine, we are told, works like “Antabuse” and causes a patient who drinks alcohol after ingesting it to become violently ill. Sam is able to determine that the patient’s mother is purposefully spiking his food with coprine-containing mushrooms to get him to stop drinking. Rather than tell Dave the truth about the poisoning, Sam tells him that he is allergic to alcohol.

• It’s amazing this all happens in one day: patient becomes ill and all his lab tests including cultures — which take several days to grow — are negative. The son becomes ill and his fancy and expensive blood tests are run and manage to come back the same day.
• Antabuse (generic name disulfiram) is a drug that interferes with the breakdown of alcohol in the human body. The alcohol is only partially metabolized and becomes acetaldehyde, a noxious chemical. This accumulates in the body and causes nausea, vomiting, and severe abdominal pain. Antabuse is prescribed in certain situations to help patients with alcohol problems stop drinking. It is not widely used because, in my experience, patients still drink when taking it, and now instead of an alcoholic patient, you have a violently ill still alcoholic patient.
  • Flagyl (generic name metronidazole), an antibiotic, has a similar effect on alcohol metabolism and we advise patients not to drink when on the medication, or even for several days after.
  • Pete is right that Coprine has the same effect as Antabuse.
• Never lie to patient. Sure, it’s tempting and seems like an easy way out sometimes, but it’s never a good idea. Sooner or later, they’ll find out and there goes all their trustin you. For another thing, how would you document it? Does Sam write in the medical record what really happened, the lie he told, or both? It’s a medicolegal nightmare. If the patient drops dead of coprine toxicity and the police discover Sam knew all along he was being poisoned, yet didn’t warn him or tell the police, Sam’s days of practicing medicine are long over.