Crozet Annals of Medicine: Lightning Strikes

Crozet Annals
of Medicine

by Dr. Robert Reiser

You always remember your first time. I remember the first time I ever saw a patient clinically. I was a first-year medical student trying to get some exposure to real medicine.

I wandered down to the University Hospital ER and was accepted by the attending physician and put to work.

The senior surgical resident on duty sent me in to see an 18-year-old college freshman with a constellation of symptoms and signs I couldn’t make heads or tails of. I did not have a clue what any of it meant. Total blank. This was very discouraging to me as I had just finished my one and only course in medical school on obtaining a history, doing an exam, and making a diagnosis, and I thought I had picked up a thing or two. I wondered if I would ever be capable of learning the practice of medicine. I reassured myself that the patient must have a difficult-to-diagnose disease and reported that to the surgical resident.

The resident was a hard-bitten veteran of the ER and she laughed out loud at my feeble attempts to piece together a diagnosis. Without further discussion, she swept into the room, did a rapid and focused history and physical and pronounced the patient to be suffering from a cold, at best, but more likely from exam avoidance (it was college finals week).

After a brief discussion with the ER attending physician, the patient was discharged with no time off from exams.

This renewed my discouragement; I could not even diagnose a cold, or worse, recognize a healthy college coed. Boy, this medicine stuff was going to be even harder than I thought. What would I do when faced with real disease? As it turned out, I was going to find out much sooner than I thought.

Two days later, I was reading the college daily newspaper at breakfast and noticed a blurb about a freshman who had died the day before. What really caught my attention was the unusual name of the student, which was the same as the name of my first patient. To this day, I remember her name. Renee. It means reborn.

As I read the article I became a little alarmed. According to her roommate, the student had gone to the ER the day before her death and had been told she had a cold. She had returned to her dorm and collapsed, dying less than 12 hours later of fulminant meningococcal septicemia. Wow, I thought yet again, this medicine really is a tricky business. A “cold” could also be a fatal disease. Who could tell who was sick?

But my greatest immediate concern was the last part of the story, which said that anyone who had contact with this unfortunate girl had been contacted and placed on antibiotics to prevent a similar fate from happening to them. I hadn’t been contacted! I was going to die—after treating only one patient. Such is the mindset of a first-year medical student.

I went directly back to the ER and explained my situation to a sympathetic nurse (she herself was on antibiotics for the same thing). She confirmed that the dead girl was indeed my first patient and presented me to the same ER attending physician for advice on antibiotic selection. I also needed some professional guidance in dealing with the grief in all of this and some explanation of how an error of this magnitude could occur.

His only advice to me was to “toughen up.” He refused to prescribe antibiotics.

Purpura fulminans—a purple rash that strikes like lightning.

Fortunately, my infant son Michael’s pediatrician recognized the slight risk to me and the very real risk to Michael (infants are at high risk to get this disease from adult carriers) when my wife called him for advice, and he prescribed the correct antibiotics. His kindly manner when we saw him reminded me that the ER doc was not typical of all physicians. Just like that my family’s health was assured and my career was back on track. Such is the influence of a capable physician.

Meningococcemia and meningococcal meningitis are two closely related illnesses caused by a nasty bacterium called Neisseria meningitidis. College freshmen like my patient are a group at particular risk and many colleges are requiring all incoming students to be vaccinated against Neisseria meningitidis. I concur with this recommendation and vaccinated all my kids before they went off to college. Fortunately, even in this group meningococcal disease is a very rare occurrence in the U.S. Other significant risk factors include communal beer drinking, kissing and cigarette smoking. Saturday night at college in other words.

Symptoms of meningococcal disease include body aches, flu-like symptoms, stiff neck and headache and most characteristically, and ominously, a diffuse red-blue speckled rash. All physicians are trained to look for this rash, so associated is it with severe disease.

The rash is called purpura fulminans, Latin for a purple rash that strikes like lightning.

The disease progresses incredibly rapidly, with collapse occurring within hours of symptom onset. Up to 70 percent of patients die, usually within 24 hours.

Since my very first patient died over twenty years ago, I have treated many thousands of patients, but I have never forgotten Renee.