Sunday, March 14, 2010

Diagnosis - High Altitude -

The middle-aged woman lay in the intensive-care unit, observing the tumult around her. "At least I won't die alone," she said to herself. She squeezed her husband's hand. Though she hadn't felt well for more than a month, it was not until earlier that day that it occurred to her that she might be dying.

In the afternoon she had taken her teenage daughter shopping. As her daughter disappeared down an aisle, the woman struggled to keep up. Her breath was rapid and ragged. She could hear her blood pounding with each heartbeat. Suddenly the whole right side of the world seemed to go out of focus, color and shapes blending together. She didn't want to frighten her daughter, so she said nothing. "Please just let me get home," she prayed silently. She drove with her bad eye shut, and when she got home she promptly lay down. When the phone rang, she put it to her ear without opening her eyes. "Could you come to my office right now?" Dr. Andrea Needleman, her new physician, asked. "And bring your husband?"

The patient saw Needleman the day before, because her regular doctor of nearly 20 years didn't seem to be listening to her. She was 50 and had always been healthy — until now. The symptoms began while she was visiting friends in Ecuador. Their house was high in the Andes; when the fatigue and weakness first hit her, she figured it was the altitude and would pass. But it didn't. Then the nausea and diarrhea started. In the airport, on the way home, she felt so sick and weak that she couldn't even carry her purse. Since returning, all she wanted to do was sleep.

In her office, Needleman pulled a couple of pages from a file. The blood tests provided some answers but prompted important questions as well. The patient was severely anemic — that's why she felt so weak and tired. Her platelets, an essential component of the clotting system, were low, and her kidneys were hardly working. She needed to go to the hospital. "Now?" the patient asked, her voice quavering. Yes, now. Needleman wasn't sure what was going on, but she was very sure that her patient needed to be in the hospital until they figured it out.

When the patient arrived at the emergency room, her blood pressure was 225/115 — terrifyingly high. A CT scan showed no sign of a stroke, but her intermittently blurred vision suggested that her spiking blood pressure was taking a toll. The initial workup revealed an important clue. The I.C.U. doctor saw fragments of red blood cells in her blood. From that, he knew that abnormal clots were forming inside the blood vessels. These intravascular clots were causing the damage: her red blood cells were being torn apart as they were forced through the vessels. That was why she was so anemic. The platelet-filled clots also obstructed the blood vessels, starving the kidneys and other organs. As Needleman explained the results, she saw rising alarm in her patient's eyes. "It's going to be O.K.," Needleman said, with as much confidence as she could muster. "We know how to treat this."

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