My clinical experience was linking
A case that set me to thinking,
It wasn’t the lead
But porphyria instead
And it was aggravated by drinking.
Morning conference included a discussion of a patient with psychiatric problems, severe recurrent abdominal pain, constipation, and neurologic problems including diffuse whole body pain. We threw ideas back and forth across the table. I really didn’t have much to add. I’m a front line doc, I’m not a specialist and if my colleagues have looked at a patient I can offer a different point of view and not much else. But it was fun to be in the discussion.
Half the morning patients didn’t arrive. In the time freed up by the no-shows I called patients about abnormal lab results and made arrangements for follow-ups of other problems.
One of the morning patients, when asked if I could write about him, said “My life is an open book, write what you want.” He had a problem with anger, he said, and before he moved to Barrow he spent fifteen years in prison. Twenty years ago he left Anchorage for a two-week vacation in Barrow. He quit drinking and spent his own money for three years of counseling. He is a hard-working family man, a solid citizen. In many ways he has become the person he chose to be.
We talked about how many people in Barrow have quit drinking. Some have used the church, some have used AA, and some have just quit.
I brought lunch, shepherd’s pie, back to the apartment. Bethany and I shared generous portions and did improvisational comedy. We marveled at how bright and clear the air was, and made frivolous speculation about what the red and white Canadian Coast Guard cutter was doing, anchored 800 yards outside our window.
After lunch I sought out an exit interview with the acting Clinical Director. Most of what I talked about was the healthy part of the medical subculture in Barrow and why I’d had such a great time. I had a few constructive suggestions.
Afternoon walk-in clinic brought the parade of the human condition, drama and irony, the diamonds in the grit. At one point, responding to yet another patient’s request to refill all of the other prescriptions, I didn’t say, “Make an appointment, this is too much for one visit.” I said, “Sure. It’s my last day,” and I grinned. But I gently asked that the patient be kind to other doctors in the future.
I don’t have many publications to my credit, but one of them was entitled Looking For The Lead, and it was published in The Hudson Monitor. A patient who should have had lead poisoning didn’t; he had porphyria.
The porphyrias are a group of rare disorders in the synthesis of heme (the red stuff in hemoglobin). I have seen about three dozen cases; the very long story of why I would even look involves a friendship with a thoughtful surgeon and a unique sequence of patients.
It was porphyria that drove George III of England mad, leading directly to the formation of the United States and weakening the monarchy of Great Britain. The symptoms of the disease include psychiatric problems, severe recurrent abdominal pain, constipation, and neurologic problems including diffuse whole body pain.
Thus, when the luck of the draw brought me the last patient of the day with that symptom complex, I thought of porphyria. I had to scurry around to the lab to get the right twenty-four hour urine test ordered.
Treatment will be more about avoiding drugs, especially alcohol, than about taking them.
I won’t be here when the lab results are back.