Sunday, September 11, 2011

Think Like a Doctor: A Case of Hiccups

The Challenge: Can you solve a medical mystery involving a middle-aged man with unrelenting hiccups?

The Diagnosis column of The New York Times Magazine regularly asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you’ll find a summary of a quirky new case as well as links to lab reports and images that will provide you with the same information as those who originally solved this medical mystery. My usual hero is a doctor, but in this case, the diagnosis was made by a physician assistant.

This month’s puzzle not only gives everyone a chance to play “House” (as in the T.V. doctor), but it also gives readers a unique insight into the challenges emergency room doctors face when presented with an unusual problem and a patient who isn’t under the care of a personal physician.

The first reader to solve the case gets a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction that you could hold your own on morning rounds. Let’s get started.

The Presenting Problem:

A 46-year-old man comes to the emergency room with a two-day history of hiccups.

The Patient’s Story:

The 46 year-old-man lay still in the bed, trying not to wake his wife, waiting. The next spasm came right on time: his chest jumped. The bed shifted. She didn’t move. He couldn’t believe she was sleeping through this storm of hiccups, but she was. As he waited for the next spasm, the man relaxed his throat so that the spasm of inhaled air passed with barely a sound. He had been hiccupping two to three times a minute for nearly 24 hours.

The problem started the morning before. He awoke at his usual time and ate breakfast with his wife and four children. Then he opened his tiny luggage storefront downstairs from his home in a small New York City neighborhood. And at some point that morning, he started hiccupping.  Getting the hiccups wasn’t such a remarkable event — until they didn’t go away.

He tried all the usual treatments. He held his breath. He drank a glass after glass of cold water. He thought scary thoughts. But no matter what he did, every 20 to 30 seconds his chest would jump, and his throat would close, cutting short the involuntary inward gasp of air.

It was really just a minor inconvenience; and a source of humor for his customers as he hiccupped his way through his pitch on each of the bags he sold. He made it through the day, through dinner and went to bed at his usual hour. But the hiccups were still going strong, in the middle of the night. The man rolled over and tried again to get to sleep.

When he woke the next morning they were still there. Now he was starting to worry. In the afternoon, he called the emergency room. Was it normal to have hiccups for two whole days? A triage nurse urged him to come to the hospital.

The Doctor’s Exam:

The patient arrived at Metropolitan Hospital, on Manhattan’s Upper East Side, around 3 p.m. The emergency room was boiling with activity, but finally a young man with dark hair and a dimple in his chin came up to the stretcher in the hallway where the patient lay. He introduced himself as Steve Ferrante, the physician’s assistant assigned to see him.

Just looking at the patient, it was clear to Mr. Ferrante that he appeared to be pretty healthy. He radiated a kind of vigor and health not common in many of the patients who came to the E.R. Mr. Ferrante suspected this man had no doctor because he hadn’t needed one. Until now.

The patient didn’t smoke, didn’t drink, took no medication. He had undergone two hernia operations – one three years earlier and one earlier that week.

Mr. Ferrante questioned the man closely. Did he have any other symptoms besides the hiccups? No — no chest pain, no shortness of breath, no fever, no chills, no coughing, nausea, vomiting. Nothing. Other than these crazy hiccups, he felt fine. Every sentence was broken up by the quick gasps of the hiccups. Otherwise, the physical exam was completely unremarkable.

The Treatment:

Hiccups, more officially referred to as singultus, (from Latin – to catch your breath while sobbing) are repeated, spasmodic contractions of the diaphragm causing a quick inhalation, which is then cut short by an involuntary closing of the glottis. Mostly these episodes are transient and benign. Hiccups lasting more than 48 hours are considered persistent. If they last longer than a month, they are termed intractable. The longest recorded bout of hiccups lasted 60 years.

Hiccups have many causes: anything that can irritate the nerves that innervate the diaphragm can cause these little spasms. It can come from something as benign as eating too much, so that the stomach irritates the nearby diaphragm, to the more serious, like an abscess or tumor on any of the structures near the nerves that run from the brain to the diaphragm. Hiccups after surgery are thought to be due to a mild injury of this nerve (called the vagus nerve) caused by the tube that is used to help the patient breathe during surgery. Injuries to certain parts of the brain — from trauma or disease — also can cause hiccups. Toxins, most commonly alcohol, can do it. So can stress.

Since the patient didn’t seem to have any other symptoms, Mr. Ferrante thought the hiccups were probably due to the surgery he’d had a few days earlier. Mr. Ferrante gave the patient a shot of one of the most effective and widely used medication to treat hiccups – an antipsychotic called Thorazine. Moments later the hiccups stopped. Cautiously optimistic, Mr. Ferrante watched the man for a while. When the hiccups didn’t return, he sent him home.

The patient walked out of the emergency room; moments later he was back. So were the hiccups.

New Symptoms:

The patient was given a second dose of Thorazine. Within minutes the patient began to feel weak and dizzy. He lay back on the stretcher, too weak to hold himself upright. As the man lay there, the churning chaos of the emergency department seemed to move further away — as if it were in another room. Then suddenly he felt his legs began to jerk and move. Now his arms too; they seemed to take on a life of their own. He felt as he couldn’t hold them still.

Mr. Ferrante quickly checked the man’s blood pressure. It had been normal but now was dangerously low. An I.V. was started and the man was given fluids to bring up his blood pressure. Blood was drawn and sent to the lab and chest X-rays were taken. The results were unremarkable. (Click on the document viewer to see the lab report.)


The Challenge:

Can you solve the case of the hiccuping luggage salesman?

Rules and Regulations: Post your diagnosis and questions for Dr. Sanders in the Comments section below. The correct answer will appear tomorrow on the Well blog. Winners will be contacted. Select reader comments may also appear in a coming issue of the New York Times Magazine.

Statue in Cardiff-by-the-Sea adorned in fire gear in 9/11 tribute

FireXXX The statue at Cardiff-by-the-Sea in northern San Diego County, often adorned by pranksters, was suitably attired this weekend as a tribute to the fallen from the Sept. 11 terrorist attacks.

Nobody knows who did it, but the statue of a young surfer was wearing firefighter gear with an American flag in one hand and a "Never Forget 9/11 United We Stand" sign on the statue's pedestal.

Tourists and locals were taking pictures.

ALSO:

Full coverage: A nation remembers 9/11 

Southland commemorate anniversary of attacks

Photos: The world observes 9/11

--Tony Perry in San Diego

 

Photo: The Cardiff-by-the-Sea statue in 9/11 remembrance mode. Credit: Tony Perry / Los Angeles Times

 

Suspect arrested in North Hollywood shooting

A 25-year-old man is being held in lieu of $1-million bail in connection with a fatal shooting in North Hollywood, a Los Angeles Police Department spokeswoman said Sunday.

Caitan Arrequin was arrested Saturday evening on suspicion of killing 43-year-old Rafael Flores Vaca in an apartment in the 7600 block of Laurel Canyon Boulevard, Officer Karen Rayner said.

The shooting occurred about 1 a.m. Saturday. Police responded to a report of an assault with a deadly weapon. When they got to the apartment, officers found Vaca, who had been shot multiple times. He was taken to a local hospital and pronounced dead there.

Police officers detained Arrequin immediately after the shooting as he left the scene, Rayner said. He was arrested later in the day after police searched his apartment and found evidence that they said pointed to him as a suspect, Rayner said.

Officers are still investigating the cause, but they said it may be gang-related.

--Anna Gorman

ALSO:

Gang member threatened to stab boy, police say

Passenger arrested on suspicion of breaking taxi window in Newport Beach

San Juan Capistrano man charged in blackout altercation

 

Reader photos: Southern California Moments, Day 254

Click through for more photos of Southern California Moments

Hopes rising: A box kite attempts to fly above Santa Monica Beach in this photo by Cindi Kauffman on Aug. 19.

Every day of 2011, we're featuring reader-submitted photos of Southern California Moments. Follow us on Twitter and visit the Southern California Moments homepage for more on this series.

9/11 anniversary: Southern California remembers

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Commemoration ceremonies took place throughout Southern California on Sunday to mark the 10th anniversary of the Sept. 11 terrorist attacks, and several more were scheduled for the afternoon.  

In Culver City, the bells at City Hall rang at 6:59 a.m., the same minute (Pacific time) that the World Trade Center's south tower collapsed in New York in 2011. In Echo Park, Los Angeles firefighters and other rescue workers who went to New York to assist in the aftermath of the attack gathered to remember the dead. On display during the ceremony was a 22-foot steel column that was originally part of the Twin Towers lobby.

Several events were planned for Malibu, where nearly 3,000 American flags dotted the lawn at Pepperdine University. The school held a memorial service in the morning and had scheduled a screening of "United 93." At 4 p.m., Beverly Hills officials planned to unveil a memorial garden to honor those who lost their lives.

ALSO:

San Diego tap water declared safe; boil warning lifted

Bomb scare on Los Angeles bus leads to passenger's arrest

Crackdown on unruly Rose Bowl tailgaters off to smooth start

-- Anna Gorman

Photo: Rumi Joon Maran Alborzi, left,  rests on the shoulder of her father, Ali Alborz, right during an interfaith community service at USC'S Bovard Auditorium. The service was held in commemoration of the Sept. 11, 2001, attacks. (Francine Orr / Los Angeles Times)

Fighter jets escort LAX flight to JFK

An American Airlines flight that took off from Los Angeles International Airport on Sunday was escorted by fighter jets into John F. Kennedy airport after three people refused to leave the bathroom, according to the Federal Bureau of Investigation.

Flight No. 34 took off at 8 a.m. in Los Angeles and landed safely at 4:15 p.m. in New York. The incident is not believed to related to terrorism, FBI spokeswoman Kelly Langmesser said. Agents are on the ground interviewing people and conducting an investigation, she said.

"It might have been just some unruly passengers," she said. "Out of an abundance of caution, it kind of got red-flagged."

An air marshall was on board the flight and secured the cockpit when the passengers refused to exit the bathroom, Langmesser said. Law enforcement was notified and the plane was escorted during the last few hundred miles.

ALSO:

Bomb scare on Los Angeles bus leads to passenger's arrest

9/11 anniversary: Police boost security at Port of Los Angeles

-- Anna Gorman

Proposed Starbucks gets mixed reception from Montrose merchants

A proposed Starbucks on Honolulu Avenue in the Montrose Shopping Park is getting mixed reviews from local business owners who say the corporate chain may not mesh with the independent image of the area.

Starbucks plans to open in the 1,840-square-foot storefront that currently houses Color Me Mine on the southeast corner of Honolulu and Ocean View Boulevard, but it must first secure a conditional-use permit to change the space from retail to fast food because it has more than eight seats.

Maureen Palacios, owner of Once Upon A Time bookstore and treasurer for the Montrose Shopping Park Assn., said during a recent board meeting that a Starbucks would increase vehicle traffic and hurt parking in the district, according to the Valley Sun.

ALSO:

Tiger from San Diego Zoo kills mate at El Paso Zoo

San Juan Capistrano man charged in blackout altercation

Surf Dog Surf-A-Thon delayed by pollution due to San Diego blackout

-- Mark Kellam and Brittany Levine, Times Community News

9/11 anniversary: Police boost security at Port of Los Angeles

Ports As a precaution during the 10th anniversary of Sept. 11, police at the Port of Los Angeles said Sunday they have stepped up patrols both on land and water.

“Given the significance of the week leading into 9/11, we have increased security,” said port spokesman Phillip Sanfield. The agency added patrols and is working more closely with the U.S. Coast Guard, the Los Angeles County Sheriff’s Department and the police departments in Los Angeles and Long Beach. Sea marshals are also boarding more boats and vessels entering the harbor, Sanfield said.

Sanfield said there had not been any incidents Sunday and there were no known threats. “We haven’t had any incidents today but we are on alert,” he said.

Port police are responsible for safety at the seaport and the nearby harbor communities. The port police and other law enforcement partners do patrols and surveillance by boat, bicycle, automobile and helicopter. There are also dive teams on hand, Sanfield said. 

ALSO:

San Juan Capistrano man charged in blackout altercation

Bomb scare on Los Angeles bus leads to passenger's arrest

Surf Dog Surf-A-Thon delayed by pollution due to San Diego blackout

-- Anna Gorman

Photo: Sgt. Ralph Edwards watches from the bow of a Los Angeles Port Police boat as fellow officers check out a sport fishing vessel last week. Credit: Al Seib / Los Angeles Times

San Diego tap water declared safe; boil warning lifted

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The water in all San Diego neighorhoods is again safe to drink without boiling, Mayor Jerry Sanders announced Sunday morning.

In the aftermath of Thursday's regional blackout, residents in eight neighborhoods were warned that tap water should be boiled before being used for drinking or cooking.

The outage had caused a loss of pressure in some water pipes, leading to the risk of contamination.

But tests done by city public utilities' department workers at dozens of sampling sites over two days found no contamination, and the boiling warning was lifted, Sanders said.

"We recognize this precaution was an inconvenience for those in the affected neighborhoods," Sanders said. "We're grateful for their patience and cooperation."

ALSO:

Tiger from San Diego Zoo kills mate at El Paso Zoo

San Juan Capistrano man charged in blackout altercation

Surf Dog Surf-A-Thon delayed by pollution due to San Diego blackout

-- Tony Perry in San Diego

Photo: San Diego skyline during Thursday night's blackout, illuminated only by emergency lights. Credit: Mark J. Terrill / Associated Press

Man faces terror charge after fake bomb is found on L.A. bus

Wilshire - Vermont L.A. sheriff's officials arrested a 62-year-old man after finding what appeared to be a fake explosive device on a Metro bus in Koreatown on Saturday night.

Eugenio Paredes was arrested on suspicion of making terrorist threats and possession of a hoax explosive device, according to the department. The device was contained in a suitcase.

Passengers were evacuated from the bus near Vermont Avenue and Wilshire Boulevard as detectives with the Los Angeles County Sheriff's Department Arson/Explosives Detail arrived about 6 p.m., said Lt. Kimberly Unland.

Red Line and Purple Line trains bypassed the Wilshire/Vermont subway station, and buses made detours around the intersection as a precaution.

ALSO:

Full coverage: Southern California blackout

Arizona power company baffled by events that led to outage

Power company employee caused massive blackout, utility says

-- Tony Barboza and Shelby Grad

Map: The intersection near which bus passengers were evacuated. Credit: Mapping L.A.

Lightning sparks dozens of fires, downing trees and utility poles

Viewer rananthony04 captured a lightning bolt over Pinon Hills Saturday. (KTLA-TV / Sept. 10, 2011)

Saturday's unusual rain storms brought lightning that sparked more than 50 fires in Kern County alone, keeping firefighters busy.

Firefighters also responded to numerous lightning-caused fires in Orange County and the Inland Empire. In Westminster, Los Alamitos and Stanton, the strikes downed power lines, felled trees, set utility poles on fire and sparked small blazes in backyards.

"It went through and did a pretty good number on us," Orange County Fire Capt. Marc Stone said.

Lightning sparked a handful of fires around Los Angeles — most of them smoldering trees and rooftops that went out by the time firefighters arrived, said Brian Humphrey, a spokesman for the city's fire department.

The storm moved out Saturday evening.

ALSO:

Tiger from San Diego Zoo kills mate at El Paso Zoo

San Juan Capistrano man charged in blackout altercation

Surf Dog Surf-A-Thon delayed by pollution due to San Diego blackout

-- Tony Barboza and Sam Quinones

Photo: Lightning in the Antelope Valley on Saturday. Credit: KTLA News

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