29. The Lawyer

'Lisa, I'm sorry, I won't be able to help you today. I'm having one of those.'

Jake looked sick and sweaty. His eyes could barely open as he talked to me on the stairs of the hospital.

'Are you in pain? Let me prescribe you some painkillers.' I worried for him, even though I had to present a morbidity and mortality conference in a few minutes.

'No, don't worry about it. The pain is gone now, I am just not good enough to go there.'

'Don't sweat on it, Jake. Go rest. Use the on-call room. I'll check up on you after my conference, okay?'

Jake had been a patient of mine since I started my residency at Brooklyn Hospital. He was an athletic 35-year-old lawyer who had no major health issues except for a hard-to-treat abdominal pain. 

I saw Jake very often since he was hired by the hospital. He was always running some errands in his impeccable suit. 

'Looking sharp, Jake.' I used to say when I ran into him at the hospital.

'Looking tired, Dr. Diaz.' He always replied teasingly. 

'You know they pay us to look like this right?' 

James had what seemed like an unusual presentation of gastritis. He had a burning epigastric pain that happened in short intermittent episodes rather than continuous pain. We had scoped him a year back and it was positive for H. Pylori. He was treated with triple therapy and labs showed that it worked, but the pain was hardly better.

Of course we didn't stop there. We ended up investigating everything else we could think of, abdominal CT scan was negative, and even acute intermittent porphyria workup was done and was negative.

Jake had basically given up, and to be honest, the doctors too, myself included. He continued to go to the appointments and we continued prescribing him proton pump inhibitors and pain killers but nothing seemed to change. Since his episodes of pain were so isolated it was also hard to ascertain whether any treatment was working or not.

Honestly I was not that worried until that day of the conference. I had asked him to attend so that he could make some remarks at the end on his legal perspective of the case and he kindly agreed.

I had never seen him sick like that. Every time he showed up he was not in crisis, and I had no idea what the crisis looked like until that day.

I gave my presentation and it wasn't great, to be honest. My mind was only half on it, and I'm sure people could tell. I just wanted it to be over so I could figure out what was wrong with Jake.

'Hey, what's up with you today? You seemed a bit distracted.' Peter asked me on the way out of the room.

'I'm worried about Jake.'

'The lawyer?' Kate asked while biting on her protein bar.

'Yes. He is my patient at the clinic and he is sick today. He was supposed to have gone to my presentation.' My mind couldn't stop spiraling over what we had missed. 'And I think I'm missing something.' I almost whispered between my teeth. No way that that was just gastritis.

'You want help?' Peter gave that smirk he had learned from Jax. 'We're pretty smart.' He winked at Kate.

'Oh, I know, Dr. Allen.' I let out a half-hearted laugh. 'I'll meet you at lunch and then you guys help me. I'm just going to check on Jake first.'

Jake wasn't in the on-call room which actually got me even more worried. I called him and after a few rings he picked up the phone. He thanked me for the call and said he was back at work, feeling better, thank God.

I told Kate and Peter all about Jake's case. They paid attention to every detail and asked several follow-up questions. When we got to any relevant labs, all of our work up for him was negative. 

We spent a few minutes arguing whether there could be any false negatives. After all, he had H pylori which can be a hard-to-kill bacteria. Could it be possible the antibiotics were not effective and that the second endoscopy could be a false negative?

'That's too many ifs.' Peter sighed, and he was right. 'If we're honest, not even his pain looks like gastritis.'

'You're right.' I was frustrated.

'Okay, so let's reroute.' Kate tried to cheer me up. 'What else could we use to characterize the pain?' They were both staring at me and I couldn't really remember anything else about his pain. 'Did anything ever feel off to you?'

'Well…' I said after a couple of minutes. 'Jake seemed off when I talked to him before the conference. He was very sleepy and sick-looking, but he told me he was in no pain anymore. And when I called him an hour later he was doing great again. That was off.'

'How exactly did he look like? Peter pressed me.

'I don't know, sleepy, slow…' I opened my eyes and mouth in surprise that this line of thought got me somewhere.

'What?' They both asked.

'He looked post-ictal.'

It was a long shot and a rare disease that is much more common in kids, but I convinced my attending to get him an electroencephalogram, and surprisingly enough the abnormal waves were there. After treatment with antiepileptics, his symptoms finally subsided. This was the first and only time I ever saw a case of abdominal epilepsy. I have to admit that after this I ordered a few other EEGs for patients with refractory abdominal pain, but none came back abnormal. Even so, if I only learned about this condition to help this one patient, it was still worth it. And that’s why rare disease matters.

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EEG: Electroencephalogram; Tt: treatment.

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