0:00

Diagnosis

0:06

is at the heart of what doctors do.

0:08

And medical school were taught the basics.

0:11

We refine it during residency, but

0:14

good doctors are constantly honing

0:16

their ability to identify illness.

0:19

Thinking is our most important procedure. Right?

0:21

So just like we teach other procedures

0:23

in medicine like how to take out an

0:25

appendix or how to deliver a baby or

0:28

how to do an examination of the eyes. Thinking

0:30

has a series of steps and each one of them

0:32

can be isolated and practiced and critiqued.

0:35

That's my friend, doctor Goprit Dollywal.

0:37

He's a professor at the University of California,

0:40

San Francisco. And a physician

0:42

at the San Francisco VA hospital.

0:45

Most of Garete's time is spent teaching

0:48

and seeing patients. But

0:50

he has another job too. My

0:52

side hustle is that I study

0:54

how doctors think and how their mind comes

0:56

to diagnosis. How do doctors think?

0:59

Pretty well. I'm biased. I think we do it alright, but

1:01

there's room to improve. Caprete

1:04

has been improving his own diagnostic skills

1:06

for a long

1:07

time. He's pretty good at it.

1:09

And in episodes five and ten of Freakonomics

1:12

MD, we put him to the test.

1:15

My final diagnosis is that when

1:17

he's outside enjoying the sun and

1:19

the fresh air from time to time,

1:20

he may come across a mosquito. And

1:22

if that's the case, he is at risk for getting

1:24

West Nile virus. We

1:27

wanted to bring Gopreit back for another

1:29

go round so that he could show off his

1:31

skills but also so that we could

1:33

try to stump him. From

1:37

the Freakonomics Radio Network, this is

1:39

FreakonomicsMD. I'm Bob

1:41

Bujena. Today on the show, I'll

1:43

tell Caprit, and you, the

1:45

story of a sixty year old man

1:48

who was shopping at the supermarket when

1:50

he

1:50

collapsed. And was found to

1:52

have no pulse. This is one

1:54

of the most serious medical emergencies

1:56

you can have. So What

1:58

caused this man to suddenly lose

2:00

consciousness? The most common

2:02

thing is that a heart attack is happening.

2:05

And how does CapReit's mind work as he tries

2:07

to get to the bottom of this or any

2:09

medical

2:10

mystery. Doctors go through the

2:12

discussion of all the possibilities but

2:14

they're really waiting for one clue

2:16

on which the whole case will be solved.

2:32

So I'm gonna present some information to

2:34

you and I'm gonna pause along

2:36

the way and get your reaction,

2:39

try to understand what you're thinking

2:41

at that moment, what additional

2:43

tests, what additional information you

2:45

might want. And if I have that information, I'll give

2:47

it to you. How's that sound? That

2:49

sounds great. Since

2:51

nineteen twenty three, the New England Journal

2:53

of Medicine has been publishing case

2:55

reports drawn from the records the

2:57

Massachusetts General Hospital where

2:59

it happened to work. So when

3:01

it decided to present a case to doctor Capri

3:04

Dollywal, That's where I went

3:06

looking. We've chain some of the details,

3:08

but most of what you hear about this patient

3:11

and his condition as I describe it

3:13

to Caprita is based on

3:15

one of this vast collection of

3:17

case records. Alright.

3:23

So, this is the story. A sixty year

3:26

old man was shopping

3:28

at the supermarket and he collapsed.

3:30

He was completely unresponsive. Someone

3:33

called nine eleven paramedics

3:36

arrived just a couple of minutes later

3:38

And when they did, the man had

3:40

no pulse. They started CPR

3:43

basically instantly. After about

3:45

a couple of minutes, they were able to place an

3:47

AED device or automated external

3:50

defibrillator on the chest,

3:52

and they measured his heart rhythm and it

3:54

was in a rhythm called ventricular fibrillation.

3:57

They shocked them a few times. They gave

3:59

them medications. And

4:01

after ten to fifteen minutes

4:03

of continuous CPR and

4:06

shocks, they were finally able to

4:08

get a pulse. And that's when they made a decision

4:11

to transport him to the hospital.

4:13

When you hear this, what are you starting to think?

4:15

This is one of the most serious medical

4:17

emergencies you can

4:18

have, which is the heart going into a fatal

4:20

rhythm. If you back up, what happened

4:22

to the grocery store is he fell,

4:25

he fell almost certainly because

4:27

he lost consciousness, which many says

4:29

brain stopped working, and we always wonder when the

4:31

brain doesn't work well. Why that is?

4:33

And there's generally two problems either

4:35

something has happened intrinsic to

4:37

the brain, for instance, a seizure is

4:39

happening, where the brain was okay,

4:41

but the heart and the circulatory system

4:44

didn't pump blood to the brain. Almost

4:46

certainly, we know that's the case here

4:48

because the AED detected

4:50

that there was a very serious rhythm called

4:52

ventricular fibrillation. First

4:54

and foremost, our major concern is whether

4:56

he might be having a heart attack. Which

4:58

can cause arrhythmia, heart failure,

5:00

and if not treated in a situation like this

5:02

could lead to death. Those are things we're

5:04

focusing on right off the bat. Comes into

5:06

the emergency room, and we're trying to prevent the

5:08

recurrence of this heart rhythm again.

5:10

What is the difference between a heart attack

5:13

and cardiac arrest? The heart is

5:15

a huge muscle. It has large arteries

5:17

that feed it blood that sometimes get

5:19

blocked. And if there's a block in those arteries,

5:21

then the heart will be starved of

5:23

oxygen that leads to tissue damage

5:25

and the electrical system of the heart

5:27

goes haywire and instead of functioning

5:29

normally. It starts to fire

5:31

haphazardly. And if it's really erratic, the

5:33

heart no longer can function.

5:35

Cardiac arrest is when that electrical

5:37

activity is disorganized and essentially

5:39

doesn't allow the heart to pump effectively.

5:42

In the term ventricular fibrillation, what does that

5:44

mean to you? It's essentially the most

5:46

serious version of that where the

5:48

electroactivity is completely erratic

5:50

and disorganized and non functional.

5:52

That's like a massive short circuit.

5:54

Besides heart attack, what are the other

5:56

things that you're thinking about that could cause cardiac

5:59

arrest? The heart is dependent on a lot of

6:01

things to go right in order for it to function. It

6:03

has to have appropriate level of

6:05

oxygen. The electrical system is

6:07

dependent on us having certain chemicals

6:09

in the blood, like potassium and magnesium.

6:11

Those are very low. Those are another

6:13

reason that the heart can't have an electrical

6:15

short circuit like this. Sometimes we

6:17

have substances that people may take,

6:19

like methamphetamine and cocaine that overstimulate

6:21

the heart -- Mhmm. -- and can lead to

6:24

arrhythmia. Those are all things that we consider

6:26

along with the heart attack idea. Alright.

6:32

So like I said, he was transported to

6:34

the emergency department. It took about

6:36

forty five minutes from the time he'd collapsed

6:38

to the time he was actually rolled in to

6:40

the ED and evaluated. When

6:42

he arrived to the ED, he did have a pulse,

6:45

but he was still completely unresponsive,

6:48

the emergency department team decided

6:51

to intubate him and they

6:53

gave him insulin and extras

6:55

which is a sugar and a couple of other

6:57

medications literally before we're

7:00

talking right now. You were in the ED all day today.

7:02

Is that right? That's what I was all day. Imagine

7:05

that you are in the ED and

7:07

you're evaluating this patient. What

7:09

are the things you're gonna wanna get

7:11

information on at this point

7:13

above and beyond what I already told you.

7:15

Well, if there's a chance to get more history

7:18

from bystanders at the supermarket

7:20

or EMS or paramedics or maybe even

7:22

family members, we certainly like to get that. So

7:24

there's this acquisition of key medical

7:26

data, like his vital signs matter,

7:28

you know, what's his heart rate pulse.

7:30

What's this oxygen level? I think

7:32

of those blood tests that I mentioned, things that

7:34

are either a marker of a heart attack or

7:36

a measure of levels like potassium

7:38

or magnesium in the blood. Our

7:40

knee kg, of course, is very important for

7:43

us to confirm the rhythm that was seen or see

7:45

if there's evidence of a heart attack. Those

7:47

are some of the basic things that we'd be spending

7:49

our energy on early on. Someone

7:54

in the ED was actually trying to contact

7:56

the patient's family to get more

7:58

information on the man's medical

8:00

and social history, and we'll get some of that

8:03

soon in terms of his vitals when he came

8:05

in. He was intubated by the time

8:07

we're getting this information and his oxygenation

8:10

was actually okay. His

8:12

heart rate was quite high, one

8:14

thirties to one forties, and

8:16

his blood pressure was somewhat elevated as well.

8:18

Somewhere around one hundred and sixty to one hundred

8:20

seventies. Systolic. We don't have

8:22

the bottom blood pressure, the diastolic blood

8:24

pressure. You mentioned an EKG,

8:27

you mentioned some laboratory studies to look

8:29

for attack. What else would you wanna do right now?

8:31

There's two things we're trying to figure out. Are the

8:33

vital signs stable or at least adequate?

8:36

We do have to figure out why his heart is going

8:38

so fast. We still have the

8:40

importance of studying that EKG to

8:42

make sure he's not having a heart

8:44

attack. EKG

8:48

stands for electrocardiogram, which

8:50

is a simple painless routine procedure.

8:53

You've probably had one before.

8:55

Electrodes are briefly attached to your

8:58

chest, arms, and legs to

9:00

measure your heart's electrical signals.

9:03

An EKG reading consists of

9:05

spikes and dips cold waves.

9:07

Actually, they look a lot like the Freakonomics

9:09

MD logo. Each of

9:11

these waves has a name and tells

9:13

healthcare professionals a lot

9:15

about how well your heart is

9:17

functioning. The patient I'm

9:19

describing to Capri had a troubling

9:22

EKG. It showed that his heart had

9:24

been irritated, possibly as

9:26

a result of past coronary

9:28

artery disease, or

9:30

because of the active problem we're

9:32

seeing now. Overall,

9:34

the EKG was suggestive of a

9:36

heart attack but not definitively

9:38

so. Some of the way variations

9:41

indicated to Gareep that the

9:43

patient could be deficient in

9:45

certain electrolytes. Like potassium

9:47

that keep the heart beating normally.

9:50

There are other

9:53

test results Garete would like to see

9:55

though, the measurement that might

9:57

help us most judge whether a heart attack is

9:59

happening or not, it's called troponin. I

10:01

think if there was the capacity to

10:03

do an echocardiogram, which is an ultrasound

10:05

of the heart, that would be really

10:08

informative. It would tell us how well the heart

10:10

is pumping. I think without a doubt a cardiologist would

10:12

be called at this point to help

10:14

with some of these decisions, including the question

10:16

about is there enough data to

10:18

be concerned that the patient has had a

10:20

heart attack, even if we don't have one smoking

10:23

gun, to take him to the cardiac

10:25

catheterization lab and take a direct picture

10:27

of those heart vessels that may have been

10:29

blocked and set off this whole thing. The

10:31

patient's echocardiogram showed

10:33

that the left ventricle was really

10:35

not working well. CapRe will

10:37

explain what this means in a few minutes.

10:39

A chest x-ray revealed

10:41

that the lungs were clear and a

10:43

CT scan of the head

10:45

found no evidence of a stroke

10:47

or bleeding in the brain. But

10:52

the patient's lab results were sort

10:54

of all over the place. His

10:56

sodium and phosphorus were elevated.

10:58

And so was his calcium level,

11:00

which was fifteen milligrams per

11:03

deciliter. His glucose or

11:05

blood sugar was really

11:07

high around three hundred milligrams per

11:09

deciliter. His white blood cell

11:11

count which is a marker of inflammation

11:13

was also high. His blood

11:15

work showed that his markers for liver

11:17

injury were slightly elevated,

11:19

but not too out of the ordinary. His

11:22

potassium level was three point

11:24

two and his bicarbonate was

11:26

six. Both of those numbers

11:28

are measured in milli equivalence per

11:30

liter. And both of those levels

11:32

are considered low. And

11:35

the last bit of information

11:38

which is what you asked about earlier was

11:40

several markers of cardiac injury, and one

11:42

of those was including a troponin measurement,

11:44

and that was really quite markedly

11:46

elevated. There's a lot to digest you.

11:48

You can almost take each one of those things

11:50

and form a differential diagnosis

11:52

or list of possibilities around them, and then

11:54

you can try to send size them together. Let

11:56

me just work in reverse because you said the most salient

11:58

thing which is the troponin was

12:01

elevated. Depending on how high it

12:03

was, that may suggest that active

12:05

injury is happening to the heart. The

12:07

most common thing is that a heart attack

12:09

is happening. That is to say that there

12:11

is a blocked vessel and the

12:13

blockage in oxygen why to the

12:15

heart is leading to damage, and that's what

12:17

set off the abnormal heart rhythm.

12:19

There are other interpretations to that

12:21

test, sometimes that marker of heart damage

12:23

comes about because of a blocked vessel, but

12:25

because there might be an infection to the heart

12:27

or inflammation inside the heart, we call

12:29

that myocarditis. You mentioned

12:31

left ventricular dysfunction. It's worth noting

12:33

that the heart is a four chamber

12:35

organ, and each of the chambers has

12:37

an important role. Like, there's chamber on the

12:39

right side called the right ventricle that

12:41

pumps blood to the lungs where the blood

12:43

picks up oxygen, but the real workhorse

12:45

of the heart is the left ventricle

12:47

when the left ventricle pumps blood

12:49

to the entire body. So

12:51

when that part of the heart is not working, that's

12:53

the most severe. And it can

12:55

be life threatening. The fact that he

12:57

has it not working well on the ultrasound

12:59

could be one of two things. It might have been

13:01

working just fine yesterday and today we're

13:03

discovering a new problem like a heart

13:05

attack happened. Mhmm. There's another

13:07

alternative explanation that he's

13:09

had heart injury or heart

13:12

failure that's been indolent in the

13:14

background for a period of time. And today's

13:16

event was sort of a bellwether. It was a

13:18

tipping point where the diseases become much worse

13:20

because a diseased heart can have one of these

13:22

arrhythmias, just creep up on it in the way

13:24

he did. And this is why it's

13:26

really important to be able to have information

13:28

on who this person was prior to when you first

13:30

saw him. Precisely, if we had an

13:32

echocardiogram perhaps from a year ago that told

13:34

us the was in the same state and the doctors

13:36

would have probably tried to figure out what it was

13:38

that caused it. We'd know much more than the

13:40

guesswork we're doing now. Some of the

13:42

things you mentioned are nonspecific. The white

13:44

blood cell count means the body's inflamed.

13:47

It's possible that there's an infection

13:49

that's underlying this. It's equally

13:51

plausible that this is just a reaction

13:53

to stress. So I have to put a

13:55

pin in that, but I can't draw a conclusion.

13:58

Conversely, the number you gave for a calcium

14:00

is extremely high. A calcium

14:02

of fifteen is well beyond the

14:04

normal range. Normally, it's in the eight to ten

14:06

range roughly. So

14:08

that's one clue that I'm sort of locking in

14:10

on. And then there are other

14:12

really knowable findings. Like you mentioned the

14:14

bicarbonate is six Did I hear

14:16

that correctly? That's correct. Yeah. That

14:18

is a very profound deficiency

14:20

of bicarbonate. The body

14:22

needs bicarbonate to keep a normal

14:25

acid base balance, also

14:27

called its pH balance. If

14:29

your blood is too acidic, it can lead

14:31

to a lot of problems. As

14:33

Garete mentioned, a calcium

14:35

level of fifteen is also

14:37

really concerning. High calcium

14:39

is often the result of overactive

14:42

parathyroid glands. Which can

14:44

weaken the bones, cause kidney

14:46

stones, or interfere with

14:48

how well the heart and brain

14:50

work. Another test was

14:52

performed on this patient called

14:54

an arterial blood gas. We

14:56

talked about this on the show a few

14:58

weeks ago, because it's the most

15:00

accurate way to determine someone's

15:02

oxygen level. They can tell

15:04

us other things too, like the

15:06

fact that this patient wasn't actually

15:08

too acidic despite his low

15:10

bicarbonate and that his

15:12

potassium blood level was

15:14

much lower than we had realized.

15:16

It was one point six, not

15:18

three point two. Anything below

15:20

three is considered severe. Potassium

15:23

is critical to all of our organ

15:25

systems especially the

15:27

heart. If the potassium is

15:29

as low as one point six,

15:31

that makes us think of why people have a

15:33

low potassium level. That can be

15:35

in situations where people aren't taking

15:38

enough in in their diet, but

15:40

it's more often that the potassium is

15:42

leaving the body, either it's going out of the

15:44

gastrointestinal tract. It's going out

15:46

of the urinary system.

15:48

Rarely, it's because the potassium is floating

15:50

around in the blood, but it might shift in

15:52

the cells. And one reason

15:54

can be because the person has taken a

15:56

large amount of carbohydrates, sometimes

15:58

that causes an insulin release and a

16:00

handful of people that leads to a really

16:02

exuberant response. Or another possibility

16:04

for the potassium to shift into the

16:07

cells really vigorously is that someone has

16:09

an overactive thyroid gland

16:11

and an overactive thyroid gland can sometimes

16:13

stimulate the heart to go into abnormal rhythms.

16:18

You gave me two levels of potassium,

16:20

three point two is mildly

16:22

low, but one point six is very

16:24

low. And just in general, the more

16:26

abnormal test is the more likely it's

16:28

gonna be a clue. Often

16:30

tests raise more questions than the

16:32

answer. What was causing this

16:34

patient's low potassium him

16:36

and low bicarbonate. Why

16:38

was this calcium so high? What

16:40

else do we need to know about him? After

16:43

the break, we'll hear what doctor Preet

16:45

Dolly Wall is thinking as I reveal

16:47

more about this complicated patient.

16:49

I think they're all important parts of his background.

16:51

I think none of them are telltale

16:54

signs of what's going on. I'm Bob

16:56

Bujena, and this is Freakonomics. Here's

17:15

a quick review of the case I'm disgusted

17:18

with doctor pre Dolly Wall today. A sixty

17:20

year old man collapsed in the

17:22

supermarket. Paramedics used

17:24

an AED, to shock his heart which

17:26

had gone into a dangerous, often

17:28

fatal rhythm called ventricular

17:31

fibrillation. He was brought into the

17:33

hospital and put on a ventilator His

17:35

EKG was abnormal. His blood

17:37

work was also concerning as we

17:40

discussed just before the

17:42

break. Among other results, his labs

17:44

revealed an elevated level of

17:47

troponin. Anytime someone collapses and

17:49

goes into cardiac arrest, as

17:51

this patient did, doctors have to think about

17:53

the possibility of a heart attack.

17:56

Troponin is a protein found in the

17:58

muscles of the heart. And when

18:00

the heart becomes damaged, troponin rushes

18:03

out of the muscles and into the bloodstream.

18:05

A logical next step

18:07

for this patient would be to

18:09

take him to the cardiac catheterization laboratory

18:12

to have his coronary arteries

18:15

evaluated. And that's exactly

18:17

what happened. They

18:22

evaluated his coronary arteries

18:24

and it was actually fairly unremarkable. There

18:27

was no evidence of

18:29

coronary artery blockages.

18:31

They did draw a potassium level

18:33

during the catheterization and that was also low

18:35

this time around the low 2s. So

18:37

they gave him IV potassium in

18:39

the cath lab. He

18:41

was transferred to the ICU. And

18:44

in terms of the progression of his

18:46

labs, you remember his calcium was

18:48

around fifteen first

18:50

came in, it actually fell to

18:52

about nine within a few hours. But

18:54

the potassium did remain low

18:57

while he was in and he continued to get

18:59

additional potassium by IV. The

19:01

other thing is he continued to be

19:04

unresponsive in all

19:06

of this. I think the potassium

19:08

has proven itself to be a persistent

19:10

problem. It makes me wonder about

19:12

whether it was cause all that is to say it caused

19:14

this whole. Syndrome. And

19:16

the fact that the coronary arteries were

19:18

normal is a relief, you know, no

19:20

matter what things may have detracted from the

19:22

possibility of heart attack, I think it would have been hard

19:24

to reject that hypothesis completely

19:26

-- Mhmm. -- without doing the cardiac

19:28

characterization. But now I think we have reason

19:30

to avert our gaze away from the arteries

19:32

of the heart. I wonder if there's a problem

19:34

with the muscle of the heart, like

19:36

something has infiltrated it or damaged

19:38

it, or if there's a problem with the electrical

19:40

system in the heart itself. Or

19:42

the minerals like potassium and

19:44

magnesium that depends upon the

19:46

function normally. the

19:49

me give you a little bit more history on this gentleman. He

19:52

lived at home alone,

19:54

and he used to have to

19:56

work at the airport but had retired about five years

19:59

ago. In terms of medical problems,

20:01

didn't have any history of diabetes,

20:03

or hypertension, though, remember his blood pressure

20:05

was elevated when he came in. The main

20:08

problem they had was issues with substance

20:10

abuse in the past, mostly opioids

20:13

but nothing as far as we know in the

20:15

last few years. He was a

20:17

smoker, no alcohol. But

20:19

besides this pretty limited

20:21

medical history, His family members said that

20:23

he had some chronic swelling in his

20:25

legs, and he took larynx for

20:27

that, but it wasn't clear if he

20:29

was still taking it. Someone

20:31

from the medical team actually called the local pharmacy, and

20:33

the last time he'd filled any prescription at

20:36

all was about a year ago, and

20:38

that was for Lasix. Family

20:40

said that he spent most of his time

20:43

indoors, not a lot of

20:45

exercise, not a great diet, lots of

20:47

snacks apparently. So that's the story

20:49

on who this person was

20:51

before he was found to collapse in the

20:53

grocery store. I

20:57

think they're all important parts of his background. I think none

20:59

of them are telltale signs of what's going

21:02

on. The idea that

21:04

he was even late six in the past

21:06

for leg swelling suggests that maybe

21:08

his heart problems predated

21:10

today that makes me wonder

21:13

his heart has been backing up and one of the ways the heart

21:15

backs ups into the lungs. If it keeps

21:17

backing up, it backs up into the legs

21:19

and fluid builds up there. I

21:21

noticed among the substances that he's used,

21:23

there was tobacco. Tobacco is

21:25

intriguing, not necessarily as an explanation for

21:27

today's problem, but for that calcium. That

21:29

calcium of fifteen was really

21:31

high. Mhmm. And tobacco

21:33

increases the risk for a number of cancers, a

21:35

number of cancers can cause a

21:37

very high calcium level like that. We

21:39

didn't see evidence of it in place we might look

21:41

first, which is the lungs where lung

21:43

cancer can arise from tobacco and cause

21:45

high calcium. But I took note

21:47

of that And then he's had some

21:49

struggles with substance use in the

21:51

past. I mentioned methamphetamine or

21:53

cocaine can trigger arrhythmia like

21:55

this. But we don't have any other collateral information

21:57

to decrease or increase our suspicion

21:59

of that. I'm wondering about his social

22:02

isolation. Every once in a while, we learned about

22:04

people who are very socially isolated and or

22:06

don't have access to food and they do have

22:08

vitamin deficiencies. But I think I

22:10

need more information before I chase

22:12

that down. I will say that had serum and

22:14

urine toxicology that was performed, and there

22:16

was nothing, no illicit

22:18

substances or anything that was concerning from that

22:20

perspective. That's helpful. I

22:22

think we have reason in this case to turn our

22:24

gaze elsewhere. So,

22:29

that's about all the information that I have for you.

22:31

I don't know if that's enough for you to put your

22:33

money down on what might be

22:35

going on with this gentleman. Not

22:37

yet, but maybe I'd have to define for myself what

22:39

the problem is that we're trying to solve here

22:41

that there was a man who had

22:43

an episode of ventricular

22:48

fibrillation that was not

22:50

caused by a heart attack,

22:52

but we found the signatures of a

22:55

number of, I would say, chemical imbalances

22:57

that he has has to build up in

22:59

the body, that he had a high level

23:01

of calcium and phosphorus

23:04

that he had a low potassium

23:06

and he had a high blood sugar.

23:08

All of which were kind of unexplained

23:10

based on his past medical

23:12

history One

23:16

general sense I have is that there was some

23:18

sort of excess sympathetic charge that

23:20

his body had then don't know whether it

23:22

was long standing or whether it was relatively

23:25

acute. But just that his heart

23:27

rate is going fast as white count elevated.

23:29

His blood sugar is elevated. Make me

23:31

wonder if maybe there's a chemical imbalance. And

23:33

if it's not external in the way that I mentioned,

23:36

might be internally generated.

23:38

Sometimes, our substances that the

23:40

body generates which in excess can cause these

23:42

problems like an excess of one

23:44

hormone called cortisol or

23:46

an excess of another family

23:48

of hormones called catecholamines. And

23:51

sometimes there are tumors in the adrenal

23:53

glands. This is the small hormone

23:55

generating glands that sit on top of the

23:57

kidney that might be responsible

23:59

for a large part of this profile.

24:02

So for instance, if the gland is producing too much

24:04

cortisol, it can cause problems like high

24:06

blood pressure, high sugar,

24:08

low potassium. It doesn't oftentimes

24:11

cause low bicarbonate,

24:13

but we don't have to have the patient fit every

24:15

part of the textbook. Patients don't read

24:17

the textbook we're fond of

24:18

saying, and

24:18

that certainly is the case here. I'm

24:21

even intrigued by the possibility of a

24:23

rare syndrome called pheochromocytoma,

24:25

which is that same gland instead of

24:27

producing cortisol, produces essentially

24:30

epinephrine. And some things that can present in a very

24:32

dramatic fashion that looks all the world like a

24:34

cardiovascular collapse, but it's just this

24:36

rapid release of hormones.

24:39

That would be something I'd be interested in

24:42

studying. This would require a closer

24:44

look at the heart loss, so involve CAT

24:46

scans and echocardiogram, even

24:48

sometimes a biopsy of the heart or a nuclear

24:50

medicine scan of the heart or an

24:52

MRI of the heart. I'm

24:56

intrigued to know if he was eating something

24:59

unusual. There are rare instances

25:01

where something like an excess of

25:03

licorice taken up in isolation can lead to a very low potassium and

25:05

that might have set off a cascade of events. But

25:07

it's a very particular type of licorice, by

25:09

the way. But when taken, it had

25:12

caused a very low potassium and other problems

25:14

like this. Tell me a little bit more about the

25:16

licorice, actually. I was mentioning that there's

25:18

a gland on top of the kidney

25:20

that produced is a number of hormones. One class

25:22

of hormones that matters are called the

25:24

mineralocorticoids. So believe it or

25:26

not that small gland cranks out a bunch

25:28

of different hormones. And the job

25:30

of that hormone is to keep the blood

25:32

pressure in the body intact. It has a lot of the things

25:34

it does, but it tells the body to hold on the

25:36

sodium, and it sort of rid of

25:38

potassium in a very measured way.

25:40

There's a very specific type

25:42

of licorice, which has a chemical.

25:44

I think it starts I think it's

25:47

called sric acid or something. It's actually

25:49

called glyceric acid group.

25:51

That if someone takes it in excess,

25:53

can mimic that same hormone

25:55

and what it does is it gets rid of

25:57

much more potassium than our

25:59

body would normally and can leave too

26:01

little potassium in the bloodstream and that could set

26:03

off the cast game that we are

26:06

talking about here. Okay.

26:10

Well, we're on video. You

26:12

see me smiling a little bit. What's your final diagnosis

26:15

then? I'm gonna say that although we don't have the

26:17

full complement test that we

26:19

want, based on the depth of this potassium,

26:21

based on social isolation may have found its

26:23

way into an abnormal or unusual

26:26

diet. Might be

26:28

ingesting excess black licorice

26:30

that has led to a low

26:32

potassium level leading to this cardiac

26:34

arrhythmia and subsequent medical

26:36

events. I think you clue it in on

26:38

this fact which was the potassium was

26:40

low and it continued to be low despite

26:42

attempts to replete it. I think someone

26:44

who's listening to this is gonna say, you know,

26:46

how did this guy take

26:48

a question stem, which is an

26:50

individual in a grocery store? Who

26:52

had cardiac and arrived to this pretty esoteric

26:56

diagnosis. That's not what it's like in the real world. Is

26:58

it? No. The real world, first

27:00

of all, I don't have an hour to do

27:02

it. We have far less. I

27:04

also don't have these goofy headphones on.

27:06

I think the upfront job is very much

27:08

like I described. You know, why is there a hard

27:10

attack happen are the vital signs stable. On the back

27:12

end, when the patient gets to the hospital and the

27:14

stabilization has happened, that's when we get to

27:16

sort of delve into the mysteries. Of

27:18

what might be going on. One thing that struck me, I think

27:20

this is a really good example too of where

27:22

the social history matters. Right?

27:25

We talk a lot about medicine social

27:27

determinants of health. And I think it was at least important to

27:30

know that he was living alone

27:32

and not going out too much somewhat

27:34

isolated because not

27:36

deterministic, but it does travel with sometimes

27:38

restrictive or unusual diets. Now

27:40

the truth is anyone can have a

27:42

single candy or a single type food

27:44

that they take in we probably all do for our favorites. But

27:46

just maybe if nothing else, it heightened

27:48

my consideration of his diet.

27:51

Compared to some of those other things I was mentioning that might be

27:53

the final explanation. And in the

27:55

case record from the mass general, the individual actually

27:58

passed away. Primarily

28:00

because of a failure to regain a good neurologic

28:03

prognosis. So it's unfortunate, but

28:05

there's a lot of learning that was possible in that case,

28:07

and I think we learned a lot from

28:09

you. How did it feel? Did you know where I was going?

28:11

How much uncertainty was there in your mind? Because you

28:13

kind of arrived at the right diagnosis,

28:15

but I tried awfully hard not

28:18

to give you too many clues. You

28:20

are a skilled storyteller. To

28:22

be fair, I was really jostling around

28:24

a lot of ideas. Right? This is a case

28:26

that started with a common scenario,

28:28

and I was waiting for what's called

28:30

the pivot point. Many decades ago, there was a study

28:32

of the New England Journal of Medicine CPCs where

28:34

someone looked at how the doc or solve

28:36

the cases. And the doctors go

28:38

through the differential and discussion of all

28:40

the possibilities, but they're really

28:42

waiting for one clue on which

28:44

the whole case will be solved. You can

28:47

only go so far with an abnormal heart

28:49

rhythm. You can only go so far

28:51

with a high blood pressure or a high pulse rate. You something

28:53

that kinda has both

28:55

a narrow range of possibilities and

28:57

a very organized way to analyze

28:59

it, and that's called the pivot

29:02

points. So it might be a high type of cell count

29:04

like eosinophil, so it might

29:06

be a specific X-ray finding

29:08

like a lung mass or in this case it was

29:10

a very specific lab

29:12

finding. And it wasn't clear that

29:14

potassium was going to be the answer here. You threw

29:16

out a lot of tantalizing alternatives,

29:18

right, that chase after the acidosis

29:20

in the blood to chase after the calcium

29:22

of fifteen. But one

29:24

thing that sometimes guidance is like

29:26

how wildly abnormal something is

29:29

While the acidosis was notable,

29:32

it wasn't the most severe. And while the

29:34

calcium was high, it resolved quickly.

29:36

But that potassium that

29:38

was markedly low and stayed

29:40

low. I mean, so much so that doctors were giving

29:42

potassium even after the cardiac procedure.

29:44

That was a clue that the answer was

29:47

gonna have to explain that. It may not have to explain

29:49

anything else in the case, but it was likely gonna have

29:51

to explain low

29:53

potassium. A case

29:59

presentation is a story. It's a

30:01

foundation of medical education, and

30:03

of clinical medicine in general. It's also something

30:06

I haven't done in a while. So

30:08

thank you for bearing with me and

30:10

with Capri as we work through

30:12

this patient serious and

30:14

ultimately tragic medical event to

30:16

get to the bottom of what caused

30:18

it. We rely on these cases to become

30:20

better doctors, better thinkers,

30:23

even after years in decades of

30:25

practicing medicine. And

30:27

we're grateful to patients like this one

30:29

who give us the gift of a

30:32

story. I think the best way to honor

30:34

someone's memory and generosity

30:36

if they're involved in letting us share their case is make

30:38

sure that we learn from it

30:40

and can use it to treat

30:42

other people well and maybe

30:44

solve their case at an earlier stage.

30:47

That's it for today's show. I'd like to

30:49

thank my guest and friend, Dr. Gripy

30:52

Dollywal, and thanks to you, of course,

30:54

for listening. We'd love to do more

30:56

episodes like this because medical

30:58

mysteries teach us a lot

31:00

about how the body works. Why

31:02

it sometimes doesn't? And how doctors

31:05

think. Do me a

31:07

favor. Let us know how you've thought about my chat

31:09

with Capri today. Send us an

31:11

email. Leave us a review on

31:13

Apple Podcasts, or tell your friends

31:15

about the show. Send us a

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signal. My email is

31:19

babu Freakonomics dot com. That's

31:21

BAPU at freakonomics

31:23

dot com. Coming up

31:25

next week, in medicine, when you

31:28

analyze data, it can take you to some

31:30

unexpected places. It

31:32

started to tell a story that was

31:34

horrible, which is that a small sliver

31:36

of patients We're going back over

31:38

and over for all kinds of reasons.

31:40

We're gonna revisit an episode from this

31:42

past summer in which doctor

31:44

Jeffrey Brenner told us all

31:46

about this small sliver of

31:48

patients. They were going back and

31:50

forth all the time to the hospital, but they weren't

31:52

getting care, they were getting treatment, but

31:54

they weren't getting care. Jeff and

31:56

his team developed an innovative

31:58

approach to help these complex patients,

32:00

also known as super utilizers.

32:03

But did improving their care also

32:05

decrease costs. They were

32:07

getting a lot of praise for their program and

32:09

they honestly wanted to

32:11

rigorously determine whether it was saving

32:13

money on its

32:13

own. That's coming up next week on free

32:16

MD. Thanks again for listening.

32:20

Free Freakonomics MD is part of

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