David rolled her on her side and listened to her chest. When he did so he panicked. He heard a chorus of rhonchi and rales. She was developing massive pneumonia. It was like John Tarlow all over again.
David raced back to the nurses’ station where he ordered a stat blood count as well as a portable chest film. Going over Mary Ann’s chart he found nothing abnormal. The nurses’ notes for the day suggested that she had been doing fine.
The stat blood count came back showing very little cellular response to the developing pneumonia, a situation reminiscent of both Tarlow and Kleber. The portable chest film confirmed his fear: extensive pneumonia developing in both lungs.
At a loss, David called Dr. Mieslich, the oncologist, to confer by phone. After all the trouble with Kelley he was reluctant to ask for a formal consult even though that would have been far better.
Without having seen the patient, Dr. Mieslich could offer little help. He did confirm that the last time he had seen Mary Ann in his office there had been no evidence of her ovarian cancer. At the same time he told David that her cancer had been extensive prior to treatment and that he fully expected a recurrence.
While David was on the phone with the oncologist, a nurse appeared in front of the nurses’ station and yelled that Mary Ann was convulsing.
David slammed down the phone and raced to the bedside. Mary Ann was indeed in the throes of a grand mal seizure. Her back was arched and her legs and arms were rhythmically thrashing against the bed. Fortunately, her IV had not become dislodged, and David was able to control the seizure quickly with intravenous medication. Nevertheless, in the wake of the seizure, Mary Ann remained comatose.
Returning to the nurses’ station, David put in a stat call to the CMV neurologist, Dr. Alan Prichard. Since he was in the hospital making his own rounds, he called immediately. After David told him about the seizure along with a capsule history, Dr. Prichard told David to order either a CAT scan or an MRI, whichever machine was available. He said he’d be over to see the patient as soon as he could.
David sent Mary Ann to the Imaging Center for her MRI accompanied by a nurse in case she seized again. Then he called the oncologist back, explained what had happened, and asked for a formal consult. As he’d done with Kleber and Tarlow, he also called Dr. Hasselbaum, the infectious disease specialist.
David couldn’t help but worry about Kelley’s reaction to these non-CMV consults, but David felt he had little choice. He could not allow concern about Kelley to influence his decision making in light of the grand mal seizure. The gravity of Mary Ann’s condition was apparent.
As soon as David was alerted that the MRI study was available, he dashed over to the Imaging Center. He met the neurologist in the viewing room as the first images were being processed. Along with Dr. Cantor they silently watched the cuts appear. When the study was complete David was shocked that there was no sign of a metastatic tumor. He would have sworn such a tumor was responsible for the seizure.
“At this point I cannot say why she had a seizure,” Dr. Prichard said. “It could have been some micro emboli, but I’m only speculating.”
The oncologist was equally surprised about the MRI result. “Maybe the lesion is too small for the MRI to pick up,” he suggested.
“This machine has fantastic resolution,” Dr. Cantor said. “If the tumor was too small for this baby to pick up, then the chances it could have caused a grand mal seizure are even smaller.”
The infectious disease consult was the only one with anything specific to add, but his news wasn’t good. He confirmed David’s diagnosis of extensive pneumonia. He also demonstrated that the bacteria involved was a gram-negative type organism similar but not identical to the bacteria that had caused Kleber’s and Tarlow’s pneumonia. Worse still, he suggested that Mary Ann was already in septic shock.
From the Imaging Center David sent Mary Ann to the ICU where he insisted on the most aggressive therapy available. He allowed the infectious disease consult to handle the antibiotic regimen. The respiratory care he turned over to an anesthesiologist. By then Mary Ann’s breathing was so labored she needed a respirator.