Welcome to San Diego
Steve Marcus had been at the Naval Hospital in San Diego for several days. Dr. Anna Chan had informed him that there was a daily presentation of new admissions by the house staff every morning at 7:00. Attendance was not mandatory, but she recommended Steve go if he wanted to score points with Mark Reynolds, the head of the neurology department.
It was the fourth day. There were easily sixty medical officers in the room counting both house staff and attendings. The four house staff that had been on call the day before were seated up front, crisp in their summer whites. Steve entered and took a seat along the side wall, the chairs on either side remaining empty. The scene was reminiscent of days back in medical school or residency when students and house staff presented new patients to the attendings. This was even more rigorous, as superimposed on the normally rigid discipline of academic medicine was even more rigorous standards of the United States Navy.
As a newcomer and a reservist, Steve felt inconspicuous among the room full of Medical Officers who had been on active duty for years. Maybe worse than inconspicuous—an outsider, a civilian who had been dropped into the Starship Naval Hospital due to the fortunes of war.
The officers settled in to their seats, the intern presented the first case. An eighteen year old male with a recent history of a mild viral infection had gone to the ER with new onset of clumsiness. There was no associated fever. His medical history to date had been unremarkable. His exam was significant for some mild ataxia and reflex loss. Imaging studies and laboratory data including spinal fluid were normal. The intern was seeking assistance for next steps with regard to diagnosis, management and treatment.
Everyone turned to CAPT Reynolds who proceeded to give a comprehensive discourse on the various possible causes of ataxia including cerebrovascular disease, tumors, and infection. As he finished, Mark looked at Steve, “What do you think, Steve?”
“I think the intern just described a fairly typical presentation of Miller Fisher variant of Guillain-Barre syndrome where the ataxia is predominant over any weakness. I suspect the spinal fluid was normal because you did the tap so soon after the onset of his symptoms, but if you repeat it today, you will probably find an elevated protein.
Within seconds the chief resident was in one of the chairs next to Steve, a pen and small notebook in his hands. “What can you tell me about this?” he asked softly. “Do we need to do any more studies? What’s the treatment?”
“Meet me after rounds,” Steve replied quietly so as not to disturb the session. “I’ll be happy to discuss it with you.” He sat back to watch and listen to the remaining case presentations. A feeling of gratification arose within. He had taken the first step to become an accepted member of the team.