Case 22: Let Me Rub This On You

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Twenty-four year old J.P. Tyler is as pale as his white t-shirt that’s two sizes too big. He’s lying on his back – moaning – one leg hanging off the exam table. Too weak to sit, his wife is holding a vomit basin close to his cheek. He gags and coughs as I speak, a string of mucous and drool hanging from the corner of his mouth. He looks sick – critically sick – sweaty, pale, his jugular pulse bounding off his emaciated neck. His blood pressure is low, and an intravenous line has been placed by the triage nurse.  Saline is dripping into his line like a leaky tap. I open the line wide and let it flow, and as I introduce myself, he rolls onto his side, wretches, and pleads for a painkiller.

J.P.’s problems started several months before his visit to the emergency room. It began with nausea in the mornings – some days worse than others. He occasionally skipped breakfast, then, as weeks passed, he cut it out altogether. In the early days, he’d be fine by lunch, but eventually, the queasiness would spill into the afternoon. It wasn’t until he woke up in pain, a month ago that he’d visited his family doctor. She questioned him, sent him for blood work, and an ultrasound, and asked him to keep a diary of what he ate. The tests were normal, and the diary unhelpful. Then, three weeks before I met him, the pain worsened. By then, the nausea would last all day. He stayed in bed. He missed work. And then one morning, he began vomiting. He couldn’t eat. He lost weight – twenty pounds in two weeks. And by the time he came to me, he was dry, malnourished, and in agony.

My conversation shifts to his wife when a gaping, empty wretch precludes him from answering. It’s gross – as if a stretched finger is pushing continuously at the back of his tongue. They’ve lived together for three years – this last year with her parents so they could begin saving for a down payment. “No,” she says, “before this, he’s never been sick, he doesn’t take any medications, and he’s never had surgery.” By trade, J.P. is an electrician, but now his job is at risk – in fact, because of absenteeism, he isn’t even sure if his employer will have him back. “He hasn’t been able to leave the house for two weeks,” his wife says. I ask him about his diet, his lifestyle, his habits – whether or not he smokes or drinks. He does smoke, he says – about a half-pack a day. And he used to drink occasionally, but since he can’t even keep water down, a beer with his buddies is out of the question.

I keep my physical exam short – rapid heart rate, clear but quick breaths, and an abdomen too tender to touch – especially at the top. An experienced surgeon once told me that only three things matter – the history, the history, and the history. And before I’ve even touched him, I’m fairly certain I know what’s wrong. I could stop here – and tell him what I think is wrong – but he’s so sick that I have to rule out a couple of things – like pancreatitis, or a problem with his gallbladder. I explain my working diagnosis, and my plan. “I’ll order some more IV fluid, as well as something for pain and nausea.” I look to his wife. “But there’s a good chance none of this will work.” Once his blood work is back, I say, I’ll come and see him and if my hunch is on the mark, then he’ll probably still be miserable. “But if you’re willing, there’s something we can try.”

I leave the room, and hand his chart to the nurse. She’d put him ahead of her other patients, and ushered him into the room as soon as he’d been assigned to her. “Morphine, Gravol?” she says.

“Yup,” I say, flagging down my assistant. “Let me know right when his blood work is back. I’m going to try something.”

An hour later, he’s back in the exam room. A bag of saline has given him the strength to sit up, but he’s still holding the basin, and the pain prevents him from straightening out. He agrees before I can even explain the risks of what I’m about to try – skin irritation, burning, maybe an allergic reaction. “Go for it,” he says.

“Our hospital pharmacy doesn’t carry this,” I say. “I bought this myself – thirty bucks – over the counter. I’ve had some luck with it in patients like you.”

He raises his hands and his wife helps him take off his shirt. This is the awkward part; With women, I’ll often ask a family member to massage the cream onto their backs. I use a small amount – the size of a marble – and spread it thinly across his shoulder blades, and then down to the small of his back. He can already feel the burn as he puts his shirt back on.

He stands and wheels the IV pole back to the waiting area. I document it on the chart, and, minutes later, the nurse is pointing to my words “consent obtained” her finger scrolling along my progress note. “Care to explain this?”

“It might help. I heard about it at a conference.”

“Interesting,” she says.

My assistant puts J.P. and his wife back into a room exactly an hour later. “What the hell did you do to him?” he asks. “He looks like a different person.”

“What do you mean?”

“He’s better. A hundred percent.”

“I rubbed some cream on his back.”

He’s sitting on the exam table, smiling. He’s holding a bottle of water, and as I enter the room, he takes a swig. “He’s keeping it down,” his wife says.

“This is the first time I’ve been able to drink for over a week – other than when I’m sitting in the bathtub.”

J.P. first tried marijuana in high school when he was sixteen. It was readily available at parties, and so, every couple of weekends, he’d try it. He liked the high it gave him, but never felt the need to use it regularly. It wasn’t until he was eighteen or nineteen, that he got hooked. It wasn’t the weed that got him, he says, it was the way he was smoking it. He followed the lead of his friends and began mixing marijuana into cigarettes. “I was probably hooked on the nicotine, but I definitely liked the feeling of getting high.”

He was five years into the habit before he began experiencing nausea in the mornings. When he saw his family doctor, she sent him for tests, and when they revealed no abnormalities, she had no answers. In the week leading up to see me, he was either sleeping or in the tub. “I’d sleep for two hours, then get enough strength to get into the tub. It was the only place where the nausea would go away – in a hot bath. I’d get into the tub with a bottle of Gatorade, stay there for a couple of hours, then go back to bed.”

“How many times a day were you filling the tub with hot water?”

“Five times a day,” he says. “Five or six. And remember, I’m living with my in-laws, driving them crazy. Their hot water bill was through the roof. If anyone wanted to come talk to me, they’d have to come to the bathroom. I’d spend ten hours in the tub, and the other fourteen in bed.”

He readily accepted my diagnosis – Cannabinoid Hyperemesis Syndrome (C.H.S.) – a relatively new entity – one that hadn’t even been reported when I finished my training in 2002. It’s characterized by severe abdominal pain, nausea, and vomiting, along with regular use of marijuana. The hallmark of the disease is the alleviation of symptoms with hot baths or showers.

Not all people accept this diagnosis. Patients have left the E.R. cursing, calling me an idiot, or worse. I’ve been accused of being paid by “Big Pharma” to discredit the merits of marijuana.

Six months before meeting J.P., I’d attended a conference on Emergency Medicine. One physician spoke about his challenges with C.H.S., and his success using an over the counter cream that warmed patients and soothed their symptoms.

Several months later, I called J.P. to see how he was doing. After his visit with me, he never smoked weed again. It took weeks for his pain and nausea to settle completely. To help with his symptoms, he bought the same cream I’d applied – Capsacin – which is produced by chili peppers. Like some other over-the-counter creams, it gives the sensation of heat when applied to skin. He applied it five times a day to his arms and chest. Eventually, with his cessation of weed, his symptoms resolved.

“Was it hard to stop smoking weed?”

“I don’t know if it was withdrawal, but I used to use it to calm me before bed. I had some pretty severe insomnia, so I went to see my family doctor. I showed her the literature you’d given me. She’d never heard of C.H.S. before. The next time I saw her, she told me she’d diagnosed four other people in her practice with the same thing.”

He’s telling his friends, and warning them that it could happen to them. But until it does – if it happens at all – most of his friend have decided to take their chances and keep smoking.

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One comment

  1. It’s fascinating to think of the chain of events from your attendance at the Emergency Medicine conference six months prior, to your diagnostic recollection when the patient presents, to the follow-up several months later where your patient informs you that his physician, who had never heard of CHS, had already treated four other cases. So, basically, that one correct diagnosis has led to at least five successful treatments — and likely more, now that the story has been presented in your blog. Great job!

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