Case 31: Preventive Health

“I had this great case,” I tell Brian. He smiles gently. Nods. This is as excited as he gets. Brian knows everything. He’s not a know-it-all. Unlike know-it-alls, Brian actually does know everything. I hold up the card and read it: “Who played Miss Ellie on the 80s hit TV show Dallas?”

“Barbara Bel Geddes,” he says. “Except for a short run when she was replaced by Donna Reed.”

Brian’s going to win this game before anyone else gets another turn. We don’t even need these cards. We could just use him as the question bank – pinch his nose for Geography, pull his ear for Arts and Literature, and so on. He’s also the best doctor I know. He can do it all. Family medicine, anesthesia, inpatient medicine, emergency medicine. Once, while doing relief work in a third-world village, he came across a sick patient with severe abdominal pain. He made the diagnosis, put the patient to sleep, and then, with no formal surgical training, performed a successful emergency appendectomy. And this was before the days of Youtube.

I’d been at work an hour, I tell him, when my phone rings. A nurse asks me to come quickly, and says there’s a patient with acute cyanide poisoning. Cyanide? I don’t even know what cyanide is. I mean, I know it’s poison, and that it can kill people, like anthrax, but I know little else. Is it in household compounds? Cleaners? No idea. How would someone get cyanide poisoning in the suburbs, or anywhere else for that matter.

“I just got this patient in acute fifteen,” the nurse says. “You’re not going to believe this, but she ate twenty apricot seeds between nine and ten-thirty this morning. She was warned that they may cause cyanide poisoning and she started having symptoms shortly after ingestion.”

“Apricots cause cyanide poisoning?” I ask.

“Not apricots,” she says. “The seeds. Apricot seeds.

Brian’s on a roll. The way he’s answering questions, I may not finish my story before he wins the game. He swoops up the dice with his chubby fingers, gives a shake, and throws ’em down. I make fun of his fingers from time to time, only because I’m amazed at what they can do. Watching him insert an IV line, or intubate a patient is like watching someone thread a needle with oven mitts. It’s magic.

I rush over and find the chart. The patient’s already been in the ER for thirty minutes and the proactive nurse has called Poison Control. Poison Control made a few recommendations – blood tests, intravenous fluids, and they warned about things to watch for – low blood pressure, acidity in the blood, seizures. But cyanide toxicity isn’t common, and they’re going to do a little research and call us back. While I’m reviewing the chart, I hear someone moaning in agony. I ask the nurse if that’s the patient – the cyanide poisoning. “That’s her,” she says. “Can we give her something for pain?”

The patient is about sixty years old. She’s thin and athletic. Her vital signs are stable – no fever, blood pressure is normal, as is her pulse – about a ninety-five beats per minute. She’s writhing. There’s a vomit basin next to her pillow. She’s holding her gut and breathing as if she’s in labor. “Cyanide poisoning,” her husband says. “She ate twenty apricot seeds this morning. Cyanide is a byproduct of the seeds.” I ask where her abdomen is sore and she says everywhere. I try to localize her pain, and she’s right, she’s tender everywhere. I order intravenous fluids, as well as morphine and Gravol. A nurse pops in and asks if I can come see a woman next door – a new patient with a heart rate of one-sixty. She needs cardioversion – a shock that will bring her heart back to its normal rhythm. I tell my cyanide overdose that the medication will settle her pain, and that I’ll be back. I order tests and ask the nurse to call me if she worsens while I await further instruction from Poison Control.

Brian rolls again, and someone asks the obvious question: “How and why would someone eat even one apricot seed, never mind twenty.”

“Laetrile,” Brian says, as if it’s common knowledge. “Apricot seeds were popular back in the eighties because they contain laetrile. People wanted it for its supposed cancer-fighting properties.”

After the cardioversion, I find a quiet computer and do some research. I find a case report from 1982. A sixty-eight year old woman with treatable colon cancer opted for Laetrile instead of conventional medical therapy. She started with injectable Laetrile from Mexico, but, because of cost, switched to oral tablets after two months. She was also given ‘bitter almonds’ by a friend, which, like apricot seeds, are rich in Laetrile. After eating a “slurry of water with twelve bitter almonds” (what might be called a protein-shake today), she developed a severe bout of crampy abdominal pain and collapsed. In the emergency room, she was unresponsive. Her stomach was pumped, and then, she was given the contents of a ‘cyanide treatment kit.’ Within twenty minutes of receiving this antidote, she woke, and became oriented.

I check to see if my patient’s blood results are back. They aren’t. I get called to see two more sick patients – a dehydrated 93 year old who’s fallen and suffered a deep gash across her forehead, and a sixty-year old, post-colonoscopy, who is now passing large blood clots.

An hour after my initial assessment, I’m back to my apricot seed overdose. She’s comfortable now and thanks me. I go over her story one more time. She’s healthy, takes no prescription medications, and has never had surgery. She doesn’t smoke, drinks socially, and is a business professional. She takes care of herself – she eats well, she exercises regularly and is proactive in preventive health. A friend of hers told her that apricot seeds could reduce her chances of getting cancer. “My mother died of ovarian cancer,” she later told me, “and we hear so much about cancer, we always look at ways to be proactive.”

Much like the woman in the case report, she’d developed abdominal cramping and pain. However, she didn’t lose consciousness, or become confused. Her symptoms seemed purely gastrointestinal. I examine her again. Much of her abdominal discomfort has improved, but she’s still exquisitely tender at the left, lower part of her abdomen. She’s also bloated, and when I listen to her belly, there are few bowel sounds, if any.

“I’m going to send you for a CT scan,” I say. “I’m not sure you have cyanide poisoning.”

“What do you think it is then?”

I think she may have something almost as odd as cyanide poisoning. I think she may have a bezoar. A bezoar is a mass-like accumulation in the gastrointestinal tract that can cause an obstruction. I once biked fifty miles to play in a doctors’ baseball tournament. The next day, I developed abdominal pain. It turned out to be nothing, but my medical teammates insisted it was a bug-bezoar, and encouraged me to keep my mouth closed the next time I went for a bike ride. In medical school, sunflower seeds were given as an example of a bezoar-causing food. Apricot seeds seemed like a possible culprit.

An hour later, the CT scan is back and I page the surgeon on-call. I tell him the story.

“So,” he says. “Is it a bezoar?”

“Maybe,” I say. “There’s an obstruction, but no definite bezoar.” The scan shows inflammation, thickening of the bowel wall, and fluid.

The surgeon comes down and takes my patient to the operating room. There, he finds two feet of inflamed bowel – swollen, bleeding, and ischemic (ischemic tissue is dead, or dying tissue, resulting from inadequate blood supply).  This is the area causing the painful obstruction. He removes this segment of bowel and reattaches the loose ends. There are no seeds, no bugs, and no bezoar.

Two days later, I visit my patient on the surgical ward. “So,” I say, “it turns out it wasn’t cyanide poisoning. The apricot seeds may have just been a red herring.”

“It may not have been cyanide,” she says. “But it’s way too much of a coincidence to just dismiss this as a fluke. The obstruction happened for a reason.”

She’s right. It is too much of a coincidence. One minute, she’s perfectly healthy, but after eating twenty apricot seeds, she develops an ischemic bowel.

“I guess there aren’t any large cohort studies that show that Laetrile or apricot seeds cause ischemic bowel,” Brian says, as he rolls the dice again.

“No,” I say. “Maybe this will just be another case study.”

“Or just another bit of trivia,” he says.

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  1. HI Raj,
    I love your blog. Thank you for sharing your stories! I am just wondering…given this patient’s family history of ovarian cancer, was she tested? (as possibly related to the bowel issue)

    1. I’m sure her family doctor was/is keeping an eye on her in light of her family history. The hospital visit was short, and the focus was on the bowel obstruction and its treatment. Thank you for reading and taking the time to comment. All the best!

  2. Hi doc,
    Just wanted to take a minute to say that I love reading these pieces. I’m a current paramedic and aspiring medical student, and your blog is genuinely among the things that helped me fall in love with EM.

    1. Hey Jennifer – thanks so much for reading and for the kind words. Good luck with medical school, and ya, EM has that appeal that not everyone really understands. People often come in and later say “how do you deal with it?” Meanwhile, people like us MISS it if we’re away from it too long!!!

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