Hypercalcemia (an elevated level of calcium in the blood) can be caused by a variety of malignant tumors. I know this not because I read it somewhere, but because the first patient I ever cared for had hypercalcemia.
Ten years ago I was a second-year medical student at Duke. While on my medicine clerkship at the VA hospital I was informed by my senior resident that a "great case" had just rolled into the ER. He was to be my first admission: a 67 year-old man with hypercalcemia.
I quickly ducked into the medical library and read a few paragraphs from Cecil's textbook of medicine. Armed with my new knowledge, I'd pounce into the ER and make a stunning diagnosis. I imagined myself saying, "this man clearly has milk-alakali syndrome." I would then caution him against ingesting calcium-containing antacids and send him home to recuperate uneventfully.
It didn't quite work out that way.
Mr. M. was an unfortunate sole who's diagnosis had been known for a long time. He was suffering from metastatic small cell carcinoma of the lung. The hypercalcemia was a manifestation of his malignancy. He was obtunded. His cachectic and contracted frame was loosely wrapped in urine-soaked brown flannel pajamas.
"A classic finding," I heard my resident gleefully state. "He's got nephrogenic diabetes insipidus. He can't concentrate his urine and, given his altered sate of consciousness, he's managed to piss all over himself. Just classic."
For a moment I was paralyzed. How could I take a history from this man? How could I conduct an interview? Where would I begin my examination? I didn't want to be anywhere near him. I didn't want to put my hands or my stethoscope on him. He smelled terrible. He looked worse. My resident, on the other hand, looked absolutely delighted.
"I've heard a lot about these new bisphosphonates for the treatment of hypercalcemia," he said. "We'll give them a try. We'll fix this guy. What a great case."
We admitted Mr. M. to the ward and began purging the calcium from his system. We would start by hydrating him with saline while at the same time treating him with a diuretic. The fluid would flow in through an IV, flush through his body and then drain from his bladder via a catheter. The entire process was akin to washing a dirty glass under a briskly running tap. Eventually he would be cleaned.
I arrived daily at 6AM to draw a STAT electrolyte panel. The results would be available by morning rounds and would guide our therapy for the day. I was so excited to see the calcium level drop from 16 to 14 to 13.5 that I didn't really notice that Mr. M. wasn't improving. After about 4 days, we added etidronate to the regimen. It was one of the "wonder drugs" that my resident was intent on trying. The calcium continued to plummet ...12.5...11.9...11.3...10.7. The whole team was excited, We had normalized the serum calcium level.
"He looks great on paper." my resident would say.
Unfortunately, he didn't look so good in person. Correcting his hypercalcemia had only marginally improved his mental status and in so doing had made it evident that he was in great pain. He would now withdraw his arm when I needled him for his daily blood sample, whereas before he was motionless. His respirations had become more labored and were punctuated with a groan as he exhaled. It was clear that his days were numbered.
VA social services was able to locate a distant relative of Mr. M's in Cleveland - I think it was a nephew or a grandnephew. Anyway...my resident had spoken with him and it was decided that Mr. M would not be put on life support in the event of a cardiac arrest. It was a timely decision. Mr. M died that evening. It had been eleven days since admission, although it seemed a lot longer.
"Don't feel bad, Mo," my resident told me, perhaps noting the disappointment on my face. "You did a great job. He died with normal numbers. His calcium was 8.6. That's strong work. I really think etidronate is a great drug. It's really going to have an impact on the way we treat hypercalcemia."
It was late by the time I got home. My roommate Joe was on call...obstetrics I think. I grabbed a beer and put "Astral Weeks" on the CD player. Didn't really think about much. I fell asleep in a few minutes.
[ T o n y | M a r c u
s | J a m e s | J a s o
n | R a v i | D a n i e l |
M o | P e t e r ]