When I was an intern, our chief of medicine would make a regular trip to the wards for a case presentation. The event was a high-stress affair where we all donned our clean white jackets and had our charts looking spiffy and organized, lab values charted accurately and up to the minute. The cases for discussion were usually very challenging and complicated, allowing the ward team to show its stuff with elaborate workups that included everything from A to Z.
Sometimes we showcased our management skills as we described the rescue of a poor patient with horrible wheezing and a white-out on chest X-ray with a deftly administered elixir of heparin, digoxin, and penicillin. That’s hepatadigacillin for you novices. Trust me, it works magic when you are clueless about what you are treating.
Once during one of these conferences, the chief—surrounded by a posse of interns, residents, and students, all looking anxious and fearful—went to the bedside to interview a young woman who was about 20 years old. The woman had been hospitalized for thyrotoxicosis and teetered on the precipice of thyroid storm, a very dangerous occurrence that can genuinely kill. The young woman was a veritable metabolic blast furnace, cheeks blazing red and heart racing. She was jittery and jazzed from the thyroid hormones surging through her circulation as her heart clocked 140 beats a minute.
The brain of the young woman was definitely lit up. She was witty, funny, and vivacious, and when the chief, looking formal and sober, asked her the usual questions—Have you lost any weight? Does the heat bother you?—she giggled and laughed. She utterly charmed the chief, whose usual dour visage brightened. He even cracked a smile.
When the entourage of house officers and students returned to the conference room to discuss the case, we all expected the grilling and pumping that were often the basis of rounds in those days. What is LATS? Why did you wait to give propananol? Where are indications for radioactive iodine? Instead, the chief turned reflective and, in a quiet and wistful voice, said that the saddest disease to treat was hyperthyroidism in a young woman since, as the thyroid storm abates, the radiance disappears, and the body thickens with flesh.
“When they are hyperthyroid, they are the life of the party,” the chief said with a forlorn voice. “Euthyroid, they are fat and dull.”
The chief’s comments would be considered politically incorrect today but, as I have grown older, I realize the truth of the chief’s remarks. I always remember his words and still often cite them on rounds.
The Saddest Condition to Prevent?
Like my chief, I have been feeling reflective of late. After all, I recently became eligible for Medicare. (Incidentally I was shocked to learn that Durham County, N.C., offers a choice of 36 drug plans for Medicare, although thankfully that is down from 47. Yikes, how do I choose? But that is a discussion for another column.) In my current state of mind, I have recently asked myself another question: Which disease is the saddest to prevent?
My answer was simple: gout. Hands down. No contest. The answer is gout because, outside of hypouricemic agents, prevention involves telling the patient to turn his back (this is a man’s disease, after all) on some of the great joys of life. Even if they are bad for you, eating, drinking, and other indulgences that send uric acid levels skyward are a hell of a lot of fun. A life of the metabolic straight and narrow would no doubt be good for the kidneys and joints but would leave the soul diminished, if not weakened. No more rolling the good times if you want to keep crystals at bay.
I had clear evidence of this proposition recently when I spent a Halloween weekend in New Orleans to attend a wedding. As it turns out, that particular weekend is the second busiest of the year in the Crescent City because of the simultaneous occurrence of Halloween, a home game for the Saints (“Who dat?”), and a jazz festival. The city overflowed with tourists—pumped, wild, and shy on clothing but bedecked in beads—and, in my hotel, there were about 100 people from Pittsburgh who had made the pilgrimage to the home of the reigning Super Bowl champs for a four-day party of the best gut-busting, gout-inducing behavior you can possibly imagine. Shrimp, Andouille sausage, oyster gumbo, Abita beer, and a drink called a Hurricane (a sugar-bomb extravaganza of high-fructose corn syrup and rum) are the raw materials of a uric acid load that needs more than an infusion of uricase to handle. Although the alchemists of the past could never change lead into gold, the chefs of New Orleans can turn seafood and pigs into negatively birefrengent little gems.
The Steelers fans were a high spirited and jovial lot, bedecked in black and gold, with names and numbers of their favorite players emblazoned on the backs of their official NFL-certified jerseys. The most popular were #43 (Polamalu) and #83 (Ward). The fans were as big as their heroes on the gridiron, with XXL and XXXL sizes the norm for this crowd. Pittsburgh is no longer a factory town, but whatever these guys were doing, their arms bulged and their bellies swelled, stretching the threads of their jerseys to the breaking point.
When these fans were not out painting the town red, they sat together in a bar near the hotel lobby, filling tables with empty beer bottles along with their nachos and dips. In the shifting glow of the TV fixed on ESPN, the men roared and laughed as they downed round after round and regaled each other with stories of their beloved Steelers and how, on Monday night, the defense would smash, pulverize, and maim New Orleans Saints quarterback Drew Brees.
The bar in the hotel was a tophus waiting to happen and I could imagine that, after days of pre-game festivities, when the fans would go over the Superdome for a little pregame tailgate, the uric acid of these fans would rise like the mercury in a thermometer on a hot summer day. Indeed, at the clip these fellows were eating and drinking, the temperature in the Superdome would likely rise an entire degree from the conflagration as thousands of inflammasomes fired off simultaneously in toes and knees.
What’s a Rheumatologist To Do?
Anticipating an epidemic of crystal-induced arthropathy from all of this high-octane indulgence, I was tempted to set up a stand outside the Superdome with a little hand-painted sign that said, “The rheumatologist is in”—although I have to wonder how many fans would know what a rheumatologist is.
As an advocate of prevention and myself a model of temperance and moderation, I should have gone up to those Steelers fans, warmed them of the dangers of excess beer, red beans, and crawfish (all worthy of a risk evaluation and management strategy, or REMS) and shown them the path to a life of synovial tranquility. They would have laughed at me, and I would have agreed. No physician likes to be a nag or be a spoilsport, but sometimes that is what public health requires. Recommending a flu shot is easy compared with recommending restraint.
Gout causes some of the worse pain in all of medicine, and yet many patients engage in behavior that can cause attacks with startling regularity. These patients have made the judgment that preventing gout by diet is not worth the effort and that they would risk a wicked attack rather than passing up a shrimp etouffee or a bowl of jambalaya. To these people, living a life without the joys that make gout a lurking danger would be both sad and foolish.
Crabmeat Sardou at Galatoire’s or colchicine?
I know my choice. What’s yours?
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.
