The Piccolo Player and His Last Tragic Tune

WHY PSYCHIATRISTS ARE PHYSICIANS FIRST

Mat was big, blonde, and a bully. She was also a Buddhist who didn’t eat meat or drink beer. She called herself Mat, short for Matilda, using a gender-neutral name long before it became fashionable.

Mat was the proverbial “Big Nurse” who bulldozed residents, attendings, and even ward chiefs. Her concern for patients distinguished her from the diabolical Nurse Ratched-although some med students compared her to Nurse Diesel from Mel Brooks’s spoof, High Anxiety (1977).

Had Mat told me that she secretly called herself “Brunhild” rather than “Mat,” and dressed like a Valkyrie in private, and imagined herself leaving her day job and auditioning for an operatic role in the Ring Cycle, I would have believed her. But, to us, she was Mat, the head nurse. It is she who is the star of this story, more than I, and more than the unfortunate patient, the piccolo player, whose preliminary diagnosis surfaced through our combined efforts.

Nick, as I shall call him, was a youngish male who was sent “upstairs” from the emergency department (ED). The ED doc called, and said, “it’s probably just drugs. You know how they are . . . I couldn’t send him home in his condition, so I sent him upstairs to psych. At least he’ll be safe there, till everything wears off.” Nick had started sobbing uncontrollably in an all-male dance hall near the hospital. “He should have been happy,” said the ER doc, who parroted the words of Nick’s friend, who said that Nick was thrilled by his Lincoln Center audition and would soon graduate from a conservatory upstate.

We assumed that Nick had been medically cleared in the ED. But there’s a reason why we should never assume, and there is no need to repeat that reason here. The timing was also telling. It was the early eighties, before medicine knew much about the plague brewing in the West Village and in San Francisco. All we knew was that Nick was too inconsolable to relate a coherent story.

Unable to speak without sobbing, he pulled out his wallet, and showed his school ID. He was indeed about to become a professional piccolo player. He was not someone who set up shop on the subways, or street corners, waiting for tourists to drop tips into his hat. Hoping to learn more about him, I asked to speak with someone from home. He nodded “yes,” so I asked him to call his brother on the phone.

That’s when it became apparent that something much more was amiss. I slid the phone across the desk, near Nick’s hand. It was a push button model in an era that had not yet envisioned auto-dial cell phones, much less speech-activated Siri. But this conservatory-trained piccolo player couldn’t dial the phone. His fingers stumbled around the keypad. His digits didn’t flip fast enough, even though he presumably had far better fine movement control that almost anyone around, save for some select neurosurgeons.

His gait was unimpaired, and his speech was clear, without slurring. The common signs of intoxication were absent. This strange sign prompted me to perform some impromptu “bedside” neurological tests even before asking the standard mental status questions used to assess memory and cognition.

Instead, I asked him to touch each finger with the opposing thumb, and then flip their hands right side up and upside down, as I observed for speed. Not surprisingly, Nick could not perform these simple tests any better than he could dial a phone. He had “dysdiadochokinesia,” a neurological sign of cerebellar dysfunction. Whatever ailed him, it was not strictly psychiatric, and it probably was more than the recreational drugs that the ED resident suspected.

Dysdiadochokinesia was a hard word to remember-and an impossible one to forget. The differential diagnosis for dysdiachokinesia was ominous: MS for starters in someone his age. Cerebellar tumors occur in much younger persons, as well as more obscure disorders, and some newer diagnoses also.

I was still contemplating the significance of this unexpected neurological sign, when Mat burst into the room, yelling, “stop.” She was a bully, for sure, but she was not an alarmist. In her hands were plastic gloves and a blue paper surgical gown, the kind that would pop up throughout hospitals soon enough. “Don’t draw bloods before you put this on,” she said, eyeing the syringe and tubes that I had lined up on a crash cart, expecting to order more laboratory tests than the ones done at Nick’s short ED encounter.

Having commandeered my attention, Mat beckoned me to exit the exam room. I pushed the cart ahead. With the patient still in sight, but outside of ear range, she whispered that she saw “thick white stuff” in his throat when she inserted the thermometer to take his temperature. She thought it was thrush.

The ED staff made no mention of this finding and recorded “WNL” in the HEENT section. Yet Mat was unmoved. A throat swab was already on the way. For someone who was ordinarily so persuasive, Mat nevertheless needed some persuasion to support her suspicions. Mat flinched when I told her about the dysdiadochokinesia that was evident during ordinary activity, even before a formal neurological exam.

Thrush had many meanings to the medical eye and ear, but in this case, where it appeared in a young previously healthy (and probably gay) adult male, who was not on corticosteroids and was not diabetic and was not receiving chemotherapy, it said “AIDS.” And AIDS meant blood-born transmission, and a need for extreme caution to avoid acquiring or transmitting the still-deadly and ill-understood infection.

The HIV test had not yet been born. We did not yet know that the retrovirus could affect the CNS system directly. We knew that systemic candida could afflict immunocompromised individuals or cancer patients or persons on complicated antibiotic regimens that wiped out less pernicious organisms. And now it seemed likely that Nick would be the next unfortunate recipient of this diagnosis.

A few phone calls later, Nick was on his way to a medical ward, which offered a more targeted work-up and more nursing attention, at least in the short run. Over the next few months, more “Nicks” would arrive in the ER, some with neuropsychiatric symptoms and nothing but, and some who were sick enough to enter ICU immediately. Over the next few weeks, white splotches surfaced on Nick’s skin.

If only Nick’s story ended as nicely as Mozart’s The Magic Flute, where Papageno the bird catcher meets his partner. But that was not meant to be. It was painful to imagine Nick’s last act. At very best, he entered Valhalla as heroically as the deities who died in Wagner’s opera, after the skies blazed red like fire. Happy endings were not available to people like Nick in the early 1980s, but times changed by the year 2000. On the other hand, I could easily imagine how badly things might have turned out for more people on the ward, myself included, had Mat not been so astute-and had I not been a physician first, who noticed subtle neurological signs as much as straightforward psychiatric symptoms.

Disclosures:

Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.