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00:00This program dramatizes true medical enigmas reported by the doctors themselves.
00:06The names and characteristics of the people have been altered.
00:10When we enter a hospital, we think the doctors have all the answers.
00:16They don't.
00:20Nathan Crawford, two fights in the middle range.
00:23It's well advanced.
00:24We think it's cancer.
00:25It's not what I think.
00:26I was more confused than ever.
00:28I didn't know what I was seeing.
00:30I didn't know how to help him.
00:35When I entered the room, she was talking to the walls.
00:38Go to Dr. Stark.
00:39What?
00:40This girl had neurological deficits.
00:43Does that mean she has a brain injury?
00:49At that moment, I began to question myself.
00:51If we didn't find out soon, it would be too late.
00:53I can't breathe.
00:55A chair.
00:56In my opinion, you should talk more about what she has and not about what she doesn't have.
01:00The girl could die.
01:01I needed a definitive diagnosis.
01:04Urgent.
01:07True enigmas.
01:10I won't go back. I won't go back.
01:12She had hallucinations, which was very bad.
01:15I won't do anything.
01:20Diagnosis X.
01:23My name is Angeline Ramsey.
01:25I'm an emergency doctor.
01:27I'm at the end of my residency.
01:29Six more weeks until I'm done.
01:31Then I'll be a supervisor.
01:32And I'm very excited.
01:34So you're not an actress?
01:35I'm not an actress.
01:37Everyone here is, except me.
01:41What are you going to do today?
01:42Tell me a little bit about it.
01:43Today we're going to teach a case.
01:45A case that I...
01:48attended at the emergency room.
01:50People are going to like this case.
01:53First, because it shows how easy it is to follow the wrong path.
01:59Anyway, because I'm young.
02:02And also because of what we've been through.
02:05To reach the decisions we've made.
02:10It was unforgettable.
02:11It was even memorable in my short career as a doctor.
02:16It's one of those cases that you never forget.
02:22From beginning to end, without knowing...
02:26Every step we took was an obstacle.
02:32And there was a difficult mother.
02:35She had a young daughter.
02:38And she wasn't getting better.
02:40She was getting worse.
02:42I did everything to make the right decisions.
02:49And that was really a challenging case.
02:53Is it easier to be a doctor or an actress?
02:56Being a doctor.
02:57Being a doctor is much easier than acting, no doubt.
03:01This is a new world for me.
03:03I feel like a fish out of water.
03:06Thank you very much.
03:07I'm Zachary Lutzky.
03:08I'm a doctor with emergency medicine training.
03:11I studied medicine for five years.
03:13Three of them in the residence.
03:15But now I'm alone for a few years.
03:18And I'm anxious to be here.
03:21Are you a real doctor?
03:22Yes, I'm a real doctor.
03:24I work almost every day in a hospital.
03:27And I treat real patients.
03:29But this story is about a patient I'll never forget.
03:32What are you going to do today?
03:34I'm going to stage one of the most interesting cases I've ever had.
03:38Why do you think it's interesting?
03:40Well, this case had a very, very rare diagnosis.
03:44A complete mystery.
03:46I think it's a fascinating medical episode.
03:51It was a real mystery.
03:53It required all kinds of detective work.
03:56From many people to finally find out what it was.
04:00There were several twists and turns for us to get to the final diagnosis.
04:04It's one of those cases you never forget.
04:07Let's start the scene.
04:08Are you ready?
04:09Of course I am. Let's do it.
04:11Are you ready?
04:12Let's do it.
04:14Action.
04:17Dr. Ramsey, Mr. Johnson is going to surgery.
04:21The other patients need to fill out the paperwork to go home.
04:24Here are the sheets. I'll be around if you have any questions.
04:27All right.
04:28Good luck.
04:33I can't believe what I'm seeing.
04:35Hey.
04:36Hey.
04:39When can a resident sleep around here?
04:42We spend many hours at work, under very stressful situations.
04:48I understand your pain, but this is a hospital and there are patients to visit.
04:52I know.
04:53Read three, now.
04:55The only people who understand what our lives are like are other doctors.
05:00I hate my life.
05:01We are very united, like a family.
05:04Good morning, ladies. How are you?
05:05Good.
05:06Great.
05:07Good.
05:10She's on.
05:11Let's go around.
05:13Thank God. I thought we'd catch the wolf today.
05:16I'm coming.
05:20Growing up in a family of doctors was a great influence.
05:23My father was a doctor, his father was a doctor, his brother was a doctor.
05:27And from a very young age I knew I would end up doing this.
05:30What do we have to do?
05:32Nathan Crawford.
05:34Two fights in the Middle East.
05:36Dispensed last month with a health certificate.
05:39No history of drug use or heart problems.
05:42Interned for recurring pain in the ear.
05:45No oral antibiotics.
05:47That patient was young and should be healthy.
05:49He had just left the army.
05:51His wife was pregnant for six months.
05:53And now she was in my hospital with what appeared to be a serious infection.
05:56How long ago were these infections?
05:58A few weeks ago.
05:59It was about a month ago.
06:01When I finally stopped getting sick in the morning, he started to feel bad.
06:05I can't move my head.
06:07Yesterday he had a nosebleed.
06:09So I said, come on, we need to go to the hospital.
06:12She takes good care of you, doesn't she?
06:14Oh.
06:15There's also this, Dr. Zachary.
06:17He's not hearing right.
06:22It's gotten a lot worse since he got sick.
06:25I'm not one of those people who get sick all the time.
06:28No, no, I never get sick.
06:31Never.
06:36Any family history I should know?
06:38Any chronic disease?
06:40No.
06:41His four grandparents are about 90 years old.
06:44Is he coughing blood?
06:46No.
06:47Dr. Lutzky took a look at it.
06:50He had an eruption in the lower limbs.
06:53They were red and swollen on both sides of the legs.
06:57My doctor said Julia's pregnancy made him too sensitive.
07:00It must be just an ear infection.
07:02I'm not blind.
07:03Look at him.
07:04Suddenly, a guy with an ear infection
07:06had this nosebleed and nosebleed.
07:09It's very strange for this to happen to a young patient.
07:12Can you excuse us?
07:14This patient had already seen other doctors for the same problem.
07:18It looks like your doctor is in no hurry.
07:21It increased the pressure on me.
07:23I had to figure out how to cure him.
07:25Well, I think the eruption must be an allergic reaction
07:29to antibiotics.
07:30We're going to suspend what he's taking
07:32and administer ciprofloxacin.
07:34Sammy, this is for you.
07:36This young man had a family.
07:38He had his whole life ahead of him
07:40and his symptoms weren't helping.
07:42It's obvious that his general practitioner
07:44had a very narrow view.
07:46We're not going to stick to that.
07:48We have to look at the overall picture, okay?
07:50Now I should find out what was going on.
07:52It was my challenge.
07:57What is it?
07:58A 14-year-old girl with her mother here.
08:00I looked at the file and it said,
08:0214-year-old girl.
08:04The complaint was, acting in a strange way.
08:06What do you mean?
08:07I don't know.
08:09Hi.
08:10When I came in, I saw a teenager
08:14who was out of breath, basically out of breath.
08:17Brianna Emerson, normal vital signs,
08:19no fever, no headaches.
08:21The physical exam is okay.
08:23She's taking Adderall for DDA, but no recent diseases.
08:27Well, according to her mother, she's acting strange.
08:38Brianna, is what your mother said true?
08:41I don't remember.
08:43That's her standard answer.
08:46Okay.
08:48If my mother took me to a hospital
08:50and there was nothing wrong with me,
08:53I'd be angry, I'd say.
08:55There's nothing wrong with me. She's crazy.
08:57But that girl didn't fight.
08:59She didn't argue.
09:01Her eyes were semi-open.
09:03She didn't communicate well.
09:06She didn't make eye contact.
09:08So, how's school this year?
09:11Normal.
09:13I transferred her to a private school.
09:16I'm sorry.
09:22Her grades dropped, and...
09:24Well, I know we didn't come here for that,
09:26so it's good to know.
09:28It's just that we had a rough time with her.
09:35But it was never like that.
09:38Please, Brianna, swing your legs out of bed for me.
09:41I want to do a quick exam, okay?
09:43I checked the neurological part of the exam
09:45and she had problems.
09:47Try to touch your nose and then my finger.
09:57Let's try again.
09:59Touch your nose.
10:01She couldn't touch my finger
10:03after she touched my nose.
10:05That seemed like a bad sign.
10:07Now, why don't you get up
10:10and go to Dr. Stark
10:12and take a pen out of his pocket.
10:16That's it.
10:18Very good.
10:22Brianna, be careful.
10:24Sit back down.
10:26She didn't pass the neurological exam.
10:29I need to do an urgent tomography.
10:32Okay, Lisa.
10:34I need to put Brianna in the hospital.
10:36We need to do a head tomography
10:38to check for abnormalities, okay?
10:40Great.
10:42I want a pregnancy test, drugs, and a tomography.
10:44Call the radiologist and ask for an exam now.
10:47I was very worried
10:49because this girl had neurological deficiencies.
10:54I was scared.
10:56Could this kill her?
11:03Look, Brianna, it won't hurt.
11:05Don't be afraid. I know you're brave.
11:07I admitted my patient, Brianna Emerson,
11:09to the exam because she showed signs
11:11of an altered mental state.
11:14Do you have a girlfriend?
11:16What do you think?
11:20Brianna.
11:22What's up?
11:24Are you okay?
11:25What?
11:26I'm on the other side of the glass.
11:28If you need me, raise your right hand.
11:30Okay?
11:32Great.
11:35She looks like she's out of breath.
11:37Did you see that?
11:39Did she have a fall and she doesn't remember?
11:46You'll see what she's doing
11:48without telling her mother.
11:57Interesting theories, doctor,
11:59but let's get down to business.
12:01I'm going to ask the radiologist to check again,
12:04but it seems normal.
12:06At least we have good news for her mother.
12:09But I can already hear
12:11what your next question will be.
12:18The count of leukocytes is at 11.4.
12:21It's too low for an infectious process.
12:24My patient was going through a very serious problem.
12:29He didn't respond to antibiotics,
12:31and I didn't know what to do.
12:33At the time, I knew I needed to call an otolaryngologist.
12:37I'm seeing necrosis tissue.
12:40It looks like a septum deformity.
12:43I broke my nose last year.
12:51And he didn't go to the doctor?
12:53No, it doesn't look like a scar.
12:57It looks more like a tissue wear.
12:59As it was a serious erosion of the nostrils,
13:02and he didn't respond to antibiotics,
13:05I thought it could be cancer.
13:07It was a young couple with a baby on the way,
13:09and the last thing I wanted to do
13:11was give news that would be absolutely devastating.
13:14You're going to feel discomfort, but it'll pass.
13:19If it were really cancer,
13:21with that level of destruction of the nostrils,
13:24I felt like I was in an advanced state.
13:27Everything ready in the radiology?
13:29There were other tests I had to do,
13:31but first I asked for a thoracic radiography.
13:36The tomography didn't show any signs of hemorrhage or tumor.
13:40Thank God.
13:42The blood test should arrive soon.
13:44We'll have more information then.
13:46In the meantime, I'd like to do a lumbar puncture
13:48to see if there's an infection.
13:50I know. It's very painful. I don't want her to go through that.
13:53The mother was angry, very frustrated,
13:57and that can undermine the confidence of a resident.
14:00I understand how you feel, but these tests, the blood tests,
14:04would they show any signs of drugs?
14:07They could. Are you worried about that, Mrs. Emerson?
14:10Do you know any inhalants?
14:12Inhalants are drugs.
14:14Young people smell the vapors from spray paint cans
14:17or other cans like that, and they get upset with them.
14:19I heard some of her friends were caught doing that,
14:22and the other day I found spray paint cans hidden in her room.
14:35This patient arrived with an altered mental state.
14:38She never had a fever or a headache,
14:42but she had a strange behavior, and it could be from the inhalants.
14:47Did you test the class of amphetamines?
14:50Are you questioning my efficiency?
14:53Wilson, answer, please.
14:55Adderall.
14:57I went to the lab to see Brianna Emerson's results,
15:00and I found that the pregnancy test was negative,
15:04and the toxicological test was negative for cocaine or opiates,
15:09but positive for amphetamines.
15:11It was expected. The mother told us that during the initial assessment.
15:14Bye. Thanks for the visit. It's getting late.
15:17I have one more question.
15:19How do we test inhalants?
15:22That's a good one.
15:25Unfortunately, it's out of here. I could do it, of course,
15:28but the hospital bureaucracy knows how it is. They don't allow...
15:31Inhalants don't show up in routine toxicological tests.
15:34The test is done outside, and it takes more than a week,
15:37and I didn't have a week. The girl could die in two days.
15:40I needed an urgent definitive diagnosis.
15:50So, Nate Crawford did a thoracic x-ray.
15:53Dr. Lansky, Mr. Crawford's X-ray is in the brain.
15:58I was very surprised when I saw the x-rays.
16:01He had multiple nodules in his lungs.
16:04Is it pneumonia?
16:06I don't think so.
16:08What do you think?
16:10From what I saw in Nate Crawford's x-rays, they could suggest cancer.
16:13But evaluating thoracic x-rays is complicated, even for experienced doctors.
16:17At that time, I wanted a radiologist to take a look.
16:20Someone specialized in x-rays.
16:22Ribbipol?
16:24Yes. I need a second opinion on this x-ray.
16:27He has 25 years of persistent ear infections.
16:30He doesn't react to antibiotics, and he has all this necrosis tissue in his nostrils.
16:33We think it's cancer.
16:36It's not what I think.
16:38Do you see the cavity process in the apical and posterior segments of the superior lobe?
16:42It's tuberculosis.
16:44Tuberculosis is a disease transmitted by air, caused by a bacterium.
16:48It usually appears in the lungs and can be very aggressive,
16:51destroying the tissue inside the lungs.
16:54But he doesn't have the profile.
16:56Well, actually he does.
16:58He served in the Middle East.
17:00So there's something to it.
17:02So we started to fear it was tuberculosis, something very serious.
17:05If a patient coughs, sneezes, or even breathes on other patients or doctors,
17:09they can get tuberculosis.
17:12Well, Sammy, we need to send Mook to the lab.
17:14Let's isolate Nettie as soon as possible.
17:20But is this the reason for the other things, like the ear infection?
17:24Tuberculosis didn't cause all his symptoms.
17:27Nettie, let's administer other antibiotics. You'll be fine, okay?
17:30It's too hot in here. I can't breathe.
17:33A chair.
17:36Calm down.
17:38Jolie, take a deep breath.
17:40Take a deep breath.
17:42We'll find out what it is, I promise.
17:44I had the feeling this was the tip of the iceberg
17:47of what was really happening to that patient.
17:50Wait!
17:52Wait!
17:54I'm not going to jump!
17:56Wait! I'm not going to jump!
17:58Brianna Emerson's mother had just told us
18:01that her daughter was hallucinating,
18:04seeing things that didn't exist,
18:06talking to people who weren't there.
18:08And right there, in the hospital bed, she was hallucinating.
18:11Oh my God, Brianna, calm down!
18:13Calm down!
18:15Brianna!
18:21I had to isolate my patient, Nettie Crawford, for a possible tuberculosis.
18:25Hi, dear. I'm here.
18:27But the fact is, the disease didn't explain most of the symptoms.
18:30He had several areas with a possible infection in his entire body.
18:33How is he?
18:35He's holding up.
18:37Is the aerosol gone?
18:39No, not yet, Jolie, but you don't have to worry about that, okay?
18:43Visits.
18:44Excuse me. Dr. Wolfe, where is Dr. Wolfe?
18:46In a meeting. I'm visiting the patients.
18:49There are some supervisors who are hard to stand.
18:52Sorry to disappoint you, Dr. Harper.
18:54Isn't it Wolfe's day?
18:55Dr. Harper, I don't know. You can start.
18:57But due to the condition of my patient, Brianna Emerson,
19:01I was happy to have an older and more experienced doctor to help me.
19:08Brianna Emerson, continuous hallucinations throughout the night,
19:11altered state with normal vital signs.
19:14No other symptoms.
19:16We had to give her 10 milligrams of diodone to control the hallucinations.
19:20It seems to have worked.
19:23Good morning. How are you feeling today?
19:26I'm thirsty.
19:28You should have had a lumbar puncture right away.
19:31Mom didn't want to.
19:32She believes that all symptoms were caused by inhalants.
19:36Yes, inhalants.
19:38The supervisor said inhalants?
19:40I don't think I've ever seen a case with inhalants.
19:42I've been a doctor for many years.
19:44Take the authorization for the puncture.
19:46Start with antibacterial and antiviral preventively.
19:50There's a neurological problem in this girl.
19:52Find out what it is.
19:54Harper, Whitley.
19:56When she said, let's check the infections, I took the next step.
20:00We needed a lumbar puncture right away.
20:12Do you have the results of the tests from Nat Crawford?
20:15I don't know why you expect me to do everything so fast.
20:19I'm glad I'm good at what I do.
20:24Take it.
20:27Are you kidding me?
20:29Nat Crawford's tests were negative.
20:31He didn't have tuberculosis.
20:34So I felt my heart get tight.
20:36You're welcome, champ.
20:37It was very frustrating.
20:39I even started to doubt myself.
20:45What are you doing?
20:48I'm thinking about hypotheses.
20:50The test was negative and the sediment rate was 74.
20:55That's pretty high.
20:59So it could still be cancer?
21:01Could be.
21:03Wasn't he in the Middle East?
21:05Yes.
21:06Let me see.
21:08Noel?
21:10Maybe not.
21:12But this guy could have been exposed to things we can't even imagine.
21:17But I'm sure you'd find out without me.
21:21I don't like your tone, Dr. Harper, but you're right.
21:25Unknown foreign infections.
21:28He lived in a strange country, maybe in a confined space.
21:32It could be a strange, little-known infection around here.
21:35Well, let's get Nat out of isolation.
21:38I don't think he's contagious.
21:40I was even more confused.
21:42At that moment, I needed the opinion of other specialists.
21:45Of their knowledge, to help me find out what was going on.
21:49Oncology and infectious diseases?
21:51Yeah.
21:53And if we don't find out soon, it could be too late.
21:56As a doctor, I define myself as a person who can help other people
22:01to find their problems and make them better.
22:04I was getting very upset with this case, because I couldn't find the problem.
22:08I didn't know how to help Nat.
22:11Tom.
22:16Give me five more minutes, Sam.
22:18Just five. I'll be a zombie if I don't sleep for six hours.
22:21They're all exhausted.
22:23Have some coffee and go see your patients.
22:26When you talk, it sounds easy.
22:28Dr. Whitley?
22:32Right. Let's see what we have.
22:41No, no. They don't look like cancerous nodules.
22:46Did you deal with biological weapons?
22:49We did some transports.
22:55But they never said anything about the load.
22:58It was the policy of silence.
23:00And what kind of contact did you have with the natives?
23:03Almost none.
23:05Was it bitten by some insect?
23:10So many that I lost count.
23:12The levels of complexity increased more and more,
23:15and my mind didn't rest, thinking of all the possible hypotheses.
23:24While we waited for the results of Brianna Emerson's lumbar puncture,
23:28we had to find out why she acted in such a bizarre way,
23:33why she had hallucinations, and why she couldn't get better.
23:39Is it hard to sleep?
23:41I don't even want to talk about it.
23:43The desired effects are short-lived.
23:46Inhalants.
23:48The effects last only a few hours.
23:50She's been here 24 hours, and of course,
23:52she didn't have access to any aerosol can.
23:54And another interesting thing is that this drug is used
23:57by teenagers who are generally poor and marginalized.
24:00I'm sure she's not poor.
24:02No, she's not. And you have to be very selfish
24:04to feel marginalized going to private school.
24:07We're not talking about you, but a 14-year-old girl.
24:12She's a teenager who's going through big changes in her life.
24:17It could be a first psychotic schizophrenia attack.
24:20It can happen at this age, can't it?
24:22Yes, it can. It would make perfect sense.
24:25That's why the drugs don't work.
24:28We need a psychiatrist.
24:30All right.
24:33My conversation with him has opened up many possibilities.
24:36And I'm analyzing them, but...
24:39I'm still concerned about the extent of the infection.
24:42We spoke to an infectious disease specialist
24:44to try to come up with an action plan for the grandchild.
24:47Do you think he's immunodeficient?
24:50Of course the most common cause of immunodeficiency in the world today
24:53is AIDS.
24:55The count of leukocytes and neutrophils is a little high.
24:58Wouldn't that move the hypothesis of immunodeficiency away?
25:00Yes, but in some cases of AIDS,
25:02the count of leukocytes may be high,
25:04even if the T cells remain low.
25:06So you want a blood test for HIV?
25:08Well, he said he helped transport
25:10and help patients who were injured.
25:18I'm going to get a blood test and send it to the lab.
25:21Thank you, Mike. It was very useful.
25:24He could have had contact with someone else's blood.
25:27He could have gotten it in his eyes, in his mouth,
25:29in some cut he had on his body.
25:31Did you get the tests?
25:33I did.
25:35I was looking for you.
25:37What is it, Julie?
25:39His face.
25:41Nettie, what is it?
25:43I'm not feeling well.
25:45He complained that he had trouble moving his face,
25:47and I had to reexamine him.
25:49Well, give me a big smile.
25:52Now I want you to close your eyes,
25:54both of you, very tight.
25:56I noticed that the right side of his face was paralyzed.
25:59He had difficulty raising his right eyebrow
26:01and could not close his eyes.
26:03What is this? Is he having a stroke?
26:05With this new problem, I feared it was an infection
26:08that had reached the brain.
26:10Maybe an abscess was pressing his brain stem.
26:13But he was fine a minute ago.
26:19Nettie had complications in the lungs,
26:21in the ear, nose and throat,
26:23and now also in the brain.
26:25The irony of this is that sometimes
26:27the worst thing about the patient
26:29is that he helps us make the diagnosis.
26:31The oncologist said that the picture so far
26:33doesn't look like cancer,
26:35but he's not 100% sure.
26:37Maybe it's cancer with metastases in the brain.
26:42Or maybe an unknown infection
26:44that became aggressive and reached the brain.
26:49Even so, I'm not liking it.
26:51I was hoping that this new symptom
26:53would help us solve the case.
26:55Time is running out.
27:03The psychiatrist's report.
27:05Brianna has no clear signs of mental illness
27:07and her symptoms seem to be of a non-emotional nature.
27:10So we checked the preliminary tests
27:12and found that it wasn't a bacterial infection.
27:16And according to the psychiatrist,
27:18it wasn't a psychiatric disorder.
27:20According to that report,
27:22it wasn't a bacterial infection either.
27:24Cool, so what is it?
27:26I was very frustrated.
27:28As a resident, you know,
27:30it's so hard to deal with a dead end,
27:32especially in a delicate case.
27:35Well, we have to wait to see if it's a virus,
27:38but unfortunately she's been taking antivirals
27:40for 36 hours and nothing has changed.
27:44You know I need...
27:46Brianna, Brianna, dear.
27:48She's delirious. Where are the doctors?
27:50No, you don't have to...
27:52To worsen my frustration and my fears,
27:54she was getting worse.
27:56She had another hallucination.
27:58It's better for one of you to have answers,
28:00because I think it's absurd
28:02to be here for a day and a half
28:04and you still have no idea
28:06what's going on with my daughter.
28:08It's hard for the family to understand
28:10that medicine is not fast
28:12and that we, the doctors,
28:14need to wait for the exams
28:16and other consultations
28:18and things are not so immediate.
28:21Mrs. Emerson, I understand your frustration,
28:24but I can only say that she doesn't have a bacterial infection
28:27and that the psychiatrist doesn't believe
28:29she has any mental or emotional disorder.
28:31I know I can't meddle in your work,
28:34but I think you should talk more
28:36about what she has and not about what she doesn't have.
28:39Okay.
28:40Dolores, let's suspend the antibacterials.
28:42Keep the antivirals?
28:44Yes, we can keep them.
28:46We suspended the antibacterials
28:48and decided to keep the antivirals.
28:50We hoped the antivirals would reduce the symptoms.
28:53Dr. Stark, call the neurologist.
28:57We hoped the antivirals would start to act.
29:02Guys, stop!
29:04But in the meantime,
29:06we needed to think about other causes.
29:08I needed to find out why she wasn't getting better.
29:16To better assess Nettie's brain,
29:18we did a resonance test,
29:20and the test found nothing.
29:22Absolutely nothing.
29:24No metastasis, no tumor, no sclerosis.
29:30That told me that what was causing her neurological problem
29:34didn't come from her brain.
29:36Neurocranial Paralysis.
29:38It's Bell's Paralysis, right?
29:41Right.
29:42And according to my notes,
29:43Bell's Paralysis could be a side effect
29:45of Lyme disease.
29:46Lyme disease is transmitted by carapace,
29:48and can affect multiple systems of the body,
29:50causing inflammation of the nerve,
29:51which would explain the pause paralysis.
29:53Lyme would explain many of the symptoms.
29:55I'm going to ask for a lumbar puncture.
29:57Do that.
29:58So, I asked for more blood tests
30:00and also a lumbar puncture.
30:08We asked for a neurologic consultation
30:10for our patient, Brianna Emerson.
30:12The first thing to do is an EEG.
30:15We think it could be an atypical seizure.
30:20What worries me is what we call a focal convulsion.
30:23A focal convulsion is not what people know
30:26as a typical convulsion,
30:28in which the whole body is shaking and debating.
30:31It could be a fixed look in the air,
30:36or a hallucination.
30:38Let's do the EEG,
30:40and it will show us what's going on
30:42with her electrical activity.
30:44If she has a hallucination during the exam,
30:46we'll see a specific pattern that will tell us
30:48if she's having a seizure or not.
30:50And if it's a seizure?
30:52Then we can treat her with medicine.
30:54And if it's not?
30:56Let's wait.
31:03Deep breaths.
31:05So, I did a lumbar puncture in the neck.
31:08Okay.
31:12Okay, we're done.
31:16Turn to the side.
31:18That's it.
31:22Dr. Lutzky, you need to see this.
31:26The seizure has spread.
31:28Oh, my God. I didn't even notice.
31:30Neide, did you notice?
31:33It's not the type of seizure you'd expect
31:35with Lyme disease.
31:37If she had antibiotics,
31:39that would make her allergic,
31:41and the seizure would get better.
31:43But it's getting worse.
31:45Ask the lab for a cell count
31:47to rule out meningitis now.
31:49In a patient with a fever,
31:51neurological symptoms,
31:53and a seizure that's getting worse,
31:55we need to think about meningitis.
31:58We were waiting to see
32:00if the electroencephalogram would reveal anything.
32:03And then,
32:06Hey, Beauty, hey.
32:08What is she saying?
32:10I don't know. I'm not sure.
32:12Beauty is the name of the horse she rides at school.
32:15Rhythmic delta activity
32:17intermittent with unstable waves.
32:19Your neurological function was altered.
32:22Does that mean she's having a seizure?
32:25Yeah, it looks more like a diffuse cranial process.
32:28Ms. Emerson, this is not a seizure.
32:31The neurologist quoted terms
32:33that Brianna's mother didn't understand.
32:36This was scary.
32:38Dr. Wolfe, take a look at this.
32:42These are defined abnormalities.
32:44She reveals a diffuse diffusion
32:47moderate in the cortical area of the brain.
32:52There is always a certain information
32:56that ends up being devastating for the patient.
33:00Would your daughter have a brain injury?
33:03Oh, my God!
33:07Now we knew there was something wrong
33:09with my patient's brain, Brianna Emerson.
33:12But the question was, what was the cause?
33:15We decided to do a resonance
33:17because she is more sensitive
33:19to revealing the neuronal tissue.
33:21Dr. Stark, it's better to call Dr. Ramsey.
33:26We were still treating Nat with antibiotics,
33:29but he wasn't getting any better.
33:31In fact, he was getting worse.
33:33Meningitis, negative.
33:35Lyme, negative.
33:37HIV, negative.
33:39Nasal biopsy, negative.
33:41It was confusing because all the tests were normal,
33:44including the lumbar puncture I had done.
33:47Why do I think so much good news
33:49must be bringing another bad news?
33:52That's interesting.
33:54The rate of sedimentation is still increasing.
33:57If the antibiotics he's taking are fighting the infection,
34:00that rate should drop,
34:02because we know he doesn't have immunodeficiency.
34:05I checked the rate of sedimentation,
34:07and it was high, very high, over 100.
34:09Maybe the problem was the opposite.
34:11All the time I thought the patient
34:13had a depressed immune system.
34:15Maybe the immune system was accelerated too much.
34:18I started to think about autoimmune diseases.
34:21Maybe the patient's body was attacking itself.
34:32I analyzed Brianna's resonance.
34:34The signals were intensified, which was very bad.
34:37Do you see the area of hyper-intense signals in the splenium?
34:42Yes.
34:44Do you see the area of hyper-intense signals in the splenium?
34:48That means the brain tissue was being destroyed.
34:52Now look at that white band in the splenium.
34:55My God, the myelin is breaking down.
34:57Well, that would explain the hallucinations, but...
35:00What do you think?
35:02From what this resonance shows,
35:04Brianna has encephalitis.
35:06What would cause this type of acute inflammation?
35:09Most encephalitis is caused by viral infections.
35:12The antiviral drugs aren't working, so we shouldn't rule that out.
35:15Yeah, that's the problem.
35:17She may have some resistance to medication.
35:19The resonance showed that the myelin was being destroyed,
35:22which explains her neurological deficits.
35:25We were finally on the right track.
35:30Oh, my God.
35:32Hey, Dr. Stark, can we talk for a minute?
35:34Sure.
35:36I called my resident to talk about Brianna Emerson.
35:39I think I have the diagnosis.
35:41I have terrible news.
35:43What is it?
35:45Remember when Brianna had hallucinations during the EEG
35:48and you asked her mother what she was talking about?
35:51She said Beauty was the horse that Brianna rides.
35:54She said Beauty was the horse that Brianna rides.
35:57She said Beauty was the horse that Brianna rides.
36:00She said Beauty was the horse that Brianna rides.
36:02That's right. I remember.
36:04And one of the most deadly forms of encephalitis
36:08is East Equine Encephalitis, EEL.
36:11East Equine Encephalitis is extremely rare.
36:14It's transmitted by mosquitoes that sting infected horses.
36:18Fifteen-year-olds are at greater risk.
36:20And the symptoms are exactly what she showed.
36:23And one more thing.
36:25It's associated with splenium lesion in the resonance.
36:28And it doesn't react to antivirals.
36:31Not only were her symptoms consistent with East Equine Encephalitis,
36:35but the resonance was also consistent with the disease.
36:39There's no treatment.
36:41And the mortality rate is 30%.
36:47Well, what do we do now?
36:49Go to the lab.
36:50Have someone bring a sample of the lumbar puncture
36:52to a specialized lab.
36:54If the EEL is advancing, they need to identify it.
36:57I want a confirmation before talking to the mother.
37:00All right.
37:02Unfortunately, there is no treatment for East Equine Encephalitis.
37:06In this situation, you don't want to be right.
37:11I did a battery of tests on the net
37:13to identify certain autoimmune diseases.
37:16Autoimmune diseases are defined as a combination
37:19of certain physical symptoms with specific results in tests.
37:22Lupus and rheumatoid arthritis were clearly negative.
37:26Yeah, but you also need to check...
37:28Hashimoto-Graves, scleroderma,
37:30Sjogren's syndrome, negative, negative, negative.
37:32Did I forget any negative?
37:34Unfortunately, your rheumatological panel was completely normal.
37:37I was even more confused.
37:39Sammy, I was sure it was that.
37:41I don't deal with uncertainty.
37:43Each autoimmune disease has a specific set of symptoms.
37:46There must be some physical symptom that we let pass.
37:49There's a lot of overlap.
37:52I was looking for you.
37:54It's Nate Crawford.
37:56There's something you need to see.
38:01At that time, I began to question myself.
38:03Had I discarded the hypothesis too soon,
38:06or had I gone through this type of diagnosis too quickly?
38:09Had I forgotten something?
38:14I found out when I changed the urine bag.
38:18Suddenly, Nate Crawford was urinating blood.
38:25The exam confirmed that Brianna Emerson
38:28had the East Equine Encephalitis virus.
38:32So, I just talked to the lab.
38:35It's confirmed.
38:37Brianna has IEL.
38:40Now answer me one thing.
38:42We can't do anything.
38:44What we have to do is help Mom face this.
38:47Come on, I'll talk to her.
38:49It's better to be there.
38:54Hello, Ms. Emerson.
38:56Hi.
38:57Please, have a seat.
39:01Your daughter has a very rare disease
39:03called East Equine Encephalitis.
39:05Most of the patients with this virus
39:07think they have the flu.
39:09The danger of underestimating this supposed flu
39:13is that it can advance and attack the brain.
39:16When you noticed that she had the flu,
39:18what did you do?
39:20When you noticed that she had the flu,
39:23what did you do?
39:35Oh, my God.
39:39Can you tell me if there's anything I can do?
39:43Ms. Emerson, there's no treatment.
39:51Let's keep her in the hospital
39:53and give her all the assistance we can.
39:56Over time, her body will fight the infection on its own.
40:00So she'll be fine?
40:02She'll get better?
40:04Brianna's prognosis wasn't good.
40:07However, children are very resistant,
40:10their immune systems are stronger,
40:13and usually their bodies can get better
40:15without any intervention.
40:17Brianna's young.
40:18She has a strong immune system.
40:20She has a good chance of getting over it.
40:22Okay, all right.
40:23We'll monitor her closely.
40:25Children are very resistant.
40:27The treatment is just a support.
40:33Basically, what we could do
40:35was let the disease take its course.
40:38The human body is an incredible instrument,
40:41and we trust it.
40:44I was told that Nat Crawford was urinating blood.
40:48That revealed that the systemic process
40:50that affected his organs
40:52was now affecting his kidneys.
40:54Finally, I found the last piece of the puzzle.
40:57There's a group of autoimmune diseases called vasculitis.
41:01Inflammation of the blood vessels?
41:03Exactly. Sometimes the vessels get so inflamed...
41:06Hi, Dr. Wolff.
41:07Sometimes the escape is so great
41:09that bleeding can occur in the mucous membranes.
41:13So he had nasal bleeding and ear bleeding.
41:16Right. And now that the kidneys were affected,
41:18that limits a lot of hypotheses.
41:20Something that affected both the lungs and the kidneys.
41:23There was just a bizarre syndrome
41:25that I learned in medical school,
41:27but I never thought it would happen personally.
41:29I think I know what it is.
41:31The lab just needs to confirm it.
41:33That was an epiphany for me.
41:37Dr. Lutz, can I take a look at this?
41:39In this exam, they look for blood and specific antibodies.
41:42They take these antibodies, use immunofluorescence
41:45and look at a microscope.
41:47There's a certain pattern in these antibodies
41:49that indicate a very specific disease.
41:53Do you see this immunofluorescence?
41:56Yes.
41:57It's alive.
41:59Get a biopsy of the kidney, then I'll be sure.
42:02But I think you're the culprit, doctor.
42:05I think you're right, Wilson. Good job.
42:10Wow!
42:11If it weren't for this last symptom,
42:13without the last piece of the puzzle,
42:15maybe I wouldn't have been able to diagnose the disease.
42:17Positive for cyanca.
42:21Wagner's granulomatosis.
42:23It affects the lungs and kidneys
42:26and causes tissue destruction in these organs.
42:29Multiple symptoms, one diagnosis.
42:32That's how I like it.
42:40Did you sleep a little last night?
42:42I did. In a king-size bed.
42:44It was one of the best nights of my life.
42:46You're too happy so early in the morning.
42:49What's going on?
42:51Brianna Emerson is getting better.
42:53Her disorientation has improved.
42:56Her hallucinations have decreased.
42:58She's back to being a teenager.
43:01Brianna is reacting.
43:03Her neurological deficits are improving.
43:05And if she fights with her mother, it's a good sign.
43:08She'll be back to being a normal 14-year-old girl.
43:11And Rin Dunett's biopsy
43:13confirmed Wagner's granulomatosis.
43:15Ah, how one day makes a difference.
43:20That's what it seems to me, isn't it?
43:27Now that we've found Dunett's diagnosis,
43:29we can start the treatments.
43:31And the two most common treatments
43:33are high doses of steroids and cyclophosphamide.
43:36He's kicking.
43:38I think he knows his father's getting better.
43:40And the ear infections are going away now?
43:43They're going... Actually, there's never been any infection.
43:46What we called infection
43:48was inflammatory tissue destruction in different organs.
43:52The tissues were inflamed, and then they became abnormal.
43:56We were very lucky to have been able to diagnose what Dunett had.
44:00Without treatment, Wagner's granulomatosis
44:03is fatal in 90% of cases in two years.
44:06But with treatment, he can lead a normal life.
44:09I want to get out of here soon.
44:11Because soon I'll be in a bed, and you'll take care of me.
44:16Have you thought of a name for the baby?
44:18I have an idea. How about Zack?
44:22Seriously, if we keep the treatments, I'm sure he'll be fine.
44:25Thank you very much, Doctor.
44:33At the end of the day, when you think about residency,
44:36it's not the long hours that you remember.
44:38Hi, you look good, dear. How are you feeling?
44:41I'm fine.
44:42The doctors will be here soon to talk to you, okay?
44:45Is it going to be that pretty blond doctor?
44:48It's one of the patients you treat,
44:51and one of the families you've rebuilt.
44:54Is there anyone in love?
44:56I think someone's better.
44:59I think so.
45:00Finally, the color's back on your face.
45:02Each case reminds me of why I became a doctor.
45:05And that's why I tell those who want to follow in my footsteps,
45:08it's worth every minute of lost sleep.
45:11Are you tired?
45:12Tired, but awake.
45:14You know, Dr. Lutzky,
45:16you should try to go home and be a father to Varier.
45:19Well, I'm always a doctor, I can't help it.
45:22And challenging cases like this one
45:24bring us closer to our colleagues,
45:26and make us feel like a family.
45:29Yeah, today was a family night.