Puzzling Over Medical Mysteries
By Laura Stephenson Carter
Modern medicine is so advanced, it's easy to assume nowadays that diagnostic and therapeutic choices are clear-cut. But there are still many medical mysteries, which doctors puzzle over in sessions called "morbidity and mortality" conferences. Here's an inside look at an "M&M" at DHMC.

"Good afternoon," says secondyear resident Nathaniel Hare, M.D. This week, it's his turn to relate a "mystery story" to a roomful of physicians, other health-care providers, and medical students at the Department of Medicine's Morbidity and Mortality (M&M) conference.

He'll pause in his narrative every so often, not so much to keep his audience in suspense as to give an opening to anyone who dares to solve the mystery before the end of the hour. But he knows it won't be easy. This is a case that had many of DHMC's top physicians stumped for weeks.

"The cases usually unfold like a puzzle, almost like a good mystery novel," says Donald St. Germain, M.D., acting chair of the Department of Medicine. "Everyone in the audience has the opportunity to be Sherlock Holmes as we look for clues and sort through the evidence."

"The format of the presentation permits the audience to walk in the shoes of the treating physician and struggle to understand what is going on with the patient . . .," explains neurologist James Bernat, M.D. . . .

To the Outer Banks of the Soul
By Nancy Price Graff
We talk freely nowadays about many formerly tabu health topics—cancer, alcoholism, AIDS. The last bastion of "unmentionable" disease may be mental illness. A writer and editor who has been a patient on DHMC's psychiatric ward eloquently details her struggle with chronic depression, giving an enigma a very human face.

Several years ago, just about the time I stopped dreaming, two unusual phenomena began to disturb my nights. The first struck when I lay in bed at night waiting endlessly for sleep. Random images, vivid and surreal, would begin whipping past me, each lasting no more than a fraction of a second. Half of the images were fantastic but harmless: people I had never met hurtling through space toward me, packs of dogs running . . . The other half started off benign but turned grotesque. A tennis ball coming at me over the net might suddenly metamorphose into a hideous, disembodied face just as I swung my racket at it. . . .

The other phenomenon overcame me early each morning as I was waking, usually around 4:00 a.m., after a night of sleep so short and disturbed it left me irritable and ragged. In the pale light of every dawn, I had a powerful sense that I was underwater, struggling toward the surface. . . .

My descent into major depression was not linear . . .

One More Byline
By Mary E. Daubenspeck
In which a writer chronicles her final struggle with cancer—illuminating a stormy course but elucidating what really matters in the human condition.

The late Mary Daubenspeck was many things—a dog lover, a sailor, an antique-car collector. And, above all, a writer. When she died in March of 2001, she left behind 17 volumes of personal journals. They contain descriptions of nature's unfolding glories, mundane but telling details of her daily life, and philosophical musings. And the last two chronicle her final struggle, physically and psychologically, with cancer. She had been successfully treated for cervical cancer in 1976 and breast cancer in 1991. In 1997, she was diagnosed with colon cancer. . . . Then, in March of 2000, her colon cancer recurred. In July of that year, she wrote in her journal:

An Untimely Frost
By Derrik F. Woodbury, M.D.
Death is not supposed to come to someone who is 34. Who has two toddlers. Who has a husband who loves her deeply. A Dartmouth Medical School graduate writes about coping with the aching void his wife's death has left in his own life and that of their two young sons.

Death lies on her like an untimely frost. Upon the sweetest flower of all the field.—William Shakespeare, Romeo and Juliet

Carson is waving goodbye to me from his open bedroom window as I leave for work. "Goodbye, Dad," he calls. "Don't forget your seatbelt!" he adds. He's only three years old and shouldn't be worrying about such things, but he's concerned that something might happen to me. . . .

Eight months ago, my 34-year-old wife died. A board-certified anesthesiologist, a nutrition expert, and a marathon runner whose grandparents lived well into their nineties, Kate died of an aggressive ovarian cancer. As physicians, my wife and I had altered the course of disease many times to benefit our patients, but we found ourselves powerless in the face of her relentless malignancy. She was pregnant with our third child when the diagnosis was made. One hundred days later we had lost the baby and Kate was dead . . .

Are We Hunting Too Hard?
By Jennifer Durgin
"Get screened!" "Find it early!" When it comes to cancer, these dictums are considered self-evident. But what if getting screened for cancer and finding cancer ever-earlier does not save lives? What if too much probing does more harm than good? Several DMS physicians have been asking provocative questions like these for more than a decade.

The human body is full of imperfections—most of which we simply didn't know about until recently. Now, thanks to sophisticated scanning technology, like computed tomography and magnetic resonance imaging, we're able see ourselves at a level of detail that has never before been possible. "Because we're now able to see every millimeter of the body, we of course find a lot more abnormalities in the body than we ever knew existed," says Dartmouth radiologist William Black, M.D. "What the imaging does is it makes us think, 'Oh, there is this ton of tumors out there and other diseases, so disease must really be increasing in frequency.'" But is it?

All cancers are not created equal. Some grow rapidly and invade other tissue, others grow slowly and remain noninvasive, and some don't grow at all or may even recede. Many of the cancers that doctors are finding and treating today, says Black, . . . will never cause harm, let alone death . . .

The Millennium Flight
By Susan A. Reeves, R.N.
It was New Year's Eve of 1999. Some donated organs were desperately needed for a transplant patient in Boston. But traffic would be clogging all the roads into the city, and all other possible medical helicopters were spoken for. It was a tough dilemma that faced a DHMC administrator on that momentous night.

Years from now, when my children, and their children, ask me where I was and what I was doing as the new millennium dawned, I'll tell them the story of that memorable night—of my "millennium flight."

The story begins at 6:45 p.m. on December 31, 1999. My husband, David, and I were sitting in our family room, negotiating a curfew with Dave, our 17-yearold son. . . .

Just as David and I were joking that it was about time to set the clocks ahead to midnight, wish each other a happy new year, and go to bed early, the phone rang. David answered and made the sour face that told me it was Dartmouth-Hitchcock calling for me. . . .

[A hospital] about 60 miles south of DHMC had asked if our helicopter could be on stand-by later that night "to fly some organs to Boston." . . . A transport of this nature would take [the helicopter] out of its service area for a significant amount of time—depriving northern New England of the region's only air medical transport . . .

House Calls with John
By John F. Radebaugh, M.D.
A retired member of the DMS faculty reflects on his varied career—and makes the case for the powerful healing effects of the house call.

I learned the value of making house calls early in my career and even in retirement continued to make home visits as a volunteer caregiver. The hustle and bustle of the usual medical practice allows the doctor to acquire only a superficial knowledge of the patient as a person. Sometimes the individual behind the clinical history—not to mention the patient's family and living situation—is central to the success of treatment. In addition, I have learned much from my patients, especially when I get a chance to see them in less structured settings. They have taught me the importance of taking time to listen, of digging for real answers, of regarding everyone with respect.

My interest in medicine arose during high school. . . . Then it was on to Harvard Medical School, a rotating internship at Mary Hitchcock Hospital, and a pediatrics residency at Massachusetts General Hospital.

There, I came under the influence of Dr. Frederic Blodgett, who made regular house calls in the west end of Boston, an area filled with tenement housing. . . . As he walked the streets, former patients would call down from their apartments, "Hello, Dr. Blodgett," and he'd call back to them by name . . .

Included here are the opening paragraphs of seven stories that have inspired particular comment. Some won prestigious writing awards. Some drew numerous letters to the editor. Some we still get requests for, even though they were originally published more than 10 years ago. To read the rest of any of these stories, go to this issue's Web Extras. Or contact us at DartMed@Dartmouth.edu or 603- 653-0772—and give us your mailing address and tell us which article(s) you're interested in—and we'll be glad to send you copies of them.

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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