A lesson from the heart

I ask most clinicians the same question. 'Tell me about the last patient who taught you something'. 

RH smiles a wry smile. Man hands on experience to man. He draws up a patient's notes, and together we read through the letters. The story emerges of a otherwise healthy middle-aged man who is fitted with a pacemaker. Every year thereafter we find a letter that reads;

Pacemaker checked - normal operation

The list continues for several years without excitement. Suddenly there is an aberration; frank, in black and white; 

Out of hours service. Your patient has died

The next letter is the pathologist's report. 

Cause of death: tuberculous myocarditis

I suck my teeth.

'So what do you think is the lesson here?' he asks. Turning the question around; an old trick.

I smile a wry smile. 'Always be on the lookout for tuberculous myocarditis.'

He says no, firmly but politely. He is right. The lesson is finer than that. We can no more be on the lookout for tuberculous myocarditis than we can be on the lookout for any of a million other pathological bogeymen that pepper the annals of medical literature. I know a wise old rheumatologist who speaks of 'sniper shots'; unpredictable and unavoidable, and of which this was probably an example. The concept is intrinsically unpalatable; that despite all our science, such a gross corruption of normal physiology can go unnoticed. 

There is nothing civilized about living in uncertainty.