Months after a stroke, the man was wearing out. What was wrong?

Eventually, she agreed to see Dr. Richard Kaufman, their primary care physician. Kaufman was shocked by the man’s appearance, by the way the skin on his face hung in folds as if air had been blown out of his cheeks. He had lost nearly 40 pounds. He struggled to take the few steps to the exam table. His right side, weakened by the stroke, was now accompanied by a weakness on the left side. His stroke hadn’t done that. There was something else going on. Kaufman ordered some preliminary blood tests to try to see where the problem might lie. These were the results that sent the couple to the emergency room.

It was early afternoon when Dr. Osama Kandalaft, the hospital worker on duty, has found the couple. It was December 2021 and the emergency room was exploding with a new wave of Covid cases. The patient was on a stretcher in the corridor. His wife was sitting on a stool next to him. Before meeting the man, Kandalaft reviewed the results of tests carried out in the emergency room. His kidneys were in bad shape.

Kandalaft saw a pattern in the other labs he recognized. A test showed that there was a lot of blood in the man’s urine. Yet when the urine was examined under a microscope, no blood was seen. This is because this was not blood; was a cousin of hemoglobin, myoglobin, the component of muscle that carries oxygen, which is released into the bloodstream after an injury. Widespread muscle damage could certainly explain the man’s weakness. Also, he was taking a cholesterol-lowering drug, a statin called rosuvastatin, which is known to cause muscle breakdown in some who take it. Kandalaft wasn’t sure if the statin could cause the patient to swallow problems. However, he allegedly stopped the drug and ordered a test to look for creatine kinase, another protein released by injured muscles.

Doctors often invoke Occam’s razor principle, articulated by the 14th-century philosopher William of Occam, who postulated that the simplest interpretation of any phenomenon is most likely the right one. A single and elegant explanation of suffering is often more welcomed by both doctors and patients than the more contemporary principle, attributed to the twentieth-century physician John Hickam, that “patients can have all the diseases they want.” But in the Kandalaft experience, Hickam’s complexity often fits better. Especially with a patient who was 82 and had diabetes and heart disease and had suffered a recent stroke.

The patient and his wife spent much of the night in the emergency room, waiting for a bed to open for someone who didn’t have Covid-19. It was moved to one just before dawn. Dr Andrew Sanchez, the intern assigned to patient care, woke him early the next morning to introduce himself and try to figure out how to proceed. The blood test sent by Kandalaft to look for muscle injuries had been helpful. It was 40 times higher than it should have been, indicating severe damage.

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