An Eye For An Eye

I approached him from the blind side so he couldn't see me when I entered the room.

"The doc is here, Mr. Cochran," introduced the nurse.

"Can't see out of left eye" read the chief complaint on the chart.

Mr. Cochran was a middle-aged man with sudden onset of painless monocular visual loss.

"Hi, sir, I'm Dr.____(common surname). What happenned to you?"

"All of the sudden I became blind out of my left eye, doc. Can't see a damn thing!"

"How long ago did this happen?"

"About 2 and a half hours, I thought it would go away but it didn't so I'm here. Am I having a stroke?"

I go on through the routine questions and review of systems. No other neurodeficits. No bulbar symptoms. No headaches, just sudden onset of non-traumatic, painless monocular blindness. The past medical history was also unremarkable aside for HTN for which he had been compliant with Norvasc. No history of MS.

"Have you ever had syphillis?"

"No. Heavens, no!" he sounded irate but puzzled.

"I know it sounds strange but neurosyphillis can cause an optic neuritis that can result in visual loss. It's a rare disorder these days but just thought I'd ask to be thorough."

Now come the social history...No smoking, no illicit drug use, no alcohol abuse. He denied it all...

"What do you do for a living?" I asked, already knowing the answer.

"I'm an attorney," he proudly responded. "You've probably seen my ads on the highways."

"Yes, yes. A fair settlement is no accident." (That billboard slogan is plastered all over Crack City)

"Yeah, I'm a personal injury lawyer. I have no problems telling doctors that. I get better care that way, actually. Makes you guys more careful around me."

"Yes, I know you very well, Mr. Cochran. You were the plaintiff attorney accusing me of being a baby killer, remember?!"

Pausing briefly to let him absorb the full irony of the situation, I continued, "As to being more careful around you, all that means is that you'll have a bigger medical bill because of all the unnecessary tests and consultations, but I personally treat everyone the same regardless of the circumstances."

Disclaimer - The names have been changed to protect...well, me from HIPAA. This patient was not THE famous Johnnie Cochran (October 2, 1937 – March 29, 2005), of course.

After realizing who I was, he muttered, "That was a long time ago, doc! You're not gonna hold that against me are you? The hospital settled and we dropped the case against you, as I recall."

"C'mon, you guys dropped the case against me because there WAS NO case and I refused to settle!" (See Lawsuit #4) Hold it against you?? Hold it against you?? You KNOW deep down that I wasn't responsible for that little boy's death. YOU KNOW IT!"

"Hey, a man's gotta make a living somehow."

This guy was truly pond scum. That's all he had to say? A man's gotta make a living somehow? The enormous stress and torment he put me through all these years labelling me a baby killer, and that's all he had to say? What a conceited, heartless asshole! Representing the parents of the deceased child, the li'l weasel sued the pediatricians, the health department, the hospital, and me. He spent all of that time and money and finally settled with the hospital for a lousy 10 grand. The 2 pediatricians and the health department all settled for an undisclosed amount of money. I was the only one who refused to settle. My attorney fees and such racked up over $40,000. And here's this son of a bitch in my ED seeking care for his sudden visual loss! Oh joy! Oh joy! That's the nice thing about working in the ED on weekend nights exclusively. Eventually, everyone in town will come through because nothing else is open, all the clinics are closed. Don't screw with me, because one of these days you'll need my help on a weekend night when no one else is around! A cop gave me a speeding ticket once for driving 47 in a 35 mph zone, but that's a whole 'nother story for another blog.

"Water under the bridge," I said to the weasel. "Let's get back to your eye and find out what's wrong with it."

"You know, doc. It's just business." He persisted in trying to explain himself.

"Let's not dwell on the past, Mr. Cochran," I interjected. "Your eye is what's important now."

He shut his yap up afterwards and behaved like an obedient puppy.

"Now, let's see....Are you taking any medications such as Viagra, Cialis or Levitra for erectile dysfunction?"

"What does that have to do with anything?!!" came his incensed outburst.

"Well, there have been published reports of sudden visual loss due to these drugs. You want me to be thorough now, don't you? So I gotta ask. Just doin' my job and being, as you say, more careful around you, sir. Do you have erectile dysfunction and are you on any of these drugs?" I persisted.

Hehehe. I silently giggled. Got the bastard all squirmy and riled up! hehehe. I felt like a lawyer grilling a scumbag criminal on the stand. Sscwheeeet!!!

"I haven't taken Viagra in over 6 months," he mumbled.

I scribbled "ED, not taken viagra in over 6 months" on the chart and silently giggled some more. Hehehehe.

I looked on the cardiac monitor, he was in A-fib but the rate was controlled. I quickly checked the order box for an EKG.

"It looks like you have an abnormal heart beat. You're in atrial fibrillation. Do you have a history of a-fib?"

"I had it a long time ago but it went away. I had a nuclear stress test 2 years ago and it was normal."

"Sir, is there anything else, any other medical problems that you're not telling us? You're not very forthcoming about things. You said only high blood pressure earlier and now we find out about atrial fibrillation and that you've been on viagra? Is there anything else you're witholding? You said you don't drink alcohol much, but I can smell it on you. Have you been celebrating and drinking more than usual over these holidays? Because excessive alcohol drinking can cause atrial fibrillation, what we call a Holiday Heart Syndrome."

"Yeah, I drank a little bit more than usual this past week. It's the holiday season, as you said. I did drink more than I should have. Some champagne, some martini. It's New Year Eve. But I don't consider myself an alcoholic, if that's what you're getting at. I don't drink every day."

His visual acuity was horrendous. He couldn't even see the big E on the Snellen chart. He had no head ache, no pain, and a normal Sed. Rate, thus ruling out Temporal Arteritis. His head CT was also unremarkable. His neurologic exam was also unremarkable. The slit lamp exam was unremarkable without fluorescein uptake. On tonometry, his IOP was borderline at 19, 19, and 20 on 3 separate readings, the same as the unaffected eye. On fundoscopic exam, his optic disk was pale. The cherry spot was there. He had all the classic findings of Central Retinal Artery Occlusion.


I instructed him to apply pressure and massage his left eye while we started him on acetazolemide. He was given an aspirin and was started on heparin after his head CT came back negative. His labs also showed renal insufficiency with a creatinine of 2.1, that I suspect is chronic. The RPR was still pending.

"Am I having a stroke, doc?"

"No sir. But Mr. C., we don't have a whole lot of time left," I explained to the man. "We must initiate treatment immediately because you have about 6 hours from the onset of symptoms until you become permanently blind in that eye. You have Central Retinal Artery Occlusion and it's likely due to an embolic phenomenon, a blood clot in the retinal artery of your eye. You're throwing clots because of untreated atrial fibrillation. From what you've told me, we're at about the 4 hours mark from the onset of your symptoms. We've got about a little over 2 hrs left to do everything we can to salvage things and prevent more damage to your eye and preserve whatever vision you may still have left. I've consulted an opthalmologist to come and see you. You'll probably need to have an anterior chamber paracentesis done. That entails a small needle in your eye to withdraw some fluid from the anterior chamber to decrease the intraocular pressure of your eye so that the clot can pass. I can do that, but I prefer that the opthalmologist examine your eyes first. I've already consulted the internist on call to admit you to the hospital since you do not have a primary care doctor. I've already arranged for you to get hyperbaric oxygen therapy...Hyperbaric oxygent therapy is...and we also need to consider giving you tPA, a clot buster....You also have some kidney failure, which I suspect may be chronic...."

I overwhelmed him with so much information all at once that he became like any other patient in situations of extremis. "I trust your judgement, doctor," he said quietly, "And if it means anything, no I do not think that you or anyone sued was responsible for the death of that child. I'm sorry."

Wow! There is hope for pond scum, after all. Finally some closure, for what it's worth, to a malpractice case that has plagued my psyche for years, kept me pissed off and awake many a nights as I tossed and turned. As to this attorney, his prognosis is poor in terms of regaining full vision in that eye. After his first round of HBOT, he is now able to see, but still very blurry. At least he's able to count fingers when raised up before him, whereas he was completely blind in that eye before.