Doctor Profiles of 2010

One of My Toughest Cases

PHOTOGRAPHED BY SARA ESSEX

The man whose body turned red
Erin Boh | Dermatology | Tulane Medical Center

Dr. Erin Boh frequently sees patients with debilitating skin diseases. Generally, the case is a straightforward incidence of eczema, psoriasis or any number of cutaneous diseases. However, sometimes a patient walks in with a rash that’s a complete mystery.

One such case was a 62-year-old man who seemed to be in perfectly good health other than presenting with a red rash over his entire body. After being passed from one stumped dermatologist to the next, the man ended up in Boh’s office.

“He developed what we call erythroderma, which is basically the ‘red man’ syndrome. He presented, over the course of about a month or two, with total body redness, and as a consequence of that his skin started to peel off.”

According to Boh, “red man” syndrome is like the worst sunburn imaginable, complete with peeling and itching. The patient was experiencing all of that along with losing fluid through his painfully swollen skin. The loss of fluid eventually led to his heart beating faster and working harder until finally his kidneys started to fail, meaning his skin rash had left him almost completely incapacitated.

Boh suspects that other dermatologists simply hadn’t listened to the patient, and they were quite literally only looking skin-deep for the source of his problem. “They sort of looked at the skin and thought they could treat it with topicals and this-or-that. They didn’t know what was causing it, but they didn’t even listen to him. So, he’s in my office and he’s sitting there and he’s miserable. His hands are swollen, his feet are swollen, he can’t put on shoes, his pants are kind of wet because he’s got oozey, dripping fluid from all over and he’s very, very miserable.

His joints are so swollen that he can’t put on a shirt; his wife has to dress him. So, here’s this 60-something-year-old man who’s been the pillar of strength his whole life, taking care of the family, the kids and he can’t go to the bathroom without help because he’s so devastated and crippled and swollen.”

Boh looks at skin the way a tourist looks at a map of the French Quarter – as if it holds some rare, precious knowledge. According to Boh the skin can be an incredible tool in uncovering a patient’s particular ailment, and in medical dermatology it isn’t rare to see cases where the skin gives some clue to what’s going on inside of a patient.

Years of experience have taught Boh that the best way to get to the heart of the matter is to simply listen to the patient; not only the words they are speaking, but also the internal cues a persistent doctor can pick up on. “Of course, then, the first thing we do is listen to him and hear that he has an irregular heart beat, so we recognize that what tripped him into this state of erthyroderma was his irregular heart beat.” She discovered the man was experiencing a vicious cycle of symptoms: an irregular heartbeat causing a horrible skin rash, a rash causing blood loss and blood loss causing an even more distressed heart.

Figuring out the internal problem wasn’t the end, though, as Boh still needed to understand how the whole attack had started. “Was his skin red all over because he had lymphoma? Or was it because he just had psoriasis, which was out of control because his heart wasn’t pumping right?” In order to understand exactly what was going on with the patient, she ordered a spate of biopsies and blood tests and consulted with a cardiologist. “We were able to find out from our biopsies and our blood work that the patient indeed had psoriasis. He had had an irregular heart beat which, not uncommonly, is associated with psoriasis and that irregular heartbeat had then finally made his psoriasis so bad, without causing him symptoms of his heart, that he then went to the doctor because he was red all over.”

Armed with the proper diagnosis, Boh determined the best course of treatment. “We were able, by working with the cardiologist, to put him on medicines by mouth and then subsequently an infusion. His skin and joints went totally back to normal, he was able to get put on medications for his heart and get his heart treated, and so now, years later, he continues with this infusion. And all of that came about not because he was symptomatic with his heart but it was because his skin manifested negatively to what was going on internally.”

22 years in practice
PhD in Biochemistry – 1980
MD from Tulane University – 1985
Native of New Orleans

 

The impossible baby
Peter Lu | Obstetrics and Gynecology | Fertility Institute of New Orleans

Everyone knows the old adage “If at first you don’t succeed: try, try again.” Dr. Peter Lu of the Fertility Institute of New Orleans takes this advice to heart every time he steps into his office to treat an infertile couple.

“The challenges generally come from keeping the couple optimistic that the medical science, the treatment, will find an answer for them and that we do have an answer for them.” Lu remembers a particularly difficult case he took years ago, when fertility treatment was far more obscure and unknown than it is now.

The couple had already tried numerous treatments across the country. “They did in vitro fertilization twice at the IVF center where they lived. It didn’t work, so they moved on and went to a quite well known – world-famous – fertility center in Colorado. That’s where they were evaluated and told that they weren’t going to get pregnant with their own eggs.”

Lu says that the relatively new science of fertility treatments was far from perfect at the time. Because of this, even a world-famous doctor was incapable of seeing beyond statistics and hormone profiles. Previous doctors had tested the woman and seen that her level of follicle stimulating hormone, a hormone linked to a woman’s fertility, was that of a 40-year-old woman. “The doctors were drawing on just blank statistics. What was told to the couple, that an FSH level of a 40-year-old in a 40-year-old has virtually no chance of leading to a pregnancy, was correct.”

The couple was crushed, thinking that they would never produce a child on their own, when they remembered an old college acquaintance whose wife had given birth to triplets. A call to the newly minted parents revealed that they had been treated by Dr. Lu at the Mayo Clinic in Rochester, Minn.

“They called the Mayo Clinic, really looking for me, and they found out I was in New Orleans, just a several hour drive from where they were. I remember that first consultation when they came by. They were hopeful but not expecting much, knowing that miracles aren’t just handed out. What our assessment showed was that even though she had the FSH of a 40-year-old, if we could get any eggs out of her, they’re not 40-year-old eggs; they’re 30-year-old eggs. Therefore, what’s true in a 40-year-old probably didn’t apply to this 30-year-old woman. This is well understood today, but I think 10 years ago this wasn’t appreciated.”

Lu prides himself on never turning away a difficult case just to keep his numbers up. He informed the couple that the likelihood of a pregnancy was very low, but he would treat them if they wanted to try.

Despite their misgivings, the couple decided to again take on the emotional and financial burden of IVF (each cycle costing around $20,000). “The first IVF cycle they tried a successful pregnancy didn’t occur, but she had a miscarriage, so that was a little bit more promising than it had been before. On their second IVF cycle they ended up having their little boy. IVF requires many office visits; in a course of six weeks there may be 15 office visits.

And so, it was a tremendous burden for this couple.”

Lu is most proud of making the couple feel safe in his care, even though they were so far from home. “I feel like my success in them was not so much that we were successful on the science side, but that I convinced this well-educated couple why it is that it could still work.”

The couple has since returned to Lu for more treatment, leaving with twins the second time around. “The husband always remembered his consultation with the world famous fertility doctor and we would occasionally mention, ‘You know, I’ve got to let that doctor know what eventually happened to us,’ because it was completely different from what he suggested.”

Lu remains in contact with the family, receiving Christmas cards and birthday announcements. The family even offered the Lus a place to stay during a hurricane evacuation. “I do remember that couple well. When I look at pictures of the son and his two younger siblings over the years, that’s what keeps that case in my mind.”

14 years in practice
MS from Georgetown University – 1985
MD from Georgetown University – 1989
Native of Taipei, Taiwan

The woman with brand new hands
Donald C. Faust | Hand Surgery and Orthopaedic Surgery | 2633 Napoleon Ave., Suite 600

It isn’t uncommon for an elderly woman with rheumatoid arthritis to walk into Dr. Donald Faust’s office. In fact, he could see many of the same type of case in one day. According to him, though, that doesn’t make it any easier to treat. “I’ll say prayers sometimes before I go get involved in something.”

Faust recently treated a 92-year-old woman with arthritis so severe that it had almost completely crippled both of her hands. The arthritis had caused her to lose most of the strength in her fingers, which caused frustrating clumsiness. Her joints were swollen and painful and she felt she had to hide her hands. All around, rheumatoid arthritis had taken over her life. “Just daily living she had difficulty with.” Even still, Faust remembers her as a vivacious, happy woman:  “She was a delightful lady with an Alabama accent.”

Because of the advanced stage of the disease, Faust had little room for mistake. Going into surgery, he knew that he could either greatly improve his patient’s quality of life, or he could cause even more damage. “It’s a balancing act.

You don’t want to get on a horse and then fall off the other side.”

Faust takes nothing for granted; for him, paying attention to every little detail is one of the most important aspects of his job. “It’s the joke about minor surgery: Minor surgery is what happens to other people, but when it’s you it isn’t minor. Every case I do I worry about. And if you stop worrying about it, it’s probably time to retire.”

With that in mind, Faust went ahead with the intensive procedure on the patient’s right hand in January of this year.

Faust credits his passion for carpentry and his fascination with model building for his skill in joint replacement.

“My father made boats in a bottle. You’re tying all these knots and rigging it all together and making little models.

And that’s all the surgery I do – it’s like model making in a lot of ways.”

The replacement of knee and hip joints is a commonly accepted idea among the general population; most everyone has a grandmother or grandfather with a chrome hip.  Artificial knuckle joints, though, are a bit harder to grasp.

The procedure involves taking apart a hand and then reconstructing it so that it regains its entire range of motion. The artificial joints are made out of high-tech materials made to withstand the wear and tear of being human. “The space program and the computers have been able to machine these things so remarkably now. They’re made out of chrome and silastic [a combination of silicone and plastic] and they’ve got these pyrocarbons that we use, too.”

The entire operation on the one hand took a total of about two hours. The healing process for such an involved procedure can take a long time, and Faust’s patient was bandaged for three weeks, healing completely in six weeks.

The woman was so happy with the results on her right hand that she decided to go ahead and do the surgery on her left hand, as well. Faust performed the surgery in May, and since then she has recovered and healed. Faust recently saw her for a post-op office visit where she expressed her gratitude for his ability to save her joints. “Some people have high expectations about pain and they want to have an operation, and you tell them ‘I’m not sure it’s going to help you.’ The more trouble they’re having before, the more they appreciate what you do for them. If you’re too quick to operate for pain they’re not going to appreciate the operation as much as people that have really been hurting for several years.” That was the case with this woman: she had been in so much pain for so long that the operation was like giving her a life again. “She told me she was going to a wedding and now she doesn’t have to hide her hands. She’s just so excited that she can clap now.”

Speaking of this 92-year-old woman whose life was greatly improved, Faust is clearly gratified by his work.  It’s the every day, minor surgeries and the care he takes with each of his patients that truly makes him one of the best doctors in New Orleans.

30 years in practice
BS from Loyola – 1973
MD from LSU School of Medicine – 1977
Native of New Orleans

 

Searching for a miracle cure
Oliver Sartor | Medical Oncology and Hematology | Tulane Medical Center

Dr. Oliver Sartor knows first-hand that the practice of oncology is one fraught with emotion. It is a common belief that most doctors are distant and aloof, but Sartor feels the pain of a cancer diagnosis as keenly as his patients.

Toward the beginning of his career, while working in Washington D.C., Sartor took on a patient with advanced prostate cancer. The two men bonded over their shared homeland – Louisiana – and became close friends. Though the man has long since passed, Sartor becomes visibly upset when speaking about his close friend and patient.

“He had horrible prostate cancer. He had failed surgery, radiation, hormones and had been sent to us from Houston because we were doing some crazy experimental work.”

The man’s cancer was extremely aggressive and difficult to treat, which was why he was sent to Sartor in the first place. Even from the beginning of his career, Sartor has treated patients who’ve been passed from doctor to doctor without much progress. “Most of the time people come to me because, to be blunt, they’ve got something kind of tough going on.” That was the case with this patient, whose treatment was remarkable even before he had been sent to D.C.

With the patient in his care, Sartor tried everything he knew to treat the aggressive cancer, with little success. “He went on one protocol and failed; he went on a second protocol and failed; he went on a third protocol and failed; he wasn’t doing well.” Protocols are tested and approved treatments for certain cancers. Depending on the stage and scope of the cancer, doctors determine which protocol is appropriate for each individual patient. “Prostate cancer is an unusual disease because it’s often over-treated as well as under-treated. The key is matching the right therapy with the right patient. Patients who have progressive cancers that fight all the usual stuff you’re throwing at them, they’ve got trouble.”

 With each failed protocol the cancer kept progressing, and the case was getting dire when Sartor heard about a similar case where the patient had undergone a slightly unconventional treatment. It was precisely the unconventionality of the treatment that attracted Sartor; after all, the accepted treatments had failed to produce a positive result. “A patient from Florida had done something unusual about stopping and starting a medication, and that was interesting enough to me that I thought I might try to recapitulate that in my patient.”

The results of the somewhat experimental treatment were astounding. “It was literally a miraculous response. His prostate specific antigens were 1,000; he had failed all conventional therapy and multiple external protocols. His prostate specific antigens went to undetectable and stayed there for 12 years.”

Both patient and doctor were equally surprised by the turn-around. “He said, ‘Oliver, if I was Catholic, we could get a saint out of this one,’ and it was true. It probably is the most miraculous case that I’ve ever been a part of.”

Sartor eventually moved to New Orleans, where his then-healthy patient was living. “He was a New Orleanian born and raised here, very connected. He introduced me to a million people in town at dinner parties, and I used to have lunch with him all the time.”

Unfortunately their relationship reverted back to one of doctor-and-patient when the man eventually developed a tumor on one of his kidneys. “He developed a kidney cancer, and lost a kidney because we did a nephrectomy, which is appropriate. Then he developed a kidney cancer on the other side and we did a partial nephrectomy, so he had half-of-a-half of a kidney.

Sadly, Sartor couldn’t keep his friend from death forever, and he passed away years later as a result of complications from a broken hip.

Sartor remembers the case, and the man, fondly though with a touch of sadness in his voice. “We became so close, and to eventually watch him die was just very, very painful.” Sartor continues to handle the difficult cases day in and day out, making decisions and trying new protocols just as he did years ago for his friend.

21 years in practice
MD from Tulane – 1982
Residency at Tulane – 1986
Native of Shreveport

The electromagnetic spine
Joseph T. Crapanzano | Anesthesiology | Parish Pain Specialists

Pain care is one of the most enigmatic and sometimes controversial specialties. Dr. Joseph Crapanzano knows all too well how patients can become dependent on their pain medication and how pain can change someone’s entire personality.

Crapanzano recently treated a woman who was experiencing pain in her left leg, which had resulted from a spinal surgery. “She had had several injections and developed an infection in her spine that ultimately grew into an abscess. So, she was transported to East Jefferson Hospital in an ambulance one night when she had become extremely ill, and the wound was drained.”

Though the abscess was gone, the woman’s pain persisted and she was referred to Crapanzano by a neurologist. “She arrived in my office with her husband some months after her surgery. They were a delightful couple but extremely distraught due to her severe residual left leg pain that didn’t respond to conservative therapy.”

The husband and wife were both at the end of hard-working careers and were both eager for the pain to finally be relieved, as it was making it hard for them to enjoy their retirement. “Mostly they wanted to spend time with their children and grandchildren, and spend time together. They’re not infirm and they wanted to remain active.”

Crapanzano consulted with the patient and her husband about numerous options, none of which appealed to the woman. “She didn’t like having to take pain medications and felt that they were poorly effective in relieving her pain; she didn’t like how they made her feel – the drowsiness, the grogginess. She was reluctant to get another injection because, quite frankly, she had had an injection initially that was thought to be a culprit.”

Every time a spinal injection is performed, the risk of infection is a real possibility. Crapanzano appreciated the woman’s fear of another infection and shared in her desire not to repeat it. “That can happen anytime, anywhere, to anybody. She was well cared for, but she had a complication, and it’s a complication that we fear.”

Being that the common treatments all seemed too risky or just didn’t work, Crapanzano only had one really viable option. “Ultimately it was elected to surgically place a neurostimulation device which treats the pain by creating an electromagnetic field in the epidural space within the spinal canal along the back of the spinal cord.” Specialists still aren’t clear an exactly how electromagnetism alleviates pain, but they do know that it is effective. “There are several proposed mechanisms. One is that the electromagnetic field just interrupts the pain pathways. Another is that it may stimulate certain substances in the spinal cord and central nervous system that inhibit pain transmission.

It’s probably a combination of those factors. A simple analogy would be: if you hit your funny bone, you automatically, instinctively rub it. Why do we do that? We do it because the brain picks up the pressure sensation of the rubbing and it tends to ease the pain. It distracts us from the pain.”

The device is like a small catheter, similar to ones used for epidural injections in relieving labor pains, that’s inserted into the appropriate spot on the spine. If a patient has arm pain, the device is placed in the neck area; for leg pain, it goes toward the bottom of the spine. The procedure, performed in an operating room, takes about two hours. “The most challenging part is usually to get the device and the wires placed in an area where they’re stimulating the correct portion of the body.”

Shortly after the procedure the patient made a full recovery. Her recovery was so full, in fact, that she completely stopped taking her pain medicine. “It’s a little bit amusing because most patients cling to their medications but she just dumped them. The spinal cord stimulator made her feel so good because her pain was gone, but she felt a little crummy because she stopped her medication suddenly.”

Stories like this one are what remind Crapanzano why he’s a doctor. “We are able to help our fellow human beings along life’s journey. On a recent visit to my office, as this couple was getting ready to leave, the woman stopped, looked me in the face and said ‘You saved my life by taking away this pain.’”

25 years in practice
MD from LSU – 1982
Native of New Orleans

 

Categories: Health Features, LL_Feature, Medical

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