Top Doctors’ Toughest Cases

Diagnoses are rarely as easy as television medical dramas make it seem. The human body has lots of doctor-confounding tricks up its sleeve, from tumors that masquerade as psychiatric problems to blood clots that hide behind heart attacks. Even when a diagnosis is relatively clear, it’s often a Herculean task requiring immense skill to solve medical problems correctly. The good news: our doctors are up to the task. Here, some of our Top Doctors recall their toughest cases—and their outcomes.

Trying to Start the Bleeding

Dr. Richard Karanfilian with his patient Richard Bartnik, who today admonishes anyone he sees with a sharp object.

Dr. Richard Karanfilian, a vascular surgeon at Sound Shore Medical Center, had just slogged through a hospital board meeting on a crisp October night in 1986. He was leaving the hospital when he heard the rescue squad call in a trauma alert and decided to wait for the ambulance. Paramedics arrived performing CPR on Richard Bartnik, an eight-year-old who had fallen face-down on a knife. “I was going out to the grill to get myself some sausages,” Bartnik recalls. “I tripped on the walkway, stood up, pulled the knife out of my neck, and screamed.” The knife had sliced open his neck above the collarbone, leaving a wound of indeterminate depth. Bleedings profusely, he entered cardiac arrest in the ambulance and had neither blood pressure nor pulse upon admission to the ER; he was in shock and unconscious, his pupils unresponsive to light.

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“We immediately went into full trauma code,” says Dr. Karanfilian, who led the three-hour surgery. With the boy intubated, the surgeon slipped catheters into the veins of the thigh to administer fluids and bolster circulation; in this context, not bleeding is a bad thing.

“The first positive sign we had,” Dr. Karanfilian says, “was the resumption of bleeding from the neck wound.” He rushed Bartnik to the OR, applying as much pressure to the wound as possible, and then opened the neck with a scalpel—only to realize the wound continued under the clavicle and into the chest. It was imperative to gain access to the chest to see the extent of the damage, making haste to repair any crucial blood vessels in the knife’s path. No thoracic surgeons—those who operate on the chest—were available, so it fell to Dr. Karanfilian to think fast. He realized, with horror, that he’d have to crack open the little boy’s chest in a brute-force procedure called a median sternotomy—something he hadn’t done since residency.

“We did not have modern equipment for this,” he says, “just an antiquated instrument called a sternal splitter.” Similar to pruning shears, it split Bartnik’s chest in half. “We had no choice.” Scanning Bartnik’s organs, Dr. Karanfilian found the knife had punctured the boy’s lungs—causing them to collapse—and had severed his right subclavian artery, which supplies blood to the arms and head. It had stopped just short of fatally piercing the boy’s heart. Dr. Karanfilian’s team sutured the subclavian artery, wired the sternum together, and transferred Bartnik to the ICU, anxiously watching as his vital signs remained stable. “We weren’t sure how much brain damage had occurred,” Dr. Karanfilian says. Bartnik lay unconscious on a respirator, leaving the surgeon in despair—until the boy began to stir a week later. “It was miraculous,” Dr. Karanfilian says.

Today Bartnik, 31, works for a real-estate company in Philadelphia. “When I see anyone wielding a sharp object carelessly, I have to say something, even when it’s my mom chopping carrots in the kitchen—there’s a little residual trauma,” he says. “I’m just glad I had the good fortune to arrive at the hospital before Dr. Karanfilian left.”

Correcting A Case… in The Nick of Time

Cardiologist Franklin Zimmerman, MD, realized quickly that Celia Jones had an incorrect diagnosis.

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This past July, Dr. Franklin Zimmerman was trying to focus on a meeting of the medical board—but a nagging doubt gnawed at him. Earlier that evening, the Phelps Memorial cardiologist had been asked to consult on Celia Jones, a 60-year-old woman in the emergency room who complained of multiple fainting spells, tightness in the chest, and shortness of breath. The initial diagnosis from the emergency room staff was a possible heart attack, based on an abnormal EKG and elevated cardiac enzymes. Jones was frustrated and desperate for help. Two days before, she came to the ER with similar symptoms but declined the doctor’s recommendation for hospitalization after the initial evaluation was unrevealing. But her case bothered Dr. Zimmerman.

“It was very unusual that she’d had three separate episodes of fainting,” he says. “Fainting from a heart attack is due to shock or cardiac arrhythmia; that doesn’t happen three or four times, and you don’t feel well enough to go home from the ER afterwards. Something was different about this patient.”

At that evening’s meeting, he wracked his brain for the answer. Another diagnosis flashed across his mind, and he left the meeting to call in an X-ray technician for an emergency CT angiogram. His fears were confirmed when the radiologist reported a saddle embolism: a large thrombus (blood clot) that had dislodged from the legs and traveled through the right side of the heart to wedge itself into the main pulmonary arteries, obstructing flow to the lungs. The resulting danger signs—a severe drop in blood pressure, atypical chest pain, and respiratory distress—presented themselves, deceptively, as hallmarks of a heart attack. Jones promptly received a clot dissolver, Heparin, and is today on the blood thinner Coumadin.

“Celia started out as a frustrated patient and was now so grateful we had stuck with the case,” says Dr. Zimmerman. “The embolism might have been fatal had treatment not started that evening. Medicine is sometimes like a detective story, and it really is exciting when you can solve the puzzle to help a patient.”

Blasting a Basketball-Size Tumor

Oncologist Bernard Bernhardt, MD, had to jury-rig a drug treatment to try to save his patient.

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On January 1, 1975, Sandor Lewis [not his real name] went to New Rochelle Hospital with back pain and a swollen testicle. Diagnosed with a seminoma, or testicular cancer, the 24-year-old newlywed became a patient of Dr. Bernard Bernhardt, a hematologist/oncologist at Sound Shore Medical Center. Dr. Bernhardt promptly arranged for the removal of the cancerous testicle—but not before it had spread to the lymph nodes in Lewis’s pelvis and abdomen. Soon, his belly swelled grotesquely with a basketball-size tumor that had displaced his liver, spleen, and pancreas as it grew into his back.

“The surgeon opened and closed him, calling it a hopeless case,” Dr. Bernhardt says. “It had pushed aside so many organs, it was impossible to resect.” Desperate to save his patient, the oncologist jury-rigged his own drug regimens by trial and error. “We treated him, grasping at straws for three doses, several weeks apart,” he says. This was Lewis’s only chance of survival, a long-shot gamble that paid off: within months, the tumor shrunk to the size of an orange. “When they went to re-operate, the cancer was dead; they had no trouble getting it out,” Dr. Bernhardt says.

Today, Lewis, 58, a corporate executive in Yonkers, remains close with his former doctor. “Bernie figured that if I was well enough to be in his tennis game, I was out of danger,” he quips. Initially told he’d never have children, Lewis today has two grown daughters. “You can call him a witch doctor, but he came up with the right potion,” Lewis says. Dr. Bernhardt takes pride in daring to create his own chemo—a life-saving therapy that was literally unprecedented. “How many times can you say that you cured a friend’s cancer?” he asks.

Rebuilding a Shattered Knee

Dr. Anthony Maddalo called policeman David Edwards’s knee injury “devastating.”

Knee injuries are par for the course in orthopedic surgeons’ offices, but Dr. Anthony Maddalo of Phelps Memorial Hospital Center doubted he could put David Edwards back on his feet. In October 2004, the Ossining policeman, then 34, was responding to a call when he was broadsided by a cab driver with alcohol, cocaine, and marijuana in her system. Edwards felt the steering wheel pin his thigh to the seat as his lower legs were driven backwards. The result was a complete knee dislocation—with three ruptured ligaments, a meniscal tear, and severe nerve damage causing foot drop. “That’s a devastating injury, one that’s nearly impossible to fix,” Dr. Maddalo says. The nerve damage to the foot made recovery even more unlikely. “My foot was just hanging there, drooping,” Edwards says. “They didn’t know if I’d ever get sensation back to walk again.”

With a challenge this daunting, Dr. Maddalo decided on two surgeries. He performed the first surgery in late October to clear scar tissue, relieve pressure on the peroneal nerve, and reconstruct the LCL, the ligament that runs along the side of the knee joint. Three months later, a second surgery repaired both the ACL and the PCL, the bands girding the knee joint in front and in back. The post-operative rehab determined the surgery sequence: LCL repair requires immobilization with a brace, while ACL and PCL repair calls for rapid movement—aggressive physical therapy with electric pulses sent through the leg. “First I felt nothing, then a flicker,” Edwards says. “And, slowly but surely, I could move my foot one inch.” Eighteen months of therapy restored sensation, allowing him to flex his ankle. Edwards not only learned to walk again, he rejoined the force in mid-2006. “I wasn’t ready to retire,” he says. Dr. Maddalo is still floored: “I’ve never seen such a complete recovery.”

 

 

Giving a Teenager Hips of Titanium

Kayla Suttle went to Dr. Steven Zelicof with hips that were broken and arthritic.

Six years ago, 14-year-old Kayla Suttle hobbled into the office of Dr. Steven Zelicof, chief of orthopedics at Sound Shore Medical Center. Burdened with hips that were broken and arthritic, she was counting on Dr. Zelicof to help her walk again.

“Both Kayla’s hips were shot,” Dr. Zelicof says. Suttle, of Orange County, suffers from osteogenesis imperfecta, a hereditary disorder also known as brittle bone disease, marked by deficiencies in bone mineralization that renders its victims vulnerable to injuries and fractures. “Dr. Zelicof gave me hope that I could be a normal kid,” Suttle says. A double hip replacement was her only hope, but Dr. Zelicof braced himself for a host of complications.

“Her anatomy was completely off,” he says. Pins and screws—plus a loss of blood supply to the joint—had worn away and weakened the already fragile bone, leaving it wobbly and deformed. Trying desperately to avoid replacement surgery, her doctors had cut the soft hip bone and fused the growth plate in her right hip. “We had to reconstruct the whole area,” says Dr. Zelicof, who struggled to anticipate and address every challenge—including finding a prosthetic hip that would last more than 10 years. “We weren’t dealing with a ninety-year-old,” he says. In April 2004, over the course of two surgeries, he gingerly removed the damaged joint to implant a titanium ball and socket. But Dr. Zelicof’s role didn’t end after he peeled off the gloves.

“From a rehab standpoint, the endeavor was huge,” he says. “Her leg muscles hadn’t moved in years; all those neurons had to start firing again.” He monitored the rehab closely, with encouragement that touched Suttle deeply. “I pushed myself the hardest I ever had,” says Suttle. “I was so excited to walk—and so afraid, at the same time.” By her third weekend home from the rehab facility, Suttle was walking by herself. Today she is studying to be a nurse and carries herself so gracefully, her doctor says, “she could easily be a model.”

Finding a Brain…in The Pelvis

Dr. Jonathan Slater knew that his patient wasn’t psychotic but why was she behaving so bizarrely.

Sometimes, it takes an expert psychiatrist to know when a patient doesn’t belong in his office. Such
was the case last summer when

Dr. Jonathan Slater, of NewYork-Presbyterian Morgan Stanley Children’s Hospital, saw a 14-year-old girl, S.K., who had been discharged from a psychiatric hospital. “She was hallucinating, agitated, talking to herself,” says L.K., her mother.

S.K. was initially hospitalized after she’d had seizures in her New Jersey home. Upon discharge, her family stopped at a gas station. “She lunged out of the car and ran toward the highway,” her mother says. The psychiatric hospital ran a battery of tests, deeming her psychotic and plying her with anti-psychotic medications. “She was a zombie, slumped over and drooling,” says L.K., who took her daughter to Dr. Slater in June.

“She was acting up in his office, interrupting and storming about,” says L.K. Dr. Slater immediately diagnosed S.K. as having delirium, a neurological illness with a physical explanation. “It’s often confused with psychosis,” he says, “but a normal teen doesn’t develop schizophrenia in the course of a weekend. This was not a psychotic illness.”

To root out the underlying cause, Dr. Slater admitted S.K. to New York-Presbyterian, where she set off a debate between the psychiatry and neurology departments. “She’d be confused with us, lucid with the neurologists,” he says. S.K. went through further tests, including a spinal tap, an EEG, and an MRI. Finally, her excess weight and increased facial hair prompted her doctors to order a pelvic ultrasound to rule out an endocrine disorder. What the scan found was astonishing: a germ-cell tumor inside the ovary, in which a tiny brain was growing. (Such growths, called cystic teratomas, can also harbor primitive teeth and bones.) Absorbing this news, Dr. Slater suspected that S.K.’s body was producing antibodies to attack this new brain tissue—antibodies that also turned against her own brain, leading to a condition called autoimmune encephalitis. The tumor was removed immediately, and S.K. was placed on a regimen to disable and filter out the turncoat antibodies. Today, S.K. is recovering in a cognitive rehabilitation center in New Brunswick. “All this time, encephalitis was masquerading as a psychiatric illness,” Dr. Slater says. “It was an amazing case.”

Reviving a Blood-Starved Ovary

At 2 am, Dr. Monique Regard faced tough decisions regarding Elisabeth Hart’s dying ovary.

Elisabeth Hart’s summer vacation began with a sharp pain in her abdomen on the day after school let out for summer. The 12-year-old from Mount Kisco at first thought she had ruptured her appendix—but then radiology studies revealed an ovary in distress. “Her ovary was on the brink of dying,” says Dr. Monique Regard, a pediatric gynecologist at Maria Fareri Children’s Hospital at Westchester Medical Center. “It was black and blue, twisted into knots”—likely due to the plump cysts that resulted from an endocrine disorder, called polycystic ovarian syndrome, that Hart had. “The cysts acted like a ball on a bungee cord,” says Dr. Regard, choking off blood flow to the area and starving the ovary of nourishment. “It looked like a little purple eggplant,” recalls Elisabeth’s mother, Susan Hart.

With the ovary wilting away by the minute, Dr. Regard had to decide whether to remove it or try to untwist it—a wrenching replay of a dilemma she’d faced three weeks beforehand, when she failed to save the ovary of a nine-year-old. “At two am, we were sweating it out,” she says. “We didn’t want to risk that second surgery to take it out if we failed to save it.” Nor did she want to declare the ovary dead prematurely and play roulette with Elisabeth’s future fertility.

Working with surgeon Dr. Whitney McBride, she decided to press ahead with laparoscopic surgery to sew down the ovary, anchoring it to the ligament so that, once untwisted, it would be hard for it to twist again. “It was touch-and-go,” Dr. Regard says. “I was biting my fingernails that it wasn’t too late.” Susan recalls how the entire OR locked eyes on the video monitor for an hour, waiting for her daughter’s ovary to “pink up” with blood. When it bloomed with life, a cheer arose. “I was thrilled,” Dr. Regard says. A scan at four weeks confirmed the ovary was again thriving. Today, Elisabeth is a sophomore at Fox Lane High School with a scar that’s tinier than her pinky nail. Though she’s more concerned with tests and tennis than with starting a family, her mother knows that one day she’ll be relieved to have two intact ovaries. “I don’t know how many doctors would have gone the extra mile to let my daughter hold onto full fertility,” Hart says.

Making Tough Calls About a Rare Disease

Dr. Mark Burns weighs the risks of treating a patient against the risks of not treating her.

When the treatment for a potentially lethal disease is toxic, physicians can find themselves in a Catch-22. Dr. Mark Burns, a rheumatologist at Sound Shore Medical Center, stumbled into this dilemma last January when Karen Benitez (not her real name), a 24-year-old social worker, came to his office. When blood work flagged her as anemic, a doctor had ordered a CT scan that showed an inflammation of the aorta, the largest artery in the body, charged with carrying blood from the heart to sustain the body’s organs.

“It’s one thing if a minor blood vessel is inflamed,” Dr. Burns says, “but this is the aorta.” The implications of the condition, known as aortitis, were grave. Dr. Burns knew he had to start his patient’s treatment quickly to avoid permanent damage to the vessel, but he wasn’t sure where to begin. Benitez’s condition is an extremely rare, limited form of an already rare illness called Takayasu’s Arteritis.

For guidance, Dr. Burns reached out to his colleagues. He finally decided to prescribe steroids in high doses, along with methotrexate, a potent immunosuppressive agent, since the aortitis may result from her immune system wrongfully attacking its own tissue. It wasn’t an easy decision, and the fallout has left Dr. Burns in distress: the drugs have caused severe mood changes, weight gain, vomiting, and hair loss—but “the consequences of not treating her were even worse,” he says. “If the aorta grows dangerously inflamed, Karen may need an aortic stent graft”—a surgery typical among elderly patients with hardened arteries. “That’s a daunting prospect for a twenty-four-year-old.” As he weighs the implications, his patient’s challenge has become his own.

  

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