TUESDAY, JUNE 15, 2010


KLMNO


E5 ER couldn’t rescue physician


Heart attack fells reformer who had long worked to improve care


by John Donnelly On Memorial Day, Thai


McGreivy suffered a massive heart attack while biking on Goldsboro Road in Bethesda. Paramedics rushed to the scene, where he lay unconscious with no pulse. They took him to Subur- ban Hospital’s emergency room, where a team revived his heart. McGreivy, 43, an emergency room physician himself, re- mained in a coma even as his heart showed signs of recovery. But four days after his collapse, doctors performed a scan on his brain, revealing severe damage due to a long period of oxygen deprivation. Days later, officials pronounced him brain-dead and his family authorized doctors to donate all salvageable organs to those who needed them. His story is played out daily in


emergency rooms across the country, but the difference with McGreivy was that he knew these rooms intimately and had spent not only thousands of hours in them as a doctor but also thou- sands of hours outside, thinking about how to make them run bet- ter. Long before the national health-care debate, he was a re- former, focused on issues such as improving standards and finding ways of measuring impact. McGreivy was chief financial


JAMES A. PARCELL FOR THE WASHINGTON POST


Dennis Holden, at home in Waldorf with his wife, Eileen, had an illness that is invariably fatal without treatment. His doctors have not been able to determine how he contracted the disease.


‘Depressing case’ ends with ‘amazing’ recovery


mystery continued from E1


catch up on work that seemed to be piling up at an alarming rate. “He said he hadn’t done any- thing and it was 4 p.m.,” she said, recalling that her husband was uncharacteristically near tears. “He would set a paper down and then not remember where he had just put it.”


Dennis had also begun sleep- ing a lot. He would sit down in the living room and then just drop off, like an old man. Al- though she repeatedly urged her husband to call the doctor, he did not. But Holden was increasingly aware something was wrong and felt perpetually exhausted. “It was all I could do to drag myself to work and back home,” he re- called.


A troubling incident


In February 2009, he went to see his internist. She sent him to a cardiologist for further testing, which revealed nothing out of the ordinary. A month later, while attending their son’s Friday night high school lacrosse game, Eileen no- ticed Dennis was walking strangely and had trouble navi- gating the bleachers. He told her he had hurt his back, wasn’t feel- ing well and would meet her at home. A few minutes later, her cell- phone rang. Dennis was calling from the parking lot; he couldn’t find his car. “I said, ‘Stay there. I’ll come find you,’ ” she recalled. She discovered her husband standing nearly in front of the car he did not recognize as his, speaking gibberish. Unnerved, she drove him


straight to the emergency room of a nearby community hospital. A head CT scan revealed an ex- cess of brain fluid, which could account for his confusion and dif- ficulty walking. Holden was transferred to Hopkins by ambu- lance. Doctors there thought he might be suffering from normal pressure hydrocephalus, an accu- mulation of cerebrospinal fluid on the brain. After a few days they ruled that out and ordered a barrage of tests: spinal taps, blood draws and all kinds of im- aging. They ruled out lymphoma and several other cancers; HIV; lupus; Lyme disease; West Nile virus; tuberculosis; and toxoplas- mosis, an infection caused by a parasite. Holden’s spinal tap did show


an elevated white blood cell count indicating a possible in- fection, and his chest scan re-


vealed enlarged lymph nodes. But nothing seemed to add up. He was discharged in early April in somewhat better shape; doctors told Eileen Holden they weren’t really sure what was wrong. One suggested meningi- tis, but no one knew what might be causing it. Two tests for cryp- tococcus, a fungus that can cause a form of meningitis, were nega- tive. That hadn’t seemed likely anyway; “crypto” is an opportu- nistic infection caused by pigeon droppings and is most often seen in AIDS patients with damaged immune systems. Holden’s im- mune system seemed intact, and his HIV test was negative. Holden went back to the office, barely able to function. By mid- May he was back at Hopkins. Doctors biopsied the enlarged lymph nodes in his chest. That seemed to reveal the cause of his many problems: neurosarcoido- sis, an uncommon, chronic in- flammatory disorder of unknown origin that results in abnormal cell deposits in the brain, spinal cord or other parts of the body. The disease can cause headaches, confusion and meningitis. Doctors prescribed a high dose of prednisone, a steroid that re- duces inflammation. Holden said he remembers “calling a bunch of people and telling them, ‘Yay, they know what this is.’ ” But after a week, Eileen Hold- en recalled, her husband seemed even worse. One morning he told her he felt like he was having a nervous breakdown. He had such trouble walking he was using a cane and had to attend their daughter’s high school gradua- tion in a wheelchair. Mentally he seemed vacant: He put a banana peel in the dishwasher. The cou- ple learned later that his co- workers were deeply concerned, but no one wanted to say any- thing because he was their boss. By late June he returned to the hospital. Doctors prescribed an antidepressant along with the prednisone and performed an- other spinal tap before discharg- ing him. Two nights later Eileen Holden


got an urgent call from a doctor at Hopkins. The latest spinal tap showed unmistakable signs of cryptococcus, the potentially le- thal fungal infection that had previously been ruled out after tests were negative. The fungus can attack the spinal cord and brain, causing dementia-like symptoms. And it is virtually un- known in otherwise healthy pa- tients.


Without treatment, cryptococ- cal meningitis is “invariably fa- tal,” according to an article pub-


lished last year in the online medical textbook emedicine; death can occur up to several years after the onset of symp- toms. Holden was told he needed to


return to Hopkins immediately, so doctors could wean him off steroids and begin treatment with a powerful antifungal drug that must be closely monitored because it can cause kidney dam- age.


Why the mystery? So why had previous tests been


negative for cryptococcus? The answer, Bailey and other physi- cians later determined, lay in Holden’s healthy immune sys- tem. The prednisone had sup- pressed his immune system and allowed the cryptococcal infec- tion, which had been there all along but held at bay, to blossom and show up on the spinal tap. “For some reason, these tests


aren’t as sensitive in people who don’t have AIDS,” Bailey said. Within a few days of starting the medicine, which he took for months, Holden began to show dramatic improvement. He was less confused, his headaches sub- sided and his ability to walk im- proved.


Because of his serious deterio-


ration, he needed two months of specialized occupational, physi- cal and cognitive therapy to re- gain his balance and relearn ex- ecutive skills. Last September, Holden returned to work. He said he feels almost entirely back to normal. “It was a life-changing experi-


ence,” said Holden, whose memo- ry of his illness is patchy. “I don’t know if I’d be here if it wasn’t for Eileen.” Bailey, who began treating


Holden last summer after his cor- rect diagnosis, said he searched the medical literature for cases of healthy patients who developed cryptococcal meningitis; he un- earthed only a handful, although the fungus is ubiquitous in soil and present in pigeon droppings. Holden is not a gardener, nor does he handle birds. “I have no idea how he got it, and I doubt we’ll ever know,” said Bailey, adding that he suspects the infection might have been festering for nearly a year. “I’ve never see anyone with such pro- found mental status changes get so much better. His progress is amazing.”


If you have a Medical Mystery that has been solved, e-mail medicalmysteries@washpost.com. To read previous mysteries, go to www.washingtonpost.com/health.


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officer of Medical Emergency Professionals (MEP), a company that runs emergency rooms at Shady Grove Adventist Hospital in Rockville, Germantown Emer- gency Center, Washington Coun- ty Hospital in Hagerstown, West- ern Maryland Health System in Cumberland and St. Mary’s Hos- pital in Leonardtown. In all, the group oversees the


emergency-room treatment of 300,000 patients a year; it con- tracts with each hospital, assum- ing all costs of its ER service (which often run at a huge deficit to hospitals in part because of the numbers of uninsured) for no fee.


quate quality of care and doctors with too much downtime. “There were a lot of moving


parts in trying to figure out what was going on — 15 to 20 vari- ables,’’ said Michael Cetta, MEP’s chief of business development. “But he was able to think out of the box, and identify why it wasn’t working as well as pos- sible. . . . We are trying to fix it.’’ It was a focus on patient care


that made McGreivy, the father of four boys, question the effective- ness of the emergency medical service (EMS) system. On May 29 — less than two


FAMILY PHOTO


Thai McGreivy of Bethesda helped run a business that operates five emergency rooms.


McGreivy and his partners were able to do this by finding cost-saving efficiencies even as they were determined to improve patient care. In both Hagerstown and Cumberland, their system saved hospitals hundreds of thousands of dollars a year and reduced patients’ waiting times. At St. Mary’s Hospital, where MEP took over the emergency room five years ago, surveys have shown that patient satisfaction has doubled, with more than 90 percent reporting being satisfied with their experience. Angelo Falcone, MEP’s chief


executive, said McGreivy “always talked about how we had to make the hard decisions from an effi- ciency standpoint, and make sure they positively impact patients’ health.’’ One example of this dual goal arose recently in the Hagerstown hospital, where MEP was puzzled as to why its doctors were seeing fewer patients than the target numbers set by the group. At first, McGreivy and others hired $20-an-hour scribes to take notes for doctors, but that did not get the desired results. McGreivy studied it some more, discovering that MEP’s physician assistants were seeing an unusually high number of patients, many of whom should have been seen by doctors; the result was inade-


days before his heart attack — McGreivy posted a guest blog on a site called Street Rat Crazy Sa- loon. He wrote that municipal- ities were in budget crises, and some could argue that EMS op- erations should be cut. That made sense, he said, because while spending had risen rapidly for EMS, those extra costs weren’t resulting in improved survival rates. He added, though, “I truly think most of the men and wom- en in EMS are heroes.” In the hours before doctors re- moved McGreivy’s organs for do- nation late on June 6, McGreivy’s wife, Katherine, sat in Suburban Hospital’s waiting room. She de- cided to look up her husband’s most recent blogs on an iPhone. She found the EMS post. “It gave me goose bumps,” she


said. “While we’re waiting for the whole surgery and the donation, we’re reading about his thoughts on EMS, and do they make a dif- ference in outcome. Because he was saved from an almost certain sudden death, two people are get- ting a kidney, many others are getting tissues.” And that was the irony of it all, she said. He fought hard to make things work better in emergency rooms, but even in a situation like his, when all things went right, he couldn’t ultimately be saved. “The truth is, some patients we


can’t save,” ” Falcone said. “He really got the best technology out there, but there are limits to what we can do.” health-science@washpost.com


Donnelly is a freelance health writer.


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