Category: My Strangest Cases

It was autumn of 1983 and I was a senior medical student doing a rotation with a general internist in private practice at one of the community hospitals in Columbus, Ohio. Dr. Bob Murnane epitomized the old school internist. His office was across the street from the hospital – about 100 feet from the hospital entrance. He admitted his own patients and made hospital rounds early in the morning before his outpatient appointments started at 9:00 AM. He finished up his day with late afternoon rounds on his inpatients.

He was regarded as one of the top internists in the city and consequently, his practice included a who’s who of Columbus citizenry: priests and politicians; celebrities and socialites. But he took care of anyone and everyone, whether rich or poor, famous or not. He took in 2 medical students per month and was one of the most popular elective rotations for the 4th years students at the Ohio State University. What made him such a great teacher was not just his breadth of knowledge, but his wisdom about the practice of medicine and about people in general.

One morning, the other medical student, George, and I arrived at his office at 7:30. Dr. Murnane’s nurse told us that one of his inpatients just had a cardiac arrest and Dr. Murnane had left word for us to come over to the hospital right away. We hurried across the street and ran up the stairs to the nursing unit, expecting a crowd of doctors, nurses, and respiratory therapists at her room doing cardiopulmonary resuscitation.

Instead, the door was closed and the hallway was silent. We knocked on the door and went in. The patient was lying motionless in bed and looking, well… pretty much dead. Dr. Murnane was sitting in a chair at the foot of the bed, reading the sports section of the local newspaper. Without putting the paper down, he said “Come on in boys, and have a seat”. So, George and I sat down and waited. For five minutes, the room was silent except for the rustle of newspaper pages being turned. Finally, Dr. Murnane folded the paper, set it down, and went to the bedside. He looked at his patient and felt for her carotid pulse. After about 30 seconds, he said “OK, now she’s dead”. George and I just looked at each other, with no clue as to what was going on.

After calling the family, entering a death note into the patient’s chart, and filling out her death certificate, Dr. Murnane explained. A few years earlier, one of his inpatients had a cardiac arrest and underwent CPR. Despite chest compressions, Ambu bag ventilation, and multiple doses of epinephrine, the patient never regained a pulse, even though there was weak electrical activity of the heart on the cardiac monitor. In medicine, this is called pulseless electrical activity and implies death. After several minutes of CPR and no pulse, the patient was pronounced dead, his family was notified of his death, he was covered with a sheet, and then transported to the morgue. A half hour later, the morgue attendant got the shock of his life when the patient pulled the sheet off his face, sat up, and asked what was going on. Dr. Murnane had to call the family back and tell them that there was a mistake and the patient was not actually dead.

What had happened was that the respiratory therapist had been a bit overzealous with Ambu bag ventilation (aka, bag-mask ventilation) during CPR. In the chaos and excitement of the cardiac resuscitation efforts, the therapist had been squeezing the Ambu bag too rapidly, putting too much air in the patient’s lungs too quickly. When this happens, a condition called “breath stacking” can occur where there is not enough time for the lungs to exhale one breath before the next breath is given. The lungs get a little more inflated with each breath until the lungs are hyperinflated, increasing the air pressure inside the chest. If that pressure gets too high, venous blood cannot get into the chest, so when the heart beats, there is no blood for it to pump. This can result in the heart having electrical activity but there is no palpable pulse in the peripheral arteries. This phenomenon is more likely to occur in patients with emphysema or severe asthma, whose lungs are already hyperinflated due to air trapping to begin with. The treatment for breath stacking is to continue doing chest compressions but not deliver any breaths by the Ambu bag for 30 seconds or so to allow the lungs to fully deflate and thus to allow for venous blood return to the chest and to the heart.

Ever since his presumably dead patient woke up in the morgue, Dr. Murnane always waited for a period of time after CPR efforts stopped before pronouncing a patient dead. At the end of CPR, he would check to confirm the absence of a pulse and of respirations. He would then sit down and read the sports page of the newspaper and when he had finished reading the sports section, if the patient still had no pulse or respirations, then he would pronounce that patient dead.

At the time, it seemed like another quirky Murnane-ism. But four years later, I gained a whole new appreciation for reading the sports page. I had finished my internal medicine residency and was in my first year of pulmonary and critical care medicine fellowship. At the time, our fellowship program only took one new fellow per year. The first year of fellowship was all clinical inpatient rotations and the second and third years were all research. Since I was the only clinical fellow, I would make rounds in the medical intensive care unit in the mornings and then see pulmonary consults in the afternoons.

One day, we had a patient in the MICU who had a COPD exacerbation with respiratory failure. He was intubated and on a mechanical ventilator. That afternoon, he got progressively hypotensive and bradycardic, eventually resulting in a cardiac arrest. The senior resident in the MICU ran the cardiopulmonary resuscitation efforts and called the critical care attending. After 15 minutes with no pulse, the attending physician pronounced the patient dead. The family had been holding vigil in the MICU waiting room and was brought to the patient’s bedside and told of his death. The attending physician stepped out to allow the family some time. A few minutes later, there were shouts of “Praise the Lord! Praise the Lord!” from the patient’s room. The nurses ran in to see what was going on and found the patient sitting up, wide eyed and with his mouth open. One of the family members had a camera and took the patient’s picture at that moment. A couple of weeks later, that photo was on the cover of one of the supermarket tabloids (I believe it was the National Enquirer) with the caption: “Man returns from the dead at Ohio State University”. The article included the attending physician’s name. The physician then had to change to an unlisted phone number because he got calls all day and all night from people who wanted him to resurrect their dead relatives back to life. For my part, I was just happy that I was elsewhere in the hospital seeing pulmonary consults and not in the MICU that afternoon.

In the four decades after watching Dr. Murnane read the sports page with his dead patient, I’ve participated in hundreds of cardiopulmonary resuscitation efforts. I would always pause ventilation breaths for about 30 seconds when patients were in pulseless electrical activity. I would also always wait a few minutes and re-check for a pulse and respirations after CPR had concluded before notifying family members of their loved one’s death. It took up a little bit of extra time but I never had a patient return from the dead.

October 14, 2025

This is one of a series of posts on the strangest cases I ever saw.

“Code Blue, rear entrance to the emergency room.” I was an internal medicine resident on call one night as the medical admitting resident in 1986 when I heard the overhead announcement. The medical admitting resident was the senior resident who decided which ER patients needed hospital admission and what service to admit them to. The medical admitting resident was also the designated leader of the cardiopulmonary resuscitation team when a code blue was called to alert staff that a patient was in cardiac arrest. Along with the medical admitting resident, the other doctors who were required to go to all code blues were the senior surgical resident on call (to put in central venous lines) and the senior anesthesia resident on call (to establish an airway).

At the time, the rear entrance to the emergency room led to the hospital loading dock area. Patients never entered or exited there – it was only used by staff and for delivery of hospital supplies. So, I thought it was a pretty unusual place for a code blue to be called but I ran down the stairs to the rear entrance anyway.

I was the first code team member to arrive and when I opened the door, there was no one there. The senior surgical resident arrived a few seconds later. We both walked out into the loading dock area trying to determine what was going on. We didn’t see anyone so we figured that it must have been a false alarm or was called to the wrong location. So we turned around to go back inside the hospital and it was then that we saw a hand dangling over the roof overhang above the ER rear entrance door.

That roof was about 9 feet above the ground and there was no way to climb up onto it. The senior surgical resident flagged down a guy driving a pickup truck on 12th Ave., by the entrance to the loading dock. He parked his truck under the roof overhang. The surgery resident and I climbed on top of the hood and then on top of the cab of the truck and pulled ourselves up onto the roof.

There, we found a guy who looked to be in his 20’s who was unresponsive and looking pretty banged up with physical signs of severe blunt force trauma. Together, we performed CPR for about 5 or 10 minutes but it was pretty clear that the two of us were not going to be able to do an optimal resuscitation effort on the roof. So, we put a neck brace on him and passed him over the edge of the roof to other hospital staff members who put him on a gurney and continued CPR while rolling him into the emergency department. In the ER, it was pretty clear that no amount of CPR was going to bring him back, so they pronounced him dead. Just before pronouncing him, the ER physician had a portable chest and head x-ray taken. I saw the head x-ray and it looked like an egg shell that had cracked apart after being dropped on the floor.

Later that night, it was determined that he was an inpatient in Upham Hall, the psychiatric hospital that was part of our medical center and located on the other side of the loading dock area. He had been admitted after attempting suicide and was in a locked nursing unit of the psychiatric hospital. The windows of that unit looked out over the rear entrance to the emergency department. Earlier in the evening, he had told another one of the psychiatry inpatients to watch a particular window on the 11th floor of the hospital. Somehow (we never did figure out exactly how), he escaped the locked nursing unit, went in a back entrance of the main hospital, and took the elevator to the 11th floor. Next to the elevator, there was a small window about 4 feet above the floor. He had forced it open, climbed through, and jumped. The other psychiatric inpatient watched him jump and then alerted the psychiatry nurse who then got on the phone to the hospital operator to call the code blue.

After nearly 4 decades of being a resident, a fellow, and a critical care attending, I’ve participated in CPR efforts on hundreds of patients. I’ve taken the Advanced Cardiac Life Support certification or recertification course 19 times. I’ve seen a lot of patients in cardiac arrest. But only once did I have to climb onto a pickup truck to do CPR on a roof.

July 16, 2025

I was having some work done on my house last month and during his lunch break, one of the workers said to me when he found out I was a pulmonary and critical care doctor: “I’ll bet you’ve seen some things.” And like any doctor, I have. So, I decided to write a series of posts about some of the strange and unusual cases I’ve seen over the years. And I’m going to start off with two cases of hypothyroidism.

A case of catatonia

Back in 1984, I was an intern on the general internal medicine service and got called down to the ER one night to admit a 17-year-old girl with an enlarged heart. Her family had brought her to the hospital because her behavior had become increasingly erratic. For several years, she had been falling behind in school. She did not participate in school sports because she just didn’t have the energy to keep up with the other kids. For several weeks, she had been getting increasingly withdrawn and then earlier in the day had become completely unresponsive.

When she arrived at our ER, she was catatonic. You could hold her arm up and it would just stay there. She stared straight ahead without answering any questions. The ER resident diagnosed catatonic schizophrenia and called the psychiatry resident to admit her to the psychiatric hospital that was a part of our medical center. A routine admission chest x-ray was ordered and it unexpectedly showed an enlarged heart. The medical center policy was that if a psychiatric patient had any untreated medical condition, that patient would be admitted to one of the medical services on a med/surg unit and would be followed by the psychiatry consultation service until the medical condition was stabilized and then the patient would be transferred to the psychiatry hospital.

So, I went down to do her admission history and physical exam. Sure enough, she was stuporous and non-verbal. I could reposition her arms and legs and they would just remain in whatever position I put them. And she just didn’t look right – we used to call the look an “FLK” (funny looking kid) – you couldn’t put your finger on it but they just didn’t look quite right; many of them had genetic conditions. Her face was round and sort of puffy. She was short for a 17-year-old, less than 5 feet tall. And she seemed pudgy. Her eyelids appeared thickened and doughy, almost like they were swollen and her lips were large.

The next morning, we got an echocardiogram to evaluate the enlarged heart and found that she had an enormous pericardial effusion. In working up her effusion, we ordered a TSH test and it came greater than 100 mIU/L (normal is less than 4 mIU/L and highest level the lab reported was 100 mIU/L). TSH stands for thyroid stimulating hormone. TSH is made by the pituitary gland and signals the thyroid gland to make thyroid hormone. If the thyroid gland is not working properly, the pituitary responds by making more TSH to flog the thyroid into making more thyroid hormone. A level over 100 is incredibly high and indicates severe and long-standing hypothyroidism, one of the causes of a pericardial effusion.

We started her on thyroid hormone replacement – one of the few times I’ve given intravenous thyroid hormone. Within 3 days, she was talking normally, walking normally, and her pericardial effusion was improving.

As it turns out, she was actually diagnosed with congenital hypothyroidism as an infant and was started on oral thyroid hormone replacement therapy. Her pediatrician told her parents that she would need to take it for the rest of her life. But when she was a few years old, her grandmother (a religious zealot) proclaimed to the family that thyroid hormone replacement was a potion made by the devil to steal children’s souls. So, her parents stopped giving it to her. Over the years, she had stunted growth, had intellectual impairment, and developed a cretinoid appearance. All of that culminated in catatonia and a pericardial effusion from severe hypothyroidism.

After her discharge from the hospital, I followed her in our general medicine resident’s clinic for the next two and a half years. With re-initiation of daily thyroid hormone replacement therapy, she slimmed down, graduated from high school, and even did some modeling as her cretinoid facial appearance changed to that of a regular young woman’s. In other words, she became a normal person again. The moral of the story is that thyroid hormone replacement therapy is not made by the devil.

A case of prolonged coma

In the 1990’s, our hospital contracted with a long-term acute care hospital (LTACH) called Intensiva (Intensiva later became Select Specialty Hospitals). LTACHs were designated by Medicare to be specialized hospitals that cared for patients with long lengths of stay – in other words outlier patients who could not be discharged from a regular acute care hospital in a reasonable period of time. Regular acute care hospitals are paid by Medicare based on a patient’s DRG (diagnosis-related group), regardless of how many days they are in the hospital. LTACH’s specialize in caring for outlier patients who require hospital care for more than 30 days – Medicare would then pay the LTACH based on the number of days the patient required hospitalization instead of based on the patient’s diagnosis. Common conditions that resulted in admission to an LTACH were respiratory failure requiring prolonged weaning from a mechanical ventilator, complex would care, and infections requiring prolonged intravenous antibiotics.

Intensiva leased part of the 11th floor of our hospital. Our medical intensive care unit was on another part of the 11th floor so it made it easy to transfer patients from our MICU to Intensiva. Furthermore, Intensiva purchased certain services from our hospital, such as radiology and laboratory testing, making it easy to get diagnostic tests. Most of our hospital’s physicians got credentialed in Intensiva so that patients transferred from our hospital to Intensiva could have continuity of care by consultants. Because most of the patients admitted to Intensiva came from our MICU, we (the pulmonary and critical care physicians) were the primary attending physician for all of the patients in Intensiva. On occasion, we did get patients from our surgical intensive care unit or from other hospitals’ intensive care units admitted to Intensiva but we were the attending physicians for all of them. I was the medical director of Intensiva and split my time between the MICU and Intensiva – attending one month in the MICU and the next month in Intensiva. At the time, LTACHs were popping up all over the country, with several in Central Ohio. Our LTACH specialized in ventilator weaning so the largest group of patients we admitted were those with respiratory failure.

One day, we had a patient transferred from an ICU in Mansfield, Ohio. He had been in a motor vehicle accident and was not waking up from a coma. He also had respiratory failure and could not be weaned from a mechanical ventilator. So, the trauma surgeon in Mansfield performed a tracheostomy to keep him connected to a ventilator and performed a percutaneous gastrostomy feeding tube (PEG tube) to feed him.

In approaching a patient with failure to wean from the ventilator, the first step is to identify all of the contributions to respiratory failure. Some of the common reasons in a multiple trauma patient are pre-existing lung disease (like COPD), untreated infection, mucus plugging with atelectasis, paralyzed diaphragm, malnutrition, respiratory muscle deconditioning, fluid overload, electrolyte disturbances, anemia, and undiagnosed heart failure. So, my own routine approach to a new patient with respiratory failure was to start with a thorough history and physical exam and then order a chest x-ray, an EKG, an echocardiogram, a CBC (to check for anemia), a blood electrolyte panel, and a nutritional assessment.

This patient was a relatively young guy in his mid-30’s with no previous medical illnesses. His wife told me that he did not take any medications and seemed healthy prior to his accident. He had some soft tissue injury with bruises and contusions but no broken bones. He had sustained minor head trauma but a head CT had not shown any significant damage to his brain. But he was in a coma and just wouldn’t wake up.

As physicians, our best teachers are our patients – we learn the most from the patients that we encounter. Ever since my patient with catatonia from hypothyroidism more than a decade earlier, I had always held that every patient in a coma should have their thyroid tested once. So a TSH level was one of my routine admission lab tests for patients with coma or failure to wean from the ventilator. And my comatose trauma patient’s was 84 mIU/L. Intravenous thyroid hormone replacement is a bit tricky and requires a high level of monitoring so I was uncomfortable giving it outside of a regular intensive care unit. Therefore, we started him on a liquid form of the thyroid hormone replacement given through his feeding tube. Two days later, he was awake. Three days later, he was off of the mechanical ventilator. A week later, he was walking with the physical therapist and we removed his tracheostomy tube. A month after his admission to Intensiva, he was discharged home as a normal person. If his TSH level had not been checked, he likely would have spent the rest of his life in a skilled nursing facility, hooked up to a ventilator.

A weird gland

The thyroid is a weird gland. If it produces too much thyroid hormone, you get sick. If it produces too little thyroid hormone, you get sick. In either case, patients can present with a myriad of symptoms that frequently mimic other medical conditions. Hypothyroidism can be caused by many things – autoimmune conditions, inflammation, iodine deficiency, surgery, side effect of certain medications, radiation, and genetic conditions, just to name a few. In milder forms, hypothyroidism is a sneaky medical condition and can present with non-specific symptoms of fatigue, depression, weight gain, and memory loss. The good news is that it is easily treated, as long as the physician thinks about it and tests for it and as long as your grandmother doesn’t believe that the treatment is a potion created by Satan.

April 30, 2025