Son as Doctor: Part 2, The Bad

When a fever isn’t “just a virus”, and being the doctor-son gets much harder.

Drawing by Anne Sax.

In the first piece in this series, being my father’s doctor meant making a diagnosis off a photo and recommending a week of antivirals. Easy-peasy.

In Part 2, things got harder. Much harder.

It was early 2019, a Monday afternoon at 1:55 PM. From a medical education perspective, it was still very much in the Before Times — before Covid, before so much of our teaching moved to “live streaming” or “virtual,” or whatever euphemism you prefer for speaking to faceless learners in Zoom Land.

Back then, in-person events still dominated medical education. I was about to give a lecture to two hundred or so primary care providers at a large downtown Boston hotel for a Harvard postgraduate course. Maybe the topic was “Update on Oral Antibiotics,” or “Can’t Miss ID Diagnoses,” or “Why ID Physicians Are the Best Looking Doctors.”

(Certainly not that last one.)

Just before the course director introduced me, however, I saw that my father was calling from his cell phone. Two things of note:

First, his technophobia notwithstanding, he’d joined the cell phone era — enthusiastically. He bought one of the zippiest, flashiest iPhones, despite using approximately 0.01% of its capabilities, if that. He liked nice things, and the moment he heard there was an option with “Pro” in the name, he was all in.

Second, at age 87, he was slowly — and I mean slowly — winding down his psychiatric practice. Several days a week he still walked the three blocks to his office on East 87th Street to see patients, and he would only call us during the 10 minutes between appointments at the top of each hour. That’s how I remembered the time so precisely. If he called at 1:55 PM, there was a 2 PM patient on his schedule.

I silenced my phone, gave my lecture, and called him back at 2:55.

Me: Hi Dad, I saw you called. What’s up?

Dad: Hello, Paul. For the last two days, I’ve been having fevers, along with rigors. I felt better this morning after taking two aspirin, so I was able to walk to work.

I got the full history: Saturday evening, he started to feel tired, and flushed. He and my mother canceled their dinner plans. Later that night came chills (he called them rigors, the medical term — he’s a doctor, remember?), then a fever of 101.6. He took aspirin and went to bed early, only to wake drenched in sweat.

Sunday he felt better, but not normal. Plus, his right hip — the artificial one — felt “stiff.” He repeated several times that it wasn’t “pain,” just “stiff.” No other symptoms.

Sunday night brought more chills and another fever.

Now it was Monday, day three. Based on the pattern, I knew the aspirin he’d taken that morning would wear off, and his fever would probably spike again soon.

Back to our first conversation that fateful Monday:

Me: Dad, I’m worried. You’ll probably have another fever later today when the aspirin wears off. Men your age don’t get fevers like that without a reason. You need to have it evaluated.

Dad: I’ll call my doctor if I have another fever tonight.

Me: Can you do me a favor and call him anyway? Today. I’m sure he’ll suggest some testing.

He didn’t call his doctor.

Maybe he didn’t because, up until that point, my father had never had a major medical illness. Despite decades of heavy smoking — he quit only when I started medical school — a robust appetite, and zero interest in exercise (unless walking to his office counted), he’d been remarkably healthy. His only concessions to aging I knew about had been an annoying foot drop he developed in his late 70s, and progressive hip arthritis that prompted an elective hip replacement that had been uncomplicated.

It’s the one he mentioned was “stiff.”

But the fevers didn’t go away, and the “stiff” hip got stiffer. Eventually he relented. He went in for evaluation — first to his primary care doctor, then for blood tests, then urgently for a CT scan, then to interventional radiology for aspiration of some fluid around that hip.

It’s the one he mentioned as being “stiff”. I’m foreshadowing something, in case you hadn’t noticed.

The diagnosis: E. coli bacteremia with secondary seeding of his artificial hip.

Translated to plain English: a common bacterium, normally confined to our gastrointestinal or urinary tract, had spilled into his bloodstream and “seeded” the artificial joint.

The bloodstream infection was bad enough; the involvement of the prosthetic hip made it much, much worse. These joint infections are a big deal — high morbidity, high failure rates, major life impact. It’s so serious that there’s an entire subspecialty within our field of Infectious Diseases devoted to musculoskeletal infections, with these artificial joint infections occupying a major part of what people who chose this path do.

In such unfortunate circumstances, the orthopedic surgeon is called back in. They must remove the infected joint, wash out the area extensively, and then choose one of two paths:

1. The “one-stage exchange”: removing the infected prosthesis (or component) and placing a new one in the same surgery.
   Pro: one operation, faster recovery.
   Con: higher risk the new hip becomes infected.

2. The “two-stage exchange” — removing the prosthesis, placing a temporary spacer, giving weeks of antibiotics, and re-implanting a new hip only after the infection appears controlled.

   Pro: higher long-term cure rates.

   Con: long, difficult recovery; prolonged immobility; cure still not 100% guaranteed.

Note that neither option is “take some antibiotics for a week and you’re all set.” Given my father’s age, the surgeon chose a one-stage exchange, a perfectly reasonable decision.

Forgive me for briefly stepping into the role of a major character here, but I need to explain how I handled the diagnosis of E. coli infection of my father’s prosthetic hip — especially as an ID doctor.

The quick answer? I was nervous. Nervous because it’s a serious problem, nervous because I’ve seen some similar cases go horribly wrong, and nervous because my relationship with my father growing up was very much driven by a strong desire not to disappoint him — and even more importantly, to avoid making him angry.

Although generally kind and generous to my brother, sister, and me, his fathering style was anything but laid back. He expected the best out of his children (“best” defined by his narrow standards of academic and professional achievement), and when my siblings and I didn’t make the grade, he could get quite angry. Cruel, even.

My sister Anne described it perfectly in this picture she drew, thinking back to when she was choosing a career for herself; it shows how we struggled to gain his approval, and to avoid his disappointment — which could quickly turn to wrath:

My sister wanted to be an artist; my brother, a professional athlete; my father would have none of it.

Me?

So each day of my father’s illness with the infected hip felt like a test of sorts, a chance for me to make the grade in a situation with high stakes both literally and emotionally. I’m not saying this makes any sense — I was not my father’s doctor, after all, and the years of shouting and anger from him were long past, as thankfully he’d mellowed with age. But that’s how it felt.

To pass the test, I was in regular contact with his ID consultant, grateful to have someone who spoke my language. I kept my family informed along the way, sending brief updates like this one:

The lab should identify the best antibiotics in a couple of days. He’ll need IV therapy through a special IV called a PICC (peripherally inserted central catheter) line for at least a few weeks to get the infection under control. He’ll need help getting up and moving again.

My father stayed in the hospital about a week, then went home with that PICC line to receive intravenous antibiotics for another five weeks. From a bit over 200 miles away, I stayed in frequent contact with him and his doctors, trying to outline to him the best possible scenarios for his recovery as the days slowly ticked by.

Ultimately, my father made it through the recovery. My mother mastered the home IV routine like a champ. He stayed on antibiotic pills, as recurrence would have been devastating (we sometimes do this in older patients). And the infection never recurred.

That’s the good news.

The not-so-good news? The hip was never the same. Like a garment that has been tailored one time too many, it never felt quite right again; it added to the pre-existing foot drop, and together these made it increasingly hard for him to walk long distances. He never could keep up with my mother again.

Worse, the hip would periodically pop out at unpredictable times, prompting late-night ambulance trips to the emergency room, with long waits and a front-row exposure to the chaos and inefficiency of U.S. healthcare. These became particularly nightmarish during the pandemic.

Did I pass the test? Who knows — I think he was grateful for my input during this difficult illness, though don’t remember his saying anything like, “Paul, it’s so helpful having an ID doctor in the family at a time like this,” or “I can’t tell you how reassuring it is to have you there to answer my questions and address my fears.” In fact, I remember hearing this more from my siblings than I did from him.

What I do recall is that I saw him move with the caution of someone who suddenly, and unwillingly, recognizes his own mortality.

That mortality would be the theme of Part 3, The Ugly — if I ever have the courage to write about it.