Most of my clients and readers have at least one horror story about how they or a loved one suffered through a severe illness that took far too long for their doctors to solve. This is another in a series of such cases.
I met Dan Jones [all names changed to protect the privacy of patients] at a problem-solving workshop I was conducting in Madison, Wisconsin. Dan revealed that he had suffered through serious sinus infections for over fifteen years, with pain so bad that he would only half-kiddingly ask his wife to “lock up the gun rack”. To make matters worse, his daughter Karen had begun to experience the same debilitating symptoms, and neither of them had any idea what was causing it. Various medical specialists had examined them over the years and were at a loss to explain the repeated nature of the problem as it seemed to come and go for no discernable reason. Each doctor offered up a different possibility—everything from Vitamin D deficiency, to mold and dust allergy, to depression—one even suggested he might have to get rid of his dogs, as he strongly suspected Dan had an allergy to pet dander.
Each time the symptoms returned, they did so with such severity that one or both of them would be incapacitated for weeks at a time, unable to work or go to school. The doctors tried vainly to correct the problem with repeated doses of heavy-duty antibiotics designed to stem the infection and through surgical procedures that involved scraping away the inflamed tissues or irrigating the nasal passages with a caustic cleansing solution. None of these measures stopped the infections from coming back, and often only served to prolong and deepen Dan and Karen’s suffering.
With Dan’s consent, we systematically began working through his problem. This involved the careful collection and organization of very specific information in a systematic and structured manner, so that nothing of potential relevance could be overlooked. As I began to ask pointed questions, unconsciously the group provided vague or incomplete answers. More than once, Dan expressed doubt about our ability to get to the root of the problem. But I continued to prevail upon him the importance of answering the questions as fully and carefully as possible, and to be patient in collecting all the required information before jumping to any conclusions.
After defining the problem, which Dan simply and clearly stated as “repeated sinus infections”, our next step was to identify others close to him and his daughter Karen who he might also expect to exhibit similar symptoms, but never did. This was important so that we could later rule out suspected causes that didn’t explain these facts, and also look for unique characteristics between the affected persons and those not similarly affected, in an effort to uncover new possible causes. It didn’t take us long to identify a very interesting but perplexing fact: neither his wife nor his other daughter, who lived in the same household and shared in most of the same family activities, had ever experienced any sign of these symptoms.
We then asked him to describe the symptoms, which initially he articulated in two words: “severe pain.” I asked him to describe more carefully the precise nature of the pain: was it a shooting pain, a tingling pain, a radiating pain—there were hundreds of different types of pain. As we considered all the different possibilities, Dan volunteered that the pain was very specific and localized: it was a ‘burning’ and ‘throbbing’ pain, centered directly behind his nose, radiating at times to the teeth and jaws.
This was a good start, but we were far from finished describing the symptoms. What other symptoms did he and his daughter exhibit from time to time, closely associated (in timing and nature) with the pain he just described? Dan mentioned that he often experienced ‘sinus infections’ at these same times. How did he know it was a sinus infection, I asked, what were the (other) presenting symptoms? He said that he experienced watery eyes, pressure in his sinus cavities, and excessive mucus discharge. I then asked the group an odd, but revealing question: “What kind of mucus, and how much?” After some reflection, he clarified that it was thick and copious―and a unique color. What color was that? It was an unusual brownish-green, not the normal color one would expect from this type of infection. We continued to probe and capture the entire array of associated symptoms, which included headaches, plugged ears, and the occasional “bloody nose.” Plus, it often hurt to touch the skin around the sinus area, even when he didn’t have a sinus infection.
As the information was presented, we captured all the data in Dan’s own words on a series of easel pads which were posted in clear view for the entire team to see. We had already begun to reveal some new and interesting information—information which none of his doctors had uncovered in his many visits with all manner of specialists. Although Dan had begun to describe what he was feeling and experiencing quite specifically, we still weren’t quite done evaluating the symptoms. For the same reason we had previously pinpointed both the affected persons (Dan and his daughter Karen) as well as the non-affected persons (his other closely-related family, friends, and colleagues), we also needed to understand exactly what symptoms he was not experiencing. He had pain in his sinuses, teeth, and jaw—did he ever have a sore throat, or fever? “None of those,” Dan confirmed. He had excessive mucus discharge, but never any coughing or chest congestion; his breathing was otherwise normal. And his headaches, though typically painful, never escalated to migraines, or a more severe level. The most debilitating pain was always a burning feeling centered in the middle of his face, behind his nose and in his upper jaw.
Now it was time to ask about the geographic locations where Dan and Karen experienced the problem, as well as where they did not occur. At first, he said ‘everywhere’, but I asked him to slow down and think about it more carefully. Where did he and his family travel and work, and did they experience the symptoms there as well? Upon reflection, Dan indicated that yes—“oddly enough”—he and Karen only experienced the symptoms when they were at home—never, for instance, on their many family camping trips to Lake Joy or Osseo in the surrounding countryside. When I then asked if there was any one specific location in their home where they noticed their symptoms were more prevalent, he once again surprisingly indicated that they were usually much worse whenever they were in the basement, where he kept his home office, and Karen had her bedroom.
With this disclosure, our problem-solving team immediately wanted to jump to all manner of conclusions pertaining to causes relating to mold, radon, and carpet out-gassing, but I insisted we stay focused and remain objective in order to make sure we didn’t miss any relevant facts—and only then would we carefully and systematically evaluate all the possible causes. I asked where else Dan and his family had traveled where he would expect to have experienced these same symptoms but never did. He and his wife had lived in many other houses and locations during their married life in various places in the Midwest, but had never experienced the bad sinus infection problem until moving to Fennimore. How about on vacations and various other destinations? He indicated that no one had ever had the slightest sign of any trouble on their many vacations over the years to points further south, or on their many camping trips not far from home.
Next, I wanted to know about the specific timing of the problem. When did Dan and Karen first experience their problem, and when since then? For Dan, he said it happened shortly after he moved into their current house in 1992. How long after he moved into the house, and what time of year? Not right away, Dan revealed, after some consideration—it was a few months after they moved in. How long exactly? He couldn’t remember specifically, except to say that it was in late fall or early winter of that year. When I asked about Karen’s first experience with the problem, he said hers started a few years later, in the fall of 2000. How often since then, I asked, had they both experienced this problem, and at what times of the year? After some deliberation, Dan volunteered that the symptoms seemed to start near the onset of cold weather every year, and that they would come and go randomly and frequently over the winter months. They rarely if ever manifested during the warmer months of the year.
Once again, our team began bombarding Dan with questions about what they do differently around the house in wintertime, and a number of new possibilities were speculated as to the possible causes of her problem. And once again, I had to rein in the team’s enthusiasm to jump to conclusions, and refocus them on sticking to the plan. There was still plenty of important information to uncover before we could objectively and competently evaluate all the possible causes.
Now it was time to search for distinctions between the specific persons, places, and times where they had experienced the problem, compared to those where they did not. This would be critical to identify, because the underlying cause was likely to be found in one or more of the unique characteristics of these affected elements—otherwise all the other ones would similarly be affected. We began to probe more deeply into these areas, and the entire team shifted nearer the easel as they sensed we were about to uncover some important new details.
We started by comparing the affected persons—Dan and Karen—with the others family members who could have experienced these same symptoms, but never did. What was common or shared about these two, and also different when compared to the others? At first, it appeared there were too many differences to count, since our group said every person is unique and each of us is different from everyone else in so many ways. But we had been careful to identify a closely related set of individuals who suffered from the problem as well as those who didn’t, and I asked Dan to ponder the issue carefully: “What was unique about him and his daughter Karen, that neither of the others did or shared?” There were of course a variety of differences between each family member, relating to age, jobs, school activities, etc. But there was only one thing that Dan could think of that was common between him and his daughter Karen: they were both more physically active in sports and exercise.
Although this was an interesting disclosure, most people in our group were perplexed to see how this could be playing a primary role in contributing to their problem, since it didn’t fit most of the other data that had been previously mentioned. Nonetheless, we captured the new information and added it to our list of facts on the easel. We were sure we were missing something, but Dan simply couldn’t think of anything else that was meaningfully different about the two of them, compared to the others. I encouraged the group not to worry, since there were still many more areas to investigate in our search for differentiating characteristics, and because when our comparative information was this full and robust, we often don’t find many unique distinctions.
The next category to investigate was the locations where Dan and Karen experienced their symptoms compared to those where they hadn’t. What was different or unique about their house in Fennimore (where they first experienced their problem) compared to the many other places they had lived, worked, and visited? More specifically, what was different about the basement of the house—where they both experienced their symptoms to a greater degree—than the other areas of the house? This of course was where Dan kept his workshop and home office, and where Karen’s bedroom was located. But when I asked what was shared by the two of them in this location (that they didn’t do or share elsewhere in the house), Dan’s surprising answer was: this was also where they kept a home exercise studio—that only the two of them ever used.
Although this was an interesting disclosure, the group was at a loss once again to see the relevance of this information, since it didn’t seem to fit the problem, and some expressed their dismay that we weren’t finding a single ‘smoking gun’. Many were beginning to get restless, and wanted to begin debating their favorite suspects against the facts. But we had one more area in our problem description to search for relevant distinctions before moving on to brainstorming and investigating possible causes. I asked Dan what was different about that time of year—late fall/early winter, when he said he and his daughter had first experienced her symptoms and subsequently experienced a recurrence each year. The obvious answer was colder temperatures. What else? The leaves are falling, and snow is beginning to cover the ground. Yes, what else? I asked Dan to think about anything and everything—especially as it pertained to his use of the house (and the basement in particular) that occurs at this time of year, every year. Suddenly, some lights went on in Dan’s mind, and he exclaimed: “That’s the time of year when we first turn on the wood stove in our house—and it’s located in the basement!”
Our group was surprised, and dumbfounded. This was an extremely interesting fact and seemingly relevant insofar as it fit the location and timing data we identified earlier, but they were puzzled how this would cause the full constellation of unique symptoms described earlier. Not being an expert on wood stoves, I asked if anyone in our group was familiar with how this type of heat source differed from other types of heating such as forced air (gas), electric (baseboard), or (water) radiator heating. One other person had in fact used wood stoves, and indicated that this type of heating system creates a far more arid internal environment by sucking moisture out of the air, and Dan added that he did not supplement their air conditioning system with humidifiers. “How else is this type of heating system different?,” I asked. He also said that this type of heat produces quite a lot of airborne combustion by-products in the form of wood (burned) ash—which Dan validated by mentioning that soot would build up on surfaces near the stove, and create a thick coating if it wasn’t regularly cleaned.
At this point, our group could barely contain themselves. This seemed like such a strong suspect, and suddenly seemed to explain most of our previous facts. But if we were going to solve this problem permanently and conclusively, we had to be sure—and we had to be clear about the linkage. I asked the group to brainstorm specific hypotheses pertaining to the wood stove, and to articulate them in the most specific, complete, and understandable form. Eventually we came up with a very clear and compelling explanation: The lack of moisture in the basement could be drying out Dan and Karen’s nasal cavities (which would otherwise have a natural layer of defense in the form of normally moist and healthy mucous membranes), and the large quantity of airborne ash produced by the wood stove was getting into their sinus cavities and chronically irritating the now more exposed and dried out membranes. Eventually, over a long enough period of exposure, a thick enough coating of ash in these tender membranes might cause the body’s natural immunity defenses to break down, and an infection would very likely result.
That was it! Everybody was sure of it. But we had to be careful about limiting ourselves to the simplest and most convenient explanation—even one that seemed so perfect. I insisted that we carefully and thoroughly evaluate this cause, as well as all the other possible causes we and his doctors had considered earlier, against the full body of facts we had described so far in outlining the problem. We had to be sure it fit all the data, and that it fit better than any and all other hypotheses. There was simply too much at stake, and we didn’t want to send Dan home with a false diagnosis. So we began systematically evaluating this and the other possible causes, one at a time, against the facts.
The hypothesis of allergy to livestock and/or crops didn’t explain why Dan never experienced similar problems while spending time on his parent’s farm as a youth, or why no other member of the family—who were equally exposed to these conditions and environment—never experienced related symptoms. For the same reason, we were able to rule out the possibility of out-gassing from unique building materials used in the construction of the new house, and allergy to dust or mold. And the doctors’ favorite suspect of dog allergy (which Dan had never seriously entertained because he would never consider abandoning them) didn’t explain why he and his family never experienced their symptoms on their long camping trips into the lake country with their dogs. One after another, we systematically ruled out every other possible cause—except the wood stove.
This remaining hypothesis clearly explained all the facts. The wood ash explained why the mucus discharge was usually ‘brownish-green’, and why Dan and Karen often experienced ‘bloody noses’—the viscous and browny mucus discharge from their noses might easily be mistaken for blood. The unique pain radiating to their teeth and jaws were likely side effects from the intense pain emanating from the sinus cavity, which is in near proximity just above the teeth and jaw. The feeling of pressure behind the nose was very likely due to the inflamed nature of the irritated tissues, plus the large buildup of mucus in her sinus cavity. And of course this explanation perfectly fit the unique location and timing of their problem, since this was the only place where they had used a wood stove and it was only used during the winter months—beginning in late fall/early winter. It even explained why there was a time delay in the onset of Dan’s symptoms after originally moving into his house in Fennimore: they didn’t start using the wood stove until the onset of cold weather, a few months after they moved in! Everything now fit, and it seemed so obvious. Plus, Dan said it would be relatively easy to confirm and fix the problem by making some immediate changes inside the house, such as improving the internal air circulation and adding some strategically placed humidifiers.
Dan’s first reaction to our finding was elation that he had finally gotten to the root of their longstanding problem, and that there was such an obvious and simple solution to permanently relieve them of their painful symptoms. But it didn’t take long for Dan’s attitude to turn to outrage. Why, he wanted to know, couldn’t the many doctors he and Karen had seen over the years, figure this problem out as easily as we did? Why instead had these doctors continually subjected them to such invasive diagnostic, surgical, and pharmacological procedures, choosing only to (unsuccessfully) treat their symptoms while ignoring the underlying cause? And how could a team of relative strangers determine the root cause of their problem in a couple of hours simply by asking a few straight-forward questions—especially when we didn’t know anything at all about his history or have any technical medical knowledge?
by Reid Jenner