Chapter One

Jeffery Kilmore, MD, an ears, nose and throat specialist or ENT, walked down his office hallway and stopped in front of a closed door. A black, plastic number three was attached to the wall above the door frame. His nurse, Brenda Taylor, walked beside him holding a computer tablet the size of a standard hardcover book. The days of patient’s individual manilla folders with pages of medical information inside disappeared after the introduction of computers and computer tablets. Patients’ medical information, now called electronic health records, are stored in a digital form, eliminating file cabinets. No more patient charts resting inside wooden chart holders next to patients’ exam room doors.

Nurse Taylor had already done the initial assessment of the patient a few minutes earlier. “Our patient, Tyrus Mitchell, woke up this morning deaf. Complete loss of hearing in both ears.”

She handed Jeff the tablet, who put the tablet in his white lab coat.

“The emergency room doctor called me this morning regarding Mr. Mitchell. He has Sudden Sensorineural Hearing Loss. As you know only about ten percent of people with SSHL have a recognizable cause. We only see about five patients a year in my ten years of practice. Its occurrence is less than one percent of people in the United States each year. Point one percent to be exact. Quite rare.”

Jeff opened the exam room door and walked into the room.

A man in his mid to late sixties sat on an exam table. A woman about the same age stood next to him, holding his right hand. Worried expressions conveyed their demeanor.

Jeff peered at the couple with a serious, concerned expression and nodded. “I’m sure you have a lot of questions regarding your husband’s sudden hearing loss?”

“Yes. The doctor in the ER didn’t know why he suddenly lost his hearing. We’re both scared.”

“I’m sure you and your husband are scared.”

Jeff reached into his white lab coat and removed the computer tablet containing Mr. Mitchell’s medical information obtained from Nurse Taylor earlier. He peered down at the data on the screen. The sixty-six-year-old patient didn’t take any prescription medications nor did he have any chronic illnesses. The lab results from the emergency room were normal with no evidence of medical conditions causing Mitchell’s sudden hearing loss. A healthy man sat on the exam table in front of him. Jeff turned off the patient’s medical information data, then turned on the voice caption program that would display on the tablet screen what he says, enabling the patient to read it. He turned the tablet screen toward the patient and his wife, and said slowly: “Mr. Mitchell, I talked with the emergency room doctor you saw this morning. So, you don’t have any dizziness, ringing in your ears prior to your hearing loss, or recent trauma to your body or head? And you didn’t have any hearing problems prior to waking up this morning with complete hearing loss?”

“No. I’ve always had good hearing,” he said loudly.

Jeff knew when people have significant hearing loss, they talk louder since they can’t hear their own voice. “I’ll need to do some tests to eliminate a few possible causes of your hearing loss.”

Jeff handed his tablet to Brenda as he retrieved an otoscope from an oval-shaped holder sitting on a counter to his right and placed a black plastic tapered disposal cone into the otoscope’s cone-shaped receptacle. He examined the ear canal in each ear. A minimal amount of wax or cerumen and a normal appearing eardrum or tympanic membrane peered back at him. He stepped back. “Very little wax in your ear canal, and your eardrum looks normal.”

The tablet held by his nurse faced the patient, continuing to display his oration.

“What caused my hearing loss?”

“Don’t know yet,” Jeff answered as he threw away the plastic speculum and put the otoscope back into its holder. He turned and faced the patient and his wife. “I’ll have my audiologist perform an audiogram. After the test I’ll talk to the two of you. Brenda will take you to the audiologist.”

“Thank you doctor.”

Jeff left the room and walked to his office. He knew there were only several causes of sudden SSHL and had eliminated some of the causes including head trauma, infection, Meniere disease, and multiple sclerosis since there wasn’t any history of these medical conditions. Plus, Mr. Mitchell didn’t have any associated symptoms such as dizziness, ringing of the ears, fever, or was he taking any medications affecting hearing. The audiogram would determine the severity of his hearing loss, which Jeff knew would likely be total hearing loss. He’d need graphic and concrete proof of Mr. Mitchell’s deafness to complete his medical assessment and for medical insurance coding and billing.

Fifteen minutes passed when the audiologist, Danny Miller, walked up to Jeff coming out of a patient’s exam room. “I have Mr. Mitchell’s audiogram results,” he said, handing Jeff the graph results displayed on a sheet of computer paper.

“Thanks, Danny.”

“Mr. Mitchell and his wife are in room six.” Danny handed Jeff the tablet he obtained from Nurse Taylor when she brought Mr. Mitchell to the audio testing room.

Jeff nodded as he stared at the audiogram’s results. The sensorineural and bone conduction test determined the patient had a profound hearing loss and level between one hundred and ten and one-hundred and twenty, which was the lowest numbers on the graph. Jeff knew a hearing aid wouldn’t restore Tyrus Mitchell’s hearing. An MRI, Magnetic Resonance Imaging, had been done this morning by the emergency room doctor to rule out tumors such as an acoustic neuroma, a noncancerous tumor, which develops on the eighth cranial nerve leading from the inner ear to the brain. This nerve transmits sound from the inner ear to the brain. Mr. Mitchell’s eight cranial nerve and his brain didn’t show any tumors or structural abnormalities causing his hearing loss. The patient didn’t manifest any other symptoms and all the tests done were normal other than the audiogram showing complete hearing loss, thought Jeff. He placed the audiogram results in his lab coat pocket, then opened the door to room six.

Mr. Mitchell sat on the exam table with his wife standing next to him. “What’s the verdict, doc?” Tyrus asked.

Jeff held up his tablet facing the couple. “All your tests were normal. The hearing test showed you are completely deaf. Statistically, the majority of people with sudden hearing loss will regain their hearing. About ten percent of patients will remain deaf. I can only hope you’re in the ninety percent group. Your wife will be your ears.”

Tyrus nodded. “Janet and I will do our best. Is there any treatment?”

“Yes. The most common treatment is steroids. Have you had steroid pills before?”

“Yes. When I had bronchitis last year.”

“I’ll start you on a steroid shot called methylprednisolone, then an oral steroid you’ll take for ten days. We’ll give you a shot here. You can pick up the oral steroid at your pharmacy after you leave the office. If there’s any inflammation in the inner ear the steroid should resolve it. Until we can eliminate the cause of your hearing loss, this is our only option.”

The exam room door opened. Nurse Taylor walked into the room holding a tablet and stood next to Jeff.

“We’ll be giving you a tablet with a voice caption program like the one I have here. This way you can communicate with each other. Your health insurance company should cover the cost of the tablet since it’s being used for a medical condition. Brenda will show you how to turn on the tablet and access the program. Let me know if any hearing returns, otherwise I’ll see you back in a week.”

Tyrus held out his hand and shook Jeff’s hand. “Thank you, Doctor Kilmore.”

The next three patients he examined presented with ear pain caused from an infection, abundance of wax in the external ear canal which needed removal with a suction apparatus, and perforation of the eardrum, respectively. He glanced down at his watch: four thirty. Nurse Taylor stood next to him in front of room three. Jeff sighed. The last patient of the day.

“The patient was added to today’s schedule for a sudden onset of a constant buzzing in both ears, which started when he woke up this morning. We’ve seen Karl Thompson on two other occasions in the past year for ceruminosis. The last time you saw him and removed wax from both his ears was about a month ago,” she said, peering down at the tablet containing his medical history. “Although, he never presented with tinnitus, only decreased hearing.”

Jeff nodded. “Let’s see what’s going on with Mr. Thompson.”

He grabbed the tablet from Brenda, opened the door and walked inside the room, followed by his nurse.

Karl Thompson sat on the exam table, facing them. “Hi, doctor. Back again.”

“You’ve never had buzzing or ringing in your ears before?”

“No. Never.”

“Have you recently had a head or neck injury or any pain in your jaw called temporomandibular joint disorder?”

“No, I haven’t.”

“Have you taken a new medication the past couple of days, such as ibuprofen, a water pill or diuretic, an antidepressant, or an antibiotic?

“No. I don’t take prescriptions or pain medications for any medical conditions.”

“Most people have had some form of auditory sounds emanating from inside their ears when they’re in a quiet environment, especially before falling asleep. But only lasting several seconds to a couple of minutes.”

“Wow. Never knew that fact,” Karl said.

Jeff stared down at the tablet and quickly reviewed the sixty-one-year-old patient’s medical history. It didn’t show any chronic medical conditions such as diabetes, thyroid disorder, migraines, anemia, multiple sclerosis, autoimmune disorders such as rheumatoid arthritis and lupus. All these can be associated with tinnitus. “Let’s take a look inside your ear canals.”

He handed the tablet to Brenda. He retrieved the otoscope from its holder on the counter. Jeff peered into a normal right and left ear canal. “The good news is there isn’t any wax in your ear canals.”

“What’s the bad news?”

“Hopefully, there isn’t any. I’ll need to schedule a regular x-ray to eliminate any bone disorders in the middle ear, and an MRI to rule out a brain tumor especially near the auditory and eighth cranial nerves.”

“That’s one thing I like about you doc…you don’t hold back any ominous possibilities. You tell it the way it is.”

“I’ll schedule the tests for tomorrow morning at the diagnostic center across the street. I’ll call you later tomorrow afternoon after I get the results from the radiologist. If the MRI and x-ray comes back negative, there’s a few treatments we can try to relieve or damper your ear ringing.”

“Thanks, Doctor Kilmore.”

Jeff walked out of the exam room and headed to his office, as Brenda stayed in the exam room and ordered the tests from her tablet. A moment later, he sat at his desk staring at his desktop computer, reviewing blood work and diagnostic tests he ordered on patients he had seen last week. After a usual busy Thursday, it was nice to relax at his desk and read test results. In years past, there would be a stack of patients’ charts on his desk with test results printed out and placed inside the charts. This scenario doesn’t exist anymore since patients’ medical records are now computerized and stored in a digital electronic form.

Brenda walked into the room with an apprehensive expression. “Doctor Kilmore, our patient, Karl Thompson, lost his hearing. He’s deaf. And he no longer has tinnitus.”

Jeff frowned. His previously calm demeanor exploded with a chill engulfing his entire body. “My God. Two cases of sudden hearing loss several hours apart. What’s the odds of that?”

He hurried to room three with Nurse Taylor. He had never heard of a patient having Tinnitus then apparently SSHL, nor had he ever had two patients with sudden hearing loss occurring the same day. He opened the door and walked inside.

Mr. Thompson sat on top of the exam table with a bewildered expression. “What happened, doc?”

Jeff removed his tablet and turned the screen toward his patient. “It’s a medical condition called Sudden Sensorineural Hearing Loss.”

Karl peered at the tablet’s screen. “What caused it?”

“At this point I don’t have an answer.” Jeff then went through the same questioning he had with Mr. Mitchell earlier this afternoon. Karl’s answers didn’t point to a possible cause. Danny the audiologist had left for the day. Although Jeff knew the audiogram would be the same as Tyrus Mitchell’s results. Neither of his patients had any chronic medical conditions possibly associated with SSHL. There wasn’t any evidence either of them had an infection, either a virus or bacteria, causing their sudden hearing loss. “We’ll still do the x-ray of the auditory structures and an MRI of the brain tomorrow. Have you taken steroid pills before?”

“Yes. I had a rash a few years ago and was given a steroid shot, then pills for a week.”

“Nurse Taylor will give a steroid shot. We’ll call in a prescription for oral prednisone, a steroid, at your pharmacy. It’s standard treatment for your hearing condition.”

“My wife is in the waiting room. Can you have her come in?”

“Absolutely,” Brenda answered.

“We’ll need a tablet for Mr. Thompson,” Jeff said as she was leaving the exam room.

After Karl’s wife, Sarah, entered the exam room, Jeff explained what had happened to her husband, and the etiology of Sudden Sensorineural Hearing Loss, and that a prescription for a steroid pill can be picked up at their pharmacy. “Brenda will show you how to work the tablet. If anything changes with your hearing, call our office. Since it’s after our office hours, the answering service will contact me.”

“Thank you, Doctor Kilmore,” Sarah said as she stood next to her husband holding his hand.

Jeff left the office thirty minutes later. The mid-seventy-degree temperature in late May nearing early evening felt comfortable for him and people living in central Florida. He got his six-foot-three body easily into his Chevy Traverse SUV. Jeff then glanced at the clock on the dashboard: five fifty-five P.M. The sun in a cloudless sky shined through the left side of the windshield. In three hours, an ebon curtain of night would enclose Ocala, Florida. He’d made a small pot roast yesterday for his midweek dinner. There was still enough for another meal. As a bachelor, his friends told him his cooking was equal to a fine-dining restaurant chef. He didn’t want leftovers. Someone else will be doing the cooking today, he thought, as he backed out of his designated parking space, then made a right onto Silver Springs Boulevard, and headed toward Wolfy’s Restaurant a few blocks away.

He parked behind the restaurant and walked up the back steps into Wolfy’s. There were only a few empty booths. He sat in a booth next to the front window, facing the boulevard. A couple of minutes later, the waitress took his order. Another waitress walked toward him followed by a woman in her late thirties and a man in his mid-twenties and sat them down at a booth across from him. The couple both wore high-top hiking shoes, khaki pants and tan, button-down shirts with the University of Florida logo patch on the front of their shirts.

The woman glanced to her right at Jeff with a serious expression, then back to her companion. “What a strange afternoon, don’t you think Kevin?” Asked the woman.

Before Kevin could respond, the waitress asked, “What can I get you folks to drink?”

“I’ll have water with lemon,” said the woman.

“Do you have Mountain Dew?” asked the young man.

“Yes, we do.” The waitress left to get the drinks.

Jeff was curious to know what the woman meant by the comment, “what a strange afternoon,” and what would be the response from the young man. Jeff slid a foot or two to his right on the cushioned booth’s vinyl bench, directing his hearing toward the couple, trying to block out the mixture of voices in the room.

“Doctor Clark, the bats crashing into the satellite tower in The Forest was unusual. But then when we approached that herd of five whitetail deer after collecting the dead and injured bats caught me by surprise. We were only about twenty feet away from the two fawns, two does, and a buck. None of them heard us coming. When we were only a few feet away from them, they turned around. Once they saw us, they bolted away. Like we both said…the deer had to be completely deaf.”

A chill overwhelmed Jeff.