04 February 2010

Listen to the patient

Sometimes in this job you just get lucky.  You have an elusive and/or dangerous diagnosis just dropped in your lap.  Something devastating that you would never have been able to tease out otherwise just gets handed to you by the patient.  There's a catch, though: you have to be smart enough to know when to listen to the patient, when not to blow off their crazy talk as just crazy.

So it was recently when I saw a guy with back pain.  From the chart, it didn't sound like anything complex: a middle-aged to older guy, maybe 60 or so, with a history of chronic back pain and multiple surgeries for the same.  He was on Oxycontin 80 mg three times daily (a very high dose, and a red flag for an ER doc naturally suspicious of drug-seeking behavior).  I went to see him, and it was clear in seconds that this dude was JPN: Just Plain Nuts.

He was a real character, in a good way.  He was one of those old Vietnam vets with the leather vests and long graying hair.  His wizened face bespoke many years of cigarette smoke, and his crazy eyes hinted at a long history of illegal substances.  Of course, he had no veins left from years of IV drug use, but he told me he was "too old for that shit any more," and I believed him.  He was a dedicated biker, and had not let the loss of his right leg in a motorcycle accident dampen his enthusiasm for the hobby.  He had a method, he told me, of using his prosthetic to operate the rear brake, while relying primarily on the front brake, since the poor sensitivity in the right led to overbraking and rear-wheel skids. 

It was such a mishap which had led him to lay down his Harley a couple of months before, and the road rash on his hip had developed a MRSA abscess before eventually responding to antibiotics.

This is all stuff I got from him after the fact, though.  Initially, he was in so much pain that he could barely give me any history at all.  Writhing on the gurney as much as possible without jostling his back, he was all-but-nonverbal.  He gasped, in a gravelly but intense voice, "Doc, I just know, I just know that I've got an infection in my back.  I can feel it!  It's there!"  With great effort, he sat up and stared at me with an insane expression that I remember from Hulk Hogan's glory days, lids fully retracted and teeth bared in a rictus of pain, "I can feel the infection in my eyes!  Behind my eyes!  It's fire and pressure and it's pure poison!  I just know it!"  And with that he collapsed back onto the gurney, mute, into his own private and rather unpleasant little world.

I couldn't examine him for anything.  His whole back hurt -- heck, he hurt everywhere.  Forget a neuro exam.  After about five minutes I gave up the whole effort as futile.

I mused on the "infection" thing, though.  What the hell.  Osteo?  Diskitis?  Epidural?  How would he know if he had an infection there?  No fever.  Abscess -- risk factor -- so not exactly implausible.  Did I have any evidence for it?  Not a shred.  Anything to suggest that this was just chronic pain?  Nothing but his two dozen ER visits for chronic back pain.  For some reason, I decided, "Fuck it.  I'm just going to get an MRI on his back."

This is highly unusual for me.  In our group of 40+ docs, I am the lowest utilizer of diagnostic imaging services.  Generally, I have to have a high level of concern to get an MRI from the ER (though they are far more common than they used to be).  Yeah, I also ordered the other stuff -- you know, the stuff Vijay wants before he'll authorize the MRI -- a white count, CRP, Sed rate, etc.  But it was 8AM and the radiologist must have been undercaffeinated, because he just said OK without asking any questions.

He was over at radiology as the labs started to come back: sed rate>100, CRP>200, WBC 24,000.  Wow. That all looks bad.  Glad I decided to scan him.  The MRI?  You guessed it:
epidural
Well fuck me sideways and call me a donkey, but there's the epidural abscess, just like he said it would be.  How the hell did he know?  I mean, really, how did he know?!?  Because he told me the diagnosis from the moment I saw him. 

My Irish mom used to always say that God looks after children, fools and drunks.  I don't know that this was divine intercession per se, but I consider the unlikely sequence of events: an unreliable patient asserts he has an unlikely disease, I, without supporting evidence, order the difficult-to-obtain test, the radiologist fails to erect a roadblock to the test, and against all probability, the patient has exactly what he said he did. With early surgical intervention he avoids permanent paralysis. If I hadn't listened to him...

There for the grace of God go I.



6 comments:

  1. Great catch - regardless if 'great' is luck or skill. I always worry I will miss these.

    Please tell me something: Did this guy have abnl vitals to go with his crazy CRP and so forth? Something more than a pain tachycardia or an emotional tachypnea?...a true tachy or maybe fever?

    I am early in my training, but I depend heavily on abnormal vital signs to identify 'sick'.

    Again, nice catch.
    ncc

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  2. Nice catch! My back hurts just looking at that image.

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  3. Hello, you have tried to your best. I agree with you and really liked it. Great effort... Keeps it up!!!!

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  4. That MRI should be part of an inservice that you should be giving to the whole $&^%$!! hospital. Good call, from one who knows.

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  5. I know this is old but wanted to speak to the question raised of "how did he know?"; for those with true chronic back pain, we know what our "normal" pain feels like. How it usually radiates (if it does), under what circumstances, etc. The longer you've had the pain and pay attention to what makes it better or worse, the better you get at recognizing what is "normal" to your chronic condition.

    Because of that, when something is different, feels different, we recognize it. We may not know exactly what it is, like this guy did (probably guessed based on past MRSA) but we usually know something new/different is going on. The hard part is getting a doctor to believe us.

    In April of 2010 I did some fundraising activities for a young boy who was badly burned with crappy insurance (2nd and 3rd degree over 40% of boody: chest, throat/neck, face, both arms, both hands). One of those activities was to hold a yard sale with donated items from the public. A lot of work. I was promised all kinds of help from friends who never showed (family kept their word though). End results: I started having new symptoms, new pain in areas that were not my normal (higher up in the back, more intense right SI pain radiating down R leg, more falling due to legs giving out, higher overall pain level etc.).

    It took me 18 months to convince my doctor that something was wrong. It took having my husband come with me and basically tell my doctor the same stuff I'd been telling him for 18 months to finally get the cat scan order I needed (can't do MRI..surgical steel in L SI joint from failed fusion attempts). Sure enough I had a bunch of new damage and injuries to my lower back and pelvis that was causing the intense new symptoms and change in my normal to a "new normal". I wasn't seeking medication changes either, just answers as to why my symptoms had changed and worsened.

    Sadly for many chronic pain patients, new symptoms are often ignored by doctors. Now while I wait for the biopsy of the tumor they found at L-1 (and pray its not a recurrence of a malignant phyllodes tumor like the one removed from my R breast in June 2010) I can only hope my doctor learned something from this. Not all chronic pain patients are drug seekers, many of us really do know our pain well and we know when it changes or something new is going on/adding to our normal symptoms.

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