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:
Well 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.
*This blog post was originally published at Movin' Meat*