Case 27: A Fine Line

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In the 1984 rock “mockumentary” This is Spinal Tap, a fictional band discusses the controversy surrounding one of their album covers. “There’s such a fine line between stupid and -” the lead singer says, realizing where they’d crossed the line of tastefulness.

His guitarist finishes his thought – “and clever,” he says. In life, in rock and roll, and in medicine, there is indeed a fine line between stupid, and clever.

During my first month of practice, I was at the head of the bed in a rural E.R., as Dr. Marcus Fredo* stood a few steps away, phone to his ear, as he waited to speak to a trauma surgeon. The patient, a victim of a high speed rollover, had a closed head injury and needed to get to a neurosurgeon. Stat. In trauma, doctors in rural centers have to treat patients thoroughly, while also recognizing their own limitations. Rural docs have to use clinical skill to quickly decide if, where, and how patients will be transferred out to larger centers. Their patients need resuscitation and stabilization, but time can’t be wasted if their needs exceed the resources at hand. Conversely, rural doctors can’t just ship out every patient that looks sick. Differentiating those that need urgent transfer from those who don’t is one of the many great challenges that rural physicians face.

The patient, a husky biker in his mid-forties, was barely conscious. Fredo suspected a head bleed, but the closest CT scanner was at a larger hospital, thirty minutes away. However, that hospital didn’t have a neurosurgeon – and why bother with the test when you can’t treat the problem? Hence, the decision was made to intubate the patient, and transport him to a hospital two hours away, where the CT scanner came with a trauma team, and a neurosurgeon. If there was indeed a bleed, the neurosurgeon could drill a hole into the patient’s skull and relieve the pressure.

The patient had also been scalped – his hair had been ripped cleanly, and was clinging by an island of skin – like a toupee in a convertible on a windy day. This is where I came in. The doctor had called me to tack his rug of hair back into place – a menial task perfect for a new recruit. As Fredo listened to muzak and waited for the teaching hospital to take his call, he told me about a patient he transferred years before as he was starting his own career. The patient was in his late sixties, and had a complicated medical history – uncontrolled diabetes, a couple of heart attacks, emphysema. Along with this, he had an aneurysm – a swelling of his aorta in his abdomen. It was found a couple years earlier, and periodic ultrasounds had shown that it was growing steadily. And as it grew, the aorta’s wall stretched out and weakened – like a balloon inflating to the point of bursting. He was awaiting surgery at a University Hospital, and had just had his preoperative assessment. “In the meantime,” his surgeon had told him, “if you suddenly have severe pain in your belly, get to the closest ER. Fast.”

Fredo put the phone on a counter and hit ‘speaker’ as he continued his story. “So this guy comes in, writhing in pain. His wife shows us all his records, and tells us he needs to get to a vascular surgeon as fast as possible – that his aneurysm had ruptured – she even tried to call an ambulance from inside the hospital and asked if it could take him to the city. “The guy’s got a surgical belly,” Fredo said, “firm, tender everywhere, he’s guarding. I can barely touch him. His heart rate is through the roof. I ask him a few questions – he’s passing gas and pooping normally, so it’s not a bowel obstruction. His gallbladder’s been taken out, so it’s not that either.”

“His blood pressure?” I asked.

“Blood pressure was normal,” he said, “maybe a little high, but I wasn’t going to wait around for it to drop. So I call down to the city, and the vascular surgeon says to send him down right away. We grabbed a couple of units of unmatched blood, a box full of drugs, threw in two IV lines, and jumped into the ambulance.”

“Oh God,” a nurse said. “I remember that.”

**********

Sixteen years later, I’m working in one of the busiest hospitals in the country. That being said, I’m not downtown, and I’m not at a teaching hospital. There is still no neurosurgeon in the building.

If the patient sitting across from me was seventy five, I’d barely think twice about his issue. I’d take a one minute history, get him to lie down and unbutton his pants, and tell him that a nurse would be right in – and that he’d be feeling better in no time. But not only is my patient a few years younger than I am, he doesn’t seem to be in any distress. This is worrisome. He’s a fit, smiling dude, clad in jeans and a fitted t-shirt.

“I just can’t pee,” he says.

He has no other medical history, he tells me, other than chronic back pain. The pain comes and goes, he says, and he has the occasional bout of sciatica – pain from a pinched nerve that radiates down his leg. He doesn’t take strong painkillers for this – just Tylenol or Advil – and he goes to physiotherapy regularly, which is usually enough to keep his pain under control.

“How long have you been unable to pee?”

“Just the last twenty four hours. I feel like I have to go, and I try to start, but I can’t.”

“Are you pooping okay?”

“Yeah.”

“Any accidents?”

“Accidents?”

“Yeah,” I say. “Like accidents – have you pooped your pants?”

“No,” he laughs. “Of course not.”

“Any numbness in your groin?”

“Numbness?” he says. “Well, kind of.”

“What do you mean?”

“Well it’s not exactly numb,” he says, “but I feel like I wouldn’t be able to get an erection if I had to.”

I go back to his medical history. “What about your back pain, has it been bad recently?”

“Not today,” he says. “But for a few days – earlier in the week – it was the worst back pain I’ve ever had. I couldn’t even sleep two nights ago. I was pacing the room.”

I examine him. His vital signs are normal. His chest is clear. His belly is soft, and non-tender, as is his spine. He moves easily. “One more thing,” I tell him. “I have to do a rectal exam.”

“What!”

I have to stick my finger in his bum. He quickly figures that it’s his prostate that I’m after – but it’s not the only thing I’m checking. I’m worried about Cauda Equina Syndrome (CES), a rare (neuro)surgical emergency caused by compression of the spinal cord. In most cases, this is caused by a herniated disc, which can cause lower back pain. The hallmark signs of CES are impairment of bowel, bladder, or sexual function (of which my patient is already describing two) and numbness of the area between the genitals and the anus.

Cauda Equina Syndrome isn’t an easy diagnosis to make. Symptoms are often subtle, and as such, missed. When the diagnosis is made, the story often spreads quickly, and hats are tipped to the clinician who made the call. More commonly, however, are the tales of caution – the ones that ended up in a courtroom, rather than an operating room.

He’s lying on his side, and his pants are down. Like many patients, he pities me, and tells me he’s sorry that I have to do this. He’s probably embarrassed, and I tell him that it’s okay – that it’s a routine part of the physical exam. His prostate is normal – about the size of a walnut – and smooth, with a dip in the middle. But more importantly, his rectal tone is strong. Patients with Cauda Equina syndrome can have difficulty releasing urine; conversely, they can have poor rectal tone – a loosening of the sphincter that causes poop to leak out involuntarily.  To put it simply, my patient’s lowest orifice squeezes tightly around my finger. This is a good sign.

I’m still worried, though. His only medical history is back pain, and it was severe in the days preceding his urinary retention. I ask him to try to pee, so we can get a sample. Maybe he has an infection, but this doesn’t rule out Cauda Equina Syndrome – it could be infected because urine is sitting stagnant in his bladder – growing bacteria, like a pond in the middle of summer. I also ask the nurse to scan his bladder once he’s peed – to see exactly how much he’s retaining.

I sigh. He needs an MRI. The problem with Cauda Equina Syndrome is that if he has it, his symptoms may become permanent. As CES progresses, it can lead to weakness and, eventually paralysis of the legs. I have to call the radiologist and tell her the story. Then, she’ll have to find time to squeeze him in between scheduled patients. His symptoms aren’t critical at this point. If they were, I’d follow the principles of trauma – call a neurosurgeon first – and get him to a hospital where he can get the urgent surgery he needs. But in this case, I can get the MRI at my hospital, and go from there. Sometimes, these patients have to be admitted, and held overnight, as the radiologist works to make an opening sooner than later. There is work, and great expense associated with this, but to save a patient from permanent disability, it’s worth it.

I move on. I see an ankle sprain and a chest pain, and ask my assistant to tell me when my patient’s urine and bladder scan results are back. “I’ll probably need to page radiology,” I tell him.

Ten minutes later, the results are back. It all makes sense now.

******

Fredo held up a finger to the nurse and smiled.  Hold on. Don’t give the story away.

“So the entire time we’re in this ambulance, the patient is screaming in pain. He’s sure his aorta has ruptured, and that he’s going to die. It’s a two hour ride, and his heart rate stays up the whole time, but we’re pumping him full of fluids, so, we think, we’re keeping him afloat – his blood pressure isn’t dropping.”

“More than afloat,” the nurse said.

“As we pull into University Hospital, we do a final check – have we done everything right? Staff members at larger centers often look down on rural hospitals, and the worst thing is to be criticized for being sloppy or for cutting corners. There was one thing we hadn’t done – just for the sake of completeness – that we decided to do as we were parking in the ambulance bay.”

“A catheter,” the nurse said.

Fredo is laughing now. “So we put in the catheter and almost immediately, the poor guy drains three liters of urine. On further questioning, it turned out that along with the aneurysm, he had a long history of prostate trouble. Needless to say, when his bladder emptied, his pain disappeared.”

The nurse laughed with him. “We sneaked out of there fairly quickly.”

******

My patient’s urine dip makes me feel stupid. There’s blood, but no white cells. Now it all makes sense. Had he come in three nights earlier, in severe pain and nauseated, I would have made the diagnosis in seconds. He doesn’t have Cauda Equina Syndrome. He has a kidney stone. I order a CT scan – which is immediately available – and confirm it. The severe pain a few nights earlier was a stone passing from his kidney to his bladder. And now, oddly enough, it’s stuck there, floating to the front and blocking the urinary path when he tries to pee. There isn’t much urine there – less than half a cup, and the stone is small. In a day or two, it will pass.

In a small percentage of patients, there is no blood detectable in urine during the passage of kidney stones. Had this patient been one of these rare exceptions, he may have been admitted, maybe for a day – maybe more – to get the MRI. And, then, I would have gotten word, probably with a laugh: “Hey, remember that patient you thought had Cauda Equina Syndrome? He waited two days for an MRI, and ended up having a three millimeter kidney stone.”

I’m happy that his urine told the tale, and that, at the very least, I had the more severe diagnosis at the back of my mind. I’d rather keep a patient for a day or two, and be wrong, than miss a case of Cauda Equina Syndrome, no matter how it might make me look. That being said, in medicine, as in rock n’ roll, there’s a fine line between clever, and stupid.

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*not his real name

 

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