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Monday, August 2, 2021

August 2021: A Temptation Resisted

“I have a guy with pretty bad shoulder pain," a second-year emergency medicine resident told me. “No trauma. I ordered an x-ray and some ibuprofen for pain."

This resident presenting this case was generally pretty thorough. “Maybe he needs a steroid injection for capsulitis," I said.

After reviewing the images, which were normal, we went to see him together. He was a moderately obese but otherwise healthy-appearing man in his mid-50s. He had a stoic expression of pain on his face. After introducing myself, I took a brief history.

The pain was nontraumatic, had gradual onset, and had gotten progressively worse for about 10 days. I had him remove his shirt for the exam. He had pretty free, passive range of motion of his right shoulder with minimal pain.

By habit, my next step is to observe active range of shoulder motion by having patients do a high back scratch over their head (external rotation and elevation of the humerus to scratch the middle upper back between the shoulder blades). I first demonstrated the movement for him to mimic.

He was eager to cooperate, but for some reason had difficulty. I couldn't put my finger on exactly what was wrong, so I had him do it again. This time I noticed that when his elbow reached the highest point of the movement, his forearm and hand fell against his ipsilateral upper trapezius. I had him repeat it a third time, with the same result.

A more detailed brachial plexus exam revealed he had complete absence of right triceps function and incomplete weakness of his right deltoid and trapezius. The rest of the neuro exam was unremarkable. Apparently, he had failed to notice this weakness, even when I questioned him specifically about it.

An MRI revealed a multilevel lymphoma of the cervical and upper thoracic spinal cord. He was admitted to the neurosurgery service.

Comment: It's tempting when supervising residents to assume they haven't missed anything and to endorse their plan of care without repeating the exam. I have been guilty of (and also burned by) that approach. Luckily, in this case I did my own detailed exam and noticed something wasn't right. This was a one-off case of shoulder pain that I hadn't seen before—or since.​


Thursday, July 1, 2021

July 2021: A Miss and an Angry Orthopedist

​I was on a single-coverage shift with inadequate nursing staffing. EMS brought in an elderly lady who had a fall from standing; she had injured her left wrist but no other complaints. She arrived with her forearm wrapped and in a field splint, and she was there for an hour or so before I could get to her. I placed orders for imaging and a nursing order to remove the dressing and splint. Imaging showed a comminuted distal radius fracture.

I contacted orthopedics and admitted her for open reduction internal fixation. I got busy and forgot to recheck her, and nursing missed the order to expose the extremity, and she was sent to the floor.

The next day I received a call from an angry orthopedist informing me that I'd missed an open fracture (which should have gone to the OR emergently). I was apologetic and contrite, and he complimented me for owning my mistake.

Comment

That was the only time I ever saw an open wrist fracture from a fall from standing. I was swamped, but I should have slowed down and removed the splint myself. It's tempting to cut corners in those circumstances, but obviously it is not the best thing for the patient.



Tuesday, June 1, 2021

June 2021: Correlation is Not Causation

​The triage note read, “Hit by front end loader yesterday on construction site; today can't walk."

The man was in his mid 40s, short but built like a Mack truck, in dusty work clothes. I observed him walking back to the bed without any assistance or obvious problem. “Can't walk" seemed eliminated from the list, and his credibility suffered its first strike. His short stature required that he hop up to sit on the stretcher. No problem there either. I asked the nurse who had triaged him to help interpret; they both spoke Spanish.

The day before, he had been shoveling dirt when the bucket of an earth mover bumped his back. It had not been hard enough to knock him down and he had finished his shift. Since then, he had experienced increasing difficulty walking and was convinced this minor injury was the cause.

I thought to myself that this mechanism wasn't severe enough to cause a spinal injury, and he would have been brought in by EMS the day before if it had. Was this a worker's compensation scam? Credibility strike two.

His exam was normal, and he had no marks of trauma anywhere. He had reported trouble walking, so I asked him to walk for me. He had picked up on my tone of skepticism. He hopped down and threw himself to the floor in dramatic fashion, writhing while holding his back. Clearly, he was malingering. Credibility strike three.

I got a spine x-ray, which was normal, then wrote his papers up for discharge. I put the clipboard in the “needs Spanish" pile. Later, a Spanish-speaking tech approached me, pointing at my guy: “Doc, he wants to know why he's been peeing blood for two weeks."

“That guy? I wrote his discharge order two hours ago! Why is he still here?!"

“Sorry about that, doc. We don't have enough Spanish speakers today. You want me to discharge him now?"

“Well…uh…no…get a urine sample from him, and let me know the result."

The urine was dark and bloody. I ordered BUN/creatinine so we could image him with an IVP for a kidney stone. Shortly after, I was notified by the lab that his creatinine was 9! An ECG showed peaked T-waves, and his potassium was also 9. It turned out he had acute glomerulonephritis of unknown cause. He required emergent dialysis.

Our patients often feel the need to explain their symptoms, and they have often established a causal relationship where none exists. I had incorrectly assumed that he was there for secondary gain because his story didn't make any sense. His weakness was from hyperkalemia, not trauma. This case taught me to work backward from the symptoms and formulate my own conclusions about whether the patient's explanation was correct.

His obvious malingering was an attempt to convince me there was something really wrong, but I failed to recognize that. Malingering and real pathology are not mutually exclusive!

And beware the “oh, by the way, doc" cases where you think you're finished, but you're really not. Luckily for me, I addressed his “new" complaint rather than blowing him off. He obviously would have died if I had discharged him.​


Friday, April 30, 2021

May 2021: Something for the Pain

​This case comes from More Letters from the Pit: Stories of a Physician's Odyssey in Emergency Medicine, by Patrick Crocker, DO. It was edited, and is used with permission.

Pain is a subjective experience, but one with objective observable signs. Often a patient chatting cheerfully on his cell phone will respond: “My pain is a 10."

The experienced clinician must often rely on his own objective observations to avoid wasting limited resources. An extreme example of this is the disruptively theatrical patient, known affectionately as “pain out of proportion to objective findings." The vast majority are simply acting out, but a few will harbor an emergency, which presents a challenge, like in this case.

EMS arrived with a patient yelling for pain meds. The paramedic rolled his eyes: “He fell on the sidewalk."

I wondered which of the four of us on that shift would draw the short straw. Turned out to be me. The curtains were open. He appeared well dressed. As he rolled over, writhing dramatically, I saw a common red flag: sunglasses at night. I winced at the realization that I was dealing with a difficult, pain medication-seeking patient.

Patients with “true" severe pain from an injury will usually lie still. I figured that I had a guy who was malingering. He reported tripping over a sprinkler head, landing on his backside on the sidewalk. For an osteoporotic 80-year-old, this mechanism could cause a fracture. But in a healthy 26-year-old? Almost unheard of. My exam was unremarkable except for his report of severe pain with even light touches to the skin. Most nonintoxicated lumbar spine fracture patients don't writhe like that; it worsens their pain.

The ED was swamped, so I offered him reassurance, two Tylenol #3, and an ice bag for his back. He accepted my offer without protest. I wasn't expecting that. An hour later, he had calmed down, but he said, “My back is still killing me, doc."

I was about to confront him regarding this charade when the words of a wise mentor stopped me: “When things aren't adding up quite right, stop and think. Recognize your perceptions may have led to false conclusions."

I decided to order x-rays. Two hours later, I viewed the films, and was horrified by what they showed: two crushed vertebrae in his lower back with retropulsed fragments. The AP view showed disruption of the normal line, like the Leaning Tower of Pisa. I prayed he hadn't writhed and thrashed his way to a spinal cord injury.

Luckily, his neurological exam was still normal. I told him this imaging finding was almost unbelievable, given his age and the innocuous mechanism.

I asked him, “Is that really how it happened?"

He swore it was. I apologized for the delay and ordered intravenous morphine. After a CT scan, the neurosurgeon took him to the OR to stabilize his lumbar spine.

Comments:

  • Don't let a judgmental attitude cloud your clinical judgment.
  • Your initial impression might be wrong, so be prepared to change it.
  • Malingering and real pathology are not mutually exclusive.​


Thursday, April 1, 2021

April 2021: ​A Challenging Stroke Diagnosis

A reader wrote in about an elderly man with diabetes he saw a number of years ago.

He had arrived by EMS with two hours of acute severe posterior/suboccipital neck pain with right arm radiation and vomiting at home. He received aspirin, nitroglycerin, morphine, and ondansetron prior to arrival. He had an extensive medical history, including a 40-year history of back and joint pain and peripheral neuropathy resulting in poor ambulation at baseline. He took warfarin for chronic atrial fibrillation.

His wife arrived later with a binder of medical records and added details to the case. He had experienced dizziness and an unsteady gait at home, but those symptoms had resolved, and at the time of the exam, his only complaint was persistent severe neck pain. He said he did not have a headache. He had attempted multiple pain medication regimens, and was using Norco 10, Soma, and gabapentin. He had also recently received an epidural steroid injection for this condition a week earlier with minimal relief. It was challenging to differentiate whether this was new or similar to prior presentations. The daughter arrived later and related prior admissions for similar symptoms.

His exam was somewhat limited by pain, but was significant for reproducible tenderness to the right posterior neck. A detailed neurologic exam was normal in the bed, and his stroke score was zero. Gait testing was attempted, but interpretation was difficult because of the severity of his pain and level of cooperation. There was no nystagmus or positional vertigo.
He was medicated repeatedly for pain, and a CTA of the head and neck were normal. I reviewed the old imaging studies, including MRI studies of the spine, and it was clear the patient had well documented degenerative changes. When I checked on the patient, he appeared to be sleeping comfortably. After several hours of observation and multiple rechecks, I reviewed the radiology reports and shared the decision regarding disposition. He expressed a clear preference to go home, so I discharged him.

Unfortunately, he returned the next day with worsening mental status. An MRI revealed a right cerebellar infarction with hemorrhagic conversion. He was intubated, and after failure to improve neurologically, was extubated and referred to a rehab facility on hospice care. He died there about two weeks after the initial presentation. His daughter wrote a letter of complaint, asserting that I should have admitted him for pain control, and should have obtained an MRI.
This was a challenging, atypical presentation of stroke. In retrospect, I’m honestly not sure what I would have done differently. My main concern with a chief complaint of neck pain was vertebral artery dissection, and this was ruled out by CTA. Although his atrial fibrillation was an obvious risk factor for stroke, his stroke score was zero, so MRI did not seem indicated.
Vertebrobasilar strokes represent three percent of all strokes. Up to 35 percent of these strokes are missed on initial presentation, and mortality rates approach 85 percent. Ten percent of posterior stroke cases have a normal NIH Stroke Scale score.