BY MICHAEL MOUW, MD
was 3 a.m. one night in 1993. I was working at an urban teaching
hospital with no MRI or real-time radiology reads on plain films and
before spiral CTs. The arrival of the man in bed 16 would have been
tough to miss. He was one of those patients you aren't exactly eager to
meet, but you're alone.
Hey, doc! I need something for back pain!
EMS was disgusted.
He says he can't walk. We found him sitting on the toilet
alone. The place had dirty needles everywhere. He left Elsewhere General
yesterday. Treated a left arm abscess.
Swamped, I managed a cursory look. Disheveled, malodorous. Obvious healing skin graft to left AC fossa.
Let's sit up so I can see your back.
I pull him up. He grimaced.
Damn, doc, that hurts! I percuss his spine. Hurts everywhere. Not helpful.
Let's see you move your toes.
He might have an epidural abscess, and three patients are ahead of him for CT. No way I'll dispo before shift change.
OK. I'll give you some IV Toradol, and get some tests.
I'm allergic to Toradol.
I roll my eyes.
OK. I'll give you some morphine then.
I order labs,
a lumbar spine CT, plain films of the entire spine, and call CT to
reshuffle the queue. Thankfully, staff obtains IV access. Something is
I mount his films on the view box. Nothing obvious,
but no surprise because his pain is lumbar. I'm finally caught up, so I
return for a better exam. His legs are crossed. So much for not being
able to wiggle his toes. He wants more meds.
I thought you said you couldn't move your legs?
Then how did you get them crossed? Patellar reflexes are
brisk. Ankle jerks also brisk, plus clonus. Hmm. That means something.
I'm interrupted by the radiologist with a negative CT report. I call
Oh, yeah. That guy was always begging for pain meds.
Now I've got him!
I return to his bedside, lean on the rail. Shift change is nigh.
If you can't walk or move your legs, how did you get to the toilet? And how did you manage to cross your legs?
He reached out, placing his hand over mine on the bed rail, imploring.
Doc, I ain't lying. I can't walk.
And I believed him.
OK. Fair enough. I'll admit you to sort this out.
I called the admitting resident. She pushed back.
You want me to admit an obvious drug seeker who's malingering? Neurosurgery probably won't come to see him!
I persisted. She reluctantly agreed. I went home to bed. When I returned that night, a day-shift colleague accosted me.
Hey, remember that shooter you saw? My heart sank.
Medicine sent him home after you left, and radiology called
him back. X-rays are in there. They sent EMS, and on return he had
flaccid paraplegia. Went straight to the OR.
I check the
films. Only now, illustrating my incompetence, there's an arrow pointing
to the space that had previously contained his now-collapsed T10.
Luckily, he had complete return of function after drainage of his huge
- My judgment was clouded by my visceral reaction to a malingering drug-seeker. I didn't study his films closely enough.
- Cognitive overload: Did I mention it was single coverage, and I was swamped?
deficiency: Clonus is a long tract sign that was signaling the onset of
cord compression. I should have been armed with that finding and called
- Shift change: Need I say more?
Plus one for considering spinal abscess, but minus two for anchoring on
lumbar. Spinal pain doesn't localize accurately. I've had two cases of
spinal abscess since then where this lesson served me well. I had to
push past MRI tech objections to image the entire spine rather than just
Malingering and real pathology are not mutually exclusive.