Monday, August 01, 2005

This 75 year old man presented to the Urgent Care one evening after a day of golfing. A very unusual presentation, in that he had no history of any significant medical problems, was on no medications and had no history of any significant injuries.

He presented about 7pm with 3 hours of low back pain. He stated that he felt somewhat embarassed about coming in for something so trivial, but that his wife had made him. How many times have we heard that?

He had spent the early afternoon golfing, as was his usual habit. Again, as usual, he went for a soak in the hot tub. As he was getting out, he twisted to place his foot down and felt a sudden onset of sharp low back pain. He pointed to his left lower back area.

On exam, his vital signs were normal and stable. He appeared comfortable and in no distress. He did use his hands on the arms of the chair when asked to stand and was slow to step up onto the exam table.

He was tender to palpation across the low back, especially on the left and there was moderate muscular spasm.

The young doctor, only about 6 months out of internship, was moonlighting in the Urgent Care. She felt comfortable with this presentation and ordered a lumbar spine series, confident she would see degenerative changes.

And she did. What 75 year-old man doesn't have degenerative changes on an LS spine xray?

She informed the patient and his family of her diagnosis: lumbar strain with muscle spasm. She advised the use of Tylenol #3 and robaxin. The patient seemed comfortable with this diagnosis and advice and prepared to leave.

However, the patient's son asked to speak with the doc outside the room. He told her of his concern for his father. "He never complains of pain. You need to understand that for this man to come to the doctor, especially at night, he would have to be in a great amount of pain. More than he would get from a lumbar sprain. And he didn't tell he threw up on the patio as he got out of the hot tub. Are you sure it's OK to go home?"

Upon further interview, the patient admitted that he had been nauseated since the time the back pain began. He also described vague diffuse abdominal discomfort, but no pain.

The doc looked at the x-rays again. Was there something there that she had missed? Were those whitish irregular arcs significant? They measured about 14cm apart at greatest distance.

She went back for further exam. The patient had good distal pulses and no bruit over the abdomen or femorals. No history of claudication. No pulsatile mass in this moderately obese man.

She called the vascular surgeon on call for her group. He scoffed when she told him of her concern and the distance between the arcs on the x-ray. "No aneurysm could be 14cm, it would have ruptured long before that!" he exclaimed. Nonetheless, he agreed to accept the patient for transfer to the ER.

She advised the patient and his family of her concerns. She advised them to drive straight to the ER and not stop at McDonald's on the way there.

On her way home, the inexperienced doc found herself in the middle of a panic attack. She suddenly realized how foolish it had been to send the patient by private vehicle and not by ambulance. What if they went home instead of to the hospital? What if he died in the car on the way? Am I good enough to be doing this?

One week later she got a call from an unusually polite vascular surgeon. Somewhat abashed, he apologized and explained what had been the result of her transfer.

The ER doc had performed a CT scan of the abdomen and called the vascular surgeon about a 10cm abdominal aortic aneurysm. Remember that plain films magnify about 40%? Well, 14cm is 140% of 10cm, isn't it?

After evaluating the patient in the ER, the surgeon decided to postpone surgery until the morning, given the stable condition. As he was leaving the ER, he reconsidered. He called his partner to come in to assist and went to the OR.

They were standing outside the operating room as the elevator door opened and the nurse and the tech wheeled the stretcher down the hall. As they passed the two surgeons, the patient passed out and became very pale.

They threw the pulseless patient onto the OR table, opened the chest and cross-clamped the aorta. Four days later he walked out of the hospital, already planning his next golf date.

Sometimes it is better to be lucky than to be good.