Archive for September 26th, 2020

TRYING TO AVOID PITFALLS

September 26, 2020

A recent article in the medical section of the Times told the story of a man with chronic buttock pain who ended up with being diagnosed with Crohn’s disease with sacroiliac arthritis. 

It only took 10 years. The cause was discovered by accident when the man had a colonoscopy and an alert GI doc noted that the ilieocecal valve was scarred. He passed the scope further into the distal ileum and found inflammatory changes consistent with Crohn’s disease. The patient has since done well with strong anti-inflammatory agents. He had never had overt symptoms of Crohn’s. So many of the things I once learned in medicine have been shown not to be true, or to be different from what I originally had learned. So many of the conditions that were once untreatable now are. 

I remembered from medical school being told that a barium enema (which is how we imaged the colon back then) had to reflux into the ilium or the appendix to be able to say it was complete. It’s not enough to say the cecum—the beginning of the large bowel— was viewed.  What looked like the wall of the cecum in one instance was a large tumor. Had one not looked for the appendix, which was impossible in that situation, or the ileocecal valve, which was very difficult to find, the tumor itself might not have been appreciated.  Cecal tumors themselves are difficult to pick up.  I learned that lesson.

I thought of the good specialists who told us medical students about conditions in their field we didn’t want to miss. That bailed me out in my internship the night I examined a scrub nurse in the ED with a scalpel wound to the palm of her hand.  Everything looked fine; she could move everything and feel everything, and there was minimal bleeding.

I called the hand surgeon anyway. I had learned that puncture wounds of the palm were dangerous.  He came in, thanking me for calling him.  A few weeks later, I happened by the nurse, who took me aside and thanked me for saving her hand.  I was surprised and asked her what happened.

“I had a significant hematoma drained,” she said. “Had nothing been done quickly, I could have lost significant function and might not be able to work. Thank you.”  I had forgotten about that day.

Or the patient who complained of something in his eye where nothing was found. I either had to find the object, find a corneal scar, or call an ophthalmologist.  Something was wrong until proven otherwise when a person complains of a sensation that something is in his eye.

Or the Fireman 1/c on board my ship, who had a red eye that might have passed for conjunctivitis, except the inflammation encircled the iris. He had acute iritis, and I had to treat him with steroid eye drops. Iritis is not something one wants to miss. I would never see another case. But I found that one.

Or the patient with progressive loss of vision that was felt to need glasses.  The only problem was that the pupil had a very poor reaction to light on that side, but reacted briskly when light was shone into the other eye.  This meant the optic nerve was compromised, called an afferent pupillary defect, since the afferent pathway is involved.  In this instance, the patient had a meningioma compressing the optic nerve. Another trick to screen for optic nerve disease is to look for red desaturation, have the patient compare the degree of redness with each eye. The afflicted eye will not see the red nearly as bright.

It can also work in reverse.  Many with poor visual acuity may have remarkable improvement looking through a pinhole, which can be easily made. When such improvement occurs, the visual problem is always refractive, for visual defects of optic nerve origin do not improve by looking through a pinhole.

Or the man I saw in the Morenci, Arizona clinic, 3 hours’ drive from Tucson, whose neurological exam was fine, but he had a soft lump on his cheek. These look like sebaceous cysts that should be drained, but I was taught well about parotid gland tumor presentation, and the one thing one never does with parotid tumors is stick a needle into them, for it will enhance spread. He was sent to Tucson where a surgeon cured him.

Hoarseness?  The patient has two weeks to get better before one must do a laryngoscopy looking for vocal cord paralysis due to recurrent nerve injury perhaps due to a condition like a malignant lung tumor.

Possible pneumothorax?  Get an inspiration-expiration film, where the difference is sufficient to show air where it does not belong. I can still remember what room I was in at Denver General Hospital when I saw a case on a Saturday morning, the second month of my internship, 46 years ago.

When I was in practice, a patient with a cerebellar infarct was admitted to the floor. I put in a call to a neurosurgeon, because while at the time the patient was in no distress, the affected brain can swell and compromise the lower brain stem quickly, leading to death.  Potentially enlarging cerebellar lesions are dangerous and deserve respect.  I asked the nurses to “check frequently,” without needing to take vital signs, which saved them time and underscored the need to watch the patient often. The next day, I found the patient post-op in the ICU, awake. The swelling had become significant, the brain stem was becoming compromised, and the swollen, infarcted cerebellum was removed. He made an excellent recovery.

My wife had two cases where there was a clearcut breast malignancy on the mammogram but nothing found by either the surgeon or pathologist.  In the former, missing the malignancy led to a second mammogram—uncomfortable to go through post-operatively—and a subsequent change in the hospital system, so that X-Rays were required to be taken of the specimen before closure, to ensure that the lesion was in the specimen and not still in the patient. In the latter instance, the pathologist was told he had to go back and find the cancer, because it was in the specimen, and it was cancer. It was found.

On the psychiatry rotation I learned never to be shy about asking about suicidal ideation, and I asked about it scores of times in practice, to evaluate depression. Not one person was ever angry with me for asking. Virtually all had thought about suicide; very few had gone to the next step, which was determining how they would do it.

Or, the routine physical exam which I did on a sailor before he left the Navy. I felt his abdomen, something I had done hundreds of times, and the large mass I felt surprised me. The sailor had been unaware of it. He would turn out to have lymphoma.

While I have long forgotten the details, I remember calling in consults to orthopedic surgeons using words like “valgus” and “varus,” rotational deformity, distracted or overriding, and discussing vessels, skin, nerve, tendon, joint, and muscle, for that was how I was taught. 

I learned that when I argued with myself about whether I should do a spinal tap, just do it. More than once, I discovered something that was useful. Sometimes, one had to get the spinal fluid a different way. I had an obese diabetic with a stiff neck at 2 am in the ED one night. A spinal needle could not reach her meninges through the back, so I punctured the skin just below the base of the skull, “walking” the needle down the occipital bone, until I reached the cisterna magna, finding white fluid indicative of a bacterial meningitis. She did survive.

I hope along the way some of my teachings may have been useful, like checking level of consciousness by “What does it take to arouse them?” “What do they do when they are aroused?” and “Are they getting better or worse?”  The last was an attempt to remind people that being medically stable requires at least two observations, not one. I don’t know if the same approach is used today in teaching medical students, but I hope they do finish training knowing not only the potential pitfalls in their specialty but many of the ones in other specialties, too.