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The man with no spine... - Nobody wears a white coat any more... — LiveJournal
...a tribute to becoming a doctor.
The man with no spine...
Med chief again.
The following is a little disturbing and a little technical. Feel free to ask questions.

B calls me the other night - the resident who always caps the service by midnight. "You gotta come down to the ER. Now. You'll never see this again."

I head down to the ER. We talk for a while about the patient who's probably in fulminant hypovolemic shock, with a side order of rhabdomyolysis and a sprinkling of sepsis for a while - the usual ICU type orders, thyroid, old records, why-did-someone-operate-on-his-brain kind of thing. It's almost routine, although I never quite get over the heart-thumping anxiety of someone saying "ICU". He's beginning to stabilize, after four liters of IV saline, antibiotics, and a hint of Levophed to bring his blood pressure up. He can open his eyes and mumble, at least. Then she pulls on my arm.

You gotta come see this. You gotta.
We don N-95 respirator masks (the orange "duckbill" TB masks you have to be specially fitted to wear) and step into the room.

Patient is a late-fiftiesh male, past psychiatric history of schizophrenia, with a ten-year history of a lesion on his left cheek, approximately 2 centimeters across at the time of this examination. He notes a four-year history of intermittent swelling of the extremities, progressively developing nodules (left ear, right ear, chin, chest) and diffuse rash. He presents to the ED tonight with a two month history of swelling of his head and a two-week history of progressive weakness and inability to walk, culminating in the inability to raise his head without lifting it in his hands due to his weakness. He complains of neck pain. He has previously been evaluated for this but has refused diagnostic biopsy. He declines Western medicine treatments and has been using vinegar on his lesions and herbal remedies prescribed by a preventive health doctor whose name he does not recall.
I don't mind herbal treatments, folks, but somewhere along here I wish he would have noticed that he was getting worse.

I'm looking at a man whose bald scalp is swollen and pitted by edema, fully half an inch deep throughout. His head appeared nearly twice the appropriate size. On one ear he had a 3/4 inch growth that looked like nothing good - cauliflower surface, protrusions, edema around it, good blood supply. The other ear was completely deformed - nearly replaced by more of the same. And there was nothing but swelling around his jaw, his neck, his chest, his arms...
And I'm staring at an inch-wide spot on his left cheek that looked like someone had pasted a picture of malignant melanoma onto his face. And all I could think was "He's going to die."

CT scans of head, neck, and chest had been done by the ER. I started with the cross-table and anteroposterior X-rays, and that was where things got really bad, because all I could see was shoulders and skull. This man has no spine. I said it out loud, I think. B nodded. "Look at the CT scan." Everywhere, from the base of the skull to below the clavicles, the normal configuration of the vertebrae was replaced by swirling masses of soft tissue and thready remnants of bone. The tumor, whatever it was, had not only eroded the bone but almost completely replaced it. He couldn't lift his head - not from weakness, but from lack of muscle attachments to move his head around.
Later, Neurosurgery and I sat at the chart talking. "I don't know how this man isn't dead," he said, shaking his head. "There's nothing there. If he sneezed he'd kink his cord and die."

He's considering having the back of his skull fused by means of steel rods to the intact vertebrae at his waist, so that he doesn't do exactly that. We're waiting on pathology. Nobody knows exactly what this is, but it's not good. We're banking on metastatic melanoma, with a lifespan measured in weeks remaining. He wants us to give him a B12 shot so he can move his neck again, then go to Florida, eat health food and be cured. He refuses to hear the discussion about code status - feigns sleep, orders us out of the room, or changes the subject - and every time someone says 'cancer' he acts like it's the first time. "Oh no, Doctor. It can't be that. Nobody's ever told me that before." We don't know if he's crazy, or toxic, or in denial, or a lot of things, but running a Code Blue on this man would be like trying to intubate macaroni - and inevitably fatal.

Our current plan is to get him a diagnosis, some pain medications, and Hospice. If he wants to go to Florida, we figure it's better than dying here in the snow. What can you do?
16 whispers echo . o O ( ... ) O o . whisper a word
jillofthejungle From: jillofthejungle Date: March 28th, 2008 02:00 am (UTC) (etched in stone)
Whoa. Just...whoa.

I guess all you can do is get him back to Florida if that's where he really wants to be...

ayradyss From: ayradyss Date: March 28th, 2008 10:48 am (UTC) (etched in stone)
Yeah. We'll see what happens.
turnberryknkn From: turnberryknkn Date: March 28th, 2008 02:37 am (UTC) (etched in stone)
That's a remarkable -- and tragic -- story.

May I have your permission to link?
ayradyss From: ayradyss Date: March 28th, 2008 02:42 am (UTC) (etched in stone)
You have standing permission :)
From: broken_onewon1 Date: March 28th, 2008 02:58 am (UTC) (etched in stone)
Sounds like a candidate for a Darwin award to me let him sneeze.
coanteen From: coanteen Date: March 28th, 2008 08:40 am (UTC) (etched in stone)
Awww, you made me laugh and now I'm going to hell.

I really with I could see the imaging.
ayradyss From: ayradyss Date: March 28th, 2008 10:46 am (UTC) (etched in stone)
"Here sir, hold this feather..."
deadrose From: deadrose Date: March 28th, 2008 03:10 am (UTC) (etched in stone)
I'm having visions of Joe Buck and Rizzo on the Greyhound. Hope he makes it to Florida and gets his sunshine.
ayradyss From: ayradyss Date: March 28th, 2008 10:46 am (UTC) (etched in stone)
So do I.
fyrfitrmedic From: fyrfitrmedic Date: March 28th, 2008 03:33 am (UTC) (etched in stone)
Wow. I saw a patient like that in the prehospital realm maybe a dozen years ago; his "cure" was wearing a soft c-collar. He went to the Ed, got admitted and died upstairs a week later.
ayradyss From: ayradyss Date: March 28th, 2008 10:43 am (UTC) (etched in stone)
I don't want him to die in the hospital...it's such a sad place to be.
fyrfitrmedic From: fyrfitrmedic Date: March 28th, 2008 12:11 pm (UTC) (etched in stone)
[nodding in agreement]
evilstorm From: evilstorm Date: March 28th, 2008 07:23 am (UTC) (etched in stone)
Yeah, sometimes...I don't think paternalism has lost its place in modern medicine. Not quite yet.
ayradyss From: ayradyss Date: March 28th, 2008 10:43 am (UTC) (etched in stone)
Me either. Sometimes, people don't know what they want, because they don't want to hear it.
ashrie From: ashrie Date: March 28th, 2008 10:54 am (UTC) (etched in stone)
That is intense...

I think it would be best for him to go back to Florida, perhaps he will leave more peacefully there. It certainly is not the most ideal of situations, but... who knows what the best thing to do in this situation is either...
Cases like this, I think, just show how much knowledge of the human body still needs to be discovered...

rimrunner From: rimrunner Date: March 28th, 2008 03:18 pm (UTC) (etched in stone)
16 whispers echo . o O ( ... ) O o . whisper a word