The Radioactive MRI

The ED is a remarkable place; it’s where you get to be on the frontline of all emergent (and non-emergent) medical presentations. You get to step in at the very onset of disease, or at the worst day of someone’s life you get to be the big difference. You may also get a case that really really gets under your skin, not because of the intricate, complicate nature of the presentation, but because there sometimes may not be a medical problem to rectify.

I once had a patient (I am glad it was once!) who came in with what I had been told was a headache. I didn’t read the card, and I called the patient, and took them to a nearby cubicle to for my assessment. She was a youngish female, accompanied by her mother, and the patient walked comfortably into the room, and onto the examination trolley. The only outward sign of anything being wrong was the large pair of sunglasses on the patient was wearing; it was after 10 pm.

I introduced myself and asked her what had brought her to ED today. Presumably because she was so unwell, she couldn’t really tell me, so her mother volunteered the information that her daughter had had an MRI scan that had damaged her brain somehow and caused her internal injury. I stared at them, blankly. I looked down at the ED card in my hands. This is what it said in the presenting complaint (I kid you not): Had MRI today which was severely painful. Mum concerned that scanner has ?burnt brain. Why, oh WHY did I have to pick up this card? *sigh*

‘Come again?’ I managed. Both mother and daughter sighed deeply. ‘My daughter had an MRI today. She began to get a headache during the scan, and not knowing whether or not this was to be expected, she went on with it, she has a very high threshold of pain you see. My daughter is very brave. After the scan we also noticed that her right cheek looked very red and sunburnt! Please do something, because I have a feeling if this is what is happening on the outside, who knows what’s going on on the inside! Her brain might be burning!’

I just continued to stare. They seemed ok, IQ-wise. Both looked like they were respectable, well-educated, well-dressed. They genuinely thought this situation was a medical possibility, bless them. It was a good few seconds before I realised they were looking at me expectantly. I offered Mum a tissue (she seemed to be in tears!) and the patient a glass of water. I tried to ascertain if there had been any trauma to her head or her face while getting the scan done. She experienced no nausea or vomiting, no dizziness, no other ill effects at all. She had no metallic implants that would have caused a problem during an MRI. She still had the headache, even though a good 10 hours had passed since her scan. I tried to convey to her that there was no scientific or medical reason for her to experience these symptoms from being ‘exposed’ to an MRI scan, as it did not actually entail any radiation exposure. But apparently a relative or family friend had done some research into the hazards of MRI scans and reckoned she needed to come to ED because of radiation exposure, and ‘maybe they had targeted the radiation to the wrong place’. I took a deep breath, explained how the MRI machines work, and that it was basically just a large magnet and it was basically testing the alignment of various particles of the body, and formed an image based on how each particle moved in the magnet’s field, based on what tissue it was a part of. There were no x-rays or radiation involved. I tried the reassurance method. Then I tried explaining the science. But both mum and daughter were having none of it.

Her examination was (surprise!) unremarkable. It was more of a therapeutic examination rather than me actually looking for any abnormality caused by having the MRI. But I had to make sure I dotted all my ‘i’s and crossed off all my ‘t’s, before I told her that essentially there was nothing wrong with her and that the MRI is the safest scan modality requiring no radiation etc whatsoever. Did she believe me? That would be no.

Against my better judgement, I sought senior advice; I could see this conversation was going nowhere. I requested one of my seniors to come review her independently, see what conclusion he arrived at, and to then tell the patient his independent findings. When this happened, wouldn’t you know it, she apparently got convinced, and was happy to go home.

So yes, the ED is an amazing place. But some interactions may make you decide that you do not want to live on this planet anymore.

Firecracker

So I was in Minors, and the next card I pick up is of a 68 year old male and I read the triage nurse’s notes and…I can not understand what she means by “linulated banger wart af n left hand, wounds to thumb and index finger”. So something happened in a different language that resulted in wounds to the thumb and forefinger of this gentleman. He did something to a banger? Did she mean a badger? This should be interesting. Could she have written it in a more confusing manner? Doubtful.

I called his name and he walked into the cubicle, with a blood-stained (soaked?) dressings wrapped around his left hand. I introduced myself and admitted downright that I had no idea what had happened to him, so could he tell me in his own words? He told me he was a farmer, and essentially to scare away birds and small animals, they light up this firecracker type thing at the end of a long rope, and with the help of the rope swing it up into the sky and it lands far away into the field, and explodes with a loud bang (hence called a banger!), acts as a sort of loud scarecrow, if you will. And what had happened today? “Well I have been doing this for years: I never use the rope, I just take it and light it in my hands and then lob it off into the distance. And I just have been very lucky these past 45 years!” So he basically miscalculated the timing this time, and it exploded in his hand before he could lob it. It now dawned on me what the triage nurse’s writing meant. lighted banger went off in left hand, wounds to thumb and index finger.

So anyway, I exposed his wound after donning some gloves. As I began to unravel the dressings my nose detected the heavy smell of burnt gunpowder/spent explosive caps in those toy pistols we used to play with as children. His thumb had born the most of it, with the nail literally split down the middle, the edges flaring up and out; the soft tissue of the pulp of the thumb was shredded, and all I could think of was how I was meant to stitch the nail back together, with no rest-of-the-thumb left to hold the sutures together.

His sensations were still remarkably intact, and the wound was oozing, but not profusely bleeding. He had a similar but smaller, less extensive wound on the index finger of the same hand, and a few other small spots that had singed or burned. He had full range of motion, surprisingly, of all interphalyngeal joints; nevertheless I realised I needed to get an x-ray done to rule out any bony injury, before progressing to the matter of how to fix this.

x-rays were requested, and they showed as expected a comminuted (read shattered) fracture of the distal phalynx of the thumb (an open comminuted fracture, since the skin/flesh was denuded over the fracture segment) and a simple fracture of the distal phalanx of the index finger as well.

Orhthopedics! My job was done! I bleeped the orthopaedics registrar (with half of my brain telling me it might get shoved on to plastics) but he very kindly agreed to come down to review the patient, and that was that. I decided to go take a break after this. But he had other plans in mind for me. He requested I do a ring block around the base of both the injured digits, so the finger and thumb would become anaesthetised and he could give it a good clean. A ring block is essentially local anaesthetic injected into the base of the finger or thumb in question, on either side, which numbs the nerves supplying the finger and you achieve localised sensation loss (temporarily) used mostly for nail bed injuries or nail-related procedures. I injected his thumb, not a problem, two jabs and all was amazing. I then moved on to the index finger, first jab was alright (3rd in total, including those of the thumb) but the second (or 4th?) as I was injecting it he said oh I feel a bit hot, and i feel a bit sweaty and I feel like I maybe am about to pass out and…oh here I go. And off he went. *kerplunk* fainted right in the chair. We quickly moved him onto a trolley, he came round quickly, very embarrassed. I re-assured him, even though I had just almost shit my pants thinking please be ok please be ok. My external facade was calm and cool, you gave us quite a fright sir, but you’re alright, don’t worry about it, these things happen  while on the inside I could feel my teeth clenched so hard I thought the muscle in my temple would pop out. The orthopedic reg was still stood in a corner, and he looked like he had shit his pants. I reminded him to come forward and continue. We administered the rest of the local anaesthetic, and the ortho reg happily cleaned the wound of any debris that may have collected in the wound(s), washed it with copious amounts of saline. He then cleaned the wound and dried it and applied an impressive dressing to the hand (the thumb and index finger were deemed best to heal this way). The rest of the plan of management involved IV antibiotics stat (he opted for gentamycin and flucloxacillin), and oral antibiotics to go home with (co-amoxiclav x 7 days), and we all remembered the tetanus toxoid, which was administered, and the patient went on his way. He was to return to orthopaedics fracture clinic the following week.

Take-home message: 1) Lie patients down when injecting them with things. However macho or well-adjusted to the pain or the trauma the patient might seem, you would be surprised at what a needle and the sensation of local anaesthetic being injected into any part of your body can do for your consciousness. *kerplunk*
2) never use ‘bangers’ or any explosives in your own hands, you may think you have it covered, but a firecracker in your hands might just be a case of having too much on your hands.
3) never question a triage nurse’s writing. or any nurse’s for that matter. Karma will hit you back with such a vengeance you won’t ever forget it.

The case of the Valentine’s Finger – a confusion about management plans

62 year old male, known to have rheumatoid arthritis, on naproxen for it regularly, attended ED with the complaint of discoloration and numbness of the right ring finger; he turned out to be a lesson in management.

Upon my review at 7AM, the patient had been in the department about 2.5 hours. He reported that he wore heavy gloves (his usual) at work (works in the produce section of Tesco’s) and he removed his gloves at around 1AM and noticed the ring finger of his right hand to be darker coloured than the rest of his hands. It was painless and he didn’t recall bruising or injuring it in any way. He thought nothing of it, and put it down to his glove having rubbed off some color on to his finger. 3 hours later, his manager examined his finger and noticed it was colder than the rest of his hands. He was then advised to attend ED. When I saw him, a good 6+ hours had passed since he first noticed the discoloration. There was absolutely no pain, no history of trauma, on examination, there was a significantly darker discoloration of his ring finger, isolated, also appeared slightly swollen, had full range of motion, and capillary refill could not be assessed because the finger did not blanch on pressure. Radial and ulnar pulse were palpable of the affected arm. There was no sensation loss at the ring finger. There wasn’t any tourniquet effect of anything like a tight glove or a ring. He denied any drugs of abuse, had never smoked in his life and was not allergic to anything. He had no prior history of any such symptom, no prior personal or family history of any clots or bleeding or vascular disorders. To make matters slightly worse, he had injured himself in some accident, causing a deformity of the distal phalynx of this finger, with a rudimentary distorted nail bed.
All his observations were within normal limits. There wasn’t much else of note per examination. Are you on board this thought process with me?

I was at a loss to figure out what was going on and what was causing this patient his symptoms. He felt fine within himself. He actually found it quite funny that I couldn’t figure out what was going on. I went through all differentials of this sort of symptoms, but it didn’t fulfil any criteria for …anything. It didn’t look like an arterial ischemia, because it wasn’t pale, nor painful. It did look like venous congestion, but I could not for the life of me figure out why he would suddenly have an isolated venous congestion of just a single digit. And also, since it had been 6-8 hours since symptoms started, was there anything else I could do? I Decided to seek senior advice.

I excused myself, and went to ask for senior support. I discussed it with a register, who kindly came in, examined the patient, spoke to them, excused themselves and…asked a second registrar (there were no consultants available at that time) He also came in, spoke to the patient,  etc etc… and to the mirth of the patient, all FOUR of the doctors who came in were equally stumped. The last registrar advised after seeing the patient himself to send him home, and to recall to the consultant review clinic the next day, as he felt this was not vascular in origin. I did as I was advised. Documented everything and sent the patient home. Patient was also happy with this plan. Was still laughing as he left, thinking he was some sort of medical marvel (he was!) who had confused all the doctors (he had!)

I still wasn’t happy, as even though we had done all we could, I had been no closer to finding out the how or the why or even the what behind the patient’s bizarre presentation. I then went to the consultant when they came on shift a while later. She did sort of freak out that i wanted to seek advice about a patient AFTER I had sent them home. I told her that I had sought the advice of whoever was available to me at the time, but since that still left quite a few unanswered questions (what why how) I wanted to know what she would have done in my place, or atleast what she would have advised me had I had the opportunity of asking her at the time.

Now thinking about it, and having discussed with the ED consultant, I have a better plan of action: I should have discussed it with vascular surgery, and sought their opinion. I also probably should have considered investigating for a cervical rib, something she strongly suggested.

A cervical rib is an extra first rib, that can potentially cause pressure on blood vessels or nerves as they arise in the arm and may cause symptoms distally down the arm. This case doesn’t really suggest that sort of presentation, but still it would be worthwhile to do it for completeness.
An assessment or opinion from vascular surgery would have been optimum. I did end up speaking to vascular surgery after the patient left, to ask them for further advice. They advised that since they hadn’t seen the patient, they would have recommended ruling out a cervical rib (surprise!), and giving a stat dose of enoxaparin, and sending him home on apixaban, and recalling him in for a vascular surgery review within a week. I discussed this plan with my consultant who for the first time during this whole debacle, agreed with me that anticoagulation in this particular case was not indicated.

In my defence, I thought at the time I was doing the right thing, I was confused as to how to proceed further and so sought senior help from the sources available to me; it was more than one source!

I now know that I had the option of asking for specialist advice as well, which even if I disagreed with their plan would have guided me a bit further and made me more confident in that I had utilised all the resources available to me in order to optimally manage what turned out to be a very confusing patient.

The patient turned up the next day, and the consultant reviewing him went through my notes, but could not understand why I had been so concerned as to call him back for a review. As the patient’s symptoms had somehow magically vanished over the course of 24 hours, all that was left was a slight discoloration – no swelling, no movement problems and definitely no numbness or congestion or schema. Hallelujah!

If anyone has any bright ideas about how they would have managed this case, please let me know in the comments section. I really should start taking pictures of these bizarre presentations, and uploading them here, as for some reason, they do magically disappear and all that is left is my description of it! Anyways, do let me know about your thoughts.

An Interesting Rash

And no, not interesting in the funny-because-it’s-in-a-funny-place but more because it was a bit… inexplicable.

So a few months ago when I was on my acute medicine rotation as part of my ED training, I came across a bizarre presentation. This young-ish (so I admit, I can’t remember his age!) about 40-something year old, came in with a bizarre rash that had been ongoing and worsening for the past 3 days. He noticed a non-blanching pinpoint rash that started on his hands and forearms, and (not that he noticed initially) his lower legs, and then also started sprouting on his chest. It was very petechial looking, yet his platelet counts were within normal limits, and he had no prior bleeding or clotting disorders, and his PT/APTT etc were all normal. Denied any history of drug usage, and was on only one medication, something innocuous like omeprazole, and the rash was not painful or itchy or cause any unpleasant symptoms (Other than the fact that it was there!) There was nothing significant in his history, no contact from any allergens, no history of any atopy or allergy. I sought my consultant’s opinion, she was equally puzzled. It was all quite bizarre, and we were all ready to send him home after much hemming and hawing, with a prescription for a basic antihistamine. I wrote it out and got the nurses to give him a pack to go home with. 15 minutes later, the nurse came to me and said bizarre-rash-guy wanted to have a word. I went in and found, to my further astonishment, that his rash had suddenly disappeared. Like completely. Whatever was causing his symptoms over the past 3 days, had now suddenly, without warning and certainly without any helpful insight from me or any of the rest of the staff, completely and utterly vanished. I literally searched for it all over his skin, taking possibly more time now than when I first examined him. I recalled how I had apologised when he first came in and I admitted we hadn’t figured out what had caused the rash. And now I apologised again and admitted I couldn’t for the life of me figure out how or why it had disappeared. He must have really thought us to be useless and incompetent. But as I pointed out to him, we did end up solving his problem, albeit without any knowledge of how we managed it.

To this day I have no idea what he had, and later on my consultant and I sometimes found ourselves discussing what it could have been for weeks after this patient had left the ward. Unfortunately we had no photographic evidence, only my notes and our memories.