The Intestinal Obstruction That Wasn’t

84 year old male – known to have chronic constipation, and on warfarin for atrial fibrillation – referred in by his GP for ‘inability to open bowels for 2 weeks’ – yes you read that right folks, T-W-O W-E-E-K-S! – ‘increasing abdominal distension and abdominal pain, along with decreased appetite and a possible mass in the pelvis/abdomen going above the umbilical area’.
The nurse triaging him came to me, asking for some pain relief for the patient ‘and an enema because that’s what he usually has for his constipation’ – I decided to go see the patient myself. I stepped into the cubicle and the gentleman seemed to be in some discomfort, but he kept saying that he was in an uncomfortable position/posture rather than anything else causing him discomfort. I introduced myself and asked him what had brought him to ED – he replied by telling me he had not opened his bowels for 2 weeks now, and though was still passing wind and had passed some today, he was drinking very little and felt nauseous and omitted a few times in the past 3 days. I asked him if he had been passing urine normally, and he reported that yes he was peeing fine, but that he was drinking so less due to the nausea that only small amounts were trickling when he needed to go. I took that statement at face value and moved on. He was lying in a trolley, awake but lethargic and completely oriented. His observations were all within normal limits except for a systolic BP of 89, and his GP notes reported a background of chronically low blood pressure. I examine him, of particular note is his visibly very distended tummy – which assort but distended, feels like gaseous distention from the percussion notes, and with tinkling infrequent bowel sounds – and is quite sore particularly in the lower half of the abdomen, and I can also palpate a mass in the lower part of the abdomen – the patient reports that’s been going on for atleast 3-5 days, possibly when the vomitting began as well. This seemed very much to me to be a classic case of intestinal obstruction – and the management plan is – do baseline bloods (already very kindly done by the triage nurse), get venous access (also done), start some fluids, abdominal X-rays, nasogastric tube and surgical referral, and also catheterise patient, to monitor intake and output.
I speak to my registrar who agrees with said plan of action and while I request the X-rays and take the patient down for it, the lab apparently calls back and my registrar takes the call – the patient’s urea is 44, and the creatinine is 469, last creatinine 3 weeks ago was 141 – so he is going into renal failure, if not there already. While I seemingly faff around with the surgical consult, my registrar gets an ultrasound machine, and I assume it is to rule out a AAA, so I walk into the cubicle with him. And he explains to me a great pearl of wisdom that clearly comes with experience but is such a simple thing that I am left berating myself for not thinking about it earlier. He told me that if someone comes in with such significant renal function decline so acutely, always think of and rule out an obstructive cause for this presentation before moving on to other more sinister things. He was doing an ultrasound to look for hydronephrosis or hydroureter, which is basically the dilated urine collection channels in the kidney downwards and the reason they are dilated is due to an obstruction further down the channel. And that is exactly what he found. The left kidney was moderately enlarged but the right kidney was massive and its ureter was like a fire hydrant pipe rather than the small thin tube – and the mass in the lower part of the abdomen, going from pelvis and extending up from the umbilical area? His urinary bladder!!! I was in shock – as my registrar then gave me the second pearl of wisdom: never believe anything you are told, do not take it for granted until you have objective evidence. The patient felt he was peeing less and less because he wasn’t drinking enough. Yet he was peeing less because the channels beyond his bladder were so narrowed and obstructed that they did not allow emptying of the bladder and it just kept filling up till it was a massive huge thing floating in his belly. I at once made arrangement to catheterise the patient, whereby 2000 ml (that’s 2 litres!!!) of dark brownish urine poured forth out of him.

He had been in urinary retention for the better part of 3-4 days, possibly due to an enlarged prostate that had just gotten worse, and his constipation (though being chronic) was either a factor of his massive bladder pressing on his rectum/colon and not allowing the contents to move ahead; or (a bit like the chicken and egg thing, of which came first?) he was constipated, which gave him some abdominal pain (expected) and that pain had the added effect of causing urinary retention – anyways, after passing the catheter and draining all that urine the patient felt quite comfortable, and the surgeons took him away to do their wonderful things.

ortho/knee injury/major boo-boo

So some of you may recall in one of my previous blog posts, I saw a patient who had come in with a patellar fracture – avulsion fracture that happened when the ligament/muscle contracted and pulled off a small bit of the patella bone (also known as the kneecap). I got called to the consultant’s office recently because of this case – and I wanted to share a key element that I missed in my diagnosis/management that I wouldn’t want someone else to repeat.

So to recap (in case i am flattering myself and no one has actually read the afore-mentioned blog post :p) This was a 40 something year old male, with a football injury. Now when I say football injury, it wasn’t your usual contact trauma. No. He hadn’t played in a while, and without warming up very well, he began playing. He went in to kick the stationary ball, and as he pivoted on his left leg, and used his right leg to go in for the kick, he heard (felt?) a crack in his left leg which was basically his weight-bearing leg as he went in for the kick and he stopped there without being able to kick the ball. He was able to stay standing, but felt his knee go a bit wobbly and unsteady – ‘as if I couldn’t trust to put my weight on my knee, Doc’ – and so he laid himself down on the ground. He didn’t think it was extremely painful, but certain movements did make him prone to the occasional twinge of pain. He was able to hobble on the left leg, but unable to walk properly due to the unsteadiness of his knee joint. By the time he got to the ED and was seen by myself, it had been nearly 3 hours since the injury and his knee had become quite swollen. Not red or inflamed looking but definitely quite significant soft tissue swelling, with particular tenderness overs knee cap or patella bone. On examination, there seemed to be quite a doughy consistency swelling all around the joint, and even though he was able to flex the knee, he was unable to extend the knee fully without help (I assumed due to pain).

Even though there was no direct trauma to it (in that he hadn’t knocked the knee directly onto anything) and he could put his weight on it and walk (hobble?) on his own without support, made me question whether or not I should x-ray the injury. I did end up x-raying his knee, and to my surprise (I was surprised at how surprised I was!) found him to have had an avulsion fracture of his patella. I asked the ENP what needed to be done in this case, and she advised a cricket pad splint, with a fracture clinic referral for the next possible date. This was the last day of the week and so since this wasn’t apparently a clinical emergency, he was given an appointment for the fracture clinic for the following monday (3 days after the injury) and sent home with a cricket pad splint and crutches. He felt quite comfortable with this plan.

Fast forward to a few weeks later when as I mentioned the consultant asked me to see them in their office. Needless to say, I was scared I had made the ultimate boo-boo, and went though my mind every scenario of every patient I had seen recently that had seemed like it might lead to a conversation with the consultants (I am slightly embarrassed to admit many such cases came to mind) but when the consultant mentioned this case, I was surprised, I thought I had done good management there – assessed the patient, investigated and found a fracture, dealt with it and had also safety-netted him with a fracture clinic appointment. Where did I go wrong?

To be fair, the consultant quickly reassured me that there wasn’t any major issues ongoing. I hadn’t missed anything, on the contrary I had actually picked up something. The two things that needed to be learning experiences for me from this case were:

A) it was not just a patellar avulsion, the whole of the quadriceps tendon had become ruptured – the orthopaedic team had therefore complained that while they appreciated me picking up the injury, they would have liked to deal with it sooner than the 3-days-later non-urgent clinic appointment. I should have called the orthopaedic team on call at the time and gotten this patient seen by them and they would probably have admitted him overnight and done a surgical correction the next day (which was the management of this kind of injury) and while they appreciated my very detailed examination notes from the knee exam (even my own consultant was more than slightly happy at the knee exam!), I had failed to check – or document that I had checked! – the fact that the patient could not perform extension at the knee joint, which should have raised the possibility of patellar tendon rupture

B) Never, ever, EVER use cricket pad splints for…anything in the ED! I am supposed to be reading up on the use (or discouraged use!) of these in the ED and while I haven’t yet had the chance to read up on them, I have been advised to not use these for any injuries unless expressly advised by an orthopaedic or emergency medicine consultant. Check this space again later and I will update this blog post with the WHY of this.

A third aspect of the written complaint was highlighted by my consultant, I had apparently been promoted without being aware of it (this was said in slight jest by my consultant), as the orthopedic consultant felt that it was unforgivable for ‘an ST4 EM trainee (registrar level) to have missed such a crucial management point’ – I am only a lowly year 1 trainee currently!

Anyway, the take home messages from this incident need to be addressed and learnt, and while the patient did not suffer any adverse effects and got his surgery done, and there was no harm done, it is best to be aware of all protocols and nuances of management – and when in doubt, ASK!

The back pain that became a pain in the … back!

Mechanism. Never forget mechanism of injury when assessing a patient with any sort of trauma. We tend to get distracted by other people’s assessments, or their version of events, or their assessment of injuries – do NOT fall into that trap. Always start from scratch, when you are the one responsible ultimately. And always, ALWAYS take mechanism of injury into consideration, however minimal the injuries may seem to be.

Quite a while ago now, I had a patient in ED, middle-aged female who had a background of hypertension and had previously had some chronic respiratory illness, and a heart rhythm abnormality called atrial fibrillation, for which she was on warfarin – an anticoagulant. She had come in with the history of traumatic back pain. As the story went, she had been lifting some sort of semi-heavy load outside her house, and had turned around (or intended to turn around) and fallen over backwards on 2 very low steps, in the process also managing to hit her head against a brick wall. She did not lose consciousness, and her husband heard her scream, and came out of the house at once to help her. She was unable to get up on her own, but with help got to her feet and felt fine. Due to her hitting her head, her husband felt they should get a check up, so they came into the ED. Enter yours truly – their saviour in shining armour. Or not.

I assessed the patient, took a detailed history, and fully examined her. I had in the back of my mind right from the outset that she needed a scan of the head due to her head injury while being on warfarin. She denied any neck pain, and had no palpable tenderness of the bony bits in her c-spine, or neck. She also complained of mid to lower back pain, but not in the midline, rather on the right side. I specifically felt all the palpable bony aspects of her vertebral column from top to (literal) bottom, and it did not elicit any pain. There was no bruising (surprising, since she was on an anticoagulant, and had literally landed on her back on the stairs). She had full range of motion of her majors joints, and had walked in to the department to be assessed. For all intents and purposes, her major injury was the head wound, and for that I requested a CT scan of the head. It came back as normal. I found no reason to investigate anything else. Her back pain wasn’t too severe, but I still advised her to take regular analgesia, and to seek medical help if it was worsening, or not improving after a few days, or if she had any other concerns (a typical statement for me when I discharge any patient). I sent her home with some head injury advice, instructing her husband on the red flag signs to look out for, and if any concerns to come back to us. I documented the whole encounter, and went on to see my next patient.

I found out later that the patient had returned 2-3 days later, because her back pain had not improved, rather it had become much worse, and she found it difficult to mobilise out of bed. One of my other colleagues very kindly examined her this time, there was still no bony tenderness in her back, and her pain seemed to be localised to the right side of her lower back, and my colleague agreed that it seemed very much like a soft tissue injury. However, because this was the patient’s second visit to ED with the same complaint – and the situation had worsened to the point that her activities of daily living were being hampered (like getting out of bed!) – he requested an x-ray of her thoracolumbar spine, which revealed to my extreme embarrassment and shock a wedge fracture of one of the vertebral bodies. She was admitted under orthopaedics, and I crawled into a hole and died. No I didn’t.

I read up on traumatic back pain, and I gathered as much information as I could about it. I also gave a presentation to my other colleagues in the department, as a learning point. Here is what I learnt, and I utilise this information everyday: Whenever assessing traumatic back pain, the method that I have been taught and always employed was the one I have described. What is now advised, is to not just palpate the bony prominences of the vertebrae, but to place one hand on the bony prominence of the spine at any level – with the palm resting on the back; then make a fist out of your other hand, and lightly tap the fist onto the back of the hand that is flat on the back – if it elicits any pain anywhere on the back, investigate further (do x-rays) – and assess the whole vertebral column integrity in this fashion.

I have also learnt after discussing this at length with many of my colleagues of varying seniority and specialty, that even though clinically an x-ray may not have been warranted at the first presentation, yet purely based on mechanism if you looked at it, along with her age group (women middle-aged and above are more likely to begin to have osteoporotic fractures with moderate trauma), an x-ray would not have been completely out of the question.

To this day, I am terrified when I see ‘back pain – fall’ as my next patient’s presenting complaint. But I am more, much more cautious now, and I am sharing this experience to highlight how easy it is to miss something even if you are looking for it at the right place and at the right time, and I hope this post will serve to help/guide someone to not make the same mistake I did. Cheerio!

To X-ray or not to X-ray – that is the question, but what is the answer?

Guidelines and protocols are in place for a reason. Based on years and years of experience and collated data and individual opinions of specialists etc, these guidelines are set up to aid the budding EM physician. They are not absolute though, as I learnt the hard way (a most unenjoyable way to learn!)

56 year old female, otherwise fit and well, comes in to ED one fine morning around 7am. I was part of the night team, counting the minutes down to when the day team will arrive and I will be able to go home. I was asked by the registrar to see this patient who had turned up to be assessed in the first assessment bay; she was at that time the only patient waiting to be seen (a rare occurrence in ED). I went into the makeshift cubicle (which basically meant drew the curtains around myself and the patient’s bed) introduced myself and asked her what brought her to ED that morning. She reported she had an ongoing pain in her left ankle, that she had been to her GP for. Twice. When I asked her when it first began, I was quite disappointed to find out this had been going on for a few weeks (3 I think she said!) She had been to her GP who had told her on two separate occasions that this seemed like soft tissue injury, and she was advised pain killers. She came in today because she felt she was not improving. She was into hiking and jogging and was a very fit 60 year old. The concern for her was she was unable to pursue her rigorous exercise routines due to this pain. She denied any direct trauma to the affected limb, and reported no swelling or bruising. No previous history of any joint problems (no prior medical history, actually!) and she examined very well: no bony tenderness to medial or lateral malleolus (the inner and outer parts of the ankle); she was able to put weight on it, as evidenced by the fact that she had walked into the department of her own accord without any support (and without a limp!); she had full range of motion except some difficulty in everting her foot, which reproduced the pain. There were no wounds or bruises or swellings, and full power and normal reflexes ended my examination, along with palpable pulses, good capillary refill distally and no neurological deficit. I advised her to continue taking pain relief and to seek a physiotherapist because she may have injured her muscles or a tendon/ligament and may require some specific exercises. She then suggested I x-ray it, and I explained to her why I thought it didn’t warrant an x-ray. She seemed a little less convinced but did not argue, and I sent her home. I documented everything, and thought that was the end of that.

I was called by one of my consultants a few days or weeks later, informing me that I had had a letter of complaint against me. It transpired that eventually when the pain had not gotten better over the next 10 days, despite having been seen by physiotherapy as well, the patient went private and got an x-ray done, which revealed (or so I am told) a stress fracture of the distal end of the fibula! A stress fracture! Of the fibula! The fibula is one of two long bones forming the lower part of your leg. I had never actually in my not-so-many-years of experience heard of a stress fracture involving the fibula.

My consultant was very supportive about it. She had gone through my documentation, and was quite satisfied with the plan I had made for the patient based on my assessment at that time. She agreed that based on that assessment there was no indication for the x-ray. But she taught me a few things about stress fractures that I did not know; that they are more common in the metatarsals than in the fibular end, but that in view of her age, I should have considered the possibility that she might have been osteoporotic and would be prone to fractures without any significant trauma, a detail that I had failed to factor in in my assessment of her. The experience taught me so much about how I need to remain humble in this profession that I decided to do a reflective note on it at the time and added it to my portfolio.

What have I learnt? I have a lower threshold for stress fractures in older patients, despite having no findings on examination/history suggestive of bony injury. I intend to read up on stress fractures and increase my knowledge base on the topic (and maybe blog about it in a later post!). I still intend to continue fully taking a history and doing a proper detailed examination of a patient, and then using my clinical judgement in order to decide on a plan of management for a patient.

You never know when your well-intentioned actions may be the wrong way to go, regardless of whether or not they work for the other hundreds of similar cases. So never get cocky, never get complacent, always be humble, and always, always DOCUMENT!

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.