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.

When you hear hoofbeats, think horses, not zebras. Mostly true.

But if zebras are more common in the geographical area where you are at the time, then do, please think about zebras. But I digress.

57 year old female presented to the ED with chest pain, sudden onset, associated with shortness of breath, referred to us in acute medicine (yes a lot of my talks have been acute medicine related, those are the wounds that are freshest!) to rule-out-slash-treat-for a PE (pulmonary embolism, or a clot on the lungs). So I went through the motions, history, physical exam, investigations etc. Her past history was significant for dual malignancies (breast AND colorectal, both treated with surgery and chemo/XRT as needed quite a few years back). This history is what had freaked A&E out and had sent her in our direction (we OK, she was high risk for it, but I digress again).

Her D-dimers were not elevated, which basically is a test to rule in or rule out a PE (it being positive could be for a number of reasons, including a PE, but it being negative in her case basically ruled out the possibility of a clot). Her observations (or vitals, as we called it in the good old days) were all within normal limits, so her oxygen levels and her heart rate and her blood pressure and her cooking abilities were all top notch. Well the last one wasn’t (I mean it may have been top notch but it wasn’t a vital observation. Wow, I should get a degree in digression). Her pain had since then subsided, and all the rest of her blood tests including those for infection etc like a white cell count, and a CRP (both markers for infection, something that would cause her chest pain if the infection were focussed in her chest) were also within normal limits. And to top it all, her troponins were not raised either (serially done, these are enzymes which leak out into the blood to signify myocardial damage – myocardial = heart muscle), so it essentially looked like she was ready to go home.

For every symptom or complaint that a patient has, doctors and nurses and other allied healthcare professionals are trained to go through a checklist, usually a mental one (or physical, if you like to tick off or cross things off a physical paper list) of things that can cause the afore-mentioned symptom/complaint. Another checklist that they have is of a list of investigations or manoeuvres or steps that need to be taken in order to rule in or rule out certain diagnoses. This will basically decide whether or not a patient is safe to be sent home with just reassurance, or the condition warrants further investigation but non urgently and can still be safely sent home now, to be called in for outpatient investigations and assessment at a later point, or can not be sent home at all, and would benefit most from urgent or in-hospital investigations/assessments/services. As part of the checklist of ‘chest pain’, there are innumerable causes, and as part of the workup of significant chest pain (significant being a vague term, but significant enough to warrant a trip to the doctors’ or ED or to seek medical advice) a chest X-ray is very important. I had requested the chest X-ray for this patient (or ED had done so, and I took credit for requesting it, sue me) and the consultant who did the post-take with me on this patient agreed that she could indeed go home, once the chest X-ray had been done, and unless there was something absolutely horrific on it, he saw no reason for the patient to stay in. And you can well imagine, I am not writing this post just for the heck of it (well, partly, but I do have a point) and it was related to this chest X-ray, and this is where horses and zebras and hoofbeats make a cameo. But not for the reasons you probably think.

The patient came back from her chest X-ray, I looked it up, and I saw (as you may have probably guessed by now) a huge stinking mass in her right mid and upper zone of the lung. OK my radiology colleagues (and possibly most of my other colleagues) would kill me for not saying this right; I will rephrase: There was an well-defined opacity in the right lung encompassing the right mid and upper zones, extending from the hilum medially to the chest wall laterally.It could be a pneumonia but hey, with everything under the sun being normal for her and keeping in mind her strong prior history, my mind jumped to the possibility of it being a malignancy. More like…probability of it being a malignancy. I took a deep breath to calm myself, before I could step behind the curtain to break the bad news to this grandmother of 2. I was about to do so, when the consultant rounded the corner and asked me about the x-ray. Thankfully, I took him round to have a look at the X-rays before I broke the news to this patient, because this is where the twist came (and here you thought the twist had already come and gone, and that the mass on the chest X-ray in an otherwise completely normal looking patient was the twist. No it wasn’t as you are thinking, or as I thought. And boy, am I glad I was wrong!)

The consultant took one look at the x-ray (this is after I had told him that I had found something horrible on the X-ray, it could be a pneumonia but very likely a mass that needs to be biopsied etc…) and then placed his open palm very delicately to the middle of his forehead and very matter-of-factly said the magical words: “Have you asked the patient if she has had a breast implant?” My jaw dropping to the floor and my deer-caught-in-the-embarassed-headlights look told him I hadn’t. I went and asked the pleasant question (seriously, the things we want to know about!), and sure enough, she had had a mastectomy 7 years back for her breast cancer, followed by an implant. The totally non-threatening implant that I saw on the X-ray and mistook for a life-threatening infection and/or a life-threatening malignancy. The patient smiled. I smiled. The consultant laughed (cackled more like, rubbing his hands together with glee. OK I may have imagined that last part, because he was thoroughly professional, and actually taught me something I had not thought of. Chest X-rays or just any X-rays in general, just make sure you think of anything on or under the patient’s body causing that shadow, before you jump to the worst possible conclusion, for the patient, but like in this case more so for you. Very common ones are metallic sequins looking like metastatic nodules on lung; bra-hooks being mistaken for evidence of cardiac surgery; and when yours truly had the case of the misunderstood breast implant. Sheesh!

PS: I realize all the examples I have provided were related to female patients. Please don’t call me a chauvinist or start a feminists’ war on the blog. I apologise but it is midnight, and I can not think of any helpful examples from the male population. Maybe men (and their x-rays) are just …easier to read *runs and hides*