As some of you may recall, I did a whole lot of my PhD work at Duke Hospital, even though I was working on a PhD in computer science. As a result and at the “suggestion” of my advisor, I audited a lot of first-year medicine, which at Duke is all the classroom work there is. (Other schools have two years, but Duke pushes everything into one year so med students can be research assistants paying for the experience spend a year doing research.) But I actually spent six years in the medical school, and while I didn’t take any of the clinical work I was in the community and participating in the research going on.
People often have an unrealistic picture of medical school, based on everything from Ben Casey to Doctor Kildare to House M.D. What it’s really like is a year or two of grueling classroom work, followed by two to three years of clinical rotations that put the student into all of the various topic areas. This allows them to identify the specialty to which they aspire, see real patients with real issues that confound them, and if it turns out they can’t stand the sight of blood, direct them into psychiatry.
A whole lot of these rotations include medical proverbs that — one hopes — provide some accumulated wisdom to go with the incredible pile of just basic skills like lancing a boil or telling a bacterial infection from a virus.
One such proverb is that if you hear hoof beats, think of horses, not zebras. It’s good advice — it's too easy to subconsciously want to diagnose the unusual condition you just read about, or even better, identify a condition that’s never been reported before so it can go into the literature as Smith Syndrome, first identified by Dr. Joan Smith, and make you famous in a very minor fashion. All but one time in a thousand, or one time in ten thousand, it will be something you have seen and will see repeatedly throughout your career.
But then —
I caught this longish tweet from a young doc whose whole ambition is to be just a general practitioner treating general patients. (I’ve abbreviated this a little, but go read the whole tweet, and then upvote her for being a good doctor indeed.)
I saw a young male patient], a firefighter with a wife and a toddler. He saw me at an after hours clinic for neck pain and a headache. This happened after he climbed 10 flights of stairs carrying 100lbs of gear during a fire rescue. It could have easily been dismissed for a neck sprain.
As she says, it sounded pretty mundane — a neck sprain, properly treated with NSAIDs like aspirin or ibuprofen, heat, and rest.
But he didn’t seem to be the sort to go to the doctor with just some neck pain. It didn’t ring true, and her doctoring instincts made her suspicious.
But that wouldn’t make sense. He wouldn’t come to me for just that. He wouldn’t have such urgency in his voice. He’s tough. He’s a firefighter. He’s fit and active. Surely he knows what a muscle sprain feels like. No, there had to be something else.
She examined him for neurological issues, and found nothing, but — still suspicious — sent him for a CT.
I didn’t know what I was looking for. “New severe atraumatic neck pain and headache. Rule out…” I pondered what to write on the requisition. Rule out stroke? He had no focal neurologic deficits. Rule out hemorrhage? He had no head trauma. Finally I settled on “Rule out neuropathology.” The radiologist would just have to figure it out.
Three days later he had his CT, and the results showed a right vertebral artery dissection.
In other words, one of the major arteries that supplies blood to the brain had partially come apart, and blood was pooling between layers of the arterial wall.
The stroke team was paged, he was seen promptly by neurology, put on Aspirin, and given 3 months of sick leave to recover. They believe it was caused by strenuous physical exertion, and had he been left to continue working this way, it would have inevitably lead to stroke (and permanent stroke damage), or death.
In medicine, this is known as a Bad Thing.
In fact, the neurologist said this was the first time he’d ever seen such a case of dissection caught *before* a stroke, or *before* death. It is normally a post-mortem diagnosis.
His actual family doctor later reached out to me. She saw him in follow up and said she doesn’t think she would have ordered an urgent CT in his case. He had apparently come in and expressed his gratitude for “the after hours doctor who saved my life.” What’s more, his wife is pregnant. His second baby is on the way, and he will live to see the day
Now, imagine this had happened to another patient who had the CT, and the radiologist and neurologist concluded that it was indeed just a neck sprain. This could have been a story about wasteful and expensive procedures ordered by a young and inexperienced doctor.
Instead, it's a story of a young man who was going to live to see his second child.
The moral of this story is that sometimes it really is zebras.
