The patient had a headache, and I didn't feel so well myself

Faced with a tough call on a potentially fatal condition,the author went all out. When he found out more about his patient, he knewhe'd made the right choice.

By Thomas J. Richards, MD, Family Physcian/ Ventura, CA

I was working as a staff physician at the small Lake Hospital in YellowstoneNational Park several years ago when the phone rang at the nurse's station.Nobody else was available, so I took the call myself.

"Lake," the caller began, "this is the clinic at Mammoth.Our ambulance just responded to a 43-year-old man who awoke this morningwith a severe headache and neurologic symptoms."

"What kind of symptoms?" I asked.

"Difficulty speaking and inability to use one arm."

"Do you have vital signs?"

"Yes: pulse 92, BP 170 over 100, respirations 22, temp 97, and roomair sat 91. They're putting him on some oxygen and establishing a line.You want anything else?"

"Can you get a report on his mental status? A Glasgow score?"

I waited while the caller talked to the ambulance crew.

"He's alert but anxious. GCS is 15. He's complaining of numbnessin his right arm, but moving all his extremities."

"Have the crew do vitals with neuro checks every five minutes. We'llbe waiting for him."

Lake is the only hospital--along with two small satellite clinics--inthe 2.2-million-acre Yellowstone Park. It's open from mid-May through mid-September.Since that's when most of Yellowstone's more than 3 million visitors showup, it can be very busy.

Mammoth Hot Springs is nearly 50 miles away, so it would take the ambulancean hour to make the trip, assuming it didn't run into any heavy touristor bison traffic. Meanwhile, I had other things to do, including removinga fishhook from one patient, the most common procedure at our ER.

After about 45 minutes, the ambulance driver called in a report: Thepatient's vital signs were stable, except for slightly elevated blood pressure.His arm was still somewhat numb, but getting better. There were no new neurosymptoms.

When I heard the ambulance's backup alarm, I headed for the ER. Our patientseemed okay. He was looking around, responding appropriately, breathingsteadily, not sweating. The crew gave me a final report as the nurses wheeledJohn Morgan, as I'll call him, into the nearest exam room.

I introduced myself to Morgan and his wife, who had accompanied him onthe trip. They were a pleasant couple in their 40s who looked appropriatelyconcerned about this unfortunate interruption in their summer vacation.

"So tell me," I said, "what happened this morning?"

"I really don't know," Morgan replied. "I just got thisincredible headache, and then my right arm got weak and felt funny--kindof numb and tingly."

"He couldn't talk normally either," Morgan's wife interjected.

"How do you feel now?" I asked.

"Pretty good. Back to normal, really. What do you think it was?"

Years ago, when patients asked what might be wrong with them, I wouldrun through a differential diagnosis. But that approach--which commonlyincluded a few catastrophic possibilities--scared the daylights out of people,so I don't use it anymore. Instead, I deflected Morgan's question by asking,"How does your head feel now?"

"Okay," said Morgan.

"Where did it hurt?"

"Right here," he said, putting his hand on the left side ofhis head.

"How long did the pain last?"

"Maybe a couple of minutes."

"Do you get headaches very often?"

"No."

"Ever had one like this before?"

"No, this pain was worse than anything I've ever felt--like someonesticking an ice pick in my head."

"Is your arm still tingling or numb?"

"No."

"Tell me about the trouble you had speaking."

"Well, it was like I knew what I wanted to say, but I couldn't getthe words out."

"Any trouble speaking now?"

"No. Like I said, everything seems to be back to normal."

The rest of Morgan's history was unremarkable: previously healthy andfeeling well, using no medication. The only item of interest was a cousinwho had died suddenly in her 30s from some sort of cerebrovascular disaster.

I was about to begin my physical exam when another question occurredto me: "Were you doing anything in particular when the headache began?"

Morgan seemed unsure what to say. Then he asked, nervously, "Isthat important?"

"It may be," I replied.

"Well," he said, looking at his wife, who also looked uncomfortable,"we were making love, and the headache started just as I climaxed."

"Hmmm," I said. "Thanks for being honest with me. Nowlet's have a look at you."

I did a careful physical, hoping to find some clear pathologic sign orsymptom. No such luck.

"We have a decision to make," I told Morgan. "I'm notsure what happened to you this morning. There are several things that mighthave caused your headache and other symptoms. Some of those things aren'tdangerous. But a couple of them are, and potentially fatal. From the storyyou've told me and the exam I just did, I can't tell which group your problemfalls into. The only way to be sure is to do a CT scan or MRI of your brain--whichwe can't do here."

"What is it you're worried about?" Morgan asked, forcing meinto a moment of wonderful intensity: no posturing, no hidden agendas, justone-to-one human honesty.

"It could be an aneurysm," I told him. "Or it could bea brain tumor that's bled a little and might bleed a lot more in the future."

"Where would I go for the test?" he asked.

"The closest place that can do the test and treat the problem, ifnecessary, is the regional medical center in Idaho Falls."

"How would I get there?"

"By helicopter. It's too far to drive, more than 100 miles. If youdo have something bleeding into your brain, I want to get it diagnosed andtreated as quickly as possible. I know it'll blow a hole in your vacationbudget unless you have insurance to cover it. But you can always make moremoney, and you can always return to Yellowstone. The park isn't going anywhere."

Morgan and his wife looked uncertainly at each other, and I gave thema few minutes alone to talk it over. When I returned, Morgan said, "Okay,I'll go if you really think it's necessary."

"I do," I said, and left to call the regional medical centerin Idaho Falls. I don't bother to seek insurance company authorization whensomeone's life may be at stake. (In this case, Morgan's insurance eventuallycovered the cost.)

I spent part of the hour or so it took the helicopter to get here chattingwith the Morgans. When I asked him what he did for a living, he repliedthat he was a lawyer. I tensed a little, a visceral reflex I can't help.I've never been sued, but there's always that lingering fear.

"Oh," I said pleasantly, "do you specialize in any particulartype of law?"

"No, just general law."

I couldn't help thinking that would include malpractice. Suddenly I foundmyself hoping that the helicopter would arrive quickly. Then I asked Morgan'swife about her occupation, and she replied, "I'm a lawyer also, butI do more corporate law."

"Are there other lawyers in your families?" I asked.

"Just my aunt," said Morgan. "She was still practicingin her 60s, but she had a stroke."

"I'm sorry to hear that," I said, wondering why he hadn't mentionedhis aunt earlier when I had inquired about family medical history.

"She'd have been okay," Morgan continued, "if the doctorshad listened to her when she first started having problems."

"Now we don't really know that, honey," said Mrs. Morgan.

Seeking a quick escape, I said, "I think I'll go check on that helicopter."When it finally arrived, 15 long minutes later, we loaded Morgan aboardand saw him off. He got a complete workup in Idaho Falls, including an MRI,and was discharged with a diagnosis of "coital migraine"--definitelynot a life-threatening problem.

Looking back, though, I'm still glad I decided to have Morgan transferredto the regional medical center: because it was the right thing to do, notbecause he was a lawyer.

Okay, I'm a little extra glad because of that.

Thomas Richards. The patient had a headache, and I didn't feel so well myself.

Medical Economics

1999;23:123.