This case is seared in my memory, and it has woken me up at night, on occasion, in a cold sweat. It too has its own magic.
A 50 year old man came rushing into the rooms, saying he wanted an injection for his headache, which had come on suddenly. He was between meetings, and needed to keep functioning. He said he regularly suffered from Migraines, and this was another episode, just like the others. He had an appointment with his neurologist the following day, and simply wanted medication to tide him over until then. I was due to leave in 10 minutes to watch my daughter play a Netball match, so I was relieved that this would be a quick and easy case. Shortly, I would be on my way, and he would be in his meeting, hopefully, pain-free.
Most doctors would not simply give an injection on request. We are sticklers for taking a thorough history and doing an examination to arrive at our own conclusion as to the diagnosis and treatment. This is what I proceeded to do. His examination, and in particular, his neurological examination, was completely normal. Whilst taking a history, he told me that he had ‘stuggled to find words’ earlier in the day. I pressed him on exactly what he meant by this, and in response, he said that he was probably mistaken, and might have imagined it. I should ignore that comment. Earlier, he had mentioned that he was an editor of a newspaper, and this fact, in conjunction with the strange history about words, made me uneasy.
Migraines can cause any number of neurological symptoms and signs, so it was quite in keeping with the clinical picture. But, for some reason, I could not let it go. I sheepishly asked him if he would mind if we did a MRI Brain scan, just to rule out any underlying pathology. I explained that it would probably be normal. To my surprise, he agreed.
Before he returned from the MRI department, I got an urgent call from the radiologist who was looking at his scan. He reported that this patient had an aneurysm in his brain, that had likely just burst. We were dealing with a life-threatening problem, with only one solution. I phoned an excellent neurosurgeon, in another hospital, who had him in theatre, and the aneurysm clipped, within two hours.
He came to visit me a few weeks later. The operation had been a success, but it had taken its toll. Nevertheless, he was grateful to be alive, and was hoping to get back to work soon. I was happy to see him again, six months later, when he returned to tell me that he had recovered completely, with no residual neurological deficit whatsoever.
The magic in this story is, that for an inexplicable reason, I was compelled to urgently investigate further, even though it would have been entirely reasonable not to do so, and on an afternoon that it didn’t suit me, or him, to prolong the consultation.
So why the angst about him? I think, because it’s terrifying to think he could so easily have been sent home and died. On another day, I could well have sent him home. I feel comfort and confidence when dealing in facts. I like to think that if I am careful, thorough, and follow the rules, I won’t make mistakes. Not necessarily true. Diseases don’t read the text books. How do we live with this kind of uncertainty, especially when it impacts on the lives of others, and they put their trust in us to get it right?
There, but for the grace of God, go I.