Back Pain, Back Pain, Back Pain
Back Pain #1
It was 1983. I was in the National Health Service Corps in a small town in Minnesota. The western border of the town is a river. Several miles beyond that river is a Federal Corrections facility. It’s a medium security prison with an imbedded maximum security facility for “mob snitches”. Because I was the only board certified Internist for 60 miles, I did consults there for the infirmary, which was run by a surgeon and about a half dozen Physician Assistants.
When a prisoner got ill enough, the prison sent the prisoner to our hospital. The prison would hire security guards to sit outside the door and “guard” the prisoners. These guys were usually retired and overweight. They mostly played cards and joked with the staff. There were stories about prisoners who were patients in the hospital. One of the most colorful was when a pickup truck drove up to the window of the hospital room in which a prisoner was staying and the prisoner jumped up, threw a chair through the window, jumped out into the pickup truck and they sped off, a complete jailbreak getaway.
It was different when one of the “snitches” was admitted. There was a room at one end of the hospital that had bars bolted to the outside of the windows. They put the maximum security prisoners in there and the guards were real Corrections Officers wearing flack jackets and carrying Uzi’s. Obviously, they feared a drive by shooting or something like that. We always wondered and joked about the fact that none of us (hospital staff) were ever offered a flack jacket when we were in that room.
Anyway, I got a call from the prison infirmary that they were coming in with a prisoner with back pain not responding to outpatient treatment. Of course, the prison infirmary staff thought he was malingering. Since half of the prison population went through the infirmary every day, they thought just about every one of them was malingering.
The prisoner was a 40-something black man with a lot of tattoos. This was unusual in 1983. We called him the Tattooed Man. He had been stabbed in the back in the past and had lost one of his kidneys. I did an admission history and physical. He was a pleasant guy who was deathly afraid that he had a serious kidney problem and was going to lose his only remaining kidney. I ordered the usual admitting labs and x-rays. Nothing was abnormal. I did an IVP (a now much less used imaging test for kidneys) and it was normal. Other than some tenderness in the lumbar area of his back, his physical was normal. We put him in a physical therapy program for five days and discharged him back to the prison.
Two weeks later, I got a call from the prison that they were bringing him back in; his back pain was worse and they couldn’t do anything for him. Of course, I’m wondering what the heck I could do for him, too. His readmission physical exam was still unremarkable except for some lumbar area tenderness. He was more anxious now about losing his kidney, even though his recent kidney test was normal.
Except…..this time something wasn’t normal.
I got a call from the lab technician asking me to come down to the lab. She wanted me to look at this fellow’s Complete Blood Count (CBC) and blood smear. I had a fair amount of experience reading blood smears because I personally looked at the blood smear of every patient I admitted during training and did six rotations through Hematology-Oncology. She motioned for me to look at the smear saying, “There is something seriously wrong with this guy”. His white blood cell count was over 50,000 (normal is up to 12,000). In his smear were “blasts”. These are immature precursor blood cells not usually seen in a person’s blood. In addition, the blasts had “Auer rods”, which are diagnostic of Acute Myelogenous Leukemia (AML).
I called the prison infirmary, told them what I had seen, gave them my diagnosis and told them this prisoner needed to be transferred immediately to the prison system’s tertiary hospital in Springfield Illinois. I went up to the Tattooed Man’s room and gave him my diagnosis. He thanked me for figuring out what he had. I guessed that his back pain was due to the expansion of his bone marrow in his vertebrae. The prison flew him out to Springfield the next day.
Three weeks later the infirmary surgeon called me and told me he had died.
Back Pain #2
It was 1986. I was now in New Hampshire. I was doing evening clinic. A 25 year-old man came in complaining of back pain. It just came on, he didn’t do anything to strain his back. He’d had it for about two weeks. He was healthy with no medical problems and had never had back pain before. His exam was normal except for some lumbar back tenderness.
This rang a bell in my head and I remember the Tattooed Man. I had the lab do a CBC. It was normal. I was feeling like I was being a little ridiculous about ordering the test. It’s not a test you order for back pain. I gave the patient a prescription for 800mg ibuprofen and taught him William’s back exercises. I told him if he wasn’t better in two weeks he should come back for a recheck.
I was in evening clinic two weeks later. The 25 year-old man came back in continuing to complain of back pain. It was worse. His exam was the same and he had no new symptoms. I felt compelled to order that CBC again. As I was coming out of another patient’s exam room, the lab tech was standing there in the hall. “I need you to come and look at this CBC and blood smear,” she said.
I went to the lab and saw that his CBC had a White Blood Cell count of 30,000 with blasts. I looked at the blood smear and the blasts had Auer rods. I could have been knocked over with a feather. Another Acute Myelogenous Leukemia presenting with back pain.
I had to go back to the patient’s exam room and explain what I found and what it meant. I then called Massachusetts General Hospital, got connected to the Heme-Onc resident and got the OK to send him down that night.
He got chemotherapy at Mass General and was in remission when I saw him next. He thanked me for figuring out what was going on. The Oncologists said the fact that his condition was diagnosed so early it gave him a better prognosis. They had never heard of AML presenting with back pain.
I left that practice and never heard how he made out. AML is not a good diagnosis. I always presumed he didn’t live long, but I have no idea.
Back Pain #3
It was 1991. I was in the Twin Cities, Minnesota. A 28 year-old woman I’d seen once or twice for health maintenance check-ups came in complaining of back pain. She didn’t do anything to hurt her back. She never had back pain before.
I performed a physical exam and her exam was normal except for some lumbar back tenderness. I’m getting flashbacks to the two patients above who had a similar presentation. Again, feeling a little foolish, I ordered a CBC. It was normal. I prescribed ibuprofen and taught her William’s exercises. I told her to come back in two weeks if her pain was not better.
Two weeks later, she came back in complaining of persistent back pain. Her exam was the same. I ordered a CBC. It was normal. I ordered a two-week course of physical therapy. I told her to come back at the end of her physical therapy sessions for a recheck.
Two weeks later, she came back in still complaining of the back pain, it was not any better and maybe worse. Her exam was the same. I ordered another CBC.
I got a call from the lab tech asking for me to come to the lab. Now, I was actually having an anxiety attack on the way to the lab. I looked at the CBC results and her WBC count was over 40,000 with blasts. Her blood smear blasts had, yes, Auer rods! Yikes! Another one!
I went back to the patient’s exam room and told her what I found and what it meant. I called the Oncologist and had the patient directly admitted from my office to the hospital for treatment.
For those of you who have never experienced a leukemia “induction” (that’s what they called getting high dose chemotherapy that totally wipes out your bone marrow), the patient spends 4-6 weeks (depending on how fast a patient’s bone marrow recovers) in one room in “isolation”, meaning only staff and family can enter the room and they have to be gowned, gloved and masked to prevent transmission of infection to the patient. Every other day and every weekend day I was on call, I stopped by the hospital (which was a different hospital from the one where I admitted 99% of my patients), reviewed her chart and paid her a visit. It was usually a 10-15 minute visit. She was always ingood spirits, never “down” or depressed. It was strictly a “social” visit, I never actually ordered anything for her.
She survived her induction and was sent home, but, within a month, her leukemia was back. This is always a bad sign. Again, I visited her every other day and every weekend day I was on call. About three weeks into her second induction, she got acutely ill with infection. I got a call from the Oncologist while I was in clinic informing me that she had died. It was the first week in November.
About a month later, I was seeing patients and I saw that my next “patient” was the family of this leukemia patient. We doctors always fear that something went wrong and we are about to get sued when we see something like this. I cautiously enter the exam room. There were four family members there. They explained that they were there to thank me for taking such good care of their deceased family member. I stammer out something like, “Well, I really didn’t treat her, the oncologists did everything.” One of them looked at me and said, “She always considered you to be her doctor. You were the one she identified with. We’re also here to give you something.” She handed me a Plaster of Paris ghost statue with a cast on the right leg. “She made this for you for Halloween, but she became too sick to give it to you. We wanted to make sure you got it.” I was gob-smacked!
They thanked me again and hugged me.
I still have that little Plaster of Paris statue. It’s always been a reminder to me of the power of what the patient-doctor relationship can be. If you care enough.
Here’s a photo of the statue. I keep it on my dresser.
Epilogue
I never had another patient like these three. I never ordered another CBC for a back pain patient because I never had a patient with that exact presenting story. My oncology colleagues always thought these stories were unusual, almost unbelievable. But that’s the part of practicing medicine that makes it worth-while. It’s not really the money. It’s experiences like these and patients like these.