Friday, March 07, 2008

Zebra Hunting

A good ER doc is a good Zebra hunter. A 'zebra' is a patient that has a bizarre diagnosis, often dangerous, that masquerades as a run-of-the-mill problem. You can't find zebras if you don't look for them.

A young woman with congenital deafness came in tonight after her sister ran into her at the local Wally World. The sister told me that the patient did not recognize her and was 'acting funny'. Then the step dad chimed in, "You know doc, I think she might have diabetes because she eats a whole lot of cookies, and even eats cookie dough." Hmmm.

The young lady knew the day, date, time, and place but obviously had problems talking so she appeared to be normal to me considering her deafness. The family was right though, they put me in a position where I had to do a big workup including CT of the head and I'm glad they did.

The patient has a brain tumor which is bleeding. She went off to the local tertiary care center by ambulance and the nurses looked at me like I had just derived the theory of relativity with a piece of paper and a pencil. The point of the "boy who cried wolf" story is that one day there's a wolf... or a zebra. The other point is that it's a very expensive sport.


  1. Whoa. good catch. Sometimes we discount family members' informations--nice reminder that we shouldn't take everything with a grain of salt.

  2. Wait, I'm confused.

    If I eat a lot of cookies, does that mean that I'm a Zebra? Or that I have a bleeding brain tumor?

    PS: You don't need capital letters to derive the theory of relativity with a piece of paper and a pencil, do you?

  3. no, it means you eat a lot of cookies. oreos and milk, or fresh baked toll house cookies, crispy with milk. the rest is shiite.

  4. Any focal neurology on examination??

  5. anon,

    great question. i did not do a neuro exam for two reasons. one, she walked in, so that told me a lot, but two, my off the cuff diagnosis was first break-schizophrenia and i merely did what was needed to 'medically clear' the patient.

    but given her difficulties hearing AND due to the family's insistence that she was 'not right' i knew early on i would get a CT scan, and i would have put tons of $ down on a normal result.

    another way to look at it is this, IF i had done a neurologic exam and her exam had been abnormal then i would have... ordered a CT scan.

    in retrospect, i believe a good neuro exam would have shown ataxia and dysmetria. also retrospectively, the patient told me she had been having some 'shakes' in her hand which she blamed on it getting cold one day.


  6. Dam you, now I have a headache. Good pickup, I might have made it to, but only because I pretend every patient is John Edward's cousin. You can derive the time dilation equation of relativity with a simple diagram, the Pthagorean rule, and fractions.

  7. Good job, good catch.

    I just lost a dear friend to a brain tumor. Like this lady, his friends took him to the ER cuz "something wasn't right."

    Hopefully her story has a happier ending.

  8. I remember in residency struggling through AEIOU TIPS for AMS. I then distinctly remember the chairman teaching me the concept of the "5 way," meaning blood, urine, chest xry, ekg, and ct-head. This was very liberating, hard for the zebras to escape this, $$ be damned.

  9. I'm sorry I don't get it. What kind of catch is that?
    Now if you told me you had percussed increased dullness over her cranium or heard an intracranial bruit, I'd be somewhat more impressed......
    Just a CYA catch when you get it like that 911..toodles

  10. Oldfart is a straight hater... LOL

  11. Oldfart is correct. any ER doc worth his salt would have caught this zebra.

    it's interesting for two reasons...
    1. the father was not, in fact, correct, that her daughter had caused herself diabetes by eating a lot of cookies and cookie dough (these days i'll believe anything and was fully expecting her to be in DKA without symptoms)

    2. i thought this was NOT a zebra but went through the motions because it's what i was trained to do.

    notice, oldfart, I didn't think much about myself for finding it, the nurses DID, because they don't believe in zebras, unicorns, or pain.

  12. Was I the only one who pronounced Bruit "Brute" the first time I used it during a presentation? Brew-ee still sounds gay.

  13. yes, drack, you were the only one. but it does sound extremely gay, kind of like the sound of a fart out of the massively stretched asshole of george michael.

    i did, however, witness the horror of a fourth year med student, not the sharpest tool as far as picking up social cues, tell our very famous rheumatology/internal medicine attending that the patients eyes were "perlee and eyomee." wow. he now poops from two different exits.

  14. "the nurses DID, because they don't believe in zebras, unicorns, or pain"

    My world is infinitely less stressful than yours because zebras and unicorns don't exist in it. I get to treat the horses and the zebras all the same.

    The drug seeking Migraineur, the bleeding brain tumor, and the viral meningitis will all receive the same care from me until you identify that the headache in room 17 is a loser, the headache in room 12 is sick, and the headache in room 2 needs to go to the Neuro Hospital in the Big City STAT.

    PS: We believe in pain. We don't believe in the PAIN SCALE!

  15. dearest monkey girl...
    first, go tarheels.
    second, i believe in the pain scale and you should to... it does exist, but it is shiite created by shiiteheads with nothing but shiite to do all day while drawing ther $$ from my lower lumbar area.
    third, nurses are forever telling me how so and so in such and such can't be in pain because he's asleep. well, having been on the receiving end of a bunch of titanium plates screwed into my bones and a morphine PCA pump let me correct this misperception, it is possible to appear to be asleep and still be in a fuckton of pain.
    all of this being said, no, most people have no idea what real pain is and would ask for morphine or dilala with a hangnail.
    DOOK sucks it's own penis, and it's small

  16. First, Go Tarheels! I took the night off to watch them beat the hell outta DOOK.

    Second, could you tell me on a scale of 1-10 how much a fuckton is? I'm afraid I cannot appropriately treat your pain until I have assisted JCAHO and the clipboard nurses in their mutual masturbation to the pain scale.

    Third, morphine sucks. Duh.

  17. here's where it is on the 911doc modified pain scale... increasing from 1 to ten, ten being the worst, ten being a 'frowny face with tears'...

    1 skoche
    2 weency
    3 tooth-achy
    4 bad tooth-achy
    5 pussy-full
    6 ass-load
    7 shitload
    8 balls-a-fire
    9 fuckton
    10 hillary clinton

  18. 911--I like it when you use naughty words.

    PS: If you're in pain and aren't a faking loser with "Hillary Clinton" pain, put on your call light.

  19. Nice catch!

    I had a similar patient a few years back. 14 yo kid brought in for headache. It had started the previous day and was mild "not bad" per the kid. No other symptoms except runny nose and cough. He looked great.

    As I was walking out the door to discharge him his little sister said, "well then how come he didn't know my name?". I did a neuro exam and it was normal, but decided to scan him and sure am glad I did. Large subarachnoid bleed without AVM/aneurysm. Completely a fluke thing.

    It's better to be lucky than good.

  20. 10 hillary clinton

    Ah, lovely, 911 makes me spill my coffee once again.

    Hallwayfour, your story just plain gives me the creeps. That ain't luck; that's divine intervention!

  21. One cold Camp Lejeune morning I was doing Sick Call, the daily parade of runny noses, twisted knees, and broken dreams. The last patient was a 30 something Marine Staff Sergeant from a neighboring unit, whose doctor was on Christmas leave. His headache sounded musculoskeletal, his exam was unremarkable, and being a tough guy, he hadn't even tried tylenol. The only positive finding was "Thin chart sign" a result of his only being seen for immunizations and physical exams over the previous decade. The base hospital didn't have a scanner at the time, Mr. Haney came around once a month or so with his trailer for non emergent studies. I had a bad feeling about this guy and called radiology. Nope, only hospital staff can order CTs, said Dr.X-ray, you gotta call the Neurologist. Nope, said the Neurologist, and you're an idiot for wanting a CT for a musculoskeletal headache was clearly implied but left unsaid.

  22. I had a great 'catch' like this too: Some guy died and I cut open his head and sliced up his brain and saw a tumor! I'm a genius.

  23. E, you are a genius, don't doubt it!
    You, my colleague, figured out before any of the rest of us, how to make a decent living being a doctor, and NEVER HAVING TO TALK TO THESE FUKSTIKS CALLED PATIENTS!!!Even if you never see sunlight or the outside..
    You, Sir, ROCK!!!

  24. the nurses DID, because they don't believe in zebras, unicorns, or pain.

    ROFL, true. True.

  25. No, we dont believe in pain only in those pts. who come in eating doritos who we gave dilaudid to yesterday and the day before. Everyone else we believe, well mostly, sometimes....