Rural and Frontier Medicine
Hearing hoof beats, looking for horses and finding a zebra
Words • Wendell Ellis with Chrysanne Grund
As most rural and frontier physicians are aware, when a patient presents a cluster of symptoms there is usually a common diagnosis that fits the clinical presentation. There are occasions when a much less common or even remote diagnosis can fit the clinical picture. The rule of thumb is that if it looks like a duck, walks like a duck, talks like a duck, it is a duck -- unless of course it is not. When it is not a duck is when the challenge of rural medicine is often most pronounced as it can be difficult to access appropriate care for your patient.
In December 2005, an established patient came into the clinic with neck pain. The patient, a 67-year-old rancher had been experiencing pain in his neck and shoulder area for about a month. The pain increased with sudden movements but was eased with cold packs and warm showers.
On clinical exam, the patient was noted with spasm of the sternocleidomastoid muscle with significant pain to palpation in this area. He was diagnosed with a musculoskeletal condition and started on muscle relaxant, narcotic pain medication and non-steroidal, anti-inflammatory medication.
The patient was scheduled for a follow up appointment for the following week and instructed to contact the clinic if not improved. When the patient returned for his follow up appointment, he reported some improvement with less pain and improved motion in his neck. The patient was continued on his medication and given a follow up appointment to check back in one to two weeks if not improved.
In January 2006, the patient went to the emergency room with severe pain. His pain was noted at the base of the skull and extending down the right neck, shoulder and arm. An x-ray and CT scan of the C-spine were completed and even upon my personal review, the abnormality was evident. The patient was placed in a rigid C-collar while awaiting the films presentation to the radiologist via tele-radiology equipment. The CT revealed a lytic lesion with extensive bony destruction of C2. The etiology, of course, at that point was unknown, but the need for immediate follow up was obvious.
Over the previous 12 years I have had the opportunity to develop several key relationships with specialist in various fields. At this point I was able to contact him with the information he would need to make an adequate decision regarding recommendations to make. The information I had: I have a patient with a lytic lesion at C2 and a potentially unstable cervical spine. His glorious recommendation: Send him to me.
Due to our remote location, out of helicopter range, the fixed wing air ambulance service was contacted and emergency transfer was accomplished without difficulty or complication.
One of the challenges of a rural or frontier practice is obtaining the appropriate care for your patient in a timely manner when skills beyond your own ability are required. At times, access to these specialists can be difficult, and key relationships developed over time can be a strong benefit to your patient’s care. Even though my neurosurgeon was not the final care giver for this patient, who required chemo-therapy and radiation therapy but not surgery, he was willing to coordinate this patient’s care and assist in the patient’s final positive outcome and experience. +
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The University of Kansas Medical Center