Bad Dream. Amazing!
Some time much later Dr. Frank Martin had been called another evening, again after hours, to see a 7 year old boy who had been admitted to another hospital at the other end of town, hospital Dr. Martin normally did not go to, though he was nominally in its Consulting Medical Staff. A trusted pediatrician friend of his had asked him -please!!!- to see “this young man who has odd complains about his back, does no walk well and we just don’t know what’s wrong with him. We’ve done X-Rays of his spine but they don’t show anything abnormal. His family are up here visiting from the big city, and I hear they have some social issues. We need a good expert! Frank, can you please take a look? I’ll appreciate it.”
So around six o’clock, instead of going home where supper was waiting, Dr. Martin went to the hospital to see the young man. He was in the pediatric floor, in a room by himself, his mother at his side. The complaint of low back discomfort was not accompanied by any clear meningeal or protective sciatic nerve signs. He checked him well all over with a full neurological examination lying down and sitting up and, again, he found nothing. Then he had him walk around the room and even all the way down the long hall and all he noticed was an odd lurching of his shoulders, at times jerky, other times to either side. Occasionally he would move his hips sideways without seeming to lose his balance about to fall… The doctor also took a long personal and family history, remaining with him till about 8 o’clock. And yes, his family was ‘dysfunctional’ the parents having just split a month earlier after much fighting. Dr. Martin was baffled. He wrote a long note concluding, somewhat unsure of himself, that the boy had a hysterical gait and that otherwise all was fine.
Then he went home for supper. It was nearly 9 o’clock. He discussed the case with his wife Isabel, herself a rehab R.N., but she did not have any other ideas of what might be wrong with the boy. He still felt uneasy with himself. Both went to bed by 10:30, both planning to be up at their usual 5 am…
At about 2 am Dr. Martin suddenly awoke and sat up agitated as if he had just had a nasty nightmare.
“What’s the matter?” asked his wife, startled.
“I think I may have missed something important with our young man. I just had a dream about his having ‘something’ inside his spine, perhaps something malignant. I better go back right now and check him again. I rather do it right now because in the office I have my first patient at 7 o’clock…”
“You can’t just go by a silly dream… You already checked him well… And he already had negative X-Rays…”
“Well, plain X-Rays don’t tell us that much, especially of soft tissues. If my suspicions of this dream get stronger when I recheck him, I’ll do an MRI.”
“If you feel you must, go ahead. I’ll see you later in the office by 6 or 7.”
Without bothering to shower and shave, even if it would take him no time, he was quickly on the road by 2:30 am.
The nurses were surprised to see Dr. Martin, an infrequent doctor in the ward of that hospital across town, and at such ungodly hours.
Nicolas was asleep and so was his mother, in a recliner next to him. He awoke the mother first and told her that he couldn’t sleep, concerned about her young man and that he wanted to recheck something he already had examined a few hours earlier, but a bit more carefully this time. He wanted to recheck the boy for meningeal signs, this time specifically looking for the Lhermitte’s sign and even for the Lasègue’s sign, this time being a bit more forceful than he had been earlier when he had checked for the same. [In Lhermitte’s sign, I hear, the examiner flexes foreword the patient’s head; if positive, due to some form of meningeal or cervical spine problem, the patient, often with a grin, reports an electric-like pain down the body. In Lasègue’s sign, if positive, the patient reports pain when the examiner elevates his bent leg and then straightens his knee. Here in the US, neurologists now call those Kernig and Brudzinski’s signs].
So Dr. Martin carried out both maneuvers gently with the boy still asleep and laying on his side. He did not trigger any clear sign of pain but the boy did wake up when he did the Las ègue’s maneuver.
“Good morning Nick! I am sorry for waking you up this early in the morning. I just need to check something that I did before but I am going to be a little stronger this time. It didn’t hurt you when I just did it, did it?”
The boy shook his head. Then he repeated the neck bending bringing forcefully his chin to his chest. This time Nicolas clearly brought both shoulders up and said ouch!
“Where did that hurt?”
“Down my back,”
Dr. Martin then went on to repeat the second maneuver -this time with the boy laying flat on his back- raising pretty high the boy’s one leg with his knee bent (no pain then) but then, all of a sudden, straightening his knee so his foot was way up in the air; THAT brought in Nicolas an immediate ouch! as he brought one arm to his hip and straightened his back. Both mom and the nurse in attendance were very impressed. He repeated the same maneuver with the boy’s other leg and got the same result!
‘I am right! My dream told me exactly what was going to happen. This is not hysteria. I bet he has something pressing his spinal cord inside his spinal canal! He explained to his mother the best he could what he needed to do -basically an MRI of his spine- and perhaps, if his suspicions proved right, probably some surgery with a biopsy.
“We don’t have neurosurgery residents in this hospital. I’ll need to transfer him to the neurosurgery service of the University Hospital, if it is OK with you, ma’m, and if I can at this odd hour of the night. I’ll have to make a phone call to see if the admitting resident lets me… AND if he has a bed. “
So Dr. Martin got to the nuisance part of the task right away: The phone call to the resident (he was there but the floor nurse had to wake him up) and to the Radiology Department. And not just he had to find out if the MRI was possible then, but also to see if a known neuro-radiologist there would be available to read it as it came out. And then he had to write his note in the chart, the transfer order from one hospital to the other and he had to fill out a transfer formality form. The Nurse would take care of the transportation arrangements by ambulance and the copying of the chart to go along with the patient and his mom.
They did have a bed in the neurosurgery floor of the other hospital and the resident accepted the boy. And Nick would be having an MRI of his spine (actually two, one for the upper, one for the lower part) as soon as he got there…
By the time it was all done, it was just about 5 o’clock so Dr. Frank Martin did not bother going back home for a short nap. Instead, he followed the ambulance across town to the University hospital, parked his car by the ‘short term ER’ and sat in the radiology reading room as the MRI was being done and the films were coming out. He was taking a peek too at the MRI console screen over the tech’s shoulder.
And yes, it was very abnormal: The boy had a long, amorphous soft mass all around his spinal cord filling the canal between the vertebrae from mid cervical to the bottom of the dorsal spine. His awful hunch, his dream, his bad nightmare, had pointed the way. Amazing! He had not even done a spinal tap as in the previous “Eddy’s” case where his hunch had been not of a mass, but of meningitis. The neurosurgeons would be doing a biopsy of the mass, probably with a limited open surgery, instead of a ‘transcutaneous,’ blind tap.
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Dr. Martin would later hear, with Nicolas still in the neurosurgery floor, of the results of the open biopsy with the tissue diagnosis: A nasty, Non-Hodgkin’s’ Lymphoma. The pediatric hematologist-oncologists would take from there and brought him down to the pediatric floor as the long mass, insinuated around the boy’s spinal cord and around so many nerve roots, was quite inoperable. He would have instead radiotherapy and aggressive chemo. The clinical process by which they had arrived at a diagnosis -just Dr. Martin’s overnight dream, a nightmare, a ‘hunch’- was never acknowledged, praised or discussed by his ‘academic’