As a medical student, you get asked a lot of questions, and you get pretty used to being wrong. Not all the time, but a lot of the time.
What’s important though, is that you have enough confidence to keep answering those questions, and to keep trying, because every now and then you will get it right and when you do, it’s a good feeling.
It’s also very important to ask your own questions, because no matter how silly or trivial, they will always help your learning. It can be incredibly difficult to raise your voice, especially in front of some specialists or around your peers, but, it’s best to do that now when you’re a student and you can get away with it.
Today I asked some questions regarding a patient, and I’m really glad I did.
Lower back pain is a ridiculously common compliant, something that a huge proportion of the population will suffer from at some point in their life and something that all GPs see daily. It’s vital though, that when assessing for lower back pain, to check for any potential red flags - symptoms that are particularly important and concerning, but can sometimes be missed.
This morning we saw a patient who presented to the ED by ambulance with some pretty severe lower back pain and stiffness after bending over last night. He was middle aged, history of lower back pain, no trauma, no systemic symptoms and nothing of real concern. He was admitted for pain relief but due to his history, no one really seemed concerned.
I was a bit worried that there was no actual examination or investigations performed and that I felt both were required due to the nature of the pain. Unfortunately, when I voiced these concerns to the doctor, they assured me they knew the patient and this was a routine acute lower back strain, similar to what they had in the past.
6 months ago, I would’ve nodded and continued along, not giving it a second thought, but things are different now, so I went back to see the patient for a chat.
A lower limb neurological examination showed his lower back pain wasn’t the same as his previous episodes. The pain was radiating down one leg, he had significant motor and sensory weakness down one side including loss of reflexes, he had been unable to void his bladder since he hurt his back, and when asked directly, stated that he had some numbness around his rear - all of which are red flags for a serious, time critical neurological condition known as cauda equina syndrome.
After making a call and presenting these findings to the doctor, a quick CT scan was ordered, confirming what I had found - the patient had herniated his disc at L5/S1 with some compression on the nerves.
Less than an hour after the CT was ordered, the patient was being transported to a larger tertiary centre for management and potentially surgery.
In this case, the familiarity between the doctor and the patient combined with the stoic nature of the patient and the past history, meant that a full history and examination wasn’t performed, and the diagnosis potentially missed. Fortunately for me I’d never met the patient before, and I’ve spent enough time with this doctor to be able to confidently question something, even if it’s just for my own knowledge and development. As a result, I was lucky enough to stumble across quite a serious emergency, and I was able to help that patient out.
I’m sure there are many, many, many medical students like me out there who are overly-aware of all the most serious medical problems that are highlighted in lectures and in textbooks. We are taught to always think of them first, despite the fact that they’re rarely the case.
But, if you are like that, make sure you satisfy your own thinking, whether that be asking a few more questions, performing a quick examination or asking about a certain investigation - Make sure you speak up, because you’ll learn far more from it, and you might just be able to help someone.
I need to sleep, but I’m going to be awake all night now.