better to be lucky than good

We were going to do a CEA carotid endarterectomy the other day. This guy's whole story started when he told his PCP about some foot numbness and tingling. For some reason, the PCP thought a total body CT scan would help. It didn't deliniate the source of the numbness, but it did find a mass in the right kidney.

A urology consultation was promplty obtained. When the urologist heard about his neurologic symptoms, which now included intermittent bilateral lower extremity paralysis and aphasia upon wakening, he very appropriately ordered an ultrasound study of the carotids, thinking that he was having transient ischemic attacks. This demonstrated bilateral carotid disease with the right side having greater than 75% stenosis. With or without symptoms, a 75% stenotic lesion is enough to prompt an endarterectomy.

The only problem was that his symptoms really didn't match what was going on. To have one stenotic area cause symptoms in both extremities doesn't make sense. And to have a aphasia, usually the lesion has to be on the left side, not the right.

Fortunatley, the attending who originally decided this guy needed a CEA couldn't do the case and he found a different surgeon. I'm so glad, because I kept telling the other attending, "I'm not sure we can attribute his neurologic defecits to his carotid disease." Which for a resident speaking to an attending is actually saying, "Hey! Red flag here! I don't think we should do this! We need further work up!" All of my protestations were very quickly dismissed.

This new surgeon (who is infintely better than the orignal attending) recognized the problem right away. He pulled me aside in the preop area and told me what I already knew: his symptoms didn't match his carotid disease. He wanted to postpone the surgery and get an MRI because he has a known renal mass, which is presumably malignant and he was worried about metastatic disease in the brain causing these problems.

So we got a stat MRI. It didn't show mets. It showed an acute on chronic subdural hematoma. Turns out the patient was riding his bike a few months ago and he fell. Shortly after that all his neurologic symptoms began.

If we had actually gone through with the CEA, he would have received heparin during the surgery as anticoagulation. It's routine. But for him, it would have caused him to bleed more in his brain. He could have herniated right there on the table and died.

When the second, better attending was told about all this, he simply said, "Well, I guess it's better to be lucky than to be good." But his skills as a clinician were evident. No luck there. Perhaps he meant the patient.