A Country Doctor Writes:

Ron Beck has a bad back. Sometimes he gets a bout of sciatica. It usually gets better after a week of prednisone.

Over a three day weekend, Ron went to the emergency room twice. The first time he got a shot of Toradol that did little for his pain. The second time, he got X-rays, some basic lab work and a prescription for prednisone and an urgent message for me to order an updated MRI as soon as possible. That message reached me late morning.

I called him up to see how he was doing. He was still in a great deal of pain and his leg had given out under him. But his leg did not feel numb, his back did not hurt, even with coughing, and he had full control of his urine and bowels. And then he told me his toes were blue.

I told him to come right over. His wife drove him.

On exam, his left leg seemed a little cool. His toes were indeed slightly bluish. I could not feel a pulse on top of his foot, at his ankle or even behind his knee. I listened for a long time with my pocket Doppler. There was no pulse.

I have seen a couple of cases of acute limb ischemia where the patient was in a wheelchair, writhing in agony. Ron was uncomfortable but not in agony. And this was day four of his leg pain.

“I’m worried that you’re having a vascular emergency that will need emergency surgery in Bangor. You will need a CT scan of your aorta and the blood vessels to your legs. So I want to send you to the hospital by ambulance”, I said.

“Anything, Doc”, he answered as his wife stroked his hand.

The staff called 911 and I called the emergency room. I told the doctor on duty what was going on.

“Well, if that’s what’s going on”, he said, “you’re better off sending him down the road to Mountainview Hospital, because our scanner is down and may be for the rest of the day.”

“Will you be medical control and order the crew to give him some analgesia on the way”, I asked.

“You’ve got it, we’ll keep him comfy on the way.”

A few hours went by.

“Look at this”, Autumn said as she handed me Ron’s report from the Mountainview ER.

The note said Ron had a palpable pulse on his left foot with good capillary refill. They did an ultrasound to rule out a deep vein thrombosis and sent him home. “Needs urgent lumbar MRI”, it ended.

“How are you feeling”, I asked him on the phone.

“Better, whatever they gave me finally helped the pain fairly well”, he answered.

“I’m still worried about your circulation”, I told him. “Let me see if I can get a CT scan anywhere.”

My hospital’s scanner was still down. Mountainview had no openings until the following week and neither did the only other hospital within 50 miles of us.

I called the vascular surgery office in Bangor and was able to speak to one of their doctors.

“I’ve never seen limb ischemia this outdrawn before, but I’m sure that’s what he has”, I said.

“Well, he’s had this for several days now, why don’t you just have him see me here in our clinic first thing tomorrow morning. We’ll do some noninvasive studies and take it from there.”

His pulse volume recordings were flatlined and his CT showed critical iliac stenosis. He had surgery and his limb was saved. I reported the case to the Chief Medical Officer of Mountainview Hospital.

Sometimes when you palpate for a pulse you can feel your own instead. And sometimes when examining a patient you find what you expect to find. A man with recurrent sciatica might be just another episode of the same thing. And an older doctor in a small rural clinic may just be an overreacting alarmist, looking for Zebras. But not this time.