COTW: Arm Paralysis

(from Eric)

3 weeks ago, I was covering Urgences (i.e. the ER) in Carlan’s absence, and the nurse showed me a new case.  He is a 60 year old man, very polite despite his problems, laying flat on his back, with arm paralysis, specifically bilateral shoulder and elbow paralysis, though he could still shake my hand weakly.  He said it had been there for a few weeks, and he had gotten some injections at another hospital that had helped, but now it recurred (which I doubted then, and I still doubt now).  

I examined him and found more or less what he said:  flaccid paralysis in the shoulders and elbows of both arms, no spinal deformity, but an odd bulging of his lumbar spine, which he said was painful, though he didn’t complain of leg problems, just general weakness.

I was wishing for an MRI, so I could look at his spinal cord, and wondering what on earth we could do to diagnose or treat this guy.  His lumbar spine bulge could have been TB of the spine, but it didn’t explain his arm symptoms, since a spine problem there would only affect his legs and bowel and bladder function.

So I ordered an xray of his cervical spine and another of his lumbar spine, and sent him off to our temporary xray tech: Jason.

Several weeks ago, we inaugurated our digital xray system here at Kibuye.  It seems out of place, in our otherwise very basic hospital, but Jason prioritized it on the grounds that it will save the hospital money, improve record keeping, and hopefully improve the quality of our films.

Digital X-ray at Kibuye

But the only guy in the department that could work a computer was getting married and was gone for a few weeks, so Jason became the xray tech, and so he took the films of my patient.  I didn’t really expect to find much, since only the bones are visible, and I though the heart of the problem was in the spinal cord.

Mais voilà!  However, we found that our gentleman had compression fractures in both his cervical and lumbar spine, at levels which could certainly explain his systems.  He was placed on some steroids, while we pondered what to do.

What caused this problem?  He’s not a really old guy, with no other evidence of osteoporosis.  It doesn’t look characteristic of multiple myeloma.  TB of the spine?  In two locations?  I’ve never seen that.  We checked his HIV status, and I emailed two Tenwek friends with more experience than me, and they both responded in the same fashion:  They have never seen TB of the spine in multiple locations separated by such a great distance.

So what is it?  Probably cancer.  Metastatic from somewhere.  Where?  Does it even matter?  We certainly can’t treat it at this advanced stage.

He stayed on our service for 2 1/2 weeks, each day polite and gentle, even when he lost his ability to shake hands.  Several times, he quietly suggested that we change his medicine, because the present one wasn’t helping.  We again explained that, unfortunately, there are not any other ones to give him.  His wife stayed with him, and continued to meet me with a smile each day.

Monday, we sat down and talked more in depth.  We explained that we have nothing further to offer, and that he could go home if the family could find a way to transport him.  They said OK, and took the information in the typically stoic way of people who have never expected their lives to be free of such tragedies.  We prayed together.  They thanked us.  We expressed our regrets that we couldn’t do more.  

And now he is home.  And we continue to pray for him.