There are very few oncologic emergencies. Neoplastic epidural spinal cord compression is one of them. The delay in diagnosis and treatment is often explained by the non-specific nature of the presenting signs and symptoms.
The patient developed urinary retention a couple of weeks prior to presentation. On the morning of admission he was fully functional. Later he sat down to have a cup of coffee and boom – he couldn’t feel his legs. He couldn’t get up either.
Ideally, this patient should be rushed to the Hospital with an emergent neurosurgery consult. Prompt surgical decompression of the spinal cord or radiation treatment could improve his chances for functional recovery.
The patient lives on a 500 acre farm in a remote part of the country and getting to the closest ER took some time. It did not take the ER physician a long time to recognize the potential problem. Intravenous steroids were administered. MRI of the spine clearly showed an epidural mass with spinal cord compression at T6 level.
No neurosurgeon was available in the small outlying hospital. That means that the patient had to be transferred to a bigger hospital. More time spent on arranging the transfer and getting the patient to the neurosurgeon.
All in all, it took 12 hours from the onset of symptoms to the neurosurgical evaluation. The patient had an urgent laminectomy with spinal cord decompression. The likely diagnosis is metastatic prostate cancer with T6 epidural metastasis and spinal cord compromise.
Despite the treatment with steroids and an “emergent” surgical decompression the patient remains paraplegic. His PSA is > 300. The final pathology is yet pending.
This is an unfortunate case. Despite appropriate actions and management, the patient did not receive the needed care for 12 hours after the onset of symptoms. Had he lived closer to an urban area and a bigger hospital, he might have been able to walk.
This is true not only for trauma and oncology patients. Same goes for the patients with coronary conditions and other emergencies. The unfortunate truth is that access to medical care often decreases the further you go from a major urban center.
We have come a long way since the old days when ground ambulance was the only way to transport critically ill patients. Helicopters and fixed-wing aircrafts are readily available now for transfer.
Everything takes time, though. Packing the patient for the ambulance ride or even picking up the phone and waiting for the answer on the other end wastes the precious time that could make a big difference in the patient’s outcome. The bottom line is – in the case of a medical emergency the distance from the hospital could be a deciding factor between life and death.
Ralph Gordon is a critical care physician who blogs at realICU.
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