My uncle in Sweden got hit by lightning twice. He is a stubborn farmer, who twice was a little too late getting his tractor and plow off the field in a flash thunderstorm.
Today I saw Gordon Grass, the man who had surgery for his subclavian steal that I had diagnosed recently. One of his symptoms had been dizziness and multiple falls. Gordon’s blood pressure is now equal in both arms and his brain doesn’t have to share its blood supply with his left arm anymore. But he is still dizzy and lately he has had this strange, irregular clicking in his right ear. It is definitely not his pulse. I had seen him for this a week ago and as his right eardrum looked dull and his Weber and Rinne tuning fork tests were equivocal, I prescribed a nasal steroid spray and told him that would probably clear up his symptoms.
Today he was back.
“I’ve been reading online about acoustic neuromas, and I have all the symptoms”, he said.
“Don’t you know you can only have one rare condition and you’ve already had yours”, I sad with feigned seriousness. He smiled faintly. I repeated his tuning fork tests and did a whispered voice discrimination test. His eardrum still didn’t look quite normal.
At that moment, there was a ruckus in the hallway. I excused myself and left Gordon’s room. Autumn and the receptionist were wheeling a man I’d never seen before, about my own age, down the hall in a wheelchair. He was moaning and writhing in obvious pain.
I instantly remembered Winfield Smith, a patient I had almost twenty years ago. He arrived the same way, writhing in the waiting room wheelchair, and he had an arterial embolism in his leg. We shipped him to Cityside via ambulance and he was soon on the operating table under the care of the same vascular surgeon, then new to our area, who had just taken care of Gordon Grass across the hall.
“It’s my leg, it’s a clot, just like seven years ago”, the stranger in the hall groaned.
“What happened?” I asked as we wheeled him into an empty exam room. His right shoe and sock were already off.
“I was walking to the store and this pain just grabbed me in the thigh”, he said.
“The sheriff dropped him off”, Autumn said. “He flagged the cruiser down.“
I knelt down in front of him, just like I had done when Mr. Smith rolled in the same way twenty years ago, and checked the skin temperature of his right foot. He winced at my light touch. His foot was a little dusky in color and his skin was slightly cool. I couldn’t feel any pulses.
“Let me just get my Doppler”, I said and got my little hand held device from my office.
Same result with the Doppler – no distal pulses.
“Let’s call the ambulance. I’ll alert the hospital” I began. A few minutes later the crew wheeled him down the hall to their rig and I returned to Gordon and his ticking ear.
I told Gordon that it wasn’t likely that he had an acoustic neuroma, partly because of his exam findings and also (I guessed) because the MRA’s he had before his vascular surgery probably would have picked up a tumor. I said I wanted to make a referral to Dr. Ritz, the wise old ENT specialist who bailed me out with my bacterial parotitis case a while back.
“This ticking is driving me crazy”, Gordon said.
“We sometimes prescribe low dose Valium for ear noises, because of how intolerable they can be”, I explained.
“I’ll have some then”, he quipped.