My First Day as a Spinal ESP
My name is Matthew Low and I am the Lead Clincian of Musculoskeletal Therapy Services and an Extended Scope Practitioner (ESP) in back pain in a consultant-led rheaumtology department. I have recenty been involved in the MACP executive comittee and hope to be voted in as secretary at this year’s AGM. I was asked to contribute to the blog to disuss a day in the life of a new executive comittee member. As I have only been to one exec meeting I thought I might instead write about my first and most memorable spinal ESP clinic.
Several years ago I was fortunate enough to be successfully selected to begin training as a spinal ESP. The process itself was excellent. I observed and led clinics under the direct supervision of a Consultant Rheumatologist for one clinic a week for four months. Each week I had to present topics on new areas of learning ranging from medication managment and blood tests to MRI scan interpretation and discuss my reflections with my mentoring consultant. I was then observed running a clinic independently which acted as a summative examination and I was “signed off” as competent.
I was quite nervous the day of my first clinic even though the consultant I was training under was a few doors away, seeing her own list of patients. It was made absolutely clear that if there were any problems just to knock on the door and when the time was right we could discuss them. As it turned out, my list comprised of all urgent cases.
With slightly clammy hands that were clasped onto my patient list, I called out the first one. It was a young gentleman who clearly was in pain. He hobbled toward me and shook my hand as we went into the clinic room. He had severe right-sided sciatica that he had been struggling to manage for three months. Over the last three weeks, he started to get some altered sensation in his saddle area and decreased bladder control. Clearly, this was a concern. During the physical examination he had a reduced ankle reflex, reduced power of ankle plantarflexion with a positive crossover sign and severely limited trunk movement. I was immediately suspicious of cauda equina syndrome and politely asked the patient to get as comfortable as possible as I needed to discuss his case with the consultant. So, off I trotted to knock on the consultant’s door thinking how unlucky this poor patient was to present to me on my first day. I waited about five minutes and when the consultant finished with her patient, I presented the case. The response was initially surpising – “Have you done a PR exam?” Although this is absolutely the appropriate examination, I had not covered it at all in my training and the doctor knew it! I said that I had not and the doctor hurriedly went into my clinic room and gained consent for the examination. I was then taught how to perform it (I won’t go into any detail) and was asked to contact the Orthopeadic registrar for the patient to have an urgent MRI scan. Once that was done after a stressful one hour from the begining of the consultation, I called out the next patient.
This patient presented in a wheelchair. Unfortunately, she had a number of red flags that needed to be investigated. She reported unremitting low back pain with no radiation that was of a gradual insidious onset. She had lost over a stone in 6 weeks and had taken to sleeping in her arm chair. The physical examiation was brief and confirmed her very limited movements and disabling nature of non-mechanical pain. Her neurology appeared normal. Once again, the corridors echoed with my footsteps as I headed to the consultant’s door to confirm the plan: blood tests and an urgent MRI scan of her lumbar spine. The consultant agreed and I had the challenging conversation with the patient that her back pain was unusual and we needed to exclude any nasty pathology. She was very grateful for the speedy investigations and how we were dealing with the situation.
By this stage, I had become a sweaty mess and I was very grateful that I had only three patients on my list. I walked into the waiting room and called out my last patient. To my relief, the gentleman looked up and his face was not riddled with pain. He called out “Yes, that’s me!” and proceeded to stand up. To my horror he picked up his walking stick and was stuck in flexion and had a huge list to his right. He waddled his way towards me and I invited him into the clinic room. He had a very kind nature and he explained how he enjoyed walking in the New Forest and that it was his main hobby. He reported that about ten weeks ago, he had been walking on familiar tracks and he developed right sided leg pain. It was accomponied by a rash and the pain appeared to be in the L4 dermatome. He denied any fever or weight loss and there were no other red flags. Upon physical examination, this poor chap was very unsteady on his feet, his back appeared warped with the most peculiar list to the right. All movements of his back were very painful and had no clear relationship to his leg pain. Examination of the hips were unremarkable. His neurological examination revealed profound weakness of his right quadricep, hamstring and gluteal muscle groups. His lower limb tone was normal and he had downgoing plantars and negative clonus tests. His knee reflex was absent and ankle reflex was normal. There was no evidence of a rash on his legs. I asked the patient if he had been bitten by anything and he denied it although he could not remember. Once again, the noise of my heels hitting the corridor floor on the way to the consultant’s office was audible as was the familar knock on the door. The consultant, as always, was fantastic and listened carefully to the story. She must have felt sorry for me as she reassured that because the clinic list was new it was filled by urgent patients. I recalled the patient’s presentation and immediately the consultant looked puzzled and agreed that we should scan the lumbar spine but also check for Lyme disease and filled out a blood test form. I returned to the patient and explained the situation and he appeared happy. That was my first experience of being a spinal ESP. Wow!
What came of these patients, I hear you ask!?
The first patient had his scan which showed a small central disc prolapse at L5/S1 without any neural compression! Strangly enough the patient also failed to attend any follow up appointments and I have no idea what came of him.
The second patient had bony metastasis in her lumbar and sacral spine and was followed up by the oncology team. Unfortunately, I never saw her again.
The third patient had a pristine MRI scan with absolutely nothing wrong with it. However, the blood tests showed that he did indeed have Lyme disease and was started on the appropriate medication and was already making progess.
I am in no way saying that this day was typical but it just goes to show in the immortal words of Greg Grieve… “Things are not always what they seem initially – be informed and awake”.