Sometimes it’s a zebra…spotting emergency MSK presentations in primary care

Sally is 65 and normally pretty fit and well. She is slim and has psoriatic arthritis which is very well controlled with low dose methotrexate, so when I saw her on a Monday triage list with back pain I was thinking ‘likely to be either an acute muscular gardening injury, or possibly psoriatic spondylarthritis, perhaps an osteoporotic crush fracture’ before I had even called her. Then I remembered the cognitive biases that affect our clinical reasoning that we have been discussing on our recent Hot Topics courses, and the need to switch from mindless to mindful practice.  So I gave myself a metaphorical slap round the chops, emptied my head and dialled!

Sally, like 99% of the great British public, was apologetic to bother us and highly appreciative of the call. Life is tough at the moment, but the appreciation of our patients sure helps! Anyway, it turned out that Sally also thought it was a gardening injury, and her ‘optimism bias’ was even worse than mine. But it didn’t really fit as she had been gardening on Friday morning, didn’t think she had injured herself at the time and she started getting severe back pain on the Saturday. Uhmmm. The pain was constant, severe and unlike any she had before and was getting steadily worse. Paracetamol didn’t touch it, so she had raided her husband’s codeine and this hadn’t helped either. Saturday night she had trouble sleeping and Sunday night it was difficult to lie down. There was no radiation into the legs and no cauda equina red flags. She felt unwell (‘maybe it’s the codeine’) and a bit feverish. I brought her in.

Acute MSK presentations are so common in primary care emergency settings, that the rare emergency MSK cases that need urgent referral are very easy to miss. Amongst all the horses, how do we spot the occasional zebra? To help us, late last year, excellent new UK Guidelines on Emergency MSK conditions were produced by a collection of UK joint MSK professional bodies and the RCGP. These guidelines are simple, easy to use and have a huge learning point: delaying referral of an emergency MSK presentation can have life-changing consequences for the patient. Spotting the zebra early is vital. For example, when we consider cauda equina syndrome or metastatic spinal cord compression we always ask about sensory changes, muscle weakness and bowel or bladder disturbance. But these are late signs, and prognosis is severely impaired once paralysis occurs. We need to spot potential emergency cases earlier, and the guidelines tell us how.

So, what happened to Sally?  I brought her in, and she had a clear antalgic gait. She had very localized exquisite low lumbar tenderness, but no neurological signs or symptoms. She had a slight tachycardia, easy to dismiss as she was in pain, and a low grade fever. A quick check of these guidelines, and we can see that she has red flag symptoms and given her immune suppression spinal infection needs excluding. She needed urgent referral and a MRI scan revealed spinal infection, due to a spontaneous bacterial discitis. Ironically, the gardening could have caused it after all (!) from an infected finger cut that neither Sally nor I thought was relevant.

We shall cover these new MSK guidelines with some different case scenarios for you on our brand new interactive Urgent Care course, which is suitable for all health professionals working in all primary care emergency settings whether it is daytime GP, Out of Hours care or ambulatory settings. As well as emergency MSK, we shall cover new guidelines on anaphylaxis, acute chest pain, RSV and bronchiolitis and the sick child, diabetic emergencies, and a wide collection of ‘every day’ cases that we typically see. 

The new NB Medical Urgent Care course is more interactive than ever, evidence-based and built around cases that we typically see. It is designed to help you to deliver safe, effective and evidence-based Urgent Care in a fun, thought-provoking and interactive format. Do join us on November 20^th, available afterwards on-demand on NB Plus!