The One Where Water Poured Out His Nose

“Sir, why don’t you tell us a little about why you came in to the hospital,” Dr. Weekend prompts the elderly patient, despite having heard his story from the overnight resident.

“‘Cause my head hurt. I’m not dealin’ wit’ it. Tired of it,” he snaps, clapping one hand over his left temple. “And I was bein’ confused. I got locked outta my apartment all night!”

“Okay. So your head hurt and you were a little confused. Anything else?”

“And my nose keeps runnin’ and runnin’,” he offers.

“Well, we saw a bit of a sinus infection on your CT, so that would make sense. Is it both nostrils?” Dr. Weekend continues.

“Nah. It just be the left one,” he offers with a sniff.

My attending nods and asks him to sit up in his bed so that she can go through a quick neurological exam.

And he sits up. And that’s when I see it:

He scrambles to hold a tissue to his nose, but not before I notice several drips of watery liquid pouring from his nose. My concern for this man immediately picks up a notch, and I look incredulously from my attending to my resident for signs of worry or surprise. But they don’t react.

“My nose always be drippin’ worse when I sit up,” he notes, humoring the physicians as they walk him through the neuro exam.

“That’s probably your sinus infection,” Dr. Weekend says, patting his shoulder for reassurance.

Now, I’m a third year medical student, the lowest of the low on the medical totem pole. There’s hundreds of diagnoses I have yet to experience, but I have had a run-in with a sinus infection or five. And never ever have I seen anyone with mucus pouring out of their head like water from a pitcher.

Instinctively, I’m sure of it: that’s not mucus. Despite never having seen it, I’m willing to bet this man has CSF rhinorrhea, a condition where the fluid that provides cushion to the brain is leaking through a nostril.

And suddenly, I’m faced with a difficult task: raising the possibility that the attending might be wrong in a world where in many cases, the medical student speaks only when spoken to.

We step into the hallway, and I inhale sharply.

“Dr. Weekend? Is that really just a sinus infection?” I begin slowly.

She nods. “It’s on the CT. There’s a big infection right in that left sinus,” she says insistently.

“There’s nothing else that could be?” I prompt.

“It’s the infection,” she says, her tone effectively ending the conversation. “We need to get an LP on this guy.”

And so we walked away, with me making a mental note to bring it up with the day attending on Monday.

But I wouldn’t need to. By Monday, Dr. Days has already ordered the tests and confirmed that this nasal fluid is CSF, and this man’s brain is bulging out into his nasal cavity.

—————-

This situation raises the dangers of the current medical hierarchy. Though I realize in hearing stories from trainees past, medicine has become much more open to input from students and residents, there is still this dynamic where it becomes incredibly difficult for a student to point out some attendings’ mistakes or oversights without overstepping boundaries or risking a poor evaluation.

I keep wondering if I should have pushed the issue harder with Dr. Weekend or the weekend resident, but I’m pretty sure that they both would have justified the current opinion and shrugged mine off as a silly medical student idea. I have always feared the day when my mistake led to an adverse outcome for a patient, but I never considered the possibility of recognizing a problem and being unable to convince those in power that it was a reality.

I’m grateful this man got his diagnosis, but it terrifies me to think that he may not have or he may have gotten there only after a life-threatening event. If something terrible had happened, would it have been my fault for not doing something? What was I supposed to do in this situation?

Have any of you ever had to stand up to an attending or a physician above you in the rankings? If anyone has any advice on how to approach this type of situation, I’d love to hear it in the comments.

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4 thoughts on “The One Where Water Poured Out His Nose

  1. It is a tough situation to be in. I hate it when that happens.
    I try to ask about the thing I suspect in the frame of a question. Like saying I was just considering the rest of the differential and I was thinking about thing x… Asking what they think. Or asking if we should try to rule it out where it may be more dangerous.
    People generally respond in an okay way to that. Not always. But I have found it helps with pointing things out. Plus, if you are wrong, it is good learning. If you were right, at least you tried. And if you get really concerned, talk to the resident or other attending you work with.
    Sometimes, as a student, you get put in a difficult situation. And it isn’t always fair.

    • CSF is totally normal… it’s the fluid your brain produces for cushion. What’s not so normal is when it leaks out of your skull… usually it’s due to trauma, but in this patient they were still trying to find the cause. As far as I know (I left that rotation), he’s doing just fine!

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