As a CA-1 (first year of clinical anesthesia training, second year of training after med school), I got called in the middle of the night by a floor nurse who wanted me to evaluate her patient.
"Doctor, my patient had a laparotomy a couple days ago and she has an epidural in place. We turned off the epidural today at the patient's request, but I'm concerned she may have an epidural hematoma."
An epidural catheter, when properly placed, is positioned outside the dura, or membrane surrounding the spinal cord and cerebrospinal fluid. Uncommonly, bleeding or infection may result from epidural placement. If a pocket of blood or pus grows large enough to compress the underlying spinal cord, irreparable nervous system damage may result. Needless to say, the first word that went through my mind was an obscenity. It's not polite to say those, though, so all I said out loud was, "I'll be right there."
I ran up the five flights of stairs thinking about the radiographic studies I needed to order and dreading the prospect of waking up the neurosurgeon on call to perform emergency spinal decompression. I arrived on the floor less than a minute after hanging up the phone. Predictably, the patient's nurse was nowhere to be found, so I went to the patient's bedside alone. The patient was sitting comfortably in bed reading a book.
"Ms. Smith, your nurse asked me to see you. She's concerned about your epidural."
"Oh. Well, I asked her to turn it off earlier because I wanted to walk around. And I haven't been in pain so I didn't have her turn it back on."
"When was the last time you were up walking?"
"About an hour ago."
"Any problems? Weakness or numbness in your legs?"
"No."
"Numbness or tingling along your inner thighs?"
"No."
"Have you lost control of your bladder or your bowels? Or do you have pain in your back?"
"No. I feel fine. The surgeons even said I could go home in the morning."
I performed an examination of the patient's strength and sensation. Everything was normal. I thanked the patient for her cooperation and left to find the nurse. I told her that I'd examined the patient and hadn't found anything amiss.
"What specifically made you concerned about an epidural hematoma?" I asked.
"Well, you can see it! And feel it!"
The image at the top of this post shows fluid in the epidural space. An epidural hematoma would occupy that same space. It is not something that can be seen or felt. Rather, it would be suspected due to the patient's symptoms and confirmed by MRI. The nurse must have seen the skepticism creeping over my face because she motioned for me to follow her into the patient's room. She had the patient sit forward and pointed at her back. "See? Right there!"
I looked at the patient's back. Then at the nurse. Then at the patient's back. Confusion was replaced by abject disbelief.
"Nurse, that's one of the patient's spinous processes. It's part of her vertebra. We all have them."
The nurse who was old enough to be my mother looked at me the way she might if I had told her that the sun wouldn't rise the next morning.
"You're not worried about that being an epidural hematoma?"
"No. It's part of her bone. It's supposed to be there. Have you never examined a patient's back before?"
With that, she went silent. We stared at each other, she in shock that a young doctor would speak to an experienced nurse that way and me dumbfounded that an experienced nurse would fail to identify a basic, universal part of the human body. After several moments I spoke again, giving her instructions that I have only given to one other person.
"In the future, please run all after-hours calls to the anesthesia service through your charge nurse first."
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