Shoulder Pain

 

After a new acquaintance learns that I practiced medicine in an Emergency Center, the questions are standard. One is, “What is the most unusual patient you have ever treated?” To me, that is easy.

The chief complaint was uninspiring, “Shoulder pain.” The patient was fully dressed. He described pain in his right shoulder and a peculiar lump. I asked, “What do you mean, a peculiar lump?” He answered, “This.” With that, he opened his shirt collar and pushed down on the tented skin just below the outside edge of his collarbone. The skin would easily depress and then spring back out when released. The skin was intact with no scars. Something was pushing the skin out. What could it be?

I asked, “What is under your skin?”

He said, “Nothing.”

I pushed down on the tented skin a few more times and said, “Something.”

The patient commented that he was seen in the Emergency Center about four months prior to this visit. He didn’t think it was related. At that time, he complained of a bruise on his right thigh. The physician who examined him believed he had just strained his thigh. No specific treatment was needed.

After none of my questioning revealed any additional information, I ordered an X-ray of the shoulder to check it out. X-rays at that time were developed on film and the film was viewed on lighted boxes on the wall. The X-ray showed a normal shoulder with a metal wire causing the tented skin. The wire traversed the x-ray film and disappeared out the side of the film.

That brought another line of questioning, “Where did the wire under your skin come from?” This was also fruitless.

That led to more X-rays.

A chest x-ray showed the wire descending from the shoulder, down the chest, and exiting the bottom of the film.

He was sent back the Radiology Department for the third time for a final film to find how far the wire extended. It extended to the upper right thigh.

Inspection of all the x-ray films showed a wire that started in the right shoulder region, proceeded down the superior vena cava, through the right side of the heart, down the inferior vena cava, and right iliac vein. Another smaller caliber wire was tangled like a bird’s nest in the right atrium of the heart.

The patient then revealed that he had been admitted to this hospital eight years earlier after a serious car crash. I asked for the records of that admission, but they were offsite. All the records then were on paper and kept in folders. My next step was to look at old x-rays. Old x-rays were kept in a large manila envelope. The date of the various films was written on the front of the folder.

The chest x-ray from the Emergency Center in that admission showed all types of white lines traversing the film. These included the various ECG monitor wires, the chest tube, an NG, and such. Since wire is metallic, it is very distinct as a white line. Wires are imbedded into chest tubes and nasogastric tubes to make them stand out on an x-ray. But unless one purposefully traces them, they are just background noise. After looking at a series of chest x-rays, I was able to understand what happened.

When the patient arrived at the Emergency Department after his car crash, he was immediately stabilized, monitored, and maintenance procedures were done. A chest tube was inserted to treat a pneumothorax (dropped lung). An NG (nasogastric) tube was inserted to evacuate air from his stomach. A central line was inserted to allow monitoring and infusion of fluids.

A central line is an IV that is inserted into a deeper vein than is used in the arm. They can be used to give large amounts of fluids, to give multiple medications at the same time, and to monitor fluid status. They are typically inserted into the Jugular Vein in the neck, the Subclavian Vein in the shoulder, or the Femoral Vein in the groin. The process is the same at each location. First, a large, hollow bore needle on a syringe is inserted to find the vein. Today that is done with ultrasound. Back then, we used landmarks and probing. After the vein is located, blood fills the syringe. The syringe is disconnected from the needle and while the needle is still in the vein, a flexible metallic guidewire is inserted through the inside of the needle and into the vein. The needle is pulled out leaving the guidewire in. The next step is to enlarge the tract that the needle created by pushing a dilator over the guidewire. The dilator is thin at the distal end and thicker more proximally. The dilator is then removed and replaced with the larger central line. The final step is to pull the guidewire back out the central line and secure the line to the skin so that it does not move.

We are all taught early on, never let go of the guide wire. When pulling the dilator off the guidewire, one must hold the wire on both sides of the dilator to control it. When pushing the central line in, one must hold onto the guidewire.

The chest X-ray films clearly showed that whoever put in the central line (Subclavian approach), let go of the guidewire. The guide wide can be seen to end in one x-ray toward the bottom of the film. In a successive film, the end is at the top of the film. I can only guess that the physician who inserted the central line became distracted and did not realize he had not removed the guidewire, as that would not be something he would ignore.

Anyway, this guide wire had been floating around in this fellow’s veins for the past eight years. The subclavian vein leads down to the Superior Vena Cava and thus to the right side of the heart. Continuing south, the Inferior Vena Cava leads down through the abdomen and splits into the Iliac Veins going to the Femoral Veins in each leg.

A guide wire is, in reality, two wires. To be flexible and yet stiff, it consists of a thin straight wire with a thinner wire coiled down its entire length.

For about one quarter billion heartbeats, this wire was traversing the heart. The ultrathin wire wrapped around the outside of the stiffer wire had eventually come loose and balled up like tangled fishing line in the right side of the heart. The stiffer wire floated up in down in the body. When the patient was seen in the Emergency Center four months prior, I assume the wire had punctured his Femoral Vein and caused the bleeding that resulted in the bruising on his thigh. When he arrived for my evaluation, the wire had worked its way north, poked out the side of the Subclavian Vein, and was palpable underneath the skin.

The stiffer wire was easy to remove. It just required a little slice in the skin where it was felt in front of the shoulder and pulled out. The balled-up line in the heart required removal with a heart catheter.

So much for a simple shoulder pain presentation.