I was working in an ED-based minor emergency center. My first patient of the day was a 26-year-old female with complaints of lower back pain for four weeks. She had seen her PCP one-week prior for back pain, fall and constipation. He had given her a mild narcotic analgesic, a muscle relaxant and a stool softener.  Subsequently, her pain had worsened and the constipation had not resolved. She had fallen again the day before while leaning over to make her bed.

The patient denied history of cancer, fever or other illness. Examination of her back revealed a large scar across the left scapula.  When I asked her what it was from she said she had had something removed a few years ago, but she was not sure what it was. I probed further and asked who had done the surgery. The patient gave me the name of a local plastic surgeon.  She denied the lesion was cancerous, and apparently she was not referred to oncology. The rest of the physical exam revealed mildly hyperactive reflexes in the lower extremities, and a rectal exam indicated weakened sphincter tone and stool impaction.  

While the patient was in x-ray, I put in a call to the plastic surgeon’s office. When her x-rays came back she appeared to have lesions of five lower thoracic and upper lumbar vertebrae.   went to discuss it with the radiologist, who looked at it and fell completely silent.  “How old is this person?” he asked.

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I told the radiologist my patient’s story and my concerns about the lesion on her back.  He was sure they were metastases, and we ordered an MRI.  I got back to my phone, only to hear from the plastic surgeon that the patient had had a large superficial spreading melanoma for which she was referred to oncology.  However, her mother talked her into going out of state and using alternative therapy to treat the cancer instead.   

I waited for the results of the MRI, which revealed metastases to nine of her vertebrae with some cord compression at T-10.  Finally I spoke with the patient, who was in absolute disbelief that the alternative treatment she had sought had not cured her. She could not speak and asked me to call and tell her father, who was out of state.  It was definitely the most heartbreaking situation I’ve dealt with since becoming a nurse practitioner.