AAEM NEWS
Somehow, this case had taken
us through a broad sampling of emergency medicine: psychiatry, social determinants of health, trauma and resuscitation, and toxicology and addiction medicine.”
Just Another Overnight Leslie Crosby, MD and Laura B. Roper, MD
I
t was mid-April 2020 in the peak of the COVID-19 pandemic when I had one of the more bizarre, but enlightening cases of our careers. Late in the evening during an overnight shift, I signed up for a middle-aged female patient with the chief complaint of “fall.” Vitals were normal from triage, and the patient ambulated without difficulty into her room. I walk into the room and I see a somewhat disheveled, thin older woman sitting in the bed, taking off her shoes. When I ask what brings her in, she tells me, “About eight hours ago, I was up on a ladder on my stairs putting up fairy lights when I fell down the stairs. I hurt my right hip and my chest.” She described falling from five feet up the ladder and down almost a whole flight of stairs and minimal improvement of pain with OTC Tylenol. Denies LOC, head impact, headache, neck pain, vision change, numbness, or weakness. She’s not on blood thinners. She endorsed pain in her right chest and right hip where she hit the stairs, but no shortness of breath, cough, back pain, or abdominal pain. “Don’t take this the wrong way, but, can I ask why didn’t you come to the ED earlier?” I queried. “I thought it would get better...?” replied the patient. Huh. That’s kinda weird. I note that the patient has a nervous affect, but I don’t think much of it. I perform a brief trauma exam and see she has a large bruise on her right upper chest that’s pretty tender. Her chest wall is stable and her breath sounds are equal, but I am concerned she may have a broken rib. Because she fell from so high up, I asked our nurse to throw on a C-collar as well. I walk back and present the case to my attending and chief of our department Dr. Rich Hamilton. “I think we need to make this a level II. The mechanism is really concerning to me since it sounds like she fell at least 10 feet in total. She looks pretty well otherwise, but I don’t want to miss something.” We walk back to the patient’s room and he agrees. Dr. Hamilton calls a trauma alert over the loudspeakers and the trauma team joins us in the trauma bay as we wheel in the patient.
She is NOT having it. She refuses to let us transfer her onto the trauma stretcher and starts to become agitated and combative with the nurses. We assure her that this is what we do with every patient when we are concerned they could have life-threatening injuries, and we do our best to preserve her dignity during the exposure portion of the assessment. The trauma team takes over. The more she speaks, the clearer it becomes that our patient lacks the capacity to refuse care. She is oriented to person, place, and time, but the rest of her thought content is not making any sense. There is definitely some tangential thought, with flight of ideas. She is given 2 mg midazolam and she becomes more cooperative with the assessment. The FAST exam is negative for effusion and pneumothorax. There aren’t any obvious fractures on the chest X-ray. The X-ray of the pelvis was negative for fractures... but positive for contrast in the bladder? The patient had said nothing to me about recent hospitalizations. The trauma team takes over, and my attending and I step out to put in some orders and sign out to the overnight attending. Dr. Pollianne Ward, the overnight attending watches as the patient is wheeled to CT. “I recognize her. Wasn’t she just in here?” she asked. I check the chart for other visits – none for a couple years. “No, it’s her!” she exclaimed. We review the chart of the patient Dr. Ward had seen earlier this week. The patient’s name and DOB were different, but the story was almost exactly the same. I was on shift when the patient was here and one of our chief residents, Dr. Laura Roper was taking care of her. At the previous visit, the timeline and details of the patient’s presentation did not necessitate immediate trauma team activation. However, CT scans were ordered which didn’t show any traumatic injury, but demonstrated the presence of IV contrast in the renal system. This meant that she had received scans at another institution within the past 24 hours – again, no
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COMMON SENSE MAY/JUNE 2021
