8 minute read
Just Another Overnight
Leslie Crosby, MD and Laura B. Roper, MD
It 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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record of visits to our system in that time. Our patient told us she had had a “swallow study” at a different hospital... on a Saturday... in the middle of the COVID-19 pandemic. This wasn’t adding up. By then, Dr. Roper’s patient had demanded large amounts of morphine, close to 1.5 mg/kg of morphine for a small thin woman. She “hated” her nurse and “loved” her resident... until the morphine wore off. When the trauma team recommended an MRI to better visualize structures obscured by the contrast, our patient refused the MRI, so we sent the MRI tech home. Of course, about 30 minutes after the tech had arrived home, the patient agreed to have the study... only if she would receive large amounts of anxiolytics. By the time she was due to go for the study, our patient refused the study a second time, telling Dr. Roper, “You don’t care about me, you’ve done nothing for me, you are the worst doctor, something must be going on because I am in so much pain!” The patient ended up leaving AMA without an MRI, refusing to sign the AMA form, and saying that the team “had done nothing for her” despite multiple reassessments and discussions and generous repeated doses of narcotics and anxiolytics. I had overheard Dr. Roper field a few of these phone calls, amid a thousand of her other responsibilities. She tirelessly took each of our patient’s concerns seriously, and made every effort to accommodate her, despite the verbal abuse. Our patient had accused her of being a cruel person, a monster! Of course this wasn’t true. Dr. Roper was nothing but kind and generous to her. We wouldn’t do this job if we didn’t care a great deal about our patients. Dr. Roper left that shift traumatized and emotionally exhausted, even though she had obviously tried to do what was best for our patient. Despite her numerous efforts to build a relationship and appropriately advocate for complete evaluation for suspected serious injury, she left feeling kicked in the gut. Even though the patient was showing some concerning behavior and we, of course, must give her the benefit of the doubt that it is coming from a place of real illness, our patient’s words still hurt.
Getting back to my current experience with this patient, the CT scans of head, neck, chest, abdomen, and pelvis were finally uploaded. Nada. Except for... a lot of old contrast in her bladder. Huh. That would be consistent with very recent scans.
As I catch up on my documentation, Dr. Hamilton tells me he just spoke with the patient. In the privacy of the trauma bay, Dr. Hamilton confronted our patient about how she had been intentionally signing in with different names. She snapped back similar to before, saying Crozer was a horrible place and accusing us of being incompetent. Dr. Hamilton pulled up a chair, sat down, and asked,
“What’s going on? Because none of this is making any sense.” “Don’t you get it? I am embarrassed and mortified to say this but I have a problem with narcotic addiction. I am covering up for my actions,” she confessed.
Why didn’t she say so in the first place? “Would you like help? We can connect you with addiction assistance and behavioral health resources right now!” he offered. And she agreed to try going to rehab. I spoke with our patient myself. She seemed a bit shell-shocked from the whirlwind of events, but was now completely lucid. It was like a switch was flipped. I guess there’s nothing like a trauma evaluation to help face your opioid dependence. I stepped out of the trauma bay, and I still felt pretty silly escalating the case to the trauma service. Dr. Ward assured me the case met our trauma criteria, that I had done the right thing. But regardless, I was amazed at the completely unexpected turn recent events had taken. 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. I was reminded that the reasons our patients present to the ED are often multifaceted, and not at all limited to the boundaries of what we would encounter in an anatomy and physiology textbook. It is really difficult to take a step back from the labels our biases assign to patients, like “drugseeker” or “cannabinoid hyperemesis chronic abdominal pain” or “borderline,” and explore a broad differential of our patient’s complaints... especially when there are interpersonal challenges pulling at heartstrings. Despite all this, we have the incredible opportunity and responsibility to make a positive impact in these less clear-cut, but no less critical cases. I came away from this case humbled by the weird and wild world of EM, and the privilege to be a part of it. Fortunately, there was a hopeful ending. Our patient went to the crisis center. On the way out, our patient stopped by the charge nurse station and apologized to us. I was able to follow her case, and saw that she was engaging with treatment and opening up with her small group. We wish her the best for her recovery journey.
