My charge nurse stepped out of a room and waved to get my attention. "We need a doctor in here, please," she said in a level voice. In non-ED-charge-nurse speak, this roughly translates to, "GET IN HERE RIGHT FREAKING NOW THIS PERSON IS DYING." I dropped everything and headed in.
As I entered the room, three nurses were bodily lifting a youngish-looking woman out of a wheelchair and into bed. Her head lolled as they moved her, then she seemed to go rigid and tremble for a moment. The charge nurse spoke what I was thinking. "We saw her shake like that a few minutes ago as well. Maybe she's having seizures? Her friend just dropped her at the front door and left."
I leaned over her as she went limp and groaned. I saw a fresh scrape over her left temple. "Honey? Squeeze my hand. Squeeze my hand!" Nothing. The nurses stripped her and placed her in a gown - skin looked normal, no rashes, no bruising - then I peeled back her eyelids and shone a light in her eyes. The pupils winked back at me sluggishly. The nurses were feverishly getting her hooked up to our monitors. I looked up. The blood pressure and pulse ox weren't reading... or were they? The pulse ox signal was weak and unreliable but it read 56. "Let's go ahead and put oxygen on her. Do a nonrebreather in case that number is more real than it looks.
"Do we know anything about her? Name, age? Did the friend say anything about whether she's been sick?" I continued my exam as I spoke. Neck felt supple, no swelling. A quick listen over the chest confirmed the whisper of air in both lungs. My charge nurse looked up from where she and the other nurses were trying to get IV access and shook her head. "Not really. I think the friend said something about a fall a couple of days ago, or maybe just a fall today, that she passed out. She's got a lot of track marks and it's making an IV hard."
That was enough to get started with. A hard fall can lead to bruising or even bleeding on the brain, and a bad skull fracture can displace and cause increased pressure on the brain. Any of those things can lead to seizures, or aggravate an existing seizure disorder. Or maybe there was something else going on. I could only work with what I had.
"Okay, get her to CT once we have a blood pressure - is the cuff not working or what? Maybe try getting a pressure with a manual cuff. I want to scan her head and neck." I pressed on her abdomen just for completeness' sake - wait a minute. Her abdomen is firm. What the what? A normal, healthy abdomen is soft to the touch. I pressed again and the patient groaned. My eyes shot up to her face. I pressed a third time, cautiously. The patient grimaced and her hand twitched up to mine as if to push me away.
"Guys, I think we need a pan scan. I don't know what's going on with her but her abdomen is rigid and she gave me the only response we've gotten when I pushed on it." The charge nurse and I frowned at each other. What on earth was going on here?
One of the other nurses whooped in triumph. "Got an IV! She's got a carotid pulse but no radial, by the way. I think she's probably pretty hypotensive."
"Okay. Start a liter of fluids. Start a second one once we have access, please."
500ml of fluids later, her BP had risen from undetectable to 54/32. We dumped another half liter in, then the nurses ran her down the hall to our CT scanner. I grabbed her ID to look her up in the computer, my mind whirling with a vast differential. Drug overdose? Sepsis? Perforated bowel? The sequelae of heatstroke? Seizure disorder? Her chart was not very helpful. No history of seizures that I could see; no history of anything, really, other than drug use.
The charge nurse ended the phone call she'd just taken. "Hey, that friend is back in the waiting room apparently." She and I went out to meet her. The friend was groggy in the way that only a freshly drugged heroin addict can be, her speech slow and unconcerned. "Yeah, I don't really know what happened. I think she fell off a roof a couple of days ago, is what I heard. I wasn't there. No, I don't know how high. The second floor, I think, that's where she lives. Oh wait, maybe it wasn't the roof. Maybe it was the porch? She hasn't been right since, though. She passed out a lot more today so I tried to take her to go get a drink and she passed out at the store, so I brought her here."
She fell off a roof. Or a porch.
She fell off a roof two days ago.
She fell off a roof and she's been passing out ever since.
All at once, my brain switched directions at full speed, like a train picked up and put down on a different set of tracks. This wasn't a patient with infection or an overdose or a seizure disorder; this was a trauma patient with a dangerously delayed presentation. She needed not just fluids but blood. And surgery, if her abdomen was anything to go by. The charge nurse and I shared a look, thanked the friend, and sped back into the department.
As I got back to my desk, my phone rang. It was my radiologist. You never want a call from your radiologist. I answered, braced - I thought - for bad news.
"Hey, is this patient dead?"
"What?! No. Close, but no. Why, what'd you find?"
He rattled off a list of injuries that left me speechless. There was air around the lungs. There was air around the heart. The ribs and sternum were more broken than intact. Her abdomen now housed multiple ruptured organs, and a great pool of blood gathered in the pelvis.
After that point, it was pretty straightforward. I sedated and intubated her, gave her 2 units of blood, and sent her to my nearest trauma center for further treatment*. She had a rough go of it in the trauma ICU, but the last I heard she's actually improving and expected to recover.
Now, what would you say was the most pivotal point in this case?
Some might say it was when I heard the full story from the patient's friend, since that's when I put all the pieces together. Some might say it was when I got the CT report back and learned how badly injured my poor patient was.
But I say it's actually very early on, when the nurse checked a radial pulse and when I pushed on the patient's abdomen.
You see, prior to that, we had a very sick young woman in front of us and no information. But those two pieces of physical information totally changed our course of action. The radial pulse roughly corresponds to a low-normal blood pressure (systolic around 90). Without it, you know the blood pressure is low - too low for our automated BP cuff to initially give us a reading. We started fluids immediately and I truly think this step was the initial lifesaving decision.
Now consider if I had not pushed on my patient's abdomen. There were no external signs of trauma that would have led me to get a scan of her belly. The history from the friend didn't come until later. And the scan of her head/ neck was pretty normal. So I would have been left with an extremely sick patient who had some kind of fall and had normal head/ neck imaging. Maybe I would have gotten a scan later (likely when her full panel of labs came back abnormal), but who knows what kind of delay there would have been, and what would have happened to my patient in the meantime.
So my personal takeaway from this case is to never ever neglect the physical exam. In this age of modern medicine, it's easy to get lazy and rely on labs and scans. Some doctors don't even bring their stethoscopes in the exam room anymore. The physical exam is dead, they say. Long live technology and a good history. And sometimes you can still practice good medicine that way.
But sometimes you can't.
And sometimes a physical finding or two can totally change a patient's outcome.
Long live the physical exam, I say. And hopefully it helps my patients live too.
---------------------
*For the medical people reading this who are gnashing their teeth and yelling at their screens, wondering why I didn't place chest tubes before transferring her, the answer is that I made a judgment call. Her pneumothoraces were small and stable after intubation, she was tolerating the vent fine, and the ambulance arrived quickly to transfer her. Chest tubes take like two minutes to put in - until they don't for some unforeseen reason, and then they take ages. I elected not to delay transfer since she was stable enough to go.
No comments:
Post a Comment