Nightlife in ED – A series of ‘Night’-mares (Part 2)

Second of 4 nights-in-a-row. There seemed to be no light at the end of this very, very, very long tunnel. Oh, well…

1) first card says 40 -something Male, PR bleeding x 3 days. *sigh* And he waited for my night shift on the 3rd day to seek medical advice. So I see him, apparently has had bleeding AND a slightly painful swelling … there. Thinks its haemorrhoids, has been using haemorrhoid ointment, but the bleeding hasn’t stopped. I reassure him. Ask him if he is on any regular meds, anticoagulants in particular. Nope. No associated abdominal pain, no constipation, bowels opening normally (otherwise). No recent fevers. No prior history of any bleeding (PR or otherwise!) and not ever had haemorrhoids before. Hmmmm. I obtained consent for a PR examination (yep, back passage examination) – found the swelling to be NEXT TO, and NOT coming from INSIDE the rectum – which essentially meant it was not a haemorrhoid. Very likely it was a localised gland or hair follicle that had become infected initially, swollen up with debris and when it became too big (or with the pressure of wiping) it just burst and spewed forth bloody discharge. Now looked like it was settling, no surrounding erythema, and it wasn’t painful. Rectal examination was otherwise unremarkable. Sent home with advice, did not need to have blood tests – some sitz baths and just good hygiene practises and red flag signs explained, advised to seek medical advice if any further concerns.

2) Next card – picked up the patient, put my name against it, got the notes, took down the blood test results and stepped into the cubicle – introduced myself…and got told the patient had already been seen by another doctor. They had just forgotten to … pick up the notes, write in them, write their name against the patient’s name in the list – anyway, I apologised to them and went to look at the waiting list to pick up the next one.

3) Next patient was a very cute little old lady, walked into he cubicle to be assessed, with her daughter in attendance. Was in the parking lot of a grocery store, went to deposit the trolley after she was done, misjudged a kerb (?miscalculated her footing?) and tripped, fell face-first onto the concrete, came in with a nose injury and some facial abrasions. By the time I reviewed her her wounds had been tended to and she was no longer bleeding. She had a superficial cut on the end of her nose (steristripped) and a few scratches around the nose. She hadn’t lost consciousness, not actually hit her head (witnessed by daughter who had been present) and was not on any anticoagulants. It had been more than 3-4 hours, she had not experienced any nausea or vomiting. I examined her for bony facial tenderness anywhere (there was none, apart from slight tenderness of her nose, understandable, but not really helpful in deciding whether it was a fracture or just soft tissue swelling/injury) – did a neurological examination, and she was able to walk without any discomfort in her hips. She was, for all intents and purposes ‘good to go’. The rest of her history and examination were unremarkable; I sent her home with nose injury advice – no need to x-ray it, yes it could be a fracture, but nothing needs to be done about it. Wait for a few days, upto a week, if after the swelling dies down, it’s still painful or there is an obvious deformity, go to your GP, they will sort out an ENT outpatient review. Otherwise, just continue with your routine, just don’t blow your nose or wipe too hard for the next few days. I sent her home with some head injury advice as well (look out for nausea, vomitting, severe headache, visual disturbance or any weakness, LOC or unusual behaviour) and the daughter was happy to keep an eye on mum for the next 24 hours. Job done. Next!

4) 9 year old female with abdominal pain that she awoke with, while at grandmother’s house, called mum to pick her up as was ‘in a lot of pain’. No pain since mum picked her up, and very happily playing in the play area. All my instincts told me this was a young child just seeking attention to get mommy to pick her up and take her home, probably because she was bored. I went through the motions, but I knew what was up. Or atleast I thought I knew. Abdomen was soft, non – tender, no bruising. No fevers reported, and all her observations were within normal limits. Mum was very concerned as this had happened on quite a few prior occasions (red flag!) and only when the child was without the mum (further red flag!) but the child was never with the same person – so it wasn’t as much an avoidance of a single sinister person (s) as it was a ‘mommy-I-miss-you-can-you-please-come-get-me?’ I treated it as such. BUT…as part of the workup of children with abdominal pain, we did a urine dip, even though she didn’t really complain of any urinary problems – it came back positive for a UTI. *oops…almost missed it being judgemental and complacent* Sent home with antibiotics, advised to followup with the GP for culture results, etc. Also made sure GP was aware in my discharge letter to him, that she had complained of abdominal pain, and it had been a frequent thing previously, and only this first time she was found to have a UTI. And so could he be aware and be on the lookout for further such occurrences, in case…something needed to be done or …something else thought of. Sigh. Difficult jobs we have. And unpleasant to even think about.

5) middle-aged male, who came in with chest pain, and after my full assessment we found that he actually had severe pain in his right flank (don’t ask how it was translated into him having chest pain) – loin, going to groin, very typical of renal colic and coupled with a positive urine dip for blood, was very likely a kidney stone. He was pain-free after the PR diclofenac (always works wonders!), and his blood creatinine levels were normal, and there was no signs of an infection on his bloods or his urine. So I sent him home, analgesia advice and and outpatient CT KUB (gold standard, diagnostic) and to go back to his GP if any further concerns.

6) 8 week old infant, brought in by mum (and referred in by out of hours GP – or OOHGP) because of failure to thrive. He was formula fed, and unfortunately did not seem to be gaining any weight since 3rd week of life, and mum had switched 4 different formulas (formulae?) and was now on a 5th one, trying a lactose-free one. He was quite an adorable child, very responsive, happy, alert – but bring that bottle close to him and he cried. And cried. And cried. And the mom cried. And by the next 45 minutes of trying to coax him to drink something – I was about ready to cry myself! Examination – wise he was fine, no abdominal lumps etc, he was passing formed stools, still greenish, and his wet nappies, though decreased, were still ongoing. So he was getting his fluid intake from somewhere – and weighing him we found he had actually gained some weight. Not a lot, mind you, but some. We tried to counsel the mum. Me. The nurse. The registrar I called. But the mum was having none of it. She was convinced there was something wrong, this was her third child, she was not a novice at this, and she was absolutely distraught. I tried to explain to her…but no. So we spoke to the paediatric registrar, and she very happily (and very kindly) accepted to admit the patient – less for the patient’s sake, but more because of parental anxiety and ‘at-the-end-of-her-tetherness’ of the mum. She agreed the child was gaining weight and producing urine and not vomiting, and was alert and all his observations were normal, so while things weren’t absolutely perfect with his feeding, things weren’t quite as horrible as initially thought.

After I took a 30 minute break around 4 in the morning – things became a bit too haphazard to describe in too much details. Barndoor abdominal pain with normal examination/bloods/observations (sent home); Barndoor chest pain with a normal ECG but abnormal initial bloods (admitted) and 2 back-to-back rests patients concluded my shift. This last part was such a blur that I won’t be able to do justice to it on this post – I might do a day of rests patients and give you an idea of the resus type cases that we see. But that is a story for another day. I went home and almost collapsed into bed. Glad to be able to sleep but at the same time, knowing at the back of my mind that I would get up and go back to the old drawing board in a few hours. Lovely. ZzzzzzZzZZZzzzzz….

The back pain that became a pain in the … back!

Mechanism. Never forget mechanism of injury when assessing a patient with any sort of trauma. We tend to get distracted by other people’s assessments, or their version of events, or their assessment of injuries – do NOT fall into that trap. Always start from scratch, when you are the one responsible ultimately. And always, ALWAYS take mechanism of injury into consideration, however minimal the injuries may seem to be.

Quite a while ago now, I had a patient in ED, middle-aged female who had a background of hypertension and had previously had some chronic respiratory illness, and a heart rhythm abnormality called atrial fibrillation, for which she was on warfarin – an anticoagulant. She had come in with the history of traumatic back pain. As the story went, she had been lifting some sort of semi-heavy load outside her house, and had turned around (or intended to turn around) and fallen over backwards on 2 very low steps, in the process also managing to hit her head against a brick wall. She did not lose consciousness, and her husband heard her scream, and came out of the house at once to help her. She was unable to get up on her own, but with help got to her feet and felt fine. Due to her hitting her head, her husband felt they should get a check up, so they came into the ED. Enter yours truly – their saviour in shining armour. Or not.

I assessed the patient, took a detailed history, and fully examined her. I had in the back of my mind right from the outset that she needed a scan of the head due to her head injury while being on warfarin. She denied any neck pain, and had no palpable tenderness of the bony bits in her c-spine, or neck. She also complained of mid to lower back pain, but not in the midline, rather on the right side. I specifically felt all the palpable bony aspects of her vertebral column from top to (literal) bottom, and it did not elicit any pain. There was no bruising (surprising, since she was on an anticoagulant, and had literally landed on her back on the stairs). She had full range of motion of her majors joints, and had walked in to the department to be assessed. For all intents and purposes, her major injury was the head wound, and for that I requested a CT scan of the head. It came back as normal. I found no reason to investigate anything else. Her back pain wasn’t too severe, but I still advised her to take regular analgesia, and to seek medical help if it was worsening, or not improving after a few days, or if she had any other concerns (a typical statement for me when I discharge any patient). I sent her home with some head injury advice, instructing her husband on the red flag signs to look out for, and if any concerns to come back to us. I documented the whole encounter, and went on to see my next patient.

I found out later that the patient had returned 2-3 days later, because her back pain had not improved, rather it had become much worse, and she found it difficult to mobilise out of bed. One of my other colleagues very kindly examined her this time, there was still no bony tenderness in her back, and her pain seemed to be localised to the right side of her lower back, and my colleague agreed that it seemed very much like a soft tissue injury. However, because this was the patient’s second visit to ED with the same complaint – and the situation had worsened to the point that her activities of daily living were being hampered (like getting out of bed!) – he requested an x-ray of her thoracolumbar spine, which revealed to my extreme embarrassment and shock a wedge fracture of one of the vertebral bodies. She was admitted under orthopaedics, and I crawled into a hole and died. No I didn’t.

I read up on traumatic back pain, and I gathered as much information as I could about it. I also gave a presentation to my other colleagues in the department, as a learning point. Here is what I learnt, and I utilise this information everyday: Whenever assessing traumatic back pain, the method that I have been taught and always employed was the one I have described. What is now advised, is to not just palpate the bony prominences of the vertebrae, but to place one hand on the bony prominence of the spine at any level – with the palm resting on the back; then make a fist out of your other hand, and lightly tap the fist onto the back of the hand that is flat on the back – if it elicits any pain anywhere on the back, investigate further (do x-rays) – and assess the whole vertebral column integrity in this fashion.

I have also learnt after discussing this at length with many of my colleagues of varying seniority and specialty, that even though clinically an x-ray may not have been warranted at the first presentation, yet purely based on mechanism if you looked at it, along with her age group (women middle-aged and above are more likely to begin to have osteoporotic fractures with moderate trauma), an x-ray would not have been completely out of the question.

To this day, I am terrified when I see ‘back pain – fall’ as my next patient’s presenting complaint. But I am more, much more cautious now, and I am sharing this experience to highlight how easy it is to miss something even if you are looking for it at the right place and at the right time, and I hope this post will serve to help/guide someone to not make the same mistake I did. Cheerio!

To X-ray or not to X-ray – that is the question, but what is the answer?

Guidelines and protocols are in place for a reason. Based on years and years of experience and collated data and individual opinions of specialists etc, these guidelines are set up to aid the budding EM physician. They are not absolute though, as I learnt the hard way (a most unenjoyable way to learn!)

56 year old female, otherwise fit and well, comes in to ED one fine morning around 7am. I was part of the night team, counting the minutes down to when the day team will arrive and I will be able to go home. I was asked by the registrar to see this patient who had turned up to be assessed in the first assessment bay; she was at that time the only patient waiting to be seen (a rare occurrence in ED). I went into the makeshift cubicle (which basically meant drew the curtains around myself and the patient’s bed) introduced myself and asked her what brought her to ED that morning. She reported she had an ongoing pain in her left ankle, that she had been to her GP for. Twice. When I asked her when it first began, I was quite disappointed to find out this had been going on for a few weeks (3 I think she said!) She had been to her GP who had told her on two separate occasions that this seemed like soft tissue injury, and she was advised pain killers. She came in today because she felt she was not improving. She was into hiking and jogging and was a very fit 60 year old. The concern for her was she was unable to pursue her rigorous exercise routines due to this pain. She denied any direct trauma to the affected limb, and reported no swelling or bruising. No previous history of any joint problems (no prior medical history, actually!) and she examined very well: no bony tenderness to medial or lateral malleolus (the inner and outer parts of the ankle); she was able to put weight on it, as evidenced by the fact that she had walked into the department of her own accord without any support (and without a limp!); she had full range of motion except some difficulty in everting her foot, which reproduced the pain. There were no wounds or bruises or swellings, and full power and normal reflexes ended my examination, along with palpable pulses, good capillary refill distally and no neurological deficit. I advised her to continue taking pain relief and to seek a physiotherapist because she may have injured her muscles or a tendon/ligament and may require some specific exercises. She then suggested I x-ray it, and I explained to her why I thought it didn’t warrant an x-ray. She seemed a little less convinced but did not argue, and I sent her home. I documented everything, and thought that was the end of that.

I was called by one of my consultants a few days or weeks later, informing me that I had had a letter of complaint against me. It transpired that eventually when the pain had not gotten better over the next 10 days, despite having been seen by physiotherapy as well, the patient went private and got an x-ray done, which revealed (or so I am told) a stress fracture of the distal end of the fibula! A stress fracture! Of the fibula! The fibula is one of two long bones forming the lower part of your leg. I had never actually in my not-so-many-years of experience heard of a stress fracture involving the fibula.

My consultant was very supportive about it. She had gone through my documentation, and was quite satisfied with the plan I had made for the patient based on my assessment at that time. She agreed that based on that assessment there was no indication for the x-ray. But she taught me a few things about stress fractures that I did not know; that they are more common in the metatarsals than in the fibular end, but that in view of her age, I should have considered the possibility that she might have been osteoporotic and would be prone to fractures without any significant trauma, a detail that I had failed to factor in in my assessment of her. The experience taught me so much about how I need to remain humble in this profession that I decided to do a reflective note on it at the time and added it to my portfolio.

What have I learnt? I have a lower threshold for stress fractures in older patients, despite having no findings on examination/history suggestive of bony injury. I intend to read up on stress fractures and increase my knowledge base on the topic (and maybe blog about it in a later post!). I still intend to continue fully taking a history and doing a proper detailed examination of a patient, and then using my clinical judgement in order to decide on a plan of management for a patient.

You never know when your well-intentioned actions may be the wrong way to go, regardless of whether or not they work for the other hundreds of similar cases. So never get cocky, never get complacent, always be humble, and always, always DOCUMENT!

When you hear hoofbeats, think horses, not zebras. Mostly true.

But if zebras are more common in the geographical area where you are at the time, then do, please think about zebras. But I digress.

57 year old female presented to the ED with chest pain, sudden onset, associated with shortness of breath, referred to us in acute medicine (yes a lot of my talks have been acute medicine related, those are the wounds that are freshest!) to rule-out-slash-treat-for a PE (pulmonary embolism, or a clot on the lungs). So I went through the motions, history, physical exam, investigations etc. Her past history was significant for dual malignancies (breast AND colorectal, both treated with surgery and chemo/XRT as needed quite a few years back). This history is what had freaked A&E out and had sent her in our direction (we OK, she was high risk for it, but I digress again).

Her D-dimers were not elevated, which basically is a test to rule in or rule out a PE (it being positive could be for a number of reasons, including a PE, but it being negative in her case basically ruled out the possibility of a clot). Her observations (or vitals, as we called it in the good old days) were all within normal limits, so her oxygen levels and her heart rate and her blood pressure and her cooking abilities were all top notch. Well the last one wasn’t (I mean it may have been top notch but it wasn’t a vital observation. Wow, I should get a degree in digression). Her pain had since then subsided, and all the rest of her blood tests including those for infection etc like a white cell count, and a CRP (both markers for infection, something that would cause her chest pain if the infection were focussed in her chest) were also within normal limits. And to top it all, her troponins were not raised either (serially done, these are enzymes which leak out into the blood to signify myocardial damage – myocardial = heart muscle), so it essentially looked like she was ready to go home.

For every symptom or complaint that a patient has, doctors and nurses and other allied healthcare professionals are trained to go through a checklist, usually a mental one (or physical, if you like to tick off or cross things off a physical paper list) of things that can cause the afore-mentioned symptom/complaint. Another checklist that they have is of a list of investigations or manoeuvres or steps that need to be taken in order to rule in or rule out certain diagnoses. This will basically decide whether or not a patient is safe to be sent home with just reassurance, or the condition warrants further investigation but non urgently and can still be safely sent home now, to be called in for outpatient investigations and assessment at a later point, or can not be sent home at all, and would benefit most from urgent or in-hospital investigations/assessments/services. As part of the checklist of ‘chest pain’, there are innumerable causes, and as part of the workup of significant chest pain (significant being a vague term, but significant enough to warrant a trip to the doctors’ or ED or to seek medical advice) a chest X-ray is very important. I had requested the chest X-ray for this patient (or ED had done so, and I took credit for requesting it, sue me) and the consultant who did the post-take with me on this patient agreed that she could indeed go home, once the chest X-ray had been done, and unless there was something absolutely horrific on it, he saw no reason for the patient to stay in. And you can well imagine, I am not writing this post just for the heck of it (well, partly, but I do have a point) and it was related to this chest X-ray, and this is where horses and zebras and hoofbeats make a cameo. But not for the reasons you probably think.

The patient came back from her chest X-ray, I looked it up, and I saw (as you may have probably guessed by now) a huge stinking mass in her right mid and upper zone of the lung. OK my radiology colleagues (and possibly most of my other colleagues) would kill me for not saying this right; I will rephrase: There was an well-defined opacity in the right lung encompassing the right mid and upper zones, extending from the hilum medially to the chest wall laterally.It could be a pneumonia but hey, with everything under the sun being normal for her and keeping in mind her strong prior history, my mind jumped to the possibility of it being a malignancy. More like…probability of it being a malignancy. I took a deep breath to calm myself, before I could step behind the curtain to break the bad news to this grandmother of 2. I was about to do so, when the consultant rounded the corner and asked me about the x-ray. Thankfully, I took him round to have a look at the X-rays before I broke the news to this patient, because this is where the twist came (and here you thought the twist had already come and gone, and that the mass on the chest X-ray in an otherwise completely normal looking patient was the twist. No it wasn’t as you are thinking, or as I thought. And boy, am I glad I was wrong!)

The consultant took one look at the x-ray (this is after I had told him that I had found something horrible on the X-ray, it could be a pneumonia but very likely a mass that needs to be biopsied etc…) and then placed his open palm very delicately to the middle of his forehead and very matter-of-factly said the magical words: “Have you asked the patient if she has had a breast implant?” My jaw dropping to the floor and my deer-caught-in-the-embarassed-headlights look told him I hadn’t. I went and asked the pleasant question (seriously, the things we want to know about!), and sure enough, she had had a mastectomy 7 years back for her breast cancer, followed by an implant. The totally non-threatening implant that I saw on the X-ray and mistook for a life-threatening infection and/or a life-threatening malignancy. The patient smiled. I smiled. The consultant laughed (cackled more like, rubbing his hands together with glee. OK I may have imagined that last part, because he was thoroughly professional, and actually taught me something I had not thought of. Chest X-rays or just any X-rays in general, just make sure you think of anything on or under the patient’s body causing that shadow, before you jump to the worst possible conclusion, for the patient, but like in this case more so for you. Very common ones are metallic sequins looking like metastatic nodules on lung; bra-hooks being mistaken for evidence of cardiac surgery; and when yours truly had the case of the misunderstood breast implant. Sheesh!

PS: I realize all the examples I have provided were related to female patients. Please don’t call me a chauvinist or start a feminists’ war on the blog. I apologise but it is midnight, and I can not think of any helpful examples from the male population. Maybe men (and their x-rays) are just …easier to read *runs and hides*