A couple of years ago, my son got a clothes hanger caught in his mouth (imbedded in the lower jaw under the tongue–I can only guess that he bit down on it somehow). He dislodged it himself, but I took him to the doctor for treatment. Still, a few days later, the jaw felt hot, looked red and swollen, and he had a fever. I called the local med line and they advised me to give him fever reducer and take him to the ER (it was the weekend, no regular office was open). I gave him ibuprofen, and took him in. Of course, by the time he was triaged, the fever was down (“Well, he doesn’t have a fever.” “Not anymore, I told you that I gave him ibuprofen for the fever that he did have.” Had to say this more than once, too). When they finally called us back, and the doctor finally came in, she gave him the quickie once-over, which did NOT include even opening his mouth to check the injury. Hell, she barely glanced at his face. All the exam seemed to consist of was determining that he didn’t have a fever (“NO!! Because on the advice of YOUR med line, I GAVE HIM IBUPROFEN!!! BUT HE DID HAVE A FEVER!!!”), and sending the nurse back in to give him a shot and tell us to follow up in a few days with his regular MD. BTW, we did go see his doctor, and when I told her that the ER doc hadn’t even looked in his mouth, her shocked response was, “I believe that would have offended me!” I am glad to report that he recovered fully. But I am still boggled at the idea that I could bring someone in for a specific injury and the doctor never even come near looking at it. What I learned: don’t give fever reducers before seeing a doctor, and never again allow the doctor to leave the room until I’m sure that the exam is complete. (If I’d known that her leaving the room so quickly meant that she’d seen all she aimed to, I’d have called her back and demanded that she at least look in his mouth!)
And sometimes you get the OVERzealous ER doctors. I came in with a headache so bad that it was difficult to move, and bloodshot eyes. I had no fever, my eyes worked okay, etc.
I still got tested for:
stroke
heart attack
meningitis (despite only having one symptom, but more power to them)
aneurysm/related problems
diabetes (even though I had just gotten tested elsewhere for reasons I still don’t understand)
cancer
I went in sometime around midnight, and left after dawn.
Oh, and they didn’t identify the actual problem, but I’ll give them credit for trying.
What I’m trying to say is that the ER is made up of fallible people, and at least in my city’s case, most of those people are overworked because they’re understaffed. It doesn’t make it okay, but unless I:
Can’t walk (this headache made that difficult)
Am bleeding profusely
Have a very high fever that won’t respond to medication
Have broken a bone
I won’t go to the ER–I’ll just go to a regular doctor at his/her first available appointment.
You may be some kind of macho super-diagnoser, who can just look at a patient and come to a well-supported conclusion about his condition, but for most normal humans this requires some simple tests and questions.
As I imagine you know, if you have any medical training, spinal cord injury isn’t always obvious–and a minor spinal injury can become a serious problem.
Having been the the ER, one has a reasonable expectation that serious problems resulting from the incident for which one went to the ER will be diagnosed–that’s why you go to the fucking ER. You find me a single solid medical cite (or even a well-reasoned argument) that disputes any of this and I’ll sing the high praises of their diagnostic technique. Otherwise, how about you come up with something other than an self-righteous emoticon?
All I’m saying is, the chance of him having a spinal injury was pretty small. But it is an obvious injury to check for after a fall from a height onto the head. Good care demands that it be properly investigated.
Is anyone arguing that it is good ER care not to rule out potential complications (spine, etc.)? Or that it is good ER care to offer contradictory treatment info? Or that it is good ER care to give the patient the impression you’re not even paying attention?
These are valid complaints, and so far the usual attempts to deconstruct every pitting have not convinced me otherwise.
As stated earlier, The ER would be for treating the obvious, hence the name “Emergency”, not the potential. If in fact the potential did become reality, then they would treat it.
Ok, one vote for the ER not being responsible for catching a spinal injury when the mechanism of injury presented is falling onto one’s head. Fair enough.
Do you think the other complaints are also invalid?
Richard Parker
“IANAD, but I have some training in emergency medicine.”
Sometimes a little knowledge is a bad thing.
If there are no complaints of symptoms, then why should they. If we carry your complaint to the extreme, then they should check everyone that has ever smoked for cancer.
That’s a nice cliche you have there. Do you have anything original or interesting to say?
Well, that’s a good reason not to carry my complaint to the disanalogous extreme.
I’ll make this very simple: is checking for spinal injury by asking relevant questions, palpating the spine, and checking all four CSMs, standard procedure for a patient that has a mechanism of spinal injury?
If the answer is truly “no,” I’ll defer to your learning (because I assume from your authoratative tone that you’re an MD or an experienced EMT). But, in the interest of fighting ignorance, I’d also like to know why the answer is “no.”
Good ER care will help rule out potential complications, yes. However, lets walk through this one…
Friend uses countertop as a set of parallel bars. He has a great routine, easily getting himself on the medal stand for the home kitchen Olympics, until the dismount. He flips over, lands on head/shoulder, and gets a 2.5 from the German judge for blowing the dismount. Lets say that the average countertop is about 3.5 or 4 feet tall. Given the attempted flip, he’s maybe another foot higher, so lets call it a 5 foot fall onto his head and shoulders.
Now, he does not have any loss of conciseness. The accident was not severe enough to immediately call 911. He, I assume, sits up, goes “damn my shoulder hurts, and I have a headache.” You guys notice the bump on his head, and the potentially dislocated shoulder, sling him up,** stand him up, and walk him to the car.**
Now, some indeterminate time later after the accident (however long it took for your improvised care and a car trip) he walks into the ER.
So, let us all remember back to our A&P days, and state that your spine is pretty damn tough. We humans can take some pretty good bumps and walk away from it. I’m 6 feet tall. If I drink too much, loose my balance, and fall without catching myself, I’ll smack my head from 6 feet up. Not a whole lot of drunks die from falling over and smacking their head. The elderly may occasionally have issues with this, but I’m assuming given the entry in the kitchen Olympics that he is of age to attempt such.
He presents to the triage nurse as such. Did he specifically state that he had neck or back pain? Did he complain of any numbness or tingling in the extremities? He didn’t get knocked out. No blurred vision, slurred speech, or changes in hearing? Ruling out a possible neck injury or concussion is as much what I can see as what you tell me. The mechanism of injury is marginal, and none of the complaints are there. At best I’d be worried about some secondary impairment from swelling around the spinal cord due to tissue injury around the neck.
Now, a middle of the road doc might order a c-spine film. A conservative doc may even go for a head CT from the fall. Would I have placed him in full c-spine precautions if you called 911 and I showed up? Not likely.
Fair enough. FWIW, he did have blurred vision in one eye from the head trauma–and though he didn’t lose conciousness, he was not fully alert and oriented for a brief time after the accident. But if I had thought there was a significant chance of a spinal injury, or if he hadn’t declined my care, I probably would not have let him hop up and walk to the care without first investigating the spine a bit.
I think the MOI of falling onto your head with your body above you is a bit more severe than falling over while standing, but it’s sort of beside the point. I don’t think they should have ordered any further tests or x-rays, but it seems like prudent good care (given that his whole shoulder/lower neck area hurt from the clavicle problem and head bang) to do more than just assume no spinal injury…right?
Also, kinoons, you strike me as a reasonable judge: are the rest of my complaints unworthy of pitting?
I’m not a huge fan of trying to Monday morning QB another medical provider, so without being there and seeing exactly what was done or not done, I’m not going to say one way or another if the care was good or not. From what you described I’d be much more worried about a concussion and the possible ICB resulting from the injury (very unlikely, but possible) than a spinal injury.
I guess you could try and reach that he axially (sp) loaded his spine, and possibly had a compression fracture of the spine, but I’d have a hard time believing he’d have enough energy left from the fall to dislocate his shoulder.
Generally, when there is the possibility of spinal injury I’ll ask a patient if they have any neck or back pain. If they say no, I’ll let it go at that. If they say yes I’ll palpate their spine/neck looking for point tenderness on the spine it self, or see if the pain is lateral (therefore, generally muscular). Given the distracting injury of the dislocated shoulder it wouldn’t have been a bad idea to palpate the neck and spine, but it isn’t a heinous crime to not do so. Distal CSM can be checked just by the patients everyday movements. (I would have hoped for a little more detailed check on the hand of the dislocated shoulder)
As far as looking for other injuries, again if someone is awake enough to talk to me and make sense, if they don’t say their leg hurts, I don’t usually go looking for an injury there w/o significant MOI (high speed MVC, assaults, ect).
Discharge instructions can sometimes be misunderstood by both the staff and the patient. If he felt he was told one thing, then another, he should have stopped the nurse and asked for them to clarify. It’s as much his fault as theirs for not making it clear if he was to move the shoulder or not.
Ten minutes seems a little short for all the care, but again I was not there. A good history and physical from a doc should only take a few minutes, as well as drawing labs, tests, and such. The only thing I think might take a bit longer is the reduction of the shoulder depending on how sedated your friend was, but YMMV on that one.
Oh, and about insurance, unless the provider goes out of their way to see what insurance your friend has, they don’t know.
So all things considered, it seems like the care was about par for the course. Nothing too terribly wrong done, but nothing to make him feel special either.
:eek: It is truly amazing what kids can do to themselves.
On that note, Richard, how old is your friend?
Twenty-five. Old enough to know better, but so old that anyone was particularly surprised.
Serious question. Is it possible to have a spinal injury that results in paralysis…but the paralysis dosen’t set in till hours after the injury?
[sub]I saw in a movie once. Probably not the best place for really reliable information…[/sub]
It is possible to have a fractured vertebra but an undamaged spinal cord, which is later damaged from the pieces of vertebrae.
and its possible that I could be dealt a royal flush the first time i sit down at a poker table.
and a hard enough whack to break a piece of a vertabrae away like that is going to:
A) Hurt like all hell
B) Make your friend scream like a little girl upon palpation
C) Probably render him unconscious from the impact
Broken bones hurt, even if the bone is not real sensitve, there is tons of other enervated structures surrounding and supporting those cervical vertabrae, they don’t like rubbing on rough edges. Breaking off of a piece inside the vertabrae facing the spinal cord without serious damage to the outside and or surounding structures is highly unlikely if not impossible.
Most of the injuries commonly experienced to the neck are strained/pulled/torn muscles and damage to tendons and such unless you are playing in the kind of titanic levels of force involved in long falls and high speed car accidents its pretty tough to break or seriously damage vertabrae just because there is alot of supporting muscle in that area.
drachillix,
Maybe it’s not the type of injury you’re talking about, but I had a cracked vertebra without my symptoms being that extreme. It resulted from an auto accident going less than 40 mph. It DID hurt, but was initially diagnosed in the ER as a whiplash. However, the following day the hospital staff apparently took a longer look, and called me at home to come back in. The only treatment was a neck brace and instructions to not do anything that would cause further injury. There was no spinal cord involvement, fortunately.
Well he did say pieces
Generally speaking, this type of paralysis sets in due to swelling around the spinal cord. If the swelling persists for a long time, the pressure can result in spinal cord death. If the swelling goes down, the patient will likely make a full recovery.
Isolated neck/back fractures that do not present initially, but result in paralysis when the patient moves something funny, are extremely uncommon, but possible. Because of this many EMT’s, nurses, and doctors treat all potential spinal injuries the same. (Which I don’t agree with, but thats another arguement)
Yep. So if someone asks if that’s possible, the correct answer is “yes.”