Thursday, December 04, 2008

I don't think your arm is "bruised"

He was coming into the family doctor's office I was placed for an entirely different reason, this pleasant, absent-minded, blissfully unaware old chap. "Hello, young fellow!" he said, when I came into the room.

I returned his happy greeting, and asked what brought him in. "Oh, nothing much, just here to get my prescriptions renewed, then I'm on my way! Sorry to trouble you!" He was such a cheery guy.

"Why are you wearing that long hankerchief around your neck?" I asked him, making small talk as I started copying out his drug list.

"Oh, just for a bruise on my arm, it's a little sore. I tripped over my shoelaces while I was getting my morning paper a couple weeks ago." He held up his arm.

My eyes bugged out when I saw it.

His bruise had gone away, but he had much more than that left over - about six inches up his arm from his wrist, he had what is called a "step deformity" - his arm bone was simply no longer straight. An obvious sign, visible from across the room, that his arm was broken, not bruised.

Not surprisingly, the doctor I was working with sent him to the emergency department to get his arm casted.

On my way back home from the office at the end of the day, I stopped at the hospital and called up his x-ray on the computer. Sure enough, he had a definite Smith's fracture of his distal radius, typical of a fall onto a closed fist.

By chance, the emerg doc was walking by, saw I had dropped in to look at the x-ray, and said, "We're about to reduce that patient's fracture - do you want to do it?" Nice!

So, we put the jolly old fellow into an even more blissful state with some propofol ("milk of amnesia," as this white liquid is sometimes called), and yanked and pulled and tugged on his arm to get it back in the right place, then wrapped a cast around it. I love working in small hospitals - a pretty neat chance for followup on the patients, and no other resident or student there at the time so I could just jump in and do the procedure.

Epilogue: I didn't stick around to look at the post-reduction x-ray, but a few days later, I came back to the emergency department and called it up to see if the bones were set in the right place. Randomly enough, there was an orthopedic surgeon charting at the desk next to me, so I told him the story and asked him what he thought of the post-reduction x-ray. He was not impressed - turns out that if someone's arm has been broken for two weeks, it shouldn't be reduced in the ER because it's too far into the healing stages - surgery would have been more appropriate. Well, now I know.


Anonymous said...

Hmm, you'd think the ED physician would have known that, right?
Oh well, it sounds like it was a good experience overall.

Anonymous said...

Diprivan is the wonder drug. lol

We're learning about vent patients and administering succinylcholine and propofol to them to facilitate intubation and paralysis.

Anonymous said...

Well, there's always Haldol... :P

Just kidding. Yeah that sucks about the Emerg doc not knowing.

Anonymous said...

The real question here is why this older gentleman fell. What medications is he taking? What is his home environment like? Why was he going around that long with a broken arm - is there no one looking out for him?

This guy is probably doomed to fall again - and possibly be injured even more severely - if no attempt is made to address the cause(s).

Just my $0.02.

Bianca Castafiore? said...

"I love working in small hospitals - a pretty neat chance for followup on the patients, and no other resident or student there at the time so I could just jump in and do the procedure."

Isn't the reason for the preference of the operating room at the 2-week mark reflective of the risk of *infection*? Somehow, I'm not a fan of just jumping in, doing the procedure! Did anyone prescribe antibiotics?

Anonymous said...

It seems to be quite an experience for you! by the way did you check back on the guy? how is he now? I wish him speedy recovery!

Anonymous said...

Hey Vitum,

Were the folks in the ED made aware that this fracture was 2 weeks old? I don't believe the XRAY would look much different from 2 weeks old compared to 2 hours old-- So did the physician at the clinic communicate with those in the ED that the fracture was not recent?

Communication in health care is one of the areas we fall drastically short, but cannot afford to!