WhiteCoat

NOW You Tell Me

Paramedics bring in a three year old girl who was hit in the head by a television that had fallen off some shelves. It appeared to be a glancing blow – with some bruises to the side of the face and a bump to the back of the head. The only problem was that she was just crying on the backboard and she wouldn’t move her arms or legs.

Take a pen and squeeze the barrel against the base of your fingernail. Hurts like heck, right? I did that to the little girl a few times on each hand and all she did was cry. Didn’t flinch. Didn’t pull her hands away. Just cried. I lifted her hands up and dropped them over her face. Usually patients will pull their hands to the side. She let her hands flop right onto her nose.

I reached through the collar and pressed on her neck. Didn’t feel any step-offs or other abnormalities. Again, she just cried when I touched her neck.

Damn.

“Can we get her off the backboard?”

On the inside, I was freaking out a little. “Ummmm … NOOOOO. Are you out of your MIND? Can’t you see she’s paralyzed?”
On the outside, I stayed calm. “Just to be safe, we should probably leave the collar on until we make sure nothing is broken.”

So I bit the bullet and ordered CT scans of her head and neck.
She was over in the radiology department for quite a while. I kept checking the PACS machine to look for the films.
Finally, the images showed up.
Normal head CT.
Normal cervical spine CT.
At least that’s the way that I read them.

I went back into the room to check on her. She was up off of the board, her collar was removed, and she was playing on her mom’s iPad. Back to normal. I did another neurologic exam and everything was now normal.

Wow. Complete neurologic recovery from ionizing radiation?

So I mentioned to the patient’s parents that I was a little worried about her when she wouldn’t move her arms or legs on her initial exam.

Her dad says “That? Oh she always does that when she gets upset.”
“You mean she always just goes limp?” I asked.
“Yeah. She comes around after 20 minutes or so. Just like she did tonight. We tell her not to do that, but … you know three year olds.”

I smiled and nodded … and I thought to myself “why didn’t you tell me that BEFORE I messed my undergarments?”

And I think back to the medical school gurus who used to tell us that 90% of the patients will tell you what is wrong with them if you ask the right questions.

Not sure how to add this fact pattern to the history, though.

———————–

This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

5 Responses to “NOW You Tell Me”

  1. SeaSpray says:

    I would think the parents would’ve spoken up when they new she was going to get a CT. ?

    Well …at least she’s alright.

    Interesting that she behaves that way.

  2. Lisa K. says:

    I’m neither a parent nor a trained medical professional but wouldn’t this history raise other red flags? Some chronic neurological problem? Child abuse? How likely is it that a healthy three year old would voluntarily choose not to respond to painful stimuli?

    • GCS 15 says:

      Not necessarily and kids do the oddest things. If you look online there are even infants/kids who hold their breath to the point of going limp and blue during a tantrum or when they are upset. It’s surprisingly not harmful and more common then you’d think.

      My own daughter is almost bald on one side of her head because she pulls it out while falling asleep. I don’t know how ripping hair out is soothing , but to her it is (I try to stop her and she won’t sleep, or rips my hair out ). Another surprisingly common problem.

      Kids are more resilient then adults, and I don’t think the answer should be to jump to child abuse. One, it could be devestating if unfounded and two, it takes away resources from already stretched thin agencies.

      • Lisa K. says:

        The accusation of child abuse is devasting when it is not true. The experience of being abused as a child is more devastating particularly when no one believes it is happening. Child protective services exists to protect the welfare of children. It is hardly taking away valuable resources to ask them to fulfill their primary mission.

        That said I agree that going limp in the face of trauma is hardly a classic presentation of child abuse and that suspicion or lack thereof would rest much more strongly on the plausibility of the story of the accident.

  3. Xsurgerdoc says:

    The data indicates a 3-fold increase in brain CA at 10 years post-CT, or about an extra 1/10,000. 5 times higher with 5 CTs?? Now what? Informed consent before Head CTs in all kids? What about adults? Not a CYA issue in states with a med/mal statute of limitations, but what about a moral issue. In the clinically not indicated, but parent demand situations, I confront them with the data and you would be amazed at the change in attitude toward a “watch and wait ” attitude. A move toward guidelines in the no LOC neuro normal patient? Is size and location of a lac significant? Is cost an issue? ???

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