Its been a rough few weeks. The stories keep piling up on my desk. This one keeps coming to mind, so I figured I’d try to post it from my phone.*
An elderly patient came in by ambulance after tripping over a curb. She fell and hit her face, causing a nasal fracture and a periorbital contusion. But she was also having an increasing headache and she had proptosis. That’s a bad sign.
We got the CT scan of her brain and it confirmed our fears. She had a retrobulbar hematoma, meaning that there was an expanding blood clot behind her eye which was pushing her eyeball outwards against the eyelid. Because the lids push back to hold the eye in the socket, the expanding blood clot was putting increasing pressure on her eye. Too much pressure and the eyesight is gone permanently.
When we checked her vision, she was only able to see shapes out of that eye. We checked her pressure using a tonometer. It was 55. More bad news. Normal should be less than 20. We had to perform a canthotomy, meaning that we had to cut the ligament of the lower eyelid to bring down the pressure in the eyeball. A good article on performing a lateral canthotomy is here, including a drawing of what a retro-orbital hematoma looks like and why it needs to be treated.
We called two ophthalmologists to come in and help us, but neither one had ever seen a canthotomy or had done a canthotomy. Both said to send the patient to the trauma center.
Great. I did a canthotomy during a trauma rotation in my residency, so I guess we’re doing it here.
I actually let the resident perform the procedure. I helped her anesthetize the eye and I helped her guide the scissors in the right direction. Performing a canthotomy is a little more difficult than it looks [OK, I just proofread this post and there was no pun intended here]. The lateral canthal tendon is tough to cut.
As the resident was injecting the eye with lidocaine, I saw the patient her squeezing her hands in pain underneath the sterile drape.
I reached out and held one of them. Habit, I guess. Any time Mrs. WhiteCoat has a free hand, I like to be holding it.
The patient squeezed.
“Who is that?”
“It’s just one of the other doctors. You looked lonely.”
As the resident finished the procedure, I rubbed her hand back and forth and she squeezed a few times. Before we knew it, the procedure was done.
The patient thanked me for providing her moral support.
We pulled off the sterile drapes.
“So that’s what you look like.”
We rechecked the pressures in her eye. They had gone from 55 down to 30. Excellent.
So the resident arranged for transfer to the trauma center.
The patient’s family arrived just as the patient was being loaded onto the ambulance stretcher. I was in another room and the resident came to get me. The patient wouldn’t leave the hospital before she spoke to me.
There were several people standing around the stretcher. One by one, they came up, shook my hand, and thanked me. A couple gave me a hug, including the patient’s 4 year old great grandson who hugged my leg, although I’m sure he didn’t know why.
I told them “I think you need to be thanking the resident. She’s the one who saved your mother’s eyesight.”
Several of them chimed in together “Yeah, but you’re the one who held her hand. You were there for her when we couldn’t be.”
We called the trauma center later that day to see how the patient was doing. Pressures in her eye were down to 10. Vision was normal. A save!
It’s nice to know that she will be able so watch her great grandson’s blow out his birthday candles … with both eyes … the following week.
Sometimes emergency medicine can be pretty cool.
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.
*Making a WordPress post from a smart phone is a colossal exercise in frustration, by the way …