WhiteCoat

Thanks For Watching

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.”
I smiled.
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 …

6 Responses to “Thanks For Watching”

  1. Larry Sheldon says:

    Thanks.

    • Larry Sheldon says:

      “Sometimes emergency medicine can be pretty cool.”

      It would take a fair sprinkling of those to keep me in it. Money and fame would not do it.

      Thank you (global “you”–y’all) for being there.

  2. SeaSpray says:

    Disappointing the opthamologists wouldn’t do it. Maybe she didn’t have the time anyway – waiting for them to come in?

    Congrats to the resident and you for good teaching skills.

    And how nice that the family and patient were appreciative. Lidocaine in eye area – yikes!

    I can picture (as much as one can not knowing what you look like – more of a outline of faceless people :), you and Mrs W being one of those little elderly couples still walking hand in hand – years from now. :)

  3. DefendUSA says:

    That’s a goosebump story!! Love!

  4. Robert Lanz says:

    Jeez, don’t you guys have a social worker in your ER?
    You won’t always have the time to get to that lonely patient despite your good intentions. We see about 70,000 patients a year in our ER/trauma center and have the luxury of a SW 24/7.
    Let then have the grief!

    http://robertjlanz.wordpress.com/

    check these stories then lobby your administration for your own SW.

  5. JJ says:

    As an ophthalmologist what the 2 hacks told you is a disgrace to the profession. First, doing a canthotomy is not rocket science. You really can’t mess it up, unless you perf the globe. Any practicing ophthalmologist should know how to do them but more importantly should know what happens if you don’t. If you had listened to their advice there is a fairly high chance she would be blinded while waiting for a trip to the trauma center.

    I had a doc from an ED in the middle of nowhere call me one night with basically the same story. It would be a 90 minute trip if they dumped her into an ambulance (which was not there). I told him to document the vision, pressure and pupils, do the best he could and send her. Same result, he did the canthotomy, by the time she arrived her vision had recovered.

    Lastly, it is very important to document two things. One is vision, the other is a presence or absence of an afferent pupillary defect. If you have a retrobular hemorrhage, with decent vision and no APD (even with elevated IOP) you probably have time to wait for the ophthamologist. For me the APD and secondarily vision are the most important things to determine how quickly (or if) a canthotomy needs to be performed. We see alot of patients with a RBH, good vision, no APD, IOP 25-40 who never get a canthotomy and do fine.

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