Febrifuge Posted July 6, 2014 Share Posted July 6, 2014 Just curious. I saw a guy recently who dove off a dock, head-first and Superman-style, into what turned out to be 2 to 3 feet of water. He had sand in his hair all night so he mashed the mud and silt for sure. I saw him about 24 hours post-injury. He had no LOC when it happened, no paresthesias or neuro sx at any point. He was VERY sore and stiff early in the AM, enough to wake him up, but that improved with NSAIDs and ice. By the time I saw him, he had driven a few hundred miles back home and kind of just thought he should be checked out. I nearly shit a brick of course, in my solo suburban UCC, hearing his story. Clinically, he was all good. Sitting comfortably, ambulatory, able to rotate 45 degrees left and right, decent extension, good flexion. No posterior midline tenderness. I even added an axial loading pressure test, which I picked up someplace along the way, and that elicited nothing. He was just really sore to the soft tissues at the base of the posterior neck. No neuro anything. But he is going to haunt my dreams because according to true Canadian rules, his mechanism suggests he needs a scan. I thought about screwing around with plain x-rays (which we have) versus just sending his ass to the ER via ambulance... but then I examined him and was relieved and reassured... until I reviewed the letter of the rules. It's worth mentioning that under NEXUS, he's good, so I guess ultimately the question is whether one system or another is better or more accurate. We can go there, if you're feeling scholarly. But mostly, I'm curious: tell me what you would have done. Imagine the CT scanner is down, or you're like me and just don't have one. Have you seen people like this guy? How did they turn out? Link to comment Share on other sites More sharing options...
KMD16 Posted July 7, 2014 Share Posted July 7, 2014 Formal neurological surgery PA here. Age of pt? Hx of anticoagulant use? In your exam you mentioned your axial load test (aka spurling compression test) didn't illicit a radiculopathy sx. This test is no indicated in traumatic patient. Irrespective of pt hx and age. I would have ship him out to the ED for CT brain & complete spine. Link to comment Share on other sites More sharing options...
gbrothers98 Posted July 7, 2014 Share Posted July 7, 2014 I think if you are going to use a rule, you need to know it backwards and forwards including some of the downfalls with these rules. For instance, several years ago I attended a lecture given by the EM MD that developed the PERC rule. He clearly said his rule was not perfect and that clinical experience and gestalt can trump any rule including his. That said, if you look at the NEXUS study, it didnt say it was a foolproof rule, just that the fractures that were missed did not need significant intervention or treatment but patients still had a fractured vertebrae. Then there is this: http://www.nejm.org/doi/full/10.1056/NEJMoa031375 My bottom line with a patient such as this is I want at least 2 people to have piece of mind. That would be me and the patient. After the fact injuries and remote injuries where patients get the opportunity to downplay the significance of the mechanism and also the exact events leading up to it ie I really had a 12 pack during the course of the day and launched off the dock at a sprint but I am not going to mention that, cause me more concern because the patient is trying to bias you rather than relying on your objective interpretation of the event. So the truth here is that you had an individual with a potentially significant axial load injury to his cspine. Stop right there. Dont over think it. Image. A plain cspine series is still very valid to look for obvious unstable fractures which is your job and purpose. If this was fine then immediate CT is a judgement call but follow up is mandatory within 72 hours. He may not have a fracture but he could have a soft tissue injury that needs attention. But both I and he would be reassured since I did not get the xray vision handed out to older clinicians when they graduated from their training many moons ago. I would call this guy back, see how he is doing. If he is having symptoms, I would have him return and image him and take ownership. Good luck G. Brothers PA-C Link to comment Share on other sites More sharing options...
KMD16 Posted July 7, 2014 Share Posted July 7, 2014 ^^ Agreed. I did not have the time for more elaborative details. Simple rules: when in doubt, reach out for help or ship out. Link to comment Share on other sites More sharing options...
medic25 Posted July 7, 2014 Share Posted July 7, 2014 I think if you are going to use a rule, you need to know it backwards and forwards including some of the downfalls with these rules. For instance, several years ago I attended a lecture given by the EM MD that developed the PERC rule. He clearly said his rule was not perfect and that clinical experience and gestalt can trump any rule including his. Words to live by; clinical rules are very useful, but they need to be taken in context and your clinical judgement has to sometimes trump the rule. I took care of a woman in her 40's this week, triaged as an ESI level 4 for "rib pain". 2 weeks of pleuritic chest pain and cough, already through 2 rounds of antibiotics by PMD and pulmonologist. Technically she met all of the criteria to "PERC out", but my gestalt was that there was something more going on. Got the CTA, and she had multiple bilateral PE's. HR in the 60's, no hypoxia, but something just didn't add up with the story. If your spidey-senses (a term I prefer to gestalt) say something bad might be happening, I say pursue the workup and go with what your gut says. Link to comment Share on other sites More sharing options...
Febrifuge Posted July 7, 2014 Author Share Posted July 7, 2014 Great advice all around. Thanks to all, and keep it coming. A few small clarifications: - dude is late 20s/ early 30s. Not anticoagulated, or indeed taking anything daily. It's a great point that he is also a prime candidate for "forgetting" to mention whatever else he was up to over the weekend, so that's a gap in what I truly know about the event. - it's not really a Spurling that I learned from whoever-it-was (EM staff at one of a few possible places), it's kind of a final step if all the other C-spine testing is negative. The neck stays midline and the patient is passive, but paying attention to how the neck feels. It's probably voodoo instead of science, but is vaguely reassuring. - 30 seconds before I met the guy, I was sure I was going to send him. I'm not shy about shipping people out, and do it a fair bit. But then everything was so very benign and normal that the gestalt -- the Spidey-Sense -- surprisingly swung around the other way for me. Sure, he's a dingbat for not being evaluated sooner, for driving across the state all day, for waiting... But steady improvement and no neuro symptoms over this span of time does seem like it makes badness less likely. - The other side of that coin, and it's a very good take-home for me in this case, is that the time since injury should maybe be considered something that obscures the history rather than reveals it. This guy has been trying to convince himself he did the right thing and it's no big deal and he's just seeing me to be cautious; of course he's going to try to convince me of the same thing, intentionally or otherwise. Probably otherwise, actually. - I talked at length about how at the slightest indication of anything weird, he needs to get to the ER, for real, and I believe he got the message. My written instructions start out with "...a fracture is definintely NOT ruled out either." Ultimately, the point about reassuring him AND me is the core issue, I think. - I'll call tomorrow and see how he's doing, and make sure he gets follow-up. Link to comment Share on other sites More sharing options...
KMD16 Posted July 7, 2014 Share Posted July 7, 2014 Make sure you document your f/u phone call in his chart. Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 8, 2014 Moderator Share Posted July 8, 2014 WHAT you were trying to figure out rather to image and you did an axial load test and ROM? oh no - not a good idea.......... mechanism and ongoing pain..... I would have gotten a CT - maybe would have considered plain films if he was thin and able to get good shots - but if you don't/can't give 100% read then you would need a CT anyways....... Just no way I would try to save the $100 exam and radiation exposure on a diving accident Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted July 8, 2014 Share Posted July 8, 2014 One item that no one has mentioned that needs consideration, though is a low probability (unless the attorney later points it out to you), is an MRI to look for a traumatic syringomyelia. This is where you look for those "What was the name of that condition again?" possibilities such as Brown-Sequard syndrome, as well as other anterior, posterior, and central cord syndromes. If you're going to be assessing spinal cord issues (anyone in urgent care or EM will be) I strongly believe that you have to be familiar with Lhermette's testing and Spurling's maneuver. As an aside, and as a former spine/ED PA who has seen this more times than I care to remember, DO NOT assess biceps/triceps muscle strength with the patient upright and the elbow flapping in the breeze! Lay the patient back or have them brace the elbow on a firm surface (exam table) and THEN test (thank you Dr. ********* for teaching me this fact several decades ago as a young whipper snapper). Many patients will have subjective symptoms of weakness in a dermatomal distribution yet will test negative if you half-arse your exam. I have predominantly seen this in the triceps where you can just about slap the patient with their own hand due to their inability to resist your pressure yet when they are sat upright they are "normal". I know Bates tells you otherwise and shows you otherwise in the text as a baseline screen but in these instances you're looking for something specific based upon a specific injury with significant consequences if you get it wrong. Link to comment Share on other sites More sharing options...
KMD16 Posted July 8, 2014 Share Posted July 8, 2014 Agreed...syrinx very low probability....won't chase after it..the key here is deciding between CT vs Plain film. I will shot for CT given the mech of injury plus sensitivity/specificity of CT >>>> Plain film. Link to comment Share on other sites More sharing options...
Febrifuge Posted July 8, 2014 Author Share Posted July 8, 2014 This thread is a goldmine. Bummer it had to be the kind that makes me look dumb but, meh, I have very little by way of ego. The guy is getting follow-up and we talked at length about the need for imaging, btw. Thanks again, all. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.