Apologies in advance here. I don't normally post for stuff like this, but my overnight shift last night shook me up a little bit, and still trying to process the couple of near-misses that I had. First a little background. I work at a medium-sized community hospital in a pretty large health system. I'm on a little stretch of overnights right now. They're really hit or miss at our hospital, since you have single physician coverage for most of the night. You can have absolutely terrible ones where you start off bad and never catch up (as in you might not clear the waiting room until like 5 AM), or you might never really have more than like 4 or 5 patients in the ED after midnight. So I guess that isn't too unusual for overnight shifts in the ED, but it just seemed like in residency there wasn't quite as much variation.
I'm a smidge over 2.5 years out of residency. I firmly believe that an EM physician who thinks that they have it "figured out" is dangerously close to missing something, given the random crap that we see and deal with on a daily basis, but at the same time, I've seen quite a bit in my short career, and I think that I can handle the vast majority of what comes through the door without too much trouble. Anyways, on to last night.
My last shift started out beautiful. The first couple of hours were pretty light. People to see, but nothing too bad to deal with, and we had empty beds in both the ED and the hospital. It slowed down as the night went on, as it normally will do, and I was looking forward to a pretty decent shift overall. Then I had two patients that kind of shook me.
The first one was an older guy who came in for chest pain. Nothing too unusual, see it all the time. Within like a minute I knew I was going to be admitting him. The pain was in the chest, went up to his neck. No dyspnea, some on/off nausea, no diaphoresis. EKG looked completely normal. Something just felt a smidge off, but I didn't think too much of it. He had come in on oxygen from EMS, though it wasn't immediately obvious why. I took it off of him, and his oxygen right after was like 95%, so I didn't think too much of it. A couple of minutes later he was 93% on room air, and something still just felt weird. I couldn't quite tell what it was, and I didn't really know why, but I thought heck, maybe he has a PE. Worked a somewhat sedentary job, pulse ox a little lower than I'd expect. I actually hate d-dimers, and think they're over-ordered. If you're worried about a PE in someone who isn't young, I've always thought just scan them (criticize if you want, but that's not the purpose of the post). So I scan him. Blood pressure drifts down a little beforehand, but nothing too low. On a whim I go over like a minute after he did to CT. I walk in the room as he's getting the contrast for his CTA chest to rule out PE. And boom, right there is a huge dissection. CT tech and I just look at each other like holy crap. Call the flagship hospital (my shop doesn't have CT surgery), fly him up there for emergency surgery. His vitals got a little worse prior to flying out, so I probably would have scanned him eventually, but I didn't have a great reason to do it earlier. Shook me a little bit how lucky I got.
While I'm arranging transport for that patient, a trauma patient came in. Young guy, single-vehicle MVC rollover. Complaining of a headache and not much else. I evaluate him, order CT head, c-spine, and chest/abdomen/pelvis. The only reason for the chest/abdomen/pelvis was the mechanism. Has a small laceration to the scalp, bleeding a little but not that much. CT scans show only a facial fracture. He hadn't really complained of facial pain or tenderness, so I think that's a little weird. I'm about to go suture his lac when I think to myself "you know, maybe just scan his facial bones to make sure there isn't another fracture, the CT head doesn't get the whole face". So I send him back to CT. He comes back, and I go in the room to suture the lac. My phone goes off while I'm gloved up and about to suture, so I have a tech come in to get the phone out of my pocket. It had actually gone off three times, the first two there was nobody in the room, and they got it for the third call. They held the phone up to my ear, and radiology is now telling me that there is an epidural hematoma that they picked up on the facial bones CT. I call the flagship hospital – we don't have neurosurgery at my shop – and fly him up there. Fortunately GCS 15 and neuro exam normal upon transfer.
Basically radiology missed the epidural on the CT head. It wasn't big, but it was there when you go back and look. I hadn't looked at the images yet – I usually do before discharge – but I could have easily missed it scrolling through fast. My CT tech – who is VERY good about picking up stuff like that in real time…unofficially of course – didn't see it. It was the same radiologist that read both the CT head and then the later CT facial bones. I'm shaking a little thinking that if I hadn't ordered that second CT, this kid would have gone home, fallen asleep, and died. I know that I've missed stuff. We all do. But damn did that one hit home, and I'm not entirely sure why. I think it was just how close I was to sending that kid home.
Anyways, I apologize for the long post. Like I said, I don't normally post like this, but I'm just trying to process this.
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