Ok, allow me to don my flame-******ant suit.
This image has provoked an interesting discussion. As the above poster has stated, the rationale for scanning this patient was 1) her complaint of severe back pain and 2) her overall level of intoxication and hysteria, some of which was alcohol/drugs, and some of which was just her personality, but which we presumed could have been due in part to an acute traumatic injury. In the ED, I have Traumagram-d drunk folks for a lot less, and my attending and I both agreed that this was the best modality for rapidly assessing her injuries in her state. We recently did a study examining whether a Traumagram (a head to pelvis CT) picked up injuries that would have been missed by clinical exam and/or plain films plus FAST, and the answer was unequivocally yes.
In my department, it is possible to obtain an MRI 24/7 (albeit with a significant wait time), but in my experience, it is used less in trauma and more in the gravid R/O appy situation. One poster above asked whether the metal on the occult FB would have caused problems in an MRI, and the answer is that I don't know. I raised this question with one of my attendings, who admitted that he once accidentally MRI'd a patient with a pacemaker. He said all that happened was the wires heated up a little.
I suppose the teaching point of this case is the importance of a vaginal sweep in all trauma, even stable trauma. Rarely do we do this, though (see the "Sodomy in the ED" thread and extrapolate). I once had a female MVC brought in boarded and collared, c/o hip pain, and with a tampon in place. She stated she was on her period, so the scant vaginal oozing that was noted after the tampon was removed was thought to be menstrual blood. Turns out she had an open pelvic fracture with ramus extrusion into the vaginal vault, which was detected on digital vaginal exam after the CT showed the fracture.
The item in question was a pill bottle on a keychain. Here is the conversation with the patient, who I'll call Britney, that ensued:
ME
So we were reviewing your CT scans, and it looks like you have a foreign body in your vagina. Do you know what that might be?
BRITNEY
What, like a baby?
ME
Um, no. It looks like something you might have put there yourself.
BRITNEY
(squints eyes, feigns ignorance)
ME
Actually, it looks like a pill bottle.
BRITNEY
(eyes light up, reaches between legs)
Oh, you mean this?
(pulls out pill bottle, dangles it six inches from my face)
I just keep my Xanax and Lortab in here.
ME
In your vagina?
BRITNEY
(grabs my arm with hand that just extracted object)
No! I was just, you know, afraid that, uh, the cops were going to arrest me and stuff after the accident. So I put it there, for, like, safekeeping.
ME
Um...please don't touch me.
I spent the next half hour closing her lip lac, or rather, trying to get her to be quiet while I did so. She was admitted to L&D for fetal monitoring. BAL was 165, and UDS positive for benzos, opiates, and marijuana, which all told probably posed a far greater risk to her baby than the CT scan.
At the end, she told me that she was scared DCS might take her baby from her. She said she felt excited and happy that she was going to be a mother.
) when I just blasted right into this and it cracked me up.
