Interesting incident tonight

[ipw21]

So I'm playing 2nd base tonight in a church league slow pitch softball game. A ball is hit sharply to my right side and I just manage to get my glove on it, knocking it down right in front of the shortstop (who, it just so happens, was playing AA baseball this time last year and has a howitzer for an arm). He picks up the ball, squares himself and unloads a supersonic rocket of a throw towards first, which goes right past the first baseman's glove and nails the runner squarely on his helmetless head, knocking him to the ground with a very loud, sickening thud. So here I am, 4 weeks out of medical school, still about a month away from starting my EM residency, in a situation I did not want to find myself in. But the story gets better, because the man lying on the ground in front of me is none other than the FP who was my doctor from birth until I moved away to college. Thankfully he was OK. No LOC, alert and oriented right away, no neurological deficits. He got up and walked to the dugout on his own power. When this all went down I didn't really do anything other than just observe and try determine if he was alright. I would have felt like a jackass saying something like "I'm a doctor, everyone stay back and let me handle this." Especially faced with a "patient" who is such a more experienced doctor whom I greatly respect. Anyway, the game was over about 20 minutes later. I waited around until the crowd dispersed and then went over and talked to him. Even though he is perfectly capable of taking care of himself, I felt like I should at least make sure he was really OK. He had been hit right on the left temple, and the phrases "middle meningeal artery tear" and "lucid interval" kept running through my head. It would have been very intimidating and awkward for me to even try to assume the "Dr. role" in this situation, so I didn't. As humbly and deferentially as I could, I shared my concerns with him. He said that he felt fine but he was going to stay awake for a few hours just to make sure nothing bad was going on. I left it at that, said goodbye and went home. I'm pretty confident that he is fine, a softball is not nearly as dangerous as a baseball, but I'm just curious how others, both at my level of training and the more experienced, would have handled the situation. I'm also curious that if faced with this patient and story in the ED, how badly would you want to get a CT, if at all?

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[southerndoc]

I would CT if he has criteria of the Canadian CT rules, has an altered LOC, etc.

 

[leviathan]

So I'm playing 2nd base tonight in a church league slow pitch softball game. A ball is hit sharply to my right side and I just manage to get my glove on it, knocking it down right in front of the shortstop (who, it just so happens, was playing AA baseball this time last year and has a howitzer for an arm). He picks up the ball, squares himself and unloads a supersonic rocket of a throw towards first, which goes right past the first baseman's glove and nails the runner squarely on his helmetless head, knocking him to the ground with a very loud, sickening thud. So here I am, 4 weeks out of medical school, still about a month away from starting my EM residency, in a situation I did not want to find myself in. But the story gets better, because the man lying on the ground in front of me is none other than the FP who was my doctor from birth until I moved away to college. Thankfully he was OK. No LOC, alert and oriented right away, no neurological deficits. He got up and walked to the dugout on his own power. When this all went down I didn't really do anything other than just observe and try determine if he was alright. I would have felt like a jackass saying something like "I'm a doctor, everyone stay back and let me handle this." Especially faced with a "patient" who is such a more experienced doctor whom I greatly respect. Anyway, the game was over about 20 minutes later. I waited around until the crowd dispersed and then went over and talked to him. Even though he is perfectly capable of taking care of himself, I felt like I should at least make sure he was really OK. He had been hit right on the left temple, and the phrases "middle meningeal artery tear" and "lucid interval" kept running through my head. It would have been very intimidating and awkward for me to even try to assume the "Dr. role" in this situation, so I didn't. As humbly and deferentially as I could, I shared my concerns with him. He said that he felt fine but he was going to stay awake for a few hours just to make sure nothing bad was going on. I left it at that, said goodbye and went home. I'm pretty confident that he is fine, a softball is not nearly as dangerous as a baseball, but I'm just curious how others, both at my level of training and the more experienced, would have handled the situation. I'm also curious that if faced with this patient and story in the ED, how badly would you want to get a CT, if at all?

Based on the Canadian Head CT rules, you wouldn't need to scan him if he never even had an LOC incident from the beginning, no neuro findings, and no signs of a skull fracture. I'm not sure if being hit by a softball would be considered a dangerous mechanism (based on the speed you said he was hit), but I don't think it would.

 

[DrQuinn]

Since I'm graduating in less than a month... this is what I would do:

Assess cognition. Assess whatever CT guidelines for minimal head injury. Discuss with patient my feelings he doesn't need a CT. Document. Get the head CT or not. D/C home with close instructions.

Now, when you're out playing baseball, its a different story. I would have just kept a close eye on the guy (which seems like what you did), and played ball. Any signs of him acting weird (feeling nauseous, stumbling) woulda had me dialin' 911 on my cell uber-quick. I think you handled yourself well... especially in a situation where the patient is more than just a regular dood.

Q

 

[mikecwru]

Since I'm graduating in less than a month... this is what I would do:

Assess cognition. Assess whatever CT guidelines for minimal head injury. Discuss with patient my feelings he doesn't need a CT. Document. Get the head CT or not. D/C home with close instructions.

Now, when you're out playing baseball, its a different story. I would have just kept a close eye on the guy (which seems like what you did), and played ball. Any signs of him acting weird (feeling nauseous, stumbling) woulda had me dialin' 911 on my cell uber-quick. I think you handled yourself well... especially in a situation where the patient is more than just a regular dood.

Q

This is the line I usually use with these clinical decision rules (ankle, etc) "we know that if people come in just like you, and they meet these criteria, there is almost no chance they will have a finding on their [ct, xray, etc]" but I don't fight patients who have waited 8 hrs in the ED to get their ankle xray, etc. I will fight the "good fight" a little bit more if we're unnecessarily irradiating the hell out of a little kid, but . . .

mike

 

[ipw21]

The question about the CT was based on the mechanism part of the criteria, I wouldn't normally think that a softball to the head would be considered dangerous, but what I saw was pretty nasty. It's interesting, because had I not witnessed what happened, I wouldn't have been too concerned at all. We rarely, if ever, actually see our patients sustain the injuries we treat. Most things probably look worse than they actually are.
The CT question aside, what I was really curious about was the whole issue of finding yourself dealing with an emergency out in the real world, without any upper levels or attendings around. I guess I was hoping for some discussion about what I could have done differently or better, or suggestions on how to deal with these kinds of situations. I know I can handle the basics: call 911, do the ABC's, start CPR is necessary, etc. Is there much else that can be done while wating for help to arrive?
As a little follow up, he was apparently fine overnight, but the next day had a lot of vomitting and experienced some hearing loss. So, last I heard, he was going for a CT soon. I'll be curious to find out what happens. Thanks for the replies.

 

[mysophobe]

I came home to find my girlfriend unconscious and not breathing once. Suffice to say, medical education aside, I still needed a clean pair of shorts.

 

[leviathan]

I came home to find my girlfriend unconscious and not breathing once. Suffice to say, medical education aside, I still needed a clean pair of shorts.

What happened, if you don't mind sharing?

 

[mysophobe]

She had a hypoglycemic episode. She'd been working out all day and hadn't eaten. It happened a few times, though not quite so bad. I came home once and she was all loopy, telling me all this weird stuff that made no sense. In those situations, I'd keep her conscious and give her some apple juice and some jelly beans and she would be fine.

 

[emtcsmith]

On the topic of emergencies I always wonder if all the EMS training we do in paramedic/emt classes helps us to train for crazy crap like that as much as treating the sick and injured. A medic I followed one day in the ER got a kick out of freaking the nurses out over a sick patient and was like "isn't it fun to scare the nurses?". But to be fair some of the residents and attendings I observed handle some of the craziest stuff really well, and obviously better then I will for many years to come.

 

[colforbinMD]

On the topic of emergencies I always wonder if all the EMS training we do in paramedic/emt classes helps us to train for crazy crap like that as much as treating the sick and injured. A medic I followed one day in the ER got a kick out of freaking the nurses out over a sick patient and was like "isn't it fun to scare the nurses?". But to be fair some of the residents and attendings I observed handle some of the craziest stuff really well, and obviously better then I will for many years to come.

Where do you work that an EMT would even consider trying to scare and ER nurse. Nevermind the obvious immaturity/idiocy of such behavior, I am commenting on the improbability of it being possible. In my 6+ years of experience working in EM I find ER nurses to be all but impervious to fear or shock.

 

[flighterdoc]

On the topic of emergencies I always wonder if all the EMS training we do in paramedic/emt classes helps us to train for crazy crap like that as much as treating the sick and injured. A medic I followed one day in the ER got a kick out of freaking the nurses out over a sick patient and was like "isn't it fun to scare the nurses?". But to be fair some of the residents and attendings I observed handle some of the craziest stuff really well, and obviously better then I will for many years to come.

How stupid is this?

You're better off insulting your mother, than pissing off a nurse. Your mother, after all, might (eventually) forgive you.

 

[leviathan]

She had a hypoglycemic episode. She'd been working out all day and hadn't eaten. It happened a few times, though not quite so bad. I came home once and she was all loopy, telling me all this weird stuff that made no sense. In those situations, I'd keep her conscious and give her some apple juice and some jelly beans and she would be fine.

Ah I see I see. Yeah, one time I was out partying with my girlfriend, and then we crashed at my place. I woke her up to ask her something and she was pretty loopy and saying things that didn't make sense like what you describe.

 

[leviathan]

I know I can handle the basics: call 911, do the ABC's, start CPR is necessary, etc. Is there much else that can be done while wating for help to arrive?

Not really without BLS or ALS adjuncts + equipment. Keep the airway protected, hold c-spine, monitor ABCs and possibly try to position in a way that would help to drain the skull of blood in case of an intracranial bleed + intracranial hypertension. Then again, I don't know how useful a reverse trendelnburg position actually is in reality for reducing ICP and increasing cerebral perfusion, but the same can be said for elevating the legs in shock.

 

[bartleby]

Elevating the head (reverse Tredneleberg) is certainly helpful in reducing ICP, but particularly in the prehospital setting your main interest lies in ensuring c-spine immobilization.

 

[leviathan]

Elevating the head (reverse Tredneleberg) is certainly helpful in reducing ICP, but particularly in the prehospital setting your main interest lies in ensuring c-spine immobilization.

Just looking at this study, it reduces ICP but does not increase CPP. So if I understand correctly, it will help to prevent herniation of the brain and whatever other physical effects may result from the pressure, but it will not help to increase perfusion of the oxygen starved brain because MAP drops in reverse Trendelenburg position.

 

[bartleby]

This study is not exactly applicable to the ICU/ED, as these patinets were intraoperative and had bone flaps removed, rather than having a transcranial ICP device ("bolt") placed. As CPP (cerebral perfusion pressure) is MAP (mean arterial pressure ) - ICP, if you put someone in reverse trendelenberg, you will drop both ICP and MAP. The effect on MAP would seem to be due to decreased venous return from LE pooling. For our purposes, dropping the ICP is more of an issue than the risk of watershed infarcts from perfusion defecits.

But, as you currectly point out, if you're worried about herniation, nothing works faster than simply adjusting the bed. Truly maximzing CPP is an ICU matter which requires an arterial line and an ICP monitor.