A very spry 83 year old lady was brought in by her two daughters the other night after falling while undressing. She did not lose consciousness; however, she did have to call for assistance to get back to her feet, but that is due to her chronic knee pain. This person was not only alert and oriented times three but very adamant about not needing to be brought to the emergency department. For her age she was relatively healthy. Her only red flag was she was on coumadin for her atrial fibrillation. The only evidence of a fall was a minor abrasion on her occiput. It was hemostatic and clean appearing.
"Do not stick me! You do not need my blood for anything. I'm ready to go home!" She said aloud. A cantankerous old woman she was, but to her credit her physical exam was completely unremarkable. She didn't even have the first signs of dementia. Her family stated she was just seen a few days ago and her INR levels were appropriate.
I thought to myself I could abide by this ladies wishes and send her home, or I could do a full work up. Draw blood, check INR, and then send her to the CT scanner. I went and told my attending the story of this 83 y/o lady who fell, has a small bump as is on coumadin, that I plan to send home. His got real big as if I was the one needing a CT scan.
"Send her to the scanner. Falls with trauma on patients on coumadin get scans."
*sigh*
I wasn't disappointed at him. After all, it is ultimately his ass in court if this family sues. So I never make it a point to second guess the attending even I feel good doing the opposite. So long story short, her INR was still normal and her CT scan showed no signs of trauma, and she was discharged. Her bill from the ED and the radiology department will be at least a couple of thousand bucks. Now I'm just an intern, and I barely have time to read the emergency medicine textbooks that have been assigned. I'm sure there is a study out there that justifies this work up, but I don't know what it is. I do wonder, though, if this lady had shown up in an ED in England if she would have received the same work up, or would they have said, "Your 83 years old and you fell? Go home."
I'm not trying to say which country is right or wrong. Here, even though she didn't want it, her family got piece of mind she was not going to die from a massive head bleed, but it was at the cost of approximately $2500. In other countries she may have been sent home, at the cost of $0. Which system is better? I don't really care to be honest. Just interesting to think about the differences.
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There are studies that show that anyone over the age of 60 who fall, whether or not they struck their head or lost consciousness, are at increased risk of subdural simply due to brain atrophy and shear stress/stretch on the bridging veins across the dura. For this reason, it is generally recommended that a CT scan of the brain be performed to evaluate for bleeding, although this does not preclude the possibility of a delayed presentation of a bleed.
ReplyDeleteI do not argue that it would be cheaper, and possibly just as safe to send this patient home, but the above, in combination with the fact that this patient is on warfarin necessitates a scan.
And may I remind you, that while the final authority rests with the attending physician, residents have been named in lawsuits, although generally they are dropped from the suit.
I recommend trying to take a little time reading those textbooks you have lying around somewhere. You are almost 8 months into internship. You should be reading at least a little every day. Pick one patient a day to read about, and over the course of your residency you will have learned a lot more than flying by the seat of your pants and relying on bedside teaching and lectures. Take it from a 3rd year about to be sprung out into the wild world of attending-hood, it's a scary place to be...