Friday, August 20, 2010
Looking after an injury isn’t good enough to satisfy the doctor’s inquisitive nature. There is always another question. If Eli Manning, the New York Giant’s quarterback, shows up with a forehead laceration, the worry is not necessarily how to make the scar look good, but whether the brain underneath has been damaged. Percy Harvin collapses at the Viking’s training camp complaining of a migraine and the next medical thought deals with the potential of sudden cardiac death. So it goes in medicine. Nothing is at it seems. There are dangers lurking beneath the surface and it’s the doc’s job to look for them.
Behind every injury, there is a story. An elderly patient who f breaks a hip may just have fallen, but why? Was it because they tripped on the dog or did they pass out when they fell? Are there other injuries in addition to the broken bone? And what medicines do they take that could have led to the fall? Or do they take blood thinners like Coumadin or Plavix that could lead cause future bleeding to occur? Why do they take those medications and will that underlying illness increase the risk of an anesthetic?
Specific injuries lead the doctor to look for complications and that means more questions. Bruised ribs makes warning lights go off looking for damage to underlying organs. While it makes sense to worry about the lung, the lower ribs also protect stuff in the abdomen, including the spleen that lies underneath the left diaphragm and the liver underneath the right. Trauma to the chest wall can lead to a few days of ICU observation for a fractured spleen.
An injured wrist may appear normal on X-ray but asking about pain and tenderness in the snuffbox, an area near the base of the thumb, may be the clue that the scaphoid is broken. It may take a couple weeks for the injury to show up on plain films but the treatment in a splint or cast needs to start right away.
Sewing up lacerations is fun but takes second place to making certain nothing other than the skin is cut. Hands are tough because of the tendons, nerves and arteries that run just beneath the skin. A good looking scar doesn’t help a missed nerve injury. Does the finger feel numb or tingling? Is there burning? Does it feel cold? And while the patient may say that everything is alright, the doctor needs to examine the area and be happy that the tendons are working and the nerve and blood supply are normal. Even with all that, before the skin is closed, the doc needs to look inside and find everything in working order.
It is too easy to ignore potential pitfalls. While common things are common, the basis of medical care is to look for those things that are not and questions are where the process begins. If the patient can’t answer them adequately, family and friends may be on the witness stand. A paramedic may be the person who provides the clue. The key is to ask…and ask again.