The patient: “Sophie,” now 84, is a well-functioning, active senior who has been a patient for almost 30 years. This post is about my most recent consultation with her.
Why she contacted me: Sophie called my office after she had slipped and fallen on the ice in her bank’s parking lot, banging her head and cutting her hand. Even though the bank manager was insistent that he call an ambulance for her, she would have “none of that” and told him that her doctor (meaning me) would come and evaluate her.
How I evaluated her: With my decades of clinical experience not only in wellness but also in trauma management (from my almost two decades with the National Ski Patrol), my ability to evaluate traumatic injury and make sound medical decisions has become quite sharp. I spoke with her to determine the mechanism of injury and assess her cognitive state. I brought her into my vehicle and conducted a focal physical exam.
We decided to adopt a “watchful waiting” approach to her head injury, which appeared to be limited to facial bruising. I explained to her that if she were to be picked up by an ambulance, because of her age she would be processed in a hospital emergency department, referred to an in-house neurologist, sent for a CT scan, and probably held overnight for routine blood work and observation.
Based on my neurological assessment and lack of concerning signs, I didn’t feel that an immediate neurology consult was appropriate. I knew that I would spend the next three hours observing her and could better-confirm my decision after that time had passed.
How we addressed her problem: As she traumatized one of her hands when she fell and required a compression dressing to control bleeding, so we drove to one of the imaging centers I use and to have X-rays done on the spot. (I love having a facility where I am recognized and can come in with a patient, or send someone over, and receive immediate attention.) Within 30 minutes, I was back in my office with Sophie and chatting with the radiologist, who confirmed my suspicions from my limited physical exam that there were no fractures.
In that the damage to her hand, although extremely painful, was relatively superficial—there was no laceration or involvement of vital structures deep in the skin involving finger movement or circulation—I replaced the initial compression dressing, anointed with Neosporin, and provided her with Yunnan Paiyao, an herbal supplement from Traditional Chinese Medicine developed for trauma and excessive menses, to control the remaining bleeding.
I saw Sophie the next day and inspected the wound, then squeezed fresh aloe vera gel into the area and replaced the dressing. I also conducted another more through neurological evaluation, which was entirely negative.
The patient’s progress: I explained to Sophie that it would be wise for us to speak daily for three or four days to continue to exclude the possibility of a slow brain bleed, which initial CTs often miss but is always a concern with those over 60. But in my clinical opinion, she hadn’t needed the ambulance, emergency department, specialist, overnight stay or anything else that the local hospital would, by protocol, have provided in their abundance of caution. Such treatment would have merely led to a $10,000 bill that Medicare would have paid most of and legally indemnified the hospital against negligence. (Sophie was quick to chime in, “So who pays for Medicare really? We all do.”)
After a few weeks, Sophie returned to her exercise classes and her weekly lunches “with the girls.” The bruising on her face was almost gone. When I asked her how she explained her bruised cheek and black eye to her friends, she told me that she just says she “had been in a bar fight over a handsome gentleman!”