FEATURE
(continued from page 15)
THE BAD:
People think of drug users in the emergency department as the bane of our existence;
and honestly, it is a little discouraging seeing the rate of opioid and alcohol abuse, as well
as the same people suffering day after day. I once saw a man who complained of facial
swelling. His only PMH was that he was in recovery from a long-term heroin habit.
He stated adamantly that under no circumstances was he to receive any pain medication,
any shots, any IVs, or anything with a needle. He was deeply concerned that any needle
might trigger a relapse after hard-won sobriety. He never wanted to go back to that hell
again. My doctor brain ticked over and I knew this meant no labs and no contrasted CT.
He presented with the worst facial swelling I had ever seen, as well as a heart murmur
that was uncharacterized. He was afebrile, yet symptoms had begun over 24 hours and
were rapidly progressive. He did not have ocular tenderness, though his facial swelling
extended from his chin to his forehead and was so severe that it engulfed his periorbital
area, while his eye was, all but a sliver, shut.
I implored him and pleaded with him to accept IV antibiotics. I explained meningitis/
infected cavernous sinus thrombosis, orbital cellulitis and endocarditis. He was in no
way impaired, completely logical and was perfectly able to offer full consent—as well as
withdraw it. I gave him three oral antibiotics in the ED and performed a non-contrasted
CT with limited bedside transthoracic echo.
The diagnostic findings were concerning. We continued the discussion intermittently
over three hours and I begged him to consider surgery, or even just admission, so we
could watch him. He very respectfully declined multiple times.
As sad as his circumstances were, I empathized with his reasoning, did not discharge
him AMA, and followed his wishes. I spoke with three separate oral surgeons and even-
tually found a facial surgeon who agreed to help him on an outpatient basis. He accepted
the risk of death, stated he did not want to be in a hospital, and was very clear that dying
from meningitis was better than living as an addict.
THE GOOD:
During the warm summer months, rampant with trauma of all
types, the radio goes off again during a predictably busy shift.
Although the staff has weathered worse, everyone is growing tired
of the frequency of trauma resuscitations, more so now that shift
change is approaching.
“Be advised: this is Air EMS, we are in route to your facility, five
minutes out from scene flight. We have a young adult unconscious
male, who was involved in an unrestrained high-grade motor vehicle
accident, with multiple roll-overs. The patient was found on the side
of the road ejected from the vehicle, and is still unresponsive. Not
intubated yet, self maintained airway currently. Vitals are 110/80,
heart rate 95, sating 100 percent on 2 L NC. See you in Room 9 in
five minutes.”
The relatively stable vitals could deteriorate at any time. Diligently,
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LOUISVILLE MEDICINE
the staff falls into organized form, the nurses get blood, the tech sets
up the FAST exam, we prep intubation and chest tube equipment:
tubes, scalpels and Betadine. Attendings and residents wait in Room
9 for the trauma to arrive.
Four minutes later, “Tech to the pad” is called over the intercom,
then flight nurses appear pushing in our patient. He looked like he
was in his early 20s, still not intubated, eyes are closed, he is back–
boarded and c-collared. As we begin our primary assessment and
transfer him from the stretcher to the Room 9 bed, the flight nurses
once aga