The ER Di­aries Dr. Zachary Levine

ZOOMER Magazine - - CONTENTS - Dr. Zachary Levine gives us the 911 Dr. Zachary Levine is an emer­gency physi­cian and as­so­ci­ate pro­fes­sor in the McGill Univer­sity Depart­ment of Emer­gency Medicine.


An 82-year-old man is brought into the ER by am­bu­lance on a back­board with a hard col­lar on (used to pro­tect the cer­vi­cal spine in the case of trauma af­ter a fall). He lives with his wife and is nor­mally in­de­pen­dent but has fallen three times in the past week.


He didn’t seem to sus­tain in­jury the first two times. But the third time, he could not get up due to a pain in his chest when he moved. On ex­am­i­na­tion, he is alert but dis­ori­ented as to date and place. He is a bit rest­less. His vi­tal signs (heart rate, blood pres­sure, oxy­gen sat­u­ra­tion, res­pi­ra­tory rate and tem­per­a­ture) are nor­mal.


The trauma ex­am­i­na­tion con­sists of pri­mary and sec­ondary ex­am­i­na­tions. Dur­ing the pri­mary sur­vey, we look at air­way, breath­ing, cir­cu­la­tion, dis­abil­ity (neu­ro­log­i­cal sta­tus) and ex­po­sure (mak­ing sure to see ev­ery part of the pa­tient). Aside from his ap­par­ent con­fu­sion, the pa­tient’s pri­mary sur­vey was nor­mal. Dur­ing the sec­ondary sur­vey, we ex­am­ine from head to toe. Dur­ing this, the pa­tient was noted to have an abra­sion on his fore­head and ten­der­ness in his left ribs.


An ul­tra­sound of the pa­tient’s chest re­vealed a prob­a­ble pneu­moth­o­rax (punc­tured lung). This was con­firmed with a chest X-ray. A chest tube was in­serted into the space be­tween the in­ner and outer lin­ing of the chest cav­ity to drain air and al­low the lung to ex­pand. The pa­tient then had CT scans of his head, cer­vi­cal spine, chest and ab­domen. These were all un­re­mark­able and, aside from four bro­ken ribs – the cause of his pain and his punc­tured lung – the cause of his fall was still un­de­ter­mined.


The pa­tient was ad­mit­ted to hospi­tal to help with re­cov­ery from his punc­tured lung and to man­age the pain of his bro­ken ribs, in ad­di­tion to his con­tin­ued con­fu­sion. Fur­ther in­ves­ti­ga­tion in­cluded blood and urine tests and an elec­tro­car­dio­gram to rule out causes of con­fu­sion in­clud­ing in­fec­tion, meta­bolic ab­nor­mal­i­ties and other is­sues such as heart at­tack. The uri­nal­y­sis re­vealed white blood cells, ni­trites (an in­di­ca­tion of bac­te­ria) and bac­te­ria in the urine. Urine is usu­ally ster­ile, mean­ing no bac­te­ria, with very few or no red or white blood cells in it. An­tibi­otics were started to treat uri­nary tract in­fec­tion.


Over the next three days, the pa­tient’s con­fu­sion re­solved. It was thought that his con­fu­sion and un­steady gait – and, ul­ti­mately, his falls – were the re­sult of the uri­nary tract in­fec­tion. His pain was con­trolled. He was as­sessed by the geri­atrics team, in­clud­ing the ge­ri­a­tri­cian, the phys­io­ther­a­pist (to de­ter­mine his mo­bil­ity) and a geri­atric phar­ma­cist, who re­viewed his med­i­ca­tions to en­sure that he needed all of the med­i­ca­tions he was on and to en­sure that none of them were caus­ing harm­ful side ef­fects. The pa­tient was deemed safe for re­turn home on Day 5 with fol­low-up in the trauma clinic for re­moval of the chest tube on Day 7. By then, he was back at his usual level of func­tion.


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