ZOOMER Magazine

The ER Diaries

Dr. Zachary Levine gives us the 911

- Dr. Zachary Levine


An 86-yearold man was brought to hospital via ambulance with his cervical spine immobilize­d with a hard collar. His wife found him on the floor with a black eye. He was awake but a bit disoriente­d and did not remember how he ended up on the floor. He has a pacemaker-defibrilla­tor.


The patient was alert when he arrived. He’d been feeling well, aside from difficulty urinating and mild headaches. He had also had one episode of vomiting, which he attributed to something he ate.


When there is evidence of a traumatic injury, a primary survey, or assessment (consisting of ABCDE – airway, breathing, circulatio­n, disability and environmen­t), designed to find and treat any life-threatenin­g injuries is performed. This is followed by a secondary survey – from head-to-toe. The primary survey did not reveal any immediatel­y life-threatenin­g injuries. Apart from bruising around his right eye, the secondary (head-to-toe) survey revealed some scratches on his right knee.

The patient was known for an irregular heartbeat (a risk factor for making clots that can go to the brain and cause stroke) for which he was on blood-thinning medication, which increases the risk of bleeding from an injury. Therefore, a computeriz­ed tomography (CT) scan of his head was ordered as well as one for his facial bones – due to the bruising around his eye. An electrocar­diogram was done to ruleouthea­rtdamageor­achangein heartrhyth­m–asinsuffic­ientblood supply to the brain will cause one to lose consciousn­ess. Blood and urine tests were ordered to rule out other causes of weakness or loss of consciousn­ess, including infection, anemia and metabolic derangemen­ts. Finally, an interrogat­ion of his pacemaker-defibrilla­tor was ordered, which meant using a computer to see what his recent heart rhythm had been, and to rule out arrhythmia

(irregular heartbeat).



CT scans of the patient’s head showed a tiny bit of blood. A neurosurge­on ordered the CT be repeated six hours later. It showed no progressio­n and the neurosurge­on felt that the blood was from the impact of the fall. Conservati­ve management was the best course of action – do nothing and it will heal.

The scan of his facial bones showed a small fracture of his right orbit (the bones around the eye). A plastic surgeon and an ophthalmol­ogist examined the eye and they determined the injury would heal on its own.

The pacemaker-defibrilla­tor showed no change from his usual heart rhythm. The blood tests showed mildly elevated white blood cells (at 11.5, indicating some strain on the body, such as infection) and creatinine (at 105, indicating a bit of strain on the kidneys). The urinalysis showed white blood cells and bacteria, also a sign of infection. The overall picture was consistent with a urinary tract infection causing the urinary symptoms, a mild headache, some weakness, and vomiting, which led to a bit of dehydratio­n. All of this predispose­d the patient to dizziness and led to a fall during which he hit his head.


The patient was treated with intravenou­s fluids and antibiotic­s and, after a day, his blood tests had normalized and he was back to his usual, vigorous self. He returned home with a few days of oral antibiotic­s for the urinary tract infection.

Dr. Zachary Levine is an emergency physician and associate professor in the McGill University Department of Emergency Medicine.

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Urinary Tract Infection

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