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Why Not To Drop Your Baby On His Head

Exaggeration, drama, and histrionics are very much the rule of thumb in the ER.  Someone comes in and claims they were stabbed with an eight-inch butcher’s knife, and the police later bring in the actual weapon, and it turns out to be a three-inch penknife.  Someone claims to have taken a whole bottle of tylenol, but their serum levels turn out to be nowhere near the toxic level (or even zero).  A patient reports to you that their last pneumonia was so bad their doctor didn’t think they’d pull through, but you check the records and see they weren’t even in the ICU.  (The sole exception to this rule, of course, is the stated alcohol intake, which is usually about half to a third the actual alcohol intake.)

I’m not a nihilist here.  Some people are accurate historians, and some even minimize their issues.  As an ER doc, you never know, so take each case at face value and do whatever is reasonable and prudent to validate or refute the critical facts.  But it is fair to say that the more anxious/dramatic the historian, the more inclined I am to take their version of events with a grain of salt.

“Trust, but verify,” is the saying. So it was when I saw a kid recently for a complaint of a head injury.  They had been triaged as a “green,” for low acuity, and had been waiting patiently on a hallway gurney for over an hour before I got to them.  The dad who told me the story was absolutely beside himself.  He was sobbing and full of remorse.  He’d walked away from the changing table for just a second, and the nine-month old had tumbled right off.  It could happen to anybody.  He hit his head on something, dad wasn’t sure what, and had a huge dent in his head and (the father wept) it was “all my fault.”Looking at the child, sitting happily on the mother’s lap industriously trying to cram as many cheerios as he could fit in his little hands into his mouth, I was skeptical.  More reassuring was the mother’s complete lack of apparent concern.  She was laughing as she played with the baby and seemed to think that it was silly of them even to have come to the ER.

The rest of the history was also reassuring.  There was no loss of consciousness, immediate crying, normal activity since, no vomiting, and a perfectly well-appearing kid.  I kind of doubted he would even need a CT scan. But I could see the “goose egg” or cephalohematoma sticking out of the right parietal area, so I figured a CT scan was in the cards.  I didn’t know what to make of the reported dent, but sometimes the center of a hematoma can seem kinda spongy, so maybe that was what he meant.  I knew it simply couldn’t be anything serious, though.  A true “dent” in the skull, also known as a depressed skull fracture, is a terrible thing highly associated with epidural bleeding and severe brain injury, and not consistent with this happy kid eating cheerios.  Kids tend to do even worse than adults with these injuries because their heads are so tight and prone to increased intracranial pressure.

With a sigh, having completed a normal neuro exam, I went to look at the “dent” in the head.  I palpated the rim of the hematoma and it all felt as it should.  As my fingers worked into the center, though, I realized to my horror that it really was dented in.  And not by a small amount.  I checked a couple of times to be sure, then calmly excused myself and called the CT scanner to let them know that this kid was now #1 on their priority list. Here is his CT; I’ve helpfully pointed out the abnormality in case you couldn’t see it.


Remarkably, his brain was fine.  No bleeding, no bruising, not even much in the way of edema, or swelling of the brain directly under the fracture. We attributed this to the location; the fracture was quite high on the skull, which is an unusual place.  There are not so many blood vessels in the area to bleed.  And since he hit with very little force, there was little direct mechanical injury to the brain tissue from this low-energy impact.

It just doesn’t take much to break a baby skull.  So there you have it.  The kid did fine, and the moral of the story, if there is one, is that no matter how improbable the story you are told may seem, you always have to take the patient’s tale at face value, because sometimes they really are right.  Also, don’t drop your baby on his head.  That’s a good point to draw from this also.  But you probably already knew that.

*This blog post was originally published at Movin' Meat*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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