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But in many emergencies, you have to make do with interview and physical exam, because there may not be time for a lot of tests.
Not long ago I had a twelve-year-old boy come in with a head injury from a skateboarding accident. His father, a police officer, noticed that his son didn't 'seem right', so he brought him in to the ER.
When I did my initial exam, the child was responding appropriately to my questions, and moving all his limbs spontaneously and correctly. But within twenty minutes, his mental status had degenerated to the point where he wasn't opening his eyes at all. He couldn't speak. I suspected that he had hurt one of the blood vessels in his brain and was having what we call an epidural hemorrhage, or internal bleeding in the head.
The boy's father remained remarkably calm, and I talked with him the whole time, telling him what I was doing, and what I planned to do. It's an incredibly tense situation, and I described my thoughts to him based just on the clinical situation, without any tests to confirm them.
We put in a breathing tube, gave him some medication to reduce the pressure in his brain, and rushed him to CAT scan. We had to verify exactly how bad and where the bleeding was. I was pretty sure I knew what was happening, but we had to determine the details to help guide the surgical intervention, which was clearly necessary. The diagnosis was confirmed.
Then he was rushed to the operating room for neurosurgical intervention, where they had to open up the side of his head to release the pressure from the accumulating bleeding. Blood was pouring inside the skull, pushing the boy's brain away and creating enormous pressure in his head. After the bleeding was controlled, the pressure was released. When he woke up from the anesthesia, he was much better.
The tough part about being an emergency room doctor is that after you make all these life-saving decisions, you rarely see the patients again. So the best part of this story is that two weeks later, the boy and his father came back to the ER with a bottle of champagne. The father said to me, "I know what you did. I know if you didn't do what you did so well, he would have died. And I thank you every day."
It is so rare that someone actually gives you that positive reinforcement. And as I'm sure is true for any human being, that simple 'thank you' is just amazing to hear. Really amazing.
Dr. Jeffrey Hersh is a clinical assistant professor of Emergency Medicine at Tufts University and an attending physician of Emergency Medicine at Brigham and Women's/Faulkner Hospitals.
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