Almost lunch time, and just as suddenly as things got busy, it looks like activity is just starting to level off. I think to myself:
'Just one more case and I'll sneak out to the cafeteria for a quick bite.'
*I look at the computer for my next case. I see that Exam 3 just got a new patient. I read the nursing/triage note:
3 y/o male brought in by mom & dad with pain in the left elbow. Pain began suddenly when the patient dropped to the floor during a tantrum all while the father was still holding on to his left arm. Pain only with motion. No deformity, swelling, or ecchymosis of the arm or elbow. The incident occurred four hours ago with no improvement. No other injury or complaint.
Medical History: None
Allergies: Sulfa Drugs
Previous Hospitalizations/Surgeries: None
'This seems easy enough, Fast Track must be full because this could totally be taken care of in Fast Track.' I say to myself.
*I take a drink from my water bottle, put the bottle on the counter next to my computer and logout of the computer. I stand up and walk towards Exam room 3. The door to the exam room is ajar, but mostly open. I knock as I push the door fully open and peak my head inside.*
As I walk into the room I see a young man, probably in his mid twenties sitting on the ER gurney with a young well dressed little boy in his lap. A young woman, around the same age as the man was seated in a chair next to the bed. Both adults, who I assume are the young boy's parents, looked visibly anxious, as did the little boy himself.
*knock knock knock* 'Hi there' I say as I walk into the room with a slightly cheery attitude. All three of them look up at me as I take some hand sanitizer out of the dispenser by the door.
'I'm Dr. Grant, one of the emergency physicians here today.' I say as I finish rubbing in the hand sanitizer and extending my hand to the mother first.'Hi'
, she said happily, but obviously nervous, 'I'm Beth'
'Hello Beth, are you mom?' I asked'Yes'
she said smiling. I look over at Dad and extend my arm. '...and you must be dad.' I say as I shake his hand.'I sure am. I'm Justin'
He replied, also with a smile on his face.
I look at the boy in his father's lap. '..and what's your name big guy?' I ask in somewhat playful tone as I pull up a rolling stool and sit down in front of him.
The boy hesitated and looked up at his dad.'What's your name buddy?'
The dad said trying to coax him to speak.'Jaime
' the boy said softly.
'Well it's nice to meet you Jaime.' I say as reach for his right hand and squeeze it lightly.
I sit back and look at the parents. 'So what brings you all here on such a beautiful day?'
There was a small pause.
The mother spoke up first: 'Go ahead and tell him, you were there'
she said to him.
*I look at the father*'So I had to help my Dad with some stuff over at his house this morning, so I took Jaime with me early thing morning so he could see his his grandma and grandpa. When I was trying to leave, he wasn't having it and started throwing one of his temper tantrums. I tried coaxing him to leave, but you know how kids get at this age...'
'Oh yea,I know exactly what you mean' I say to him in understanding.'So I wait a few minutes, let him calm down, then I grab him by the arm and start to lead him out of the house. As soon as he saw the front door he threw another tantrum and just dropped to the floor while I was still holding his arm and leading him out of the house.'
I interrupt him: 'So you were leading him out of the house and he was walking next to you when he all of a sudden decided to throw another tantrum by dropping to the floor?' I ask to clarify.'Yah'
'He pulled the good old "The only way I'm leaving here is if you drag me out", huh?' I ask half amused.'Exactly'
The father replied.
'Then what happened?' I asked to continue the conversation.'I heard a little pop when he dropped to the floor and he began crying real loud. Not like a tantrum cry, but an in-pain cry...so I immediately let go of his arm.'
'...and that's his left arm you were holding on to and heard pop?' I asked to clarify.'Yea his left'
'Ok, has he been able to move his arm?' I ask.
'No, every time he moves his arm it looks like it really hurts him...but if he doesn't move it he is just fine.'
*I take a few minutes to gather his medical history and find that there is nothing that wasn't already stated on the nursing notes*
'Ok, well just based on what you're telling me about his condition and the incident itself, I'm pretty confident that I know what the problem is. It's a condition called Radial Head Subluxation, or it's often referred to as a pulled elbow.' I say as I reach for his left arm.
'Can I see you're owie?' I ask gently as I reach for his arm. He guards it with his right arm holding it against his body. I pull it towards me but feel him resist a bit. 'Please? I promise I'll make it all better'. I no longer feel resistance. 'Thank you' I say to him.
'So there's no swelling or deformity around the elbow, and it only hurts him when he moves his elbow or his arm. For this sort of thing we don't even need an X-ray, since if it was
broken, I would be seeing swelling or deformity. Now what he has going on is sort of a dislocation. There are two bones in your forearm. Your Radius and your Ulna, and what happened is when he fell to floor while you were pulling his arm upward, it put a lot of stress on the elbow and caused the annular ligament, which holds the radius and ulna together, to slip into
the elbow joint. So his pain is from the pressure of his radius on the ligament when it moves. Luckily the fix is really easy.'
*His arm is oriented palm side down, so I grab his hand and wrist with one hand and put the other had on the thumb side of his elbow, feeling for a bony outcropping in the elbow.*
'Ok, here we go' I say and begin the maneuver.
*I start to rotate his whole arm from the palm-down position to a plam up position fairly quickly*
'Ok, we're going to supinate his arm'
The boy begins to cry: 'Ow! Ow! Ow'
'I know, but it'll be over fast', I say as I start to flex his arm. He continues to cry, but just as I'm half way bending his elbow I feel a pop over the side of the elbow. Knowing that the technique was a success, I continue to flex his elbow until I can't anymore then I bring his whole arm back straight. 'There we go. I know, it hurts really bad when it pop's back in place but in 10 minutes you're going to be good as new. I promise.' I say reassuring the parents more than anything.
*I let go of his arm*
'Move your arm for me big guy.' I ask. Despite his crying, he is able to move his elbow freely now. 'See? It's all better now. How does it feel now?' I ask him. Jaime starts to calm down. and pouts 'It hurt'.
*I laugh and answer the parents questions and leave the room. I come back 10 minutes later to find Jaime running around the exam room twirling his sweatshirt in the air with his left arm*
This may have been an easy case, but it's the ones like these that make me the happiest. I chart this patient, and then sneak off to the cafeteria.