The first day of her new PGY year and Dr. Orthochick is already playing “Are You Smarter Than the ER Attending?” on her blog.
She describes the case of a patient who had a “right shoulder nerve block” after shoulder surgery and who continued to have weakness and paresthesias in his arm 12 hours after the block was performed. The patient went to emergency department and the ED physician apparently ordered CT scans of the head and neck. Then Orthochick gets called and has to get out of bed at 3AM to do a consult.
With the normal CT results in hand, she comes to the conclusion that the testing should never have been performed and that the emergency physician is no smarter than Orthochick’s sister or the patient, both of whom thought that no testing should have been performed (even though the reason the patient went to the emergency department was because he thought something was wrong). Oh, and Orthochick’s ortho attending thought the emergency attending’s workup was funny, too.
Orthochick doesn’t say what kind of “shoulder nerve block” was performed on the patient. Bier block? Interscalene block? Axillary block? Orthochick also doesn’t say what kind of anesthetic was used. Most likely Marcaine with epi – which, at least according to the manufacturer (hey, what do they know) declines to insignificant levels during the next three to six hours. Why should anyone have cause for concern when their arm is weak and has decreased sensation six hours after the medicine was supposed to have worn off?
Would I personally have obtained CT scans based upon the facts that Orthochick presented? I’m not sure. Orthochick didn’t really provide enough of a history or physical exam to make a determination. Postoperative strokes occur in between 0.05% and 7.4% of patients and Orthochick didn’t give us enough information to determine whether the patient should be more toward the 0.05% or the 7.4% end of the spectrum. It’s not like there are any $15 million judgments against physicians for missing postoperative strokes manifesting themselves as weakness in the right arm or any $1.6 million settlements when doctors were sued after a patient developed numbness and weakness in his arm after surgery on the first pages of a DuckDuckGo search or anything. Yes, I realize that the patients in both of those cases had undergone carotid surgeries and the patient in Orthochick’s post had arm surgery. Not the point. The point is that numbness and weakness in the arm after a surgery can be a sign of a stroke and that in our society there is not much tolerance for missing a postoperative stroke. I’m sure that Orthochick would have been singing an entirely different tune if the patient ended up having had a postoperative stroke and the emergency attending decided to send the patient home without performing any testing.
That reminds me. There are all these red colored (at least tn Netter’s Atlas) blood carrying tubes that can get poked, leak, and form harmful collections of blood and there are also these yellow nervey things (at least in Netter’s Atlas) in the neck besides bones and joints that can get damaged when a block is being performed.
Another important point is that in the post, Orthochick says that the patient went to the emergency department because “he didn’t realize [the block] was going to last that long.” If the surgeon or anesthesiologist had told the patient how long to expect the block to last or if Orthochick’s teaching residency program had provided the patient with a simple handout informing the patient what to expect, then there wouldn’t have been a visit to the dumb “ER” attending at 3AM to begin with, now would there? Then again, if they did tell the patient the block would last for up to 12 hours and the patient didn’t seek treatment for what ended up being a stroke or a hematoma compressing vessels/causing neuropraxia or a carotid dissection or dozens of other complications, Orthochick and her jovial attending orthopedist wouldn’t be able to blame someone else for the bad outcome.
Dr. Grumpy’s comment to the post put things in good perspective: “What’s stupid is a system that makes us practice defensive medicine to this extreme, and a culture where patients often see the slightest medical error as the Golden Ticket.”
Is this where I get to tell some of my orthopedist jokes?