A 52-year-old man presented to the ED with complaints of left shoulder and left chest pain following a bicycle accident. The patient stated he had fallen from his bicycle and landed on his left side after he turned sharply to miss a speeding car. He denied head injury, loss of consciousness, or neck pain. The patient was ambulatory after the fall and had driven himself to the ED, and complained primarily of the left shoulder and left chest pain. He described the chest pain as sharp, worsening with movement and deep inspiration. The pain also was associated with mild shortness of breath. The patient denied headache, nausea, vomiting, abdominal pain, or back pain. He was otherwise in good health and on no medications.
The patient’s vital signs on presentation were normal and his head was atraumatic. He exhibited no midline posterior cervical tenderness to palpation. The head, eyes, ears, nose, and throat (HEENT) and mouth examinations were unremarkable. The patient did have tenderness to palpation over the left clavicle and left anterior chest; there was no crepitus or subcutaneous emphysema appreciated. Breath sounds were normal, and the heart had a regular rate and rhythm without murmurs, rubs, or gallops. The abdomen was soft and nontender, without guarding or rebound. The pelvis was stable, and the patient moved all four extremities with good strength. However, he did exhibit pain with movement of his left shoulder. Peripheral pulses were 2+ and symmetrical.
The emergency physician (EP) ordered an X-ray of the chest and left shoulder, as well as urinalysis. The X-rays revealed a small left pneumothorax, a minimally displaced left clavicular fracture, and fractures of the left fourth and fifth ribs. The urinalysis results were normal. The patient was administered intravenous (IV) morphine for pain and placed on 2 L/minute oxygen via nasal cannula, with 100% oxygen saturation on pulse oximetry.
The EP consulted a pulmonologist regarding management of the pneumothorax, who recommended a 4-hour observation period in the ED, followed by a repeat chest X-ray. During the observation period, the patient remained on oxygen and continued to deny any new complaints, including headache, dizziness, or abdominal pain. His vital signs remained normal throughout the entire observation period.
While in radiology services for a repeat chest X-ray, the patient fainted and struck his head on the floor. The EP immediately ordered a noncontrast computed tomography scan of the head, which demonstrated a large intracranial bleed. The patient was taken immediately to the operating room by neurosurgery. His recovery was uneventful, and he was discharged home without obvious sequelae.
The patient sued the EP and hospital for negligent care, claiming the EP underestimated the patient’s injuries and that additional testing was warranted. The defendants argued the patient was properly evaluated based on the history and physical examination. A defense verdict was returned.
One possible criticism of this case is the consulting of a pulmonologist for the traumatic pneumothorax rather than a trauma surgeon or general surgeon. It is unclear if these specialists were not available for consult. Nevertheless, the pulmonologist’s advice to the EP was reasonable. Until just recently, it was dogma that all traumatic pneumothoraces required tube thoracostomy for management. This is still true for tension pneumothorax, hemothorax, moderate-to-large pneumothorax, symptomatic pneumothorax, or if mechanical ventilation is anticipated or needed.1 For small pneumothoraces, several management options exist, including close observation, needle or catheter aspiration, or placement of a pigtail catheter—in addition to the placement of a small (ie, 10-14 French) thoracostomy tube.2
Regardless, it does not appear the pneumothorax played a role in the patient’s hospital fall. More likely, the patient experienced a vasovagal episode. Interestingly, he never required treatment for the pneumothorax, despite requiring mechanical ventilation.
A Tragic Complication of Hemodialysis
A 58-year-old man presented to the ED with the chief complaint of bleeding from his dialysis fistula. The patient had end-stage renal disease and had been on hemodialysis (HD) for the past 3 years. He had an arteriovenous fistula (AVF) in his left arm for dialysis access, and received HD 3 days per week—every Tuesday, Thursday, and Saturday. He had completed a scheduled run of dialysis 5 hours prior to presentation, but had continued to bleed intermittently from the AVF site. The patient stated he had applied pressure multiple times to the site, but was unsuccessful in stopping the bleeding. His medical history was significant for hypertension and coronary artery disease. Regarding his social history, the patient admitted to smoking one pack of cigarettes per day and consuming alcohol on a regular basis.