07 January 2010

The honest patient historian

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.


  1. What a luck this baby had you as his doctor!
    True, always listen well to your patients, I have learned that a few times.

  2. Changing table? I used the floor about 99(and some change)% of the time.

  3. What would management for something like this involve?

  4. surgery. They elevate the fracture and fixate the fragments in alignment, or put in some sort of prothetic (rarely). If there's bleeding, they evacuate the clot.

  5. Did you try and console/reassure the dad? If so, how?

  6. a pediatric neurosurgeon sez These babies usually do great, but the CT looks very scary. We can usually drill a small hole and pop the fracture up up. BTW, Shadowfax, I am a fan of your blog. Keep up the great work

  7. When I scrolled down and saw the dent I said, "Holy sh*t" so loudly my husband wandered in from another room and asked what had happened. :) Terrific "case report."

  8. I like how for most of this post I sat here thinking "this can not be going in a good direction" as I read; and yet when I reach the end, I burst out laughing and hurt my aching ribs. Broke the tension, so thanks for that. Not so much for the sore ribs tho... jus' sayin'!
    A similar lesson I've learned from my kids is that when one of them screams and says "He hit me", it doesn't always follow that the whole story is as simple as that. "Trust but verify" is a good rule of thumb.

  9. I think I would have had a conversation with whoever did the triage. Sitting in the waiting room for over an hour???

  10. Anonymous: am I to understand you think waiting an hour is a long time? Heavens, don't come to England then!!! You can wait up to 4hrs in our Casualty if your injury isn't "life-threatening".
    When my daughter broke her arm at 2.3yo, we waited 2.5hrs before they decided to admit her to the ward to prepare her for surgery. Welcome to the NHS; perhaps the US should get used to this...


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