“Give me your tired, your poor…” – Lady Liberty Almost Got It Right
In many ways, the contemporary Emergency Department is like Ellis Island during its prime. Each day, the masses pass through the doors of the ED seeking a better life. Often made to wait in massive lines for hours on end before being processed and evaluated for admittance, emigrants must have felt similar to our patients who are made to wait while the world around them teems with action. While all are welcome (and eventually served), the ED tends to – and primarily services – the poor and indigent, particularly in urban
areas, much in the same way that the millions of impoverished immigrants passed through Ellis Island looking to start a new life in America.
So, Lady Liberty isn’t far off…In fact, all she’s probably missing is one small addition:
“Give me your sick, your broken…” – especially when you consider the overwhelming number of orthopaedic injuries evaluated and treated at emergency departments on a daily basis.
Last Friday is still a blur. I was swamped all day dealing with consults from the Trauma Bay, the ED and the inpatient floors. I started the day dealing with a polytrauma patient with multiple pelvic fractures, bilateral scapulae fractures and right proximal fibula fracture and distal tibia fracture.
After making sure she was stabilized and getting her prepped for the OR, I turned my attention to a right ankle fracture-dislocation. The medial malleolus (inside part of the ankle) was tenting the skin, and while the patient had a good pulse in her foot and she could move and feel everything, getting the patient’s ankle reduced was a priority to reduce the overall damage to the soft tissues (muscle and skin), nerves, blood vessels, as well as to reduce swelling and improve pain.
I injected lidocaine (numbing medicine) into her ankle and the ED staff gave the patient light sedative medications to facilitate my reduction attempt. I was able to get the ankle reduced rather easily (ankles tend to go in nicely with manual traction) and then placed her in a plaster splint to keep the reduction. Looking at the post-reduction/splinting Xrays, it was clear that the ankle was going to remain unstable laterally given the nature of the fibular fracture. When combined with the fact that the ankle was dislocated, we made the decision to take the patient to the OR for application of an external fixator to stabilize the ankle in appropriate orientation/reduction until it was safe to perform the definitive fixation.
After arranging for the patient to go to the OR later in the day, I returned to grinding out several other consults. About 8-10 hours later, I got a call from the OR – my chief resident was asking if I could run up and help with the ex-fix for the ankle fracture-dislocation which I had reduced earlier in the morning. I was still inundated with consult work, but there’s no way I was going to pass up the chance to get into the OR and get my hands dirty. Plus, I was on for a 24-hour shift and I figured I’d eventually be able to catch up because it had to slow down at some point, right?
It was very fulfilling to get the chance to do the case in the OR and help put on the ex-fix. It allowed me to close the loop and be involved in every step of the patient’s care that day. After finishing the case, I again returned to the grind, but less begrudgingly so…