A Near Miss

The importance of communication within a healthcare team

It was an extremely busy night in the ER, and we were very understaffed. I was the only ER tech there from 1900 to 0700, and they had me running ragged. It wasn’t even my usual shift. I had picked up to cover another tech’s time off, and another had called in sick for Covid. We were short on nurses, as always, and as the only tech, I had to help make up the difference for the missing nurses.

We had two tib-fib kiddos in, back-to-back. That’s a tibia and fibula dual fracture. The ER techs are responsible for helping the orthopedic physicians set the bones and put the temporary casts on to stabilize the kiddos enough to go home that night and follow up in the clinic in a few days. Unfortunately for me, the help needed for a tib-fib is holding traction and providing extra force to the ortho’s pull to line everything up where it’s supposed to be, and both kiddos outweighed me by a notable margin.

The first one was terrified of needles and screamed and cried throughout getting their IV for the sedation, so I was already worn out from trying to hold their arm steady for 4 attempts by 2 nurses to get the IV in the first place. They were still crying and fighting when it was time to start the sedation in the procedure room and they chewed through the ketamine like it was nothing. Normally, after the ketamine is administered and the sedation is started, they’d just kind of shut off for a bit and go mostly limp. But no, this one fought the sedative the entire time, so I was trying to hold traction on their leg while also trying to hold them still and trying to keep them from kicking the nurse doing the sedation. It was probably the toughest tib-fib I’ve ever assisted for.

We finally finished, after 3 attempts and a declaration of “close enough”, so I trudged back out to the floor to hopefully sit down for a few minutes. As was to be expected, those few minutes turned out to be about 30 seconds before I was assigned to make a splint for a baby with a suspected occult fracture. (A fracture that is present and causes pain but doesn’t show up on X-ray). The standard procedure for this was to splint the limb in a position of comfort and have the kiddo follow up for repeat X-rays in a few days or a week to see if it showed up by then. I didn’t have a lot of time before our second tib-fib was supposed to go in for sedation, so I had to get the splint done quickly.

I gather up the supplies preemptively, just making assumptions on how much of what things I would need based on the patient’s age and weight. I could just trim down any excess, and it was faster than measuring first, although a fair bit more wasteful in terms of scrap to be thrown out afterwards. It was by far the smallest splint I had ever made. Just 10 inches long using 2-inch-wide fiberglass splinting material that was comically too large even for the baby’s entire arm and shoulder. I was sorely tired and going through the process mechanically, but there was something odd enough about the baby’s behavior that it got through the fog of fatigue that surrounded my mind at the time.

Normally, with a fracture, the patient will express pain with very particular movements or points of pressure, but this baby cried every time I moved their upper arm at all. I could gently flex their elbow without complaint, but any movement at the shoulder would illicit a pain response. With the baby’s mother watching me intently, I experimented slightly and found that adduction (moving the arm toward the body) was apparently more painful than abduction (moving it away). There aren’t really any fractures that an infant could sustain that would have that effect. So, much to the baby’s chagrin, I turned up the lights in the room and took a closer look at things.

There was a bulge in the baby’s axilla (armpit) that I had previously assumed to be regular baby pudge that had an odd texture to the overlying skin. A gentle press on the bulge produced the worst crying yet, so this appeared to be the source of the pain. I asked the mother if the baby had any skin conditions, and she gave an affirmative answer and noted that she had informed the physician about it, but that the physician did not think it was the source of the baby’s apparent pain. Now, at this point, I didn’t have a lot of medical training, but I had enough experience to know that something was weird here. I pressed and prodded lightly around the bulge and determined that there was some kind of mass or other abnormality under the skin there. But I had my orders. I finished the splint and told the mother that I’d follow up with the nurse and physician about the bulge.

Once I exited the patient’s room, I quickly sought out the assigned nurse and told her about the bulge I had found. She was doubtful, but with my insistence, she passed along the information to the physician as I scurried off to assist with that second tib-fib. That one didn’t fight, but the patient was an athlete, and it was hard work to resist the muscles of their leg with my not-so-developed arms and shoulders. I fully admit that I have noodle arms and have never pretended to have significant upper body strength.

Now positively stumbling with fatigue, I left the second sedation to go check in with the baby’s nurse to find out what the physician had to say about my findings. The nurse told me that I was correct. There was something there that the physician had overlooked on exam that turned out to be a pretty significant abscess. There was a slew of new orders in for labs, an IV, medications, and admission that had been added on and I was tasked with removing the tiny splint and helping with the IV and labs.

It was a small thing. Something easy to miss on an exam given that babies are not very good at communicating where they have pain. I really only noticed it because of the manipulation I had to perform for the splint and previous experience working in a surgical practice where we saw abscesses and skin infections reasonably frequently. It was an exhausting night, but I hold no small amount of pride for catching that near miss and preventing the patient from being discharged without appropriate treatment.

That experience taught me the importance of performing thorough physical examinations that make use of all the senses at your disposal. In our osteopathic manipulative medicine coursework, there is a huge emphasis on diagnosis through palpation and physical sensation through direct contact. It’s not a terribly common practice in medicine overall, particularly not in emergency medicine, but it is a very useful skill that I intend to hone and make good use of throughout my career.