Thumbs Up!

Last night I spent my shift in the "Urgent Care" area. Every hospital has its own nomenclature- but this falls somewhere between the "Fast Track" and the "Acute area"(where I spent my first shift) in terms of acuity. The Urgent Care area is where patients with a low likelihood of admission are seen- but who still may require some type of work-up / intervention. I was stationed there with one other student, a resident, and of course, the attending physician.

It wasn't incredibly busy, and my first impression was that my evening would be spent with a lot of down time; and not much in the way of learning on this particular night. So, I decided to make the most of things and grabbed a copy of Blueprints in Emergency Medicine, 2nd edition and proceeded to do all the questions at the end of the book in between evaluating patients*.

There was a fairly steady flow of patients and I was able to see my share throughout the night. Granted, they had nowhere near the acuity of the previous nights' patients, but that is the nature of the beast. Fortunately, the attending physician was into teaching and began early-on with the interactive teaching sessions.

Several topics were covered including the management of the acutely intoxicated patient( and legal ramifications thereof), the differential for invasive diarrhea, and the evaluation of shoulder injuries. Since I am the whipping boy sub-intern, most of the questions were directed straight at me. I was feeling pretty confident since I was fielding them without any trouble at all. This of course was about to come to an abrupt end.

The patient in question was a female in her 30's who sustained a small laceration to the tip of her thumb 4 days ago. She was prescribed an antibiotic by her primary care doctor 2 days ago, when the thumb began to swell and became more painful. I conducted a brief history and exam. The thumb did not look that bad, there was no local collection of pus, and there was only minimal restriction of her range of motion while sensation in her thumb was not grossly affected. I was working on a diagnosis of local cellulitis. After quickly confirming the absence of any fevers or drug allergies(I was anticipating a change in antibiotics) I was on my way back to the attending to present the case to him. [Cue Chopin]

After what I thought was a rather complete and concise presentation, the attending said, "Let's go see her." I thought I detected a certain glisten in his eye.

The attending introduced himself to the patient and proceeded to put her through a very similar physical exam that I had just conducted. After which, we went back to the witness stand desk where the questions began:

Attending: So, what is your diagnosis?

Me: It doesn't look like an abscess, I think it is just a mild localized cellulitus**.

Attending: Mmm Hmm... [this is never good] So, what would you be concerned about given the location of the injury?

Me: umm...err...duh....I suppose It could to progress to a Felon ?

Attending: OK fine, that is right it could, but what would be a serious complication of her wound? [holding back frustration in a not-so-subtle-way]

Me: I suppose it is unlikely, but perhaps osteomyelitis would be fairly serious.

Attending: [doing his best to fight the overwhelming urge to call my lineage into question] That would be "rare". Have you ever heard of Tenosynovitis?

Me: [cue crickets chirping... as I desperately apply my "conversational Latin skills" to the problem] That is inflammation of the..uh.. tendon..[trailing off] and the... synovial space?

Attending: [wearing the look of a chess grandmaster who sees imminent victory] Close-But. Why dont you go ahead and look that up for me- and tell me Kanavel's 4 Cardinal Signs of Tenosynovitis, why it is important, and the management. I'll give you 5 minutes, then you will tell me. And then you'll teach the 3rd year when he comes back from seeing his patient.

Me: Uh, Sure. [I like this guy]

Needless to say, I looked up all there is to know about Tenosynovitis and was able to sucessfully answer the question, and proceeded to teach my fellow student about the diagnosis and management of the dreaded, Tenosynovitis. Thankfully there was a 5-Minute Consult on the bookshelf.

I have to say, I think it will be a good long while before I ever forget to consider that diagnosis again.

Tuiton for clincial roatations: ~$1000.00 per week
Cost of Dansko Clogs (inserted firmly in the mouth): ~ $90.00
Having your ego kicked in the nuts- but actually learning something that may save a finger or a hand someday: Pricelesss.



*If you are interested, there is a typo in the answer key- answers #33 and #34 are transposed.

** For the record, my diagnosis was correct; but I was wrong not to consider( or even know about) the more serious differential.

Picture credit: Wikipedia