Can you guess what the doc I missed.

Patient ambulates in s/p motorcycle crash with no loc complaining of right shoulder pain and mult. lacerations and abrasions to right hands and bilateral knees. Right shoulder and chest xray done. Right shoulder sling applied and iced. Patient keeps telling me, "thank God Im left handed". He also keeps talking about how stupid he feels and how he feels scarred (sp) since crashing his motorcycle.

Full, packed ER, and the MD is taking a while reading xrays and discharging patients. Motorcycle patient, who has his mother, baby, and two girlfriends (dont ask), is telling me that "the pain meds are working" and he really wants to go home. He is standing in the doorway taking w. the patient in the room across the hall or pacing from his room to the hall - giving me that stare- you know the one that says "hurry the F*&^ up and let me go". I had security tell him to stay in his room due to HIPAA- and to give me a break from the stares and glares.

After about an hour, I go in to discharge patient and he tells me he feels like his voice is hoarse. But he is speaking in complete sentences with no problems and he is insisting that he is ready to go home. He was dignosed with a sprained shoulder- and tells me he can feel it popping when he moves his arm. I dont feel or see any deformity. Patient discharged home w. pain meds and instructions.

Do you know why he was back in the ER the next morning????? :confuse

Rachel - still learning!!!!!!!!!!!!!!!!!!!!

[lucky1RN]

Ok...I'll go first.

Posterior dislocation? But I don't know how that would explain the hoarseness. Broken rib? Pneumothorax that wasn't picked up on the CXR? Allergic reaction to meds?

Maybe something totally unrelated to the wreck?

[HyperRNRachel]

You are smart! A large pneumo!!!!!!!!!! Not small or medium but LARGE. It was picked up by the radiologist who read the xray in the am, but by that time the patient was back in the er complaining of dyspnea and needing a chest tube.

Since a chest xray was done, what else do you think I could have done? I had one of those "feelings" when he told me he felt hoarse- but I knew the chest xray had been done and I chalked it up the the helmet strap.

Rachel

[EricJRN, MSN, RN]

How were the breath sounds?

[lucky1RN]

:yeahthat:

Breath sounds, equal rise and fall of chest, tracheal deviation, falling sats, increasing HR. Don't kick yourself about it. Why didn't the doc pick it up on the CXR?

[HyperRNRachel]

I have a crazy obsession w. lung sounds so I listen to everyones. You come in with a possible broken baby toe and I will listen to your lungs. I have only been a nurse for 2.5 years so I am still perfecting that skill. But I do not recall his right lobes being decreased. No tracheal deviations. Since his only complaint was the right shoulder- he was very specific- I did not place him on any monitor. He was speaking- almost nonstop- in complete sentences. I do my own vitals on discharge and there was not drop in pressure, increase in resp, or decrease in pulse ox. This whole thing has me feeling a little insecure. NOT alot insecure just enough to make me smarter- hopefully.

How did the pneumo get missed by the MD? I do not know. He is an excellent MD. This really has me perplexed. Its not like it started small and grew large. IT WAS LARGE to start with.

[MassED, BSN, RN]

You are smart! A large pneumo!!!!!!!!!! Not small or medium but LARGE. It was picked up by the radiologist who read the xray in the am, but by that time the patient was back in the er complaining of dyspnea and needing a chest tube.

Since a chest xray was done, what else do you think I could have done? I had one of those "feelings" when he told me he felt hoarse- but I knew the chest xray had been done and I chalked it up the the helmet strap.

Rachel

yeah, agreed with the popping with his movement. The throat issue... can't explain that one

[Penguin67]

:heartbeat:heartbeatInteresting story. A simliar thing happened to my boyfriend 5 years ago. He had a motorcycle wreck that was not his fault...there was uneven pavement and not a sign to notify anyone of that. The unexpected pavement rise caused him to lose control of the bike and flipped him off and sent the bike sliding down the interstate. (He got a nice settlement from the GA DOT and was able to rebuild the bike.)

Fortunately, he was able to walk away, but had severe road rash (aka tope layers of skin sheared from his slide down the interstate. I've seen his helmet, and I can honestly say that it saved his life. You can see where the point of impact was and also the line from his slide down the interstate. An ambulance took him to the hospital, where he was assessed and had an xray and eventually sent home with some mild pain meds. No one even did wound care on the road rash. (He doesn't ride without a jacket anymore, as that would have prevented the severity of the road rash.)

The next morning, he was spitting up blood, knew that wasn't good and headed back to the ER. They looked at his x-ray again and saw 4 broken ribs and diagnosed a bruised lung. He was admitted for a week and had extensive whirlpool therapy for wound care, and was on a PCA for awhile for pain management. He was off work for 45 days to recover, as he couldn't move much. Had a hospital bed with a trapeze bar to assist with moving around. Home health came daily for dressing changes. (This was before I knew him, or my nursing skills probably would have been used.)

Bottom line...it is motorcycle season now and we can expect to see alot of riders in the hospital. We need to all do good assessments and listen to their complaints so that injuries are not missed. Also, motorcyclists are not always the one at fault for accidents. Most are very safety conscious, but I know there are some wild ones out there. Motorists need to also be aware of morotcycles on the road and give them room and respect. Many motorcycle accidents are caused by motorists. (Remember the Steeler's QB Ben Rothliesberger who had an accident in 06, wasn't wearing a helmet as it wasn't required in PA, and he was hit by a woman who ran a light.)

Let's all be careful!

[Roy Fokker, BSN, RN]

I have a crazy obsession w. lung sounds so I listen to everyones. You come in with a possible broken baby toe and I will listen to your lungs.

Heh! I thought I was the only one

Lungs, Heart, Abdomen and a quick neuro check. Old habits die hard...

[northshore08]

Isn't there something about right shoulder pain being a sign of diaphramatic irritation? Large pneumo could have been pressing on that...Just a thought. May be the hoarseness was the first indication of deviation of trachea/lungs/chest stuff.....

Am tired and reaching for old information wayyy in the dusty past.:zzzzz

[needsmore$]

Isn't there something about right shoulder pain being a sign of diaphramatic irritation? Large pneumo could have been pressing on that...Just a thought. May be the hoarseness was the first indication of deviation of trachea/lungs/chest stuff.....

Am tired and reaching for old information wayyy in the dusty past.:zzzzz

I believe you're referring to left shoulder- Kehr's sign -- but I don't know why it couldn't also be in the right side--

Referred pain due to blood irritating the peritoneal lining/diaphragm

Hoarseness-- see I was thinking chin strap/ST neck/ laryngeal trauma-- when the pt gets clotheslined across the throat

The popping feeling in the rt shoulder, I have also had pts tell me it felt like something rolling in their shoulder-->pneumothorax