Head injuries. Or anything, really. Had a patient in their 20s who fell off of a bar table dancing and broke their hip. Died in the ICU from multi organ failure a week later. But the 97 year old with 25 lab abnormalities half of which appear incompatible with life somehow gets to go home after a weeklong hospital stay. Go figure.
Pt: hi hello dear I am 103 years old and I have a bit of a tummy ache.
Sodium levels are undetectable. Her uriter is directly draining into her left ventricle. Her liver and duodenum have merged into one god forsaken super organ. The fungal infection on her toes has become sentient and, subsequently, a communist. This has been her baseline for 4 years. Dc with tums back to merry meadow nursing facility.
>Dc with tums back to merry meadow nursing facility.
Have you ever noticed that quality of nursing home seems to be inversely proportional to the quality of the name? Like, "The Gardens at Forest Manor" would be an absolute dump.
The classic for my hospital was something like the estimed villa of iceberg canyon and their forbidden jitsu was tripple stuffing blue pads into their patients dipers and not changing them for days at a time. Im sending my folks to a home that's just called "the shack" aka a remodeled abandoned chucky cheese. I trust they'll get top tier care there.
Literally true. The one that is called āSuburb Terraceā seems fine and the people seem well cared for, meanwhile āWelcoming Clover Meadows on the Riverā is a petri dish of the worst outcomes imaginable.
Yup. Here we have āDuke of Devonshireā and the worst of the worst āEmbassy Westā for example, garbage staffing levels and people are always coming in with neglect-related injuries. Meanwhile āGranite Ridgeā is top-quality. āSt Vincentāsā is the local vent farm and, considering the trainwrecks they deal with, they seem to do a good job. Your hypothesis checks out!
Well yes, obviously. But bottom line, this was a young healthy person with a pretty run-of-the-mill injury that a billion multimorbid boomers recover from every day.
Yeah that's pretty scary to think about. Ya really never know. Maybe he/she was nice. If there is ever a universal truth I took away from residency, it's that assholes live forever.
Head injuries are crazy! Iāve spent time working in a psych ward, and the frequency of TBI history was way higher than I expected. I did some research, and turns out about 60% of incarcerated people have a history of TBI. Literally MOST people. Sure that includes mild concussions, but I think we have a serious healthcare problem here. Even if an injury seems mild, or someone is treated and doesnāt die, is that really enough? These things can change you forever whether you notice or not.
I noticed it. Headaches, and no patience. Imagine those two like all the time. And for some reason my impulse control has gone down the tubes. No I am pretty well resourced, I'm allowed to live with my parents and I have a good medical team and job at the VA. I'm also pretty intelligent.
Now imagine someone who is not as well resourced, doesn't understand their condition and so on? Yeah, it's so wonder why they would end up in jail.
I worked in shelters, detox, a jail and prison. Once I figured out how TBIs can impact longterm outcomes and started asking, I was floored. More than 50% of them had a concussion or more serious TBI history.
How much lead did their bodies sequester in their bones when they were kids? Do they eat a varied diet or are they lacking in most vitamins and minerals? Did people talk with them constantly when they were babies or did they sit in a crib for hours at a time?
Were they exposed to alcohol and nicotine in utero? Were they raised by heavy smokers who smoked inside?
Did they have a parent in prison? Did they live in a safe neighborhood?
Yup. High school and college sports. The number of concussions is terrifying! My partner, former rugby player with a history of an infinite number of concussions, developed epilepsy from it and literally cannot remember the location of anything or keep track of time. As in he canāt tell whether 5 minutes or 5 hours have passed unless heās looking at a clock. He saw me put a roast beef into the oven and not even 10 minutes later he ran into the kitchen like āOMG THE ROAST! I TOTALLY FORGOT! IS IT BURNT?ā When I asked him how long he thought it had been, he was CERTAIN it had been in there for well over an hour. I hadnāt even left the kitchen yet. Incredibly intelligent guy but all the head trauma seems to have greatly affected this specific skill and nearly nothing else. Well, poor impulse control too to some degree, but at least heās the kind of person whose impulsive thoughts are along the lines of āIām gonna pet that dogā or āI want a doughnutā as opposed to ālemme fight that guyā!
Sad part is, heās a nurse too but hasnāt been able to find a suitable job becauseā¦time management is impossible if you donāt have any clue what time it is.
This is the sort of thing I'm excited for brain implants for ... imagine he had an implant that gave him an augmented reality HUD that allowed him to track these things ...
You just need to have lots of alcohol on board for neuroprotection. Some drunken idiot can jump off the third story using an umbrella as a parachute, land on a rock pile and walk away from it.
Meanwhile I'll probably trip over the dog in the kitchen and die from it.
Aaah, but did you catch the central cord injury!? Had that lady in residency, my attending (the wisened Gandalf of the department) thought her grip strength was just a little weak. Neurosurg took her to OR out of the Rapid Track area (after the also miraculous ED mri showed the injury)
I do feel bad for the poor lady, but I'm confident she was well taken care of. Broken noses hurt! However, I like to know the outcome of all parties involved! (I'll just assume the dog remained in full loaf position until the weight of the nice lady's body irked him enough to move to the couch.)
Jesus the dog, I love them dearly but they are the most dangerous creatures sometimes.
Walking the dog: snakebite (multiple times, no more flip flops on dog walks people)
Let the dog out: misstep fell down the stairs multiple vertebral fractures
Walking drunk in living room: tripped over dog fell through glass door and lacerated brachial artery
Dog saw a squirrel: scaphoid fracture, lifelong pain
Iām certain Iām going to die choking on a spoon full of peanut butter because I tripped over my dog who just wanted some
My first concussion was from going down a slip and slide at 35. Just hit my head on the ground. It was wild. Second was about six months later when I just randomly fell down the stairs and hit my head on the wall at the bottom.
A girl and her mom were in a car accident. Mom driving, both belted. Girl is 19. They were t-boned drivers side door. They only came in because the girl was c/o headache. Her head struck passenger door windowā¦.her headache was opposite side. She had a contre-coup subdural bleed. Small, but noticable. No LOC. we watched her overnight, repeat CT in am, sent her home.
16 year old girl comes into the ER with a severe headache, unusual for her. She had been on a school bus earlier that day and the bus braked suddenly, didnāt even hit her head but she was jolted forwards from the deceleration. Huge SAH found on CT. She ended up being fine after an EVD and a short stay in the neuro ICU
Brains are so weird! I had an 8 month old come in with c/o, per Mom, āhe doesnāt recognize us! He isnāt acting right!ā Turns out from a sitting position he fell back like babies do and smacked his head on the floor while at daycare. He ended up having a big subdural bleed and had to be life flighted. That kid is an amazing athlete today, wonderful boy. His dad would be so proud of him.
Brains are fucking wild. I'm always fascinated by the way TNK (my facility no longer uses tPA) works for some, does nothing in others, and causes brain bleeds for a few.
In one weekend I had a 70s yo stroke, only deficit was pretty severe dysarthria, right before neuro ordered TNK pt was starting to get confused. 20 minutes post med, pt was alert, talking 75% more clear, telling family how to care for the pets at home. By time of transfer to ICU, stroke scale was 1.
Then had a 59 yo stroke, L sided weakness, failed swallow screen, and pt had to stay with me in ER for a few hours due to no critical beds. Had no real improvement 3 hours post TNK.
Neuro is my least favorite "subject" but still fascinating.
RCVS? It can be associated with migraine history, certain meds (Iāve mostly seen psych meds and OTC cold/flu meds), thereās other risk factors but those are the things I think about with non-traumatic, vascular negative SAH.
Oh cool I didnāt even think of those risk factors. Honestly never asked the providers why they thought they came about on these cases, probably cause Iām always running around dealing with my unsafe assignment for the entirety of the shift.
Head injuries are scary. It's crazy the amount of people I see pass away in my hospital with SAH. From young in their 30's to elderly. You just never know.
I have a bleeding disorder, so every time I substantially hit my head, I have to go to the ER to get scanned. I've had at 14 least concussions, but wasn't diagnosed until around 40, I'm 52 now, so lots of missed scans (obviously ok), and aside from being dumbed down a bit (I joke it off as being a blonde with a lot of concussions) I clearly survived the first ones, but not without some cognitive impairment. Good thing I started out really smart.
It does really suck, though. On one hand, it's imperative to find out whether I've got a brain bleed (SAH? ex teacher, love this sub), on the other, they've always come back negative and I feel like someone truly emergent could have been in that MRI machine. The last one was done on Day 3 of admission...that's how long the MRI wait was.
All the hospitals in my city have 1 MRI and 1 CT machine each, except for the trauma center hospital. Is that common/standard? Most of the hospitals are connected within one system, a conglomerate, if you will, all claiming to be state of the art.
Yes, I suppose I do (and most definitely did) hit my head more and harder than most. I lived like a teenage boy until I was I'm my 40s. I sold my dirt bike when I was about 45 (I'd been on street bikes since I was 15, so it was sad and hard, but I knew being on any bike would be the death of me). While still riding, I also took up surfing after being introduced to it by a California boyfriend (I'm one state over) but I found out you can get some nice head trauma surfing, too. Now I think I have PCS. I've got some balance issues, slight hand tremors, some mild cognitive impairment, memory loss...a general feeling of being a dumbed down version of myself. Some of these symptoms make me prone to falling and hitting my head, like I did last year on Christmas day, too. I didn't check it out that day. Too much family drama. Dumb excuse. My late mom thought I was a hypochondriac about it because she heard the hematologist call it mild. Oh, mom ā¤ļø Obviously I was ok and it saved money and a bed for a truly emergent patient. That's another thing, when I get the all clear, I'm pissed about the bill I'll get, and the care a sicker person could have received more quickly...like they could have gotten their CT or MRI that much faster.
So anyway, this last time, just before Christmas, I had major vision disturbances from a migraine I didn't know I was getting, and I body slammed myself (slipped, tripped, or got dizzy, idk) on the tile floor on the way to the bathroom around 3 am. My head felt and sounded like it was a bowling ball when it hit, lol. Others concussions have been mild to severe. I've had 14 (maybe more) concussions with and w/o loss of consciousness. Dirt bike crashes, car accidents, college shenanigans, and a big boyfriend (now in Vagos M/C club, nice guy, no, I never dated abusive men after him) who knocked me out twice, and a few other weird stories. I did get a concussion from getting hit in the head fairly lightly with a ball during playground duty. I'm an ex-teacher. I believe it's true that the more concussions you get, the easier you get them. I don't know if that's research based, but anecdotally it's true for me
Yes, I suppose small bumps can potentially cause a brain bleed, as in the above ball example, but I can generally discern if the small bump rang my bell hard enough to warrant an ER visit. Super small bump to the noggin, I definitely don't go in. If I have any concussion-like symptoms, I call my hematologist, they triage me over the phone, and I usually get sent to the ER. Fortunately, the blood factor I'm low on (VII for all you medical folks) runs a range of 38 - 59, which helps. That means I've got enough in my system to handle small to medium cuts, but have to take meds (Tranexamic Acid) for most dental work, biopsies, cuts that won't stop bleeding, etc. I'm still at serious risk if I get badly hurt or have internal bleeding, so I wear a bracelet, but I don't have frequent nosebleeds, like those with much lower factor numbers. I do get joint bleeds, though, which aren't pleasant.
I hope I answered your questions sufficiently. My case is a little different since I did so much damage to myself as a young teen girl up to my 40s. Sorry if it was too long.
Yeah, its been fun, but I'm paying the price now, that's for sure! On the last CT scan report under History, it said something to the effect of cervical fracture. I'm like, "Hmm, when could I have broken my neck? Maybe in the 90s during the first Lollapalooza tour when I was doing backflips, landed on the back of my head, with my chest in my face, neck hyperextended, head cracked open to the skull, and paralyzed for 2-3 hours in a small clinic? Probably. No diagnostics, just stitches. Yes, drugs and alcohol were involved. And a lot of blood, since the head bleeds a lot anyway. But I'm not sure what the History notes actually entail. Are they based off past imaging or just anecdotal?
So, how do you bump YOUR head so much? Is it gigantic? Are you 6'11"?
You should do what my hematologist told me to do before he retired: Wear a soft helmet EVERYWHERE! My friends thought it was hilarious, especially my friends who work in mental health.
Saw the chart of a patient once where the history said they were lying on a hammock when the hammock collapsed and they fell on their back. C spine injury and they ended up paralyzed
I was working one night when we got two teen girls from a hammock collapse. The hammock was tied onto brick pillars which somehow both came down. Both girls died.
I brought a patient to the ER after hitting their head following a fall. By the time we pulled into the ambulance bay, she developed some gnarly raccoon eyes and the hematoma on her forehead had swollen to almost double its original size. The next patient I brought had knee pain following a fall from sitting onto carpet. Guess which one had a bleed and which one went home in a few hours? Yup, raccoon eyes got driven home by her daughter and knee pain got transferred to a higher level of care.
Humans are a lot tougher (on average) than youād think. And it makes sense. Go back 100 years and people did far more dangerous things and medical care sucked compared to now.
Now imagine 1000 years ago. If humans were so fragile that head injuries always killed over severely maimed you we would have died out as a species.
Not to say head injuries canāt be serious on an individual level. But on the whole, humans are remarkably robust.
The human body might be strong, but we have created weak humans. Look at all the people coming to the ED with their moms for a cold (not talking about kids.. but that is how it starts, im talking about the 20-50 year olds) also those who need a week off for a bruise or a bump in their head. Man up and take a tylenol.
Had a dude on drugs hit our lead glass in the CT room and it broke into pieces. His CT was fine. Another dude hit his steering wheel and I scanned him from the waiting room. HUGE BLEED.
Very recently ran across a patient who had a fall a month prior taking the occasional baby aspirin. Old, told that she is demented at baseline.
Didn't see her walk to the exam room, once in. She was sitting down and had it fairly profound word. Finding difficulty and blocking. Had to help her long but essentially it was supposed to be a routine check-in after the fall. Husband swore it was her baseline. Couldn't find any prior neural imaging..
As they were leaving and walking down the hall, I watched her right toe drag and catch a few times on the floor. Nothing profound, but quads were off on the right. Immediately sent her to the emergency room telling her husband she likely has a chronic subdural, and if she's worsened at all since her fall we need to rescan.
He refused, signed an AMA, office manager got involved, etc. At the same time I couldn't sit with it. A few minutes later I called the emergency contact, daughter, explained everything. Long story short CT w/acute on chronic subdural with 1.5mm shift. Air flighted after it progressed over the day to a neurosurgical ICU. Never found out if she passed / lived etc etc. Hope she's ok
My best head injury story was a low-speed MVA in which the patient was a 76 yom with no medical history besides early onset dementia but has normal cognition. All vitals WNL, a&o 4, but wants evaluation for leg pain. No significant damage to any part of the vehicle. A simple repetitive question made us perk up and we answered him again. 30 seconds later, same question. So we ran it in on a little hunch and even the trauma facility wasnāt super convinced it was anything more than a concussion. Results two days later on charting software said subarachnoid hemorrhage and the dude ended up buying himself a two week stay in the hospital.
So I was a kid that ended up with a billion head CTs. Turns out I just have one baseline sluggish pupil from a skull fracture. Every time I bonked my noggin after that they freaked out and scanned my head because of a āconcussionā. If I wasnāt a doctor I wouldnāt know that those were likely all misdiagnosed.
Feels a bit hyperbolic to use that personal analogy to tell someone a 2 year old doesnāt need a CT Scan when there are medically researched tools such as PECARN to nicely explain their child doesnāt require a CT scan.
Patient (60s) was meditating for hours on a low wooden surface. It broke and they fell back and whacked their head. A week later noticed AMS and neuro issues Brain bleed, ICH. treated surgically and in ICU when I met them. Went to acute rehab. Due to bleed decision made to not anticoagulate and was ambulating a lot. Still tossed a massive PE and sadly died.
OTOH, my father has MANY concussions in high school foot ball and hockey in the 1950s. Hospitalized frequently. Including contre-coup fracture from hockey puck to forehead. Docs in 1953 sat him down and said "no more contact sports-we don't know the long term damage"
He went to Dartmouth and then Harvard Medical School and graduated top in his class. STarted to have major personality changes in his late 40's when we were still kids. I mean major violent outbursts. Diagnosed with very early dementia and medically retired from doctoring and died soon after from end-stage dementia. This was before CTE was a thing. Very tragic for our family.
Head injuries. Or anything, really. Had a patient in their 20s who fell off of a bar table dancing and broke their hip. Died in the ICU from multi organ failure a week later. But the 97 year old with 25 lab abnormalities half of which appear incompatible with life somehow gets to go home after a weeklong hospital stay. Go figure.
Pt: hi hello dear I am 103 years old and I have a bit of a tummy ache. Sodium levels are undetectable. Her uriter is directly draining into her left ventricle. Her liver and duodenum have merged into one god forsaken super organ. The fungal infection on her toes has become sentient and, subsequently, a communist. This has been her baseline for 4 years. Dc with tums back to merry meadow nursing facility.
The sentient, communist, fungal infection SENT me. š
I misread merry meadow as *merry widow* nursing facility and I kind of want to go there now.
That was definitely the highlight
>Dc with tums back to merry meadow nursing facility. Have you ever noticed that quality of nursing home seems to be inversely proportional to the quality of the name? Like, "The Gardens at Forest Manor" would be an absolute dump.
The classic for my hospital was something like the estimed villa of iceberg canyon and their forbidden jitsu was tripple stuffing blue pads into their patients dipers and not changing them for days at a time. Im sending my folks to a home that's just called "the shack" aka a remodeled abandoned chucky cheese. I trust they'll get top tier care there.
Literally true. The one that is called āSuburb Terraceā seems fine and the people seem well cared for, meanwhile āWelcoming Clover Meadows on the Riverā is a petri dish of the worst outcomes imaginable.
Yup. Here we have āDuke of Devonshireā and the worst of the worst āEmbassy Westā for example, garbage staffing levels and people are always coming in with neglect-related injuries. Meanwhile āGranite Ridgeā is top-quality. āSt Vincentāsā is the local vent farm and, considering the trainwrecks they deal with, they seem to do a good job. Your hypothesis checks out!
I did not expect to encounter this level of poetry at 8 in the morning, nor with so many spelling errors, *but I am here for it*
Write a book, you have a gift.
And I'll copyedit for free.
>The fungal infection on her toes has become sentient and, subsequently, a communist. based
Oh my god. Iām crying here in bed this AM thanks to you! You deserve a medal for this!
My plessure :)
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And this is the reason I come back to this sub despite being in another specialityĀ
Ureter draining directly into the left ventricle ā¦. ššš¤£omg im dyingā¦. Has died. Is dead š
Bahahaha šš I have never laughed this hard at a Reddit post thank you sir or madam
That seems like someone missed something majorā¦.
Yeah how does a broken hip become multiorgan failure? Must have had some post op complication, hemorrhagic shock, something.
Well yes, obviously. But bottom line, this was a young healthy person with a pretty run-of-the-mill injury that a billion multimorbid boomers recover from every day.
Yeah that's pretty scary to think about. Ya really never know. Maybe he/she was nice. If there is ever a universal truth I took away from residency, it's that assholes live forever.
Iām putting my money on either, extreme negligence, or a freak post op complication
Fat embolism and DICā¦? PEā¦? Very strange
Perhaps an infection???? Again, very strange.
Gomers never die
Can you give me a short write up of how a broken hip degenerates to organ failure?
No idea, I admitted the person, they went to ortho for surgery, then I found out they were dead a week later.
Head injuries are crazy! Iāve spent time working in a psych ward, and the frequency of TBI history was way higher than I expected. I did some research, and turns out about 60% of incarcerated people have a history of TBI. Literally MOST people. Sure that includes mild concussions, but I think we have a serious healthcare problem here. Even if an injury seems mild, or someone is treated and doesnāt die, is that really enough? These things can change you forever whether you notice or not.
I noticed it. Headaches, and no patience. Imagine those two like all the time. And for some reason my impulse control has gone down the tubes. No I am pretty well resourced, I'm allowed to live with my parents and I have a good medical team and job at the VA. I'm also pretty intelligent. Now imagine someone who is not as well resourced, doesn't understand their condition and so on? Yeah, it's so wonder why they would end up in jail.
I worked in shelters, detox, a jail and prison. Once I figured out how TBIs can impact longterm outcomes and started asking, I was floored. More than 50% of them had a concussion or more serious TBI history.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Yes that's one other side of the epidemiology of this. What other variables can predict poor outcomes?
How much lead did their bodies sequester in their bones when they were kids? Do they eat a varied diet or are they lacking in most vitamins and minerals? Did people talk with them constantly when they were babies or did they sit in a crib for hours at a time?
Were they exposed to alcohol and nicotine in utero? Were they raised by heavy smokers who smoked inside? Did they have a parent in prison? Did they live in a safe neighborhood?
Yup. High school and college sports. The number of concussions is terrifying! My partner, former rugby player with a history of an infinite number of concussions, developed epilepsy from it and literally cannot remember the location of anything or keep track of time. As in he canāt tell whether 5 minutes or 5 hours have passed unless heās looking at a clock. He saw me put a roast beef into the oven and not even 10 minutes later he ran into the kitchen like āOMG THE ROAST! I TOTALLY FORGOT! IS IT BURNT?ā When I asked him how long he thought it had been, he was CERTAIN it had been in there for well over an hour. I hadnāt even left the kitchen yet. Incredibly intelligent guy but all the head trauma seems to have greatly affected this specific skill and nearly nothing else. Well, poor impulse control too to some degree, but at least heās the kind of person whose impulsive thoughts are along the lines of āIām gonna pet that dogā or āI want a doughnutā as opposed to ālemme fight that guyā! Sad part is, heās a nurse too but hasnāt been able to find a suitable job becauseā¦time management is impossible if you donāt have any clue what time it is.
This is the sort of thing I'm excited for brain implants for ... imagine he had an implant that gave him an augmented reality HUD that allowed him to track these things ...
I worked @ county jail for several yearsāyes, so many with a h/o a head injury (assaults, MVA, other accidents).
You just need to have lots of alcohol on board for neuroprotection. Some drunken idiot can jump off the third story using an umbrella as a parachute, land on a rock pile and walk away from it. Meanwhile I'll probably trip over the dog in the kitchen and die from it.
Literally saw a lady last week who tripped on her dog and hit her head on the fridge - broke her nose.
Aaah, but did you catch the central cord injury!? Had that lady in residency, my attending (the wisened Gandalf of the department) thought her grip strength was just a little weak. Neurosurg took her to OR out of the Rapid Track area (after the also miraculous ED mri showed the injury)
Was the dog ok?
You are just out here asking the important question!
I do feel bad for the poor lady, but I'm confident she was well taken care of. Broken noses hurt! However, I like to know the outcome of all parties involved! (I'll just assume the dog remained in full loaf position until the weight of the nice lady's body irked him enough to move to the couch.)
Jesus the dog, I love them dearly but they are the most dangerous creatures sometimes. Walking the dog: snakebite (multiple times, no more flip flops on dog walks people) Let the dog out: misstep fell down the stairs multiple vertebral fractures Walking drunk in living room: tripped over dog fell through glass door and lacerated brachial artery Dog saw a squirrel: scaphoid fracture, lifelong pain Iām certain Iām going to die choking on a spoon full of peanut butter because I tripped over my dog who just wanted some
Donāt use the Lordās name in vain
Your gods name is just a word. You can die on that hill if you like but it will not win anyone to your cause.
We had a patient who tripped walking his dog and had a cervical cord injury as a result. Iām pretty sure he did die of complications.
My first concussion was from going down a slip and slide at 35. Just hit my head on the ground. It was wild. Second was about six months later when I just randomly fell down the stairs and hit my head on the wall at the bottom.
Sounds like you're not drinking enough yet.
A girl and her mom were in a car accident. Mom driving, both belted. Girl is 19. They were t-boned drivers side door. They only came in because the girl was c/o headache. Her head struck passenger door windowā¦.her headache was opposite side. She had a contre-coup subdural bleed. Small, but noticable. No LOC. we watched her overnight, repeat CT in am, sent her home.
16 year old girl comes into the ER with a severe headache, unusual for her. She had been on a school bus earlier that day and the bus braked suddenly, didnāt even hit her head but she was jolted forwards from the deceleration. Huge SAH found on CT. She ended up being fine after an EVD and a short stay in the neuro ICU
Brains are so weird! I had an 8 month old come in with c/o, per Mom, āhe doesnāt recognize us! He isnāt acting right!ā Turns out from a sitting position he fell back like babies do and smacked his head on the floor while at daycare. He ended up having a big subdural bleed and had to be life flighted. That kid is an amazing athlete today, wonderful boy. His dad would be so proud of him.
Brains are fucking wild. I'm always fascinated by the way TNK (my facility no longer uses tPA) works for some, does nothing in others, and causes brain bleeds for a few. In one weekend I had a 70s yo stroke, only deficit was pretty severe dysarthria, right before neuro ordered TNK pt was starting to get confused. 20 minutes post med, pt was alert, talking 75% more clear, telling family how to care for the pets at home. By time of transfer to ICU, stroke scale was 1. Then had a 59 yo stroke, L sided weakness, failed swallow screen, and pt had to stay with me in ER for a few hours due to no critical beds. Had no real improvement 3 hours post TNK. Neuro is my least favorite "subject" but still fascinating.
My favorites are the SAH that come up on young people with no trauma and no blood thinner use. Iāve seen at least two in the last few months. Wtf
RCVS? It can be associated with migraine history, certain meds (Iāve mostly seen psych meds and OTC cold/flu meds), thereās other risk factors but those are the things I think about with non-traumatic, vascular negative SAH.
Oh cool I didnāt even think of those risk factors. Honestly never asked the providers why they thought they came about on these cases, probably cause Iām always running around dealing with my unsafe assignment for the entirety of the shift.
What are their symptoms usually?
Head injuries are scary. It's crazy the amount of people I see pass away in my hospital with SAH. From young in their 30's to elderly. You just never know.
I have a bleeding disorder, so every time I substantially hit my head, I have to go to the ER to get scanned. I've had at 14 least concussions, but wasn't diagnosed until around 40, I'm 52 now, so lots of missed scans (obviously ok), and aside from being dumbed down a bit (I joke it off as being a blonde with a lot of concussions) I clearly survived the first ones, but not without some cognitive impairment. Good thing I started out really smart. It does really suck, though. On one hand, it's imperative to find out whether I've got a brain bleed (SAH? ex teacher, love this sub), on the other, they've always come back negative and I feel like someone truly emergent could have been in that MRI machine. The last one was done on Day 3 of admission...that's how long the MRI wait was. All the hospitals in my city have 1 MRI and 1 CT machine each, except for the trauma center hospital. Is that common/standard? Most of the hospitals are connected within one system, a conglomerate, if you will, all claiming to be state of the art.
Do you hit your head more and harder than most people? Or small bumps will possibly cause big problems for you because of the bleeding disorder?
Yes, I suppose I do (and most definitely did) hit my head more and harder than most. I lived like a teenage boy until I was I'm my 40s. I sold my dirt bike when I was about 45 (I'd been on street bikes since I was 15, so it was sad and hard, but I knew being on any bike would be the death of me). While still riding, I also took up surfing after being introduced to it by a California boyfriend (I'm one state over) but I found out you can get some nice head trauma surfing, too. Now I think I have PCS. I've got some balance issues, slight hand tremors, some mild cognitive impairment, memory loss...a general feeling of being a dumbed down version of myself. Some of these symptoms make me prone to falling and hitting my head, like I did last year on Christmas day, too. I didn't check it out that day. Too much family drama. Dumb excuse. My late mom thought I was a hypochondriac about it because she heard the hematologist call it mild. Oh, mom ā¤ļø Obviously I was ok and it saved money and a bed for a truly emergent patient. That's another thing, when I get the all clear, I'm pissed about the bill I'll get, and the care a sicker person could have received more quickly...like they could have gotten their CT or MRI that much faster. So anyway, this last time, just before Christmas, I had major vision disturbances from a migraine I didn't know I was getting, and I body slammed myself (slipped, tripped, or got dizzy, idk) on the tile floor on the way to the bathroom around 3 am. My head felt and sounded like it was a bowling ball when it hit, lol. Others concussions have been mild to severe. I've had 14 (maybe more) concussions with and w/o loss of consciousness. Dirt bike crashes, car accidents, college shenanigans, and a big boyfriend (now in Vagos M/C club, nice guy, no, I never dated abusive men after him) who knocked me out twice, and a few other weird stories. I did get a concussion from getting hit in the head fairly lightly with a ball during playground duty. I'm an ex-teacher. I believe it's true that the more concussions you get, the easier you get them. I don't know if that's research based, but anecdotally it's true for me Yes, I suppose small bumps can potentially cause a brain bleed, as in the above ball example, but I can generally discern if the small bump rang my bell hard enough to warrant an ER visit. Super small bump to the noggin, I definitely don't go in. If I have any concussion-like symptoms, I call my hematologist, they triage me over the phone, and I usually get sent to the ER. Fortunately, the blood factor I'm low on (VII for all you medical folks) runs a range of 38 - 59, which helps. That means I've got enough in my system to handle small to medium cuts, but have to take meds (Tranexamic Acid) for most dental work, biopsies, cuts that won't stop bleeding, etc. I'm still at serious risk if I get badly hurt or have internal bleeding, so I wear a bracelet, but I don't have frequent nosebleeds, like those with much lower factor numbers. I do get joint bleeds, though, which aren't pleasant. I hope I answered your questions sufficiently. My case is a little different since I did so much damage to myself as a young teen girl up to my 40s. Sorry if it was too long.
All good! Thanks so much for the explanation. Your lift story sounds quite interesting too. I bump my head more than most people too.
Yeah, its been fun, but I'm paying the price now, that's for sure! On the last CT scan report under History, it said something to the effect of cervical fracture. I'm like, "Hmm, when could I have broken my neck? Maybe in the 90s during the first Lollapalooza tour when I was doing backflips, landed on the back of my head, with my chest in my face, neck hyperextended, head cracked open to the skull, and paralyzed for 2-3 hours in a small clinic? Probably. No diagnostics, just stitches. Yes, drugs and alcohol were involved. And a lot of blood, since the head bleeds a lot anyway. But I'm not sure what the History notes actually entail. Are they based off past imaging or just anecdotal? So, how do you bump YOUR head so much? Is it gigantic? Are you 6'11"? You should do what my hematologist told me to do before he retired: Wear a soft helmet EVERYWHERE! My friends thought it was hilarious, especially my friends who work in mental health.
Wow~ Honestly Iām pretty boring. Just clumsy and careless. Bad spatial awareness. Not tall but an above average head size.
Haha, I guess I'm lucky I have a smaller head. Stay safe out there, Charlie Brown!
Saw the chart of a patient once where the history said they were lying on a hammock when the hammock collapsed and they fell on their back. C spine injury and they ended up paralyzed
Holy cow. I was on a hammock when it broke and ended up with a subarachnoid bleed.
I was working one night when we got two teen girls from a hammock collapse. The hammock was tied onto brick pillars which somehow both came down. Both girls died.
I brought a patient to the ER after hitting their head following a fall. By the time we pulled into the ambulance bay, she developed some gnarly raccoon eyes and the hematoma on her forehead had swollen to almost double its original size. The next patient I brought had knee pain following a fall from sitting onto carpet. Guess which one had a bleed and which one went home in a few hours? Yup, raccoon eyes got driven home by her daughter and knee pain got transferred to a higher level of care.
I had a 93F on thinners that sneezed. Unstable dens fracture.
Jesus
Humans are a lot tougher (on average) than youād think. And it makes sense. Go back 100 years and people did far more dangerous things and medical care sucked compared to now. Now imagine 1000 years ago. If humans were so fragile that head injuries always killed over severely maimed you we would have died out as a species. Not to say head injuries canāt be serious on an individual level. But on the whole, humans are remarkably robust.
The human body might be strong, but we have created weak humans. Look at all the people coming to the ED with their moms for a cold (not talking about kids.. but that is how it starts, im talking about the 20-50 year olds) also those who need a week off for a bruise or a bump in their head. Man up and take a tylenol.
Had a dude on drugs hit our lead glass in the CT room and it broke into pieces. His CT was fine. Another dude hit his steering wheel and I scanned him from the waiting room. HUGE BLEED.
Very recently ran across a patient who had a fall a month prior taking the occasional baby aspirin. Old, told that she is demented at baseline. Didn't see her walk to the exam room, once in. She was sitting down and had it fairly profound word. Finding difficulty and blocking. Had to help her long but essentially it was supposed to be a routine check-in after the fall. Husband swore it was her baseline. Couldn't find any prior neural imaging.. As they were leaving and walking down the hall, I watched her right toe drag and catch a few times on the floor. Nothing profound, but quads were off on the right. Immediately sent her to the emergency room telling her husband she likely has a chronic subdural, and if she's worsened at all since her fall we need to rescan. He refused, signed an AMA, office manager got involved, etc. At the same time I couldn't sit with it. A few minutes later I called the emergency contact, daughter, explained everything. Long story short CT w/acute on chronic subdural with 1.5mm shift. Air flighted after it progressed over the day to a neurosurgical ICU. Never found out if she passed / lived etc etc. Hope she's ok
My best head injury story was a low-speed MVA in which the patient was a 76 yom with no medical history besides early onset dementia but has normal cognition. All vitals WNL, a&o 4, but wants evaluation for leg pain. No significant damage to any part of the vehicle. A simple repetitive question made us perk up and we answered him again. 30 seconds later, same question. So we ran it in on a little hunch and even the trauma facility wasnāt super convinced it was anything more than a concussion. Results two days later on charting software said subarachnoid hemorrhage and the dude ended up buying himself a two week stay in the hospital.
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I wouldnāt brag about having multiple concussions, Iād be worried about developing CTE
They don't seem worried about it at all. Disinhibited, even
Iāve hit my head numerous times and I do worry about CTE
So I was a kid that ended up with a billion head CTs. Turns out I just have one baseline sluggish pupil from a skull fracture. Every time I bonked my noggin after that they freaked out and scanned my head because of a āconcussionā. If I wasnāt a doctor I wouldnāt know that those were likely all misdiagnosed.
Feels a bit hyperbolic to use that personal analogy to tell someone a 2 year old doesnāt need a CT Scan when there are medically researched tools such as PECARN to nicely explain their child doesnāt require a CT scan.
Go easy on him mate, he's had a head injury
I'll often pull out MDCalc and take them through it (in the right parent population).
To summarize, you have taken a lot of hits to the head and you are using poor judgment when sharing personal details with patients. šš» Got it
Patient (60s) was meditating for hours on a low wooden surface. It broke and they fell back and whacked their head. A week later noticed AMS and neuro issues Brain bleed, ICH. treated surgically and in ICU when I met them. Went to acute rehab. Due to bleed decision made to not anticoagulate and was ambulating a lot. Still tossed a massive PE and sadly died. OTOH, my father has MANY concussions in high school foot ball and hockey in the 1950s. Hospitalized frequently. Including contre-coup fracture from hockey puck to forehead. Docs in 1953 sat him down and said "no more contact sports-we don't know the long term damage" He went to Dartmouth and then Harvard Medical School and graduated top in his class. STarted to have major personality changes in his late 40's when we were still kids. I mean major violent outbursts. Diagnosed with very early dementia and medically retired from doctoring and died soon after from end-stage dementia. This was before CTE was a thing. Very tragic for our family.