Just an examples or two of something I have come to learn to be true from my short time in the ED. Distracting injuries distract.
Example 1: The first time I was exposed to this mantra, a young man was grinding a rail on his skateboard, fell, doing the proverbial “nutcracker” landing on the railing, and came to the ED with a lacerated scrotum. I was all worried about his grapes and the gaping hole in his scrotum and failed to consider that he might have other less obvious injuries. My attending did not fail in this regard and we found on x-ray that he had also fractured his pelvis. I was so locked in on the obvious injuries that I didn’t think about other injuries that might have occurred. Point noted.
Example 2: Gentlemen comes in with reports of two episodes of BRBPR (bright red blood per rectum, ie bloody stools) that day. Pressure found to be 80/40, tachy to the 130’s. The obvious thing to do is to resuscitate him with fluids, which we did. 2 liters of saline later, his pressure only ticked up about 5 points, another 2 L later and he was looking better 110/60, HR 110. Ten minutes later he was back to 80’s over 40’s. Rather than just slam more fluids into him, I literally said to myself, am I being distracted by the reports of BRBPR, is there another reason for him to be hypotensive other than blood loss? He got two more L’s regardless, but I also added a bunch of sepsis labs into the mix. Sure enough, his hemoglobin came back as 12 (pretty much normal), but he had a white count of 22 (very high, a marker of infection), and his blood gas came back with a pH of 7.14 (very acidotic ). I left before his lactate came back, but before I did leave, he was to the point where I had started him on antibiotics and was setting up for a central line. Point being, missing the boat on example 1, let me catch it on example 2, and hopefully again in the future.