Socket to me

Working at the Juvie has allowed me to see a side of the world that my middle-class, straight- laced upbringing never allowed me to see. Not that I'm complaining, mind you, it has just amazed me how naive I really was (and still am, for the most part) when it came to the differences in healthcare among the incarcerated. I know, and I knew as a child, that if I needed to go to the ER for some reason, I would be taken seriously upon admission, and treated (or even over treated) for my complaint. For the kids I work with most of the week, that's not always the case. Last Friday morning, a detainee was brought into the clinic because he had been elbowed in the eye while playing basketball. When I first saw him, he had just returned from the ER, and had been diagnosed with a contusion (a fancy name for a bruise), given a script for Lortab, and had been told to "take it easy for the next few days," by the ER physician. His stay at the ER had been brief, no imaging had been performed, no lab work drawn, and his only complaint when I saw him was some bleeding from his nose, as well as pain in his upper molars. I performed a quick exam, and aside from some impressive swelling and bruising around that eye, everything appeared normal. I was a little confused as to why they didn't get an x-ray of his face, but since he wasn't complaining of much, and his vision was 20/20, we sent him back to his room, without gym privileges until I could see him again on Monday.

Monday came, and when he returned to the clinic, something didn't look right. The swelling around the lower part of the eye socket had increased, and now his sclera (the white part of the eye) had blood in it. In addition, he stated that the nose bleeds had started coming more frequently, and the pain in his molars had grown to encompass most of his upper jaw. I re-examined his eye socket, and since I was a little more suspicious this time around, really tried to feel some sort of boney deformity along the orbital ridge. Much to my surprise, I felt a small...outcropping, for lack of a better term on the lower portion of the socket. In addition, when I palpated his nasal bone, something felt off as well. At this point, I was getting increasingly frustrated with the care he had received in the ER. Now, I'm not saying that they didn't take good care of him because he was in Juvenile Detention, but it's not like that hasn't happened before. Anyway, I called one of my friends who's a pediatric resident, and after telling her about the situation, she agreed to see him at her next available appointment, which due to the holiday season, was first thing this morning.

To make a long story short, I received a call from her this afternoon stating that she had seen the detainee earlier today, and after confirming what I had told her with her own physical exam, had ordered an x-ray of his face. It was a little suspicious, so she went ahead and ordered a CT of his head. The radiology report came back:
1.) Blow-Out fracture of the inferior portion of the orbit
2.) Free air in the surrounding subcutaneous tissue
3.) Soft tissue infiltrate into the maxillary sinus.
Holy crap. So not only had he broken the bottom portion of his eye socket, but air had leaked into the surrounding tissue, and the fracture had forced some of that same tissue into the sinus above his jaw (thus explaining the nose bleeds and the jaw pain). He now has an appointment with Facial Plastics on Monday. The sickening thing is, any one of those conditions could have warranted an immediate ENT or Plastics consult. I'd like to say that everything will be fine, and that he'll recover without having to undergo surgery, but I think those odds are slim. I know that medicine is not perfect, and you all have heard me go off on how we often over utilize x-rays and lab tests, but this is one example where using those technologies could have been a great boon to the patient.

I tell you this story not to try and point fingers at the ER, or to make myself look cool or anything like that. I simply want to point out that we all are often guilty of taking one look at someone, and immediately judging them. Just because this kid is in Juvenile Detention doesn't mean that he can't get injured – we all get sick, sometime. We as physicians should strive to give the same quality of care to all patients, be they prisoners, homeless, or multimillionaires. Never forget, it’s about seeing and treating the person as a whole.

And now for the disability quote of the day:

Written response to the question, "Have you ever worked before? If yes, in what capacity."
"Job - Shirt Runner. I was a Shirt Runner at a pizza place."

If someone could enlighten me why pizza place's need their shirts...ran, I would appreciate it.

Look beyond the handcuffs,
-DD

PS, This will be the last post until 12/28/09. Have a Merry Christmas!