The Elias sign (or, not a leg to stand on)

At morning work rounds the attending suggested we start with a patient I had seen and admitted through the Emergency Room the night before. He had reviewed my admission note and thought the group would be interested in this patient who demonstrated some of the problems of dehydration in the elderly,  But he also wanted me to demonstrate to the group an interesting physical finding I had noted in my admission write up. 

I was a third year medical student in Rochester, NY.  I generally enjoyed my ED rotation because it afforded an exposure to a wide range of medical and surgical problems, and because the interns and nurses were always willing to teach any medical student who showed an interest in learning - and helping. My eagerness sometimes got me in over my head. This particular night had been very busy and I had done an extra admission to help out. My two admissions were frail old men with vomiting, diarrhea and dehydration, roommates at a local nursing home experiencing an outbreak of a viral gastroenteritis. They both came in to the ED around 10 pm, had thick charts and complicated histories, and by the time I had finished doing my evaluations, discussing them with the intern, and writing orders, it was 3 am. I decided to catch a couple hours of sleep before I wrote my notes between 7 and 8, when work rounds were scheduled to begin. Which is what I did. Bad idea.

New physical finding? I racked my brain, but could recall nothing unusual about their exams. On the way to the floor and during our hallway discussion of fluid resuscitation and electrolyte management, I was distracted and barely noticed that the attending praised my management. Then he handed me the chart, and said we would proceed to the bedside so I could demonstrate the ‘newly discovered Elias sign.’ Holding the chart and still clueless, I led the group to the bedside, at which point he smiled and handed me a reflex hammer. With a straight face he asked,  ‘Why don’t you demonstrate his interesting lower extremity reflexes?’ 

One of the patients had had bilateral above the knee amputations; the other had not. It was now painfully obvious that I had confused the two in my written notes. For the remainder of my time in Rochester, he never missed an opportunity to refer to me (with a smile or wink that took some of the sting out) as the first to report the ‘Elias sign.’ 

Lesson learned. Documentation delayed is damaged and can be dangerous.



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