Shortcuts, humorously defined as the longest path between two points, can be dangerous in clinical medicine.

It was a busy afternoon in the emergency room, and I was hoping to get all my patients squared away in time to get to the Christmas party. I was doing well and the only loose end was a very intoxicated male in his early 30s who had presented, accompanied by two police officers, with a large through-and-through stab wound of his left forearm. His hygiene was poor and, despite the accompanying police officers, his attitude could best be described as belligerent bordering on assaultive. I had little interest in spending time with him, let alone attempting a history and examination, so I opted for what I hoped would be a quick and easy stalling tactic: I sent him down for an x-ray of his forearm, under the plausible pretense of ruling out a foreign body in his wound. In reality, I mostly wanted to give him time to sober up - and me time to socialize and enjoy some goodies at the Emergency Room Christmas party.

Ignoring the slight misgivings nagging at me, I hurried off to the ED lounge while the aide wheeled him (accompanied by the officers) to x-ray. I had been at the Christmas party barely long enough to decorate my plate with several cookies and a piece of cake when I was STAT paged to the x-ray department. With a sinking feeling (wondering if he had assauted someone) I called the x-ray department and spoke to the x-ray tech, Phyllis. 

Phyllis: “This guy with a stab wound,” she asked? “The film of the forearm looks fine. Do you want me to get a chest x-ray?”

Me: “Why would you get a chest x-ray?”

Phyllis: “His sucking chest wound.”

(She had taken off his shirt to do the film and saw what I should have looked for: evidence of another injury. Apparently he had put his left arm in font of his chest to protect himself and the assailant’s knife had slid neatly between both bones of his forearm and then penetrated his chest. A ‘sucking’ chest wound is a true emergency. Every time he inhaled, it ‘sucked’ some air in, progressively compressing the lungs. Untreated, it is often fatal.)

Me: “How’s his color? How’s his breathing? Vitals?”

Phyllis: “Not looking so good.”

Me: “On my way.”

That was it for the Christmas party. By the time I arrived in the x-ray department, he was in moderate respiratory distress. Oxygen, IV access, and a brief exam him were followed by placement of a chest tube to decompress the now minimally functional lungs. After he was stable and on his way to the floor (still accompanied by his friends in blue), I headed to the lounge. As I expected, the Christmas party was long over. I found only empty plates and crumbs. So much for the short cut.



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