A grandfather brings in his 14 year old grandson because the boy hurt his wrist … for the second time in two days. The first time he was brought to the emergency department, x-rayed, and was diagnosed with a Salter Harris Type I fracture. He was put in a splint and sent home.
This time, he was wearing the splint, fell while walking, and had more pain in his wrist. There wasn’t really any point tenderness or deformity on his exam, so I explained that we weren’t going to change the management and we didn’t need to repeat an x-ray because even if there was a small fracture, he was already in a splint.
The grandfather argued with me for several minutes because he felt the patient needed an x-ray to make sure there was no fracture. I finally got fed up trying to reason with him realized that my diagnostic skills leave something to be desired and just ordered an x-ray.
The patient and grandfather had to wait another hour to get through the line waiting for x-rays.
After the x-ray came back as normal … like I was saying, he’s already in a splint, so we aren’t going to change the management. Continue taking the ibuprofen and see the orthopedist for follow up.
“He wants a cast on his arm,” remarked Grandpa.
“I beg your pardon …”
“You need to put a cast on his arm. He wants a cast.”
“No. Sorry. We don’t put casts on in the emergency department. He has a splint to protect his wrist from injury. You need to see the orthopedist for follow up and he’ll decide whether he wants to put on a cast. That’s not something we do here.”
Then the patient chimes in.
“I want a cast NOW!”
“We don’t put casts on in the emergency department. Your arm will be protected until you see the orthopedist. The nurse has your discharge papers.”
“I’m not leaving without a cast!”
“Why do you want a cast?”
“I just DO. I want a cast NOW!”
“I’m not going to argue with you. We don’t put casts on in the emergency department and you aren’t going to get a cast put on today. It’s time for you go home now. Have a nice day.”
I left and went to see another patient, hoping that the patient would be gone by the time I was done.
Ten minutes later, I walked out of the other patient’s room to see that this kid had backed himself into a corner by the exit door, was holding onto a wheelchair, and was loudly stating “I … want … a CAAAAST!”
We called security.
Several security guards then lifted the patient onto the wheelchair and wheeled the patient out to the front of the hospital. The grandfather went to pull the car up to the door.
Then the patient jumped out of the wheelchair and started running down the street.
Grandpa pulled up in the car, rolled down his window and said “I’m not dealing with him when he’s like this. He gets out of control. You’re going to have to call the police and transfer him to a psychiatric hospital.”
The police had already been called and apprehended the patient a block away. He punched one of the officers, was put in handcuffs, and tried to bite another officer. Guess where he ended up.
Back in the emergency department – psych room.
There, the patient threatened to kill himself and everyone else in the room. He was dropping F-bombs left and right and was trying to hit and bite the staff. It didn’t take long for the patient to be put in four point restraints, and then to receive 5mg Haldol and 2mg Ativan. Funny that he didn’t complain of his wrist hurting any more.
Six hours later, we still weren’t able to find a psychiatric hospital willing to accept a violent child. Either they only took adults or they didn’t accept violent patients. The grandfather wanted to leave, but was told that he needed to stay with the patient since he was a minor.
During one of the times I went in and re-examined the patient, the grandfather looked at me and sneered “None of this would have happened if you just put on the cast like he wanted.”
I just smiled. After all, Grandpa would soon be receiving a survey to rate my clinical competence in the care of his grandchild and I do want to receive all “excellent” scores, you know.
Saddest part of the whole encounter was that one of the phlebotomists used to babysit the patient when he was younger. She said that the patient was normal until he started being put on psychiatric medications for attention deficit disorder. Now he was on four psychiatric medications and had been in and out of psychiatric hospitals for emotional outbursts such as this one.
But at least he was able to focus his attention.