Asking for help from a resident

I saw a patient in the Emergency Department last night (while working with my Foundations of Doctoring preceptor Dr. Browne) who hit his head while falling due to a witnessed tonic-clonic seizure.

It came out in the interview that he has been homeless for 2 months, has been abusing alcohol and marijuana for the same amount of time, and had been sober from both for 5 years before that. In addition to hitting his head, he was complaining of left shoulder pain, right wrist pain, and right knee pain such that he couldn't bear any weight on that leg. His past medical history was also significant for a very serious car accident a few years ago that required surgery on his left eye and left leg.

On physical exam, I didn't notice any head lacerations or bruising (around the eyes or behind the ears) that would have indicated a more serious problem. I noticed that his left eyelid was drooping noticeably (ptosis). Both pupils reacted appropriately when I shone a light in his eyes, but I couldn't reliably compare the size of one pupil to the other. I could passively move his left arm only slightly before causing him pain; he could turn his head to the left and right against resistance, but he couldn't shrug his left shoulder.

During the course of the interview and physical exam, I noticed that my patient became less responsive to my questions. He could hardly keep his eyes open, but he was also not confused, and he was able to follow commands. I became very concerned when he asked me if it was alright if he went to sleep. "Try to keep your eyes open," I said, and after thinking about it for a moment, I decided to go get help.

I interrupted two residents who were talking about another patient and very succinctly described my patient and concerns. They rushed into my patient's room, talked with him briefly, and decided to order a head CT.

The CT came back negative, and the toxicology screen came back positive. The bump on his head wasn't serious; he just needed to sober up. The drooping left eyelid was most likely caused by the car accident a few years ago.

After the excitement was over, I asked my resident if he thought it was appropriate that I asked for his help in this situation. "Absolutely, you did the right thing," he said. The patient didn't smell like alcohol, so in the absence of the toxicology screen we had no way to know what was causing his neurological changes. It's better to err on the side of safety, he said, than to let something important slip by us unheeded.

What I've heard many times over is that the good third-year medical student is a strong advocate for his or her patients and will be appropriately aggressive in that advocacy when it's necessary. It was difficult to interrupt those residents, but I felt that it was necessary to ask their opinion in this case. It was also pretty neat to see how my input directly impacted this patient's care.

I expect that third year will hold many more situations similar to this one.