It's Friday yet again, and here's another pearl from The Pitt.
Spoilers for the betting pool!
Several episodes ago, someone stole an ambulance that had been parked outside with the keys in the ignition (while there was good intent in "allowing someone to move it if needed", it was a violation of their EMS department policy). Since then, there's been a betting pool around who the perpetrator(s) are, how far the thieves would get before being stopped, and what condition the ambulance would be in. In episode 6, we get to see the results of the chase: two frat bros (sorry, one bro and one pledge) stole the ambo, decided they would take a joyride and have a merry police chase (the kind of classic mockery of Darwin that is so endemic to that demographic), and then crashed the ambulance into a tree. Tragically, that kind of impact vs a large stationary object means that this critical healthcare resource will be out of circulation. The frat bros are also injured, and are brought to the Pitt for care.
Of the two rapscallions, the pledge is in far worse condition than his senior (whose product-laden frosted tips look totally unruffled). Miles Hernandez, 18 years old, unrestrained (because of course), arrives to the ED with signs of injury to the right chest and left leg, shortness of breath with an O2 sat of 91% on ?L supplemental O2 via nasal cannula, HR 120s, BP 100s/70s. Miles exhibits easily-audible wheezing when he tries to speak, with diffuse high-pitched breath sounds on lung auscultation. Dr. Robby quickly notices that the head of Miles's right clavicle is centrally depressed, raising concern for a posterior sternoclavicular dislocation, which could compress the trachea and explain his dyspnea. The dislocation is reduced with local anesthesia and a towel clamp, with immediate improvement in Miles's vocal quality and respiratory symptoms.
A quick anatomy review — the clavicle (or "collarbone") is the bone that connects the scapula to the sternum to form the shoulder girdle. Its name comes from the Latin diminutive clavicula ("little key"), so called due to its shape and manner of articulation. The two joints of the clavicle are the sternoclavicular joint and the acromioclavicular joint, with dislocations of the latter being far more common than the former. AC dislocations classically occur in younger males playing contact sports, but can occur due to any trauma to the shoulder/extremity. Depending on the degree of injury, a high-riding/elevated clavicle might be visible/palpable on exam. The Rockwood classification of AC injuries is based primarily on the involvement of the acromioclavicular and coracoclavicular ligament complexes, with the combination of exam and radiographic findings being sufficient for determination. Type 1 and 2 injuries are usually managed nonoperatively w/ sling and orthopedics follow-up, Type 3 and up require a consult for OR reduction/stabilization (with some stable type 3 variants being eligible for nonoperative management). Complications of AC dislocation typically comprise pain and loss of function.
Sternoclavicular (SC) dislocations also occur with trauma (or hypermobility disorders) and are considered high-energy injuries. The shape of the articular surface is inherently unstable, relying on ligamentous complexes to aid in stability. Anterior dislocation results from lateral compression on the shoulder girdle resulting in rupture of the anterior joint capsule; this causes pain and a visible/palpable bump over the SC joint. The posterior joint capsule is stronger and less prone to rupture, but a posterior dislocation still may result from direct force over the anteromedial clavicle or from indirect force to the posterolateral shoulder; symptoms of compression to the airway, nerves, vessels, or esophagus may occur, and may require urgent reduction. Anterior SC dislocation can be reduced at beside with direct pressure while the ipsilateral arm is abducted 90 degrees, but the rate of recurrence in absence of ligament reconstruction is high; and with the low mechanical impact of this type of dislocation, reduction may not be needed if pain is controlled. Posterior dislocations can be reduced with the towel clip method demonstrate in The Pitt, or with the application of extension force to the abducted tractioned shoulder.
It is also possible to have a "bipolar clavicular dislocation" where both the SC and AC joints are disrupted. In the less than 50 known cases, all involved high-energy blunt trauma and all but 1 had anterior SC dislocation.
Other little lessons from episode 6:
Remember the ABCD's of ED efficiency — Always Be Constantly Dispo'ing! Getting patients out of the ED as soon as medically stable is the best tthat we can do as ED staff to address ED overcrowding.
Dr. Shamsi (surgery bigwig) demonstrates the psoas sign in appendicitis by having the patient flex his hip against resistance. The more orthodox method described by Sir Cope in 1921 involves passive extension of the patient's right hip with them lying on their left side. The test is fairly specific for appendicitis, but not sensitive (i.e. positive test rules in, but negative test does not rule out). See this article for more information.
If holding sharps: keep a tight grip and move slowly and deliberately.
Sometimes, ignorance is bliss. When giving bad news (like dead tapeworm eggs in someone's brain), ease them into it with SPIKES.
When Mel was FaceTiming her sister in the ambulance access road, I was so worried that she would get hit by an ambulance. When walking to and from the hospital, please be mindful that the laws of physics trump any laws of man. The intersection of 48th St. × 10th Ave. is especially bad with drivers running the stop signs.
Have an amazing weekend!
References:
https://www.tandfonline.com/doi/full/10.2147/ORR.S218991
https://pmc.ncbi.nlm.nih.gov/articles/PMC4832225/
https://pmc.ncbi.nlm.nih.gov/articles/PMC5174051/
https://pmc.ncbi.nlm.nih.gov/articles/PMC6435864