Massive Clusterfuck in 3...2...

Dear Doctor Mellowly:

I understand that things get busy in the ED at around nine on a Friday night. I also understand that the availability of Urdu translators is limited in this area.

Still, when you have a patient in her late eighties, with family members who can translate for you, present at your ED with excruciating neck pain, quadriparesis (weakness in all four limbs), a visible contusion on her head and one on her neck, and a history of fractures secondary to osteopenia (weakness of the bones), who fell at home, it might behoove you to do a c-spine (neck) X-ray.

Yes, yes, I know. The radiology department is busy with drunks and gunshot wounds. Still, consider doing an actual X-ray and not just a head CT. Because, you see, that would prevent you from sending your itty-bitty, fragile patient out to Sunnydale's neuro critical care unit in the middle of the night with a broken neck rather than with a stroke.

At least you were nice enough to give her an ice pack to relieve the pain from the hangman's fracture* that she had.

When she showed up in the Sunnydale NCCU, our nurse was bright enough to connect the weakness in all four limbs with the neck pain (as you failed to do) and order a c-spine. Which showed the chunk of bone floating freely in MeeMaw's spinal column. She also ordered a chest X-ray, going by that gut feeling that we nurses sometimes have, and discovered a high thoracic fracture as well.

MeeMaw, surprisingly, is fine. I transferred her this morning to the surgical CCU, where they put her in a pair of tongs that provided a few pounds of traction. I had given her ten of Decadron IV shortly before that, so the feeling in her hands and feet was beginning to come back when I left today. She's damned lucky that in the move from the ED bed to the ambulance cot, the fracture didn't take her life. And somehow, she managed not to be paralyzed over the forty miles of bumpy roads she had to ride to Sunnydale.

Seriously, dude? This was a colossal fuckup; a sentinel, never-event. And I put all the wheels in motion, along with my night-shift counterpart, to nail your ass to the wall. In fact, I recommended to my boss that he not call your hospital's risk management department to clue them in to what had happened: it was that serious.

I don't know if you were drunk on-shift (again) or what. What I *do* know is that, after misdiagnosing a rotator cuff tear, cervical myelopathy, appendicitis, and a broken neck as things that need to come to *my* unit as neurological emergencies, you deserve to be spanked.

*A "hangman's fracture" is a fracture of the part of the spine that connects your head to your neck. The usual mortality for such a critter is around 60%. As in immediate mortality; the figure rises if you include misdiagnoses from folks like Dr. Mellowly.