PDA

View Full Version : Knee and head sports injury - how would you treat?



bylinebree
01-22-2010, 07:52 AM
Hey guys (not inferring gender : )

Character gets clocked on rugby sidelines (he's a coach) and hurts knee, seems to have a concussion. Friend takes him to the ER, then to the Acute Care clinic. A nurse practitioner treats him, and the scene is in her POV so it will be more clinical. He's nauseated enough to feel like hurling, too.

What would be her protocol? Head injury first? Would they ice the knee there? What scans would be ordered for each injury? Would an anti-nausea med be given with a head injury? (it's a moderate concussion)

I've experience as a sports-parent with these things, but would like a med person's perspective.

Thanks all!

Ms Hollands
01-22-2010, 01:20 PM
Hah! I managed to kick myself in the head with my own snowboard (inverted my knee cap apparently). I knocked myself out for a short time in the process (only seconds I think). Massive pain in knee meant I didn't notice that I'd slit open my forehead. I realised when blood started pumping into my goggles.

The ambulance lady dealt solely with the bleeding. She helped me walk, but didn't look at my ski-pants covered knee at all.

At the doctors' surgery, it turned out I'd hit an artery and the doctor couldn't stop the bleeding so she didn't wait for the injection to number the area to kick in: she just went and stitched me straight away. I was in shock, so it wasn't so bad.

She told me to come back the next day about my knee because they already had a queue of people waiting for scans! She didn't even look at it.

I think this is the exception to the rule though...turns out I'd torn two ligaments and stretched my cruciad so that it was beyond repair, like stretched elastic. They made me walk to the bank to get money out to pay then and there before I could limp away.

Sorry it's not the medical point of view, but hopefully someone will be along shortly with a more accurate perspective from that side.

CarolSanDiego
01-22-2010, 11:21 PM
You might want to check Mayo Clinic's website - they do a great job of summarizing everything from signs and symptoms right through to treatment for most any condition.

Unless there was a life or limb threatening injury with the knee (like April's severe bleeding) the head injury would absolutely take priority. The NP would look for things like pupil reactiveness (shining a penlight into the eyes to make sure the pupils constrict), reflexes, probably some balance and coordination stuff (similar to DUI tests - finger to nose, stand on one leg) and the Mini-Mental Exam. You can google that, too - it's usually abbreviated at first - asking things like the person's name, the date, where they are, what happened to them and why they are in the ER or urgent care center, what they had for breakfast - crazy how someone can seem perfectly normal but then you start detecting small bits of memory missing when you ask these sorts of questions. They might possibly do a CT scan - vomiting is one of the symptoms that often means a CT scan is needed. They'd probably also screen the neck - head and neck injuries often go hand in hand. Range of motion (rotation to both sides, flexion, extension), asking about any symptoms of pain, numbness, tingling...

As for the knee- in an acute care setting, an orthopedic MD probably won't be present. They might just look at general range of motion, maybe palpate around a bit, probably order and X-ray. Probably put ice on it. Again, this is the lesser priority immediately following the injury.

(BTW, I'm a Physical Therapist who has worked in several settings, and has also worked as the first responder on the sidelines in football games)

bylinebree
01-24-2010, 02:55 AM
April - Geez, that sounds rough. My kid snapped her ACL and tore a meniscus in last yr of HS basketball - not fun!

ToddW and CarolSan - Thanks for the input. I've looked at each injury separately, but was wondering if they'd offer an anti-nausea med with a concussion? Or would that be too dangerous? It's part of "snappy dialogue" between the heroine (nurse-pract) and hero (coach) in their first scene.

When my other daughter had a kidney stone, they jabbed her with Demerol for pain...but it sure wasn't in her head.

Anyone else have wisdom to share?

Tsu Dho Nimh
01-25-2010, 12:48 AM
Hey guys (not inferring gender : )
Character gets clocked on rugby sidelines (he's a coach) and hurts knee, seems to have a concussion. Friend takes him to the ER, then to the Acute Care clinic. !

With a head injury so bad he is nauseated, he shouldn't leave the ER to go to acute care. Why do you have him going there if he's already been to ER? Unless of course, the nausea develops after the ER turned him loose.

The knee would definitely take second priority ... he'd be evaluated for the head damage first, although the knee would get iced down and maybe splinted to minimize damage until it is taken care of.

1 - did he ever lose consciousness
2 - are his reflexes equal
3 - Are his eyes responding appropriately to light
4 - personality changes?
5 - nausea, vomiting, headache?

What do you want to happen to him? I can tell you what findings would get him admitted or released, ot released "AMA" (Against Medical Advice)

I've evaluated a lot of head injuries, and "snappy dialog" when the victim is nauseated usually consists of "Here's, use this if you need to throw up", and other stellar phrases like "Look at my left ear, not the light", "Please squeeze with both hands".

bylinebree
01-25-2010, 11:33 PM
Yours in reg font, mine in bold:
With a head injury so bad he is nauseated, he shouldn't leave the ER to go to acute care. Why do you have him going there if he's already been to ER? Unless of course, the nausea develops after the ER turned him loose. -- He goes to acute care because it's an option when the ER is packed (it's in the same bldg); this is where the NP (heroine) is working, covering for the day temporarily as part of her job -- and he becomes her patient. It's a small hospital/clinic.
...
1 - did he ever lose consciousness - YES, but only a few seconds when the hit occurred.
2 - are his reflexes equal - YES
3 - Are his eyes responding appropriately to light - YES
4 - personality changes? - SHE doesn't know him, he flirts with her until he starts to feel really nauseated; she offers him a basin and stays until the rad tech comes for him.
5 - nausea, vomiting, headache? YES - NO (He doesn't vomit, though that would be a real romantic meeting, wouldn't it? : ) - YES, plus he has a shallow laceration on the side of his head that's bleeding and needs a couple of stitches.

What do you want to happen to him? When he returns from x-ray (or a scan? tell me), he's been retching but still hasn't thrown up. He's conscious and will be released to his brother to go home, where there are people who will help him. Would she (NP) offer an anti-nausea med for him, or due to the head injury -- not at all? When he complains about either a shot or pill, she wryly offers a suppository form of the med. BUT I understand that, with head injury, she might not be authorized to treat him further, just do an initial eval. then refer him to an MD - or would one come right then to further examine him?
I can tell you what findings would get him admitted or released, ot released "AMA" (Against Medical Advice) - this isn't the case here.
I've evaluated a lot of head injuries, and "snappy dialog" when the victim is nauseated usually consists of "Here's, use this if you need to throw up", and other stellar phrases like "Look at my left ear, not the light", "Please squeeze with both hands". HA - yes, she does this, summarized as she "completed a neuro screen/exam" on him. He's feisty and strong-willed, so he still attempts to ask her out during all this (though later he doesn't really recall this part)

She thinks he's funny but chalks his flirting up to a bonk on the head. What do you think of the medical part of the scenario - does it work? And thanks!

Tsu Dho Nimh
01-26-2010, 04:00 AM
If he's nauseated, she's going to immediately escalate his care to whoever is qualified to evaluate and treat head injuries. Nausea is an early sign of deteriorating condition after a head injury.

The ER docs, who should not have referred a head injury patient to her in the first place, would get back in the picture and order an MRI or CAT scan.

He's not going to be released to the care of anyone - unless he signs out AMA - until he's been kept under observation for a while because of the possibility of a small internal bleed that can suddenly go bad.

http://health.nytimes.com/health/guides/disease/subdural-hematoma/overview.html

********
Adding: If he's "perseverating" ... repeatedly asking her out, repeating the same flirty phrases as if he doesn't remember having said it a few moments earlier .... he's definitely going to be admitted because it's a strong indicator of brain injury.

She thinks he's funny but chalks his flirting up to a bonk on the head. Not medically realistic, given that aberrant behavior is a symptom of a possible subdural hematoma.

If I thought someone's behavior - funny or not - was due to having their bells rung, I'd make darned sure they were admitted for observation.

bylinebree
01-26-2010, 02:31 PM
Hmmm. Goodness. I don't want this to be a heavy major injury scene, so NO subdural hematoma! I'll take out the nausea part - don't need it for the plot/action. He can have a laceration on his head without staying for a long observation, if he has no other symptoms and his scans are clear - can't he? And a sprained knee. Period.

So, how's this?? --> AFTER he's seen by ER docs and they nix the head injury (just a cut) - she comes in to stitch him up and treat the knee, write an RX for pain/swelling and get him released. It will NOT be "AMA." He's not perseverating...and she is a serious medical professional.

As to the romance...well. If I trust you for guidance in the medical scene, I'll ask you to trust me for the romantic-aspect that develops out of this encounter - later in the story, okay?

Thanks for any more ideas you may have, TDN!

sheadakota
01-26-2010, 03:31 PM
...and she is a serious medical professional.

As to the romance...well. If I trust you for guidance in the medical scene, I'll ask you to trust me for the romantic-aspect that develops out of this encounter - later in the story, okay?

Thanks for any more ideas you may have, TDN!

Just my 2 cents- If she is a serious medical proffesional- it would be highly unlikely for her to respond to his flirting in a medical setting- not to mention unethical- I trust you on the romantic front-
But I think I would move any serious flirting to outside the medical arena.
I can't tell you how many guys have flirted with me over the years (I'm a nurse) I never took any of them serious and thought most of them (other than the harmless ones) were creepy-
I would never take a patient flirting with me seriously-

boron
01-26-2010, 04:34 PM
Bylinebriee,

this is about to happen in the US?

Not sure who is allowed to do what in US, but in reallity (in Europe):

1. Comming to a clinic, the first contact is with a nurse, who asks what happened, takes personal data (name, age..), asks about insurance, and judges, if the man needs to be checked immediately, or he can wait (there's usually some queewe). If it's a crawded clinic, this nurse stays there and accepts other patients and does not follow the man.

2. When he's invited to step into the ambulance, another nurse tells him to undress partly, checks his pulse and measures his blood pressure. She may ask again what happened. She may clean his head wound and cover it with a gauze. This is pretty much all what a nurse can do and then a doctor (a specialist, someone experienced, working there for some time already) takes him.

3. A doctor asks the man if he can recall what has happened and when, did he hit the ground with the head, asks about head and neck pain, nausea, blurred vision, unusual sounds, tingling/numbness anywhere in the body, ability to move all limbs. This takes 1-2 mins.

4. After that, the doctor asks the man to undress (keeps underpants) and performs a body examination. He checks if pupil sizes are equal and how they react to direct light, checks ears, nose, mouth, throat for eventual bleeding. He carefully checks his head for eventual bone fractures. If he suspects fracture, he asks the nurse to arrange an X-ray. If fracture is not likely, but brain damage is suspected, he asks nurse to arrange CT or MRI of the head. None of these investigations are mandatory; it depends on symptoms. The doctor listens man's heart with a stethoscope. Checks abdomen for eventual painful spots. Inspects all over his skin for injuries. Checks coordination (finger-to-nose), reflexes in elbows and knees, strenght in limbs, asks him to close eyes and asks if he feels something while touching his face, arms, legs with a gauze (checking sensitivity). Checks his knee and gives diagnosis - is it sprained, fractured, disclocated...All this may take 15-30 mins.

5. This or another doctor makes stitches to his head wound and the nurse (they are usually more nurses there) assists him - offers disinfection liquid, scalpel, scisors, needle...This part takes about 15 mins.

6. On the end of this procedure one of the nurses takes records of all what the patient has said and what was done and found - as doctor dictates her.

7. If CT/MRI is available immediately, one nurse goes with the man to a special room (may be at some distance place within a clinic or even another clinic). After CT/MRI they - the man and the nurse - come back to the first doctor, and the nurse gives the doctor imaging results. If results are OK, the doctor decides if the man can be released - the man probably signs up something.

8. The knee injury is treated by an orthopedist later that day. Aspirating fluid from the knee or a splint might be needed, probably painkillers.

9. It's not the nurse who asks if he needs some medication, but the nurse gives medication if ordered by the doctor. The nurse does not make stitches. Stitches will need to be removed after few days at the same place or by man's personal doctor.

10. I need a native English speaking doctor to proofread my health articles.

CarolSanDiego
01-27-2010, 12:23 AM
Just my 2 cents- If she is a serious medical proffesional- it would be highly unlikely for her to respond to his flirting in a medical setting- not to mention unethical- I trust you on the romantic front-
But I think I would move any serious flirting to outside the medical arena.
I can't tell you how many guys have flirted with me over the years (I'm a nurse) I never took any of them serious and thought most of them (other than the harmless ones) were creepy-
I would never take a patient flirting with me seriously-

What Sheadakota said. I'm a PT and have had plenty of guys flirting with me, too, and I don't usually take them seriously. Honestly, it's more of an irritant, because it makes the personal nature of what I must do in my job uncomfortable, no matter how attractive the patient may be. And, ditto, too, that it would be extremely unethical for any flirting whatsoever to go on in the workplace - not to say it never happens, but really, it's not only unethical but many facilities have laws against this sort of thing. It's just asking for trouble.

bylinebree
01-27-2010, 12:20 PM
No, no, she doesn't flirt BACK in the medical setting - she treats him exactly like what he is: a patient.

She's been hit-on before, she's aware and stays professional with him. But she's also human and observes he's nice-looking (its her POV). He's not "creepy." He teases and compliments her - she jokes back to distract him while she's stitching him up.

She's doesn't expect to see him again. But of course, fate intervenes and she does.

(Boron, yes - story is in America not overseas. Here there are Nurse Practitioners who can do complete physical exams, prescribe medications and do many other things. They can stitch up lacerations, and handle cases such as sports injuries and illnesses in depth -- not simply assist physicians. )

Hope that helps. I'll try very hard to write the medical aspects realistically, but there won't be tons of detail. That would slow it down.

Thanks for the great advice on this!

Tsu Dho Nimh
01-28-2010, 09:47 PM
He can have a laceration on his head without staying for a long observation, if he has no other symptoms and his scans are clear - can't he? And a sprained knee. Period.

Definitely - and if he didn't lose consciousness, they may skip the head scans and send him home after stitching him up. We first-aided and shipped out a guy with a 4-inch gash on his head, and all the docs did was stitch it and send him onward.


So, how's this?? --> AFTER he's seen by ER docs and they nix the head injury (just a cut) - she comes in to stitch him up and treat the knee, write an RX for pain/swelling and get him released.

It's hard to evaluate a knee injury for a couple of days, unless it's really bad, and then he'd be unable to put weight on it. The usual "prescription" for knee sprains is RICE (Rest, Ice, Compression, Elevation) ... send them home to prop up the knee with an ice pack to minimize swelling, kick back and watch telly for a while. Take some ibuprophen for the pain if needed, and that's all.

I'm a ski patroller, so I see lots of minor stuff. We splint some injured knees mostly to remind the victim to avoid using them, and to hold it stable during the ride down the mountain to a real doc.