Wednesday, June 09, 2010


WNL is doctor shorthand for "within normal limits". Saves a bunch of time when checking the boxes on the physical exam. The temptation is to write "WNL" whenever possible, and, therefore, it often ends up meaning "We Never Looked".

A homeless gentleman presented to my ER a few months ago. He had been hit in the head with a beer bottle. He had a suturable laceration to his scalp to prove it. He was in a lot of pain, but it was his neck  (not his forehead) that hurt him.

We spent hours with this guy, we XRay'ed and CT scanned and MRI'ed and to no avail. I pulled in a few other docs to help. We had zilch, zero, nada to go on except muscle spasm or toricollis and that's what we ended up calling it.

Two days later a friend, also an ER doc, came up to me and said, "Hey, did you take care of homeless guy X the other day?" This question will stop any ER doc in his tracks because the next thing you are about to hear is inevitably bad news.

"Yes," I said, "Why, what happened?"

"He came back last night, altered, and with a fever. I tapped him and he had meningitis... He died."

Shit. I never looked. The case went before the hospital quality control committee and I was found blameless and there was never a law suit. Cold comfort. But even with the famous retrospectoscope I would not have done anything differently. No fever, no headache, no alteration in mental status upon initial presentation... simply a hit on the head with a beer bottle and a laceration.

Occam's razor failed me here, and, ultimately, this is, in large part, why getting care in the ER is expensive. It may be true that your 'heartburn' is simply that, but could it possibly be your impending heart attack? Yes, it could, and I am going to look.


  1. That is unfortunate. Yesterday when I was working my shift at the ER one of the other doctors was telling me this story that when they discharged a patient who was wheel chair bound he "became lost" as he tried to make his way home and his wheel chair. They found him the next day as cold and stiff as ice sitting in his wheel chair 1 block away from the hospital. Apparently he had a stroke on his way back home.....So yea....

  2. Tragic as this is, we sometimes lose sight of the fact that sometimes stuff just happens. Despite protocols, training, experience etc, every once in a while we are unable to prolong the inevitable.

    Regrettable as it is, it happens. As much as you hated the outcome of this event, he presented no symptoms or complaint of what killed him, other than the pain. Pain which is not uncommon when one gets clobbered with a beer bottle.

    Rest easy Doc, stuff happens.

    Just as I finished typing this, one question came to mind. Did anyone ask him if the neck pain was present before getting popped?

    Thanks for the post.

  3. dear captain schmoe,
    as i recall the patient was schizophrenic and drunk and that part of the history was, to say the least, unclear.

  4. Sorry 911. It still sucks. But you can't do everything. I always love the people who are so pissed and they want someone to blame so the *always* blame the doctors and nurses. Seriously, sometimes crap just happens. To all of us. And doctors aren't the omnipotent all seeing Alpha and Omega, so stuff isn't perfect. Ever.

  5. Man, that really sucks. Do you think the outcome of the quality control committee's meeting would have been different if the patient hadn't been homeless and perhaps had someone there? I agree with their decision, but if some nagging family member had been there, is it likely that there would have been a lawsuit to appease them regardless of what did or did not happen?

  6. What does MDOD stand for?

  7. For some reason my dispatch center seems to think I am the only guy in town who is to be sent on calls with the homeless.

    I can't count how many calls I have been on where the initial assessment was no where near the actual condition. But I have learned one thing for sure.

    When someone who probly abused their body for most of a lifetime didn't present the way the book said he would?
    Say it ain't so.

  8. caryn,
    quality control is completely internal, so no to the first question. as to the law suit question, anyone can sue anyone else for anything at any time. the question is if they can win or not. sure, it's more likely if the patient had family that i would have been sued, but the suit would have been defended successfully as there was no negligence inolved, simply lightning striking twice in the same place.

  9. He shoulda sued whoever it was who "Altered" him....

  10. Thanks for the explanation, 911Doc!

  11. Hey 911Doc, i kind of stopped reading the ER blogs when I got out of the game myself, but I was feeling nostalgic so just stopped by to check in. Glad to see you're still blogging away.

    Sorry about your patient though, sad story. Doesn't sound like there was much you could have done differently though.

    - Amy @ HallwayFour

  12. hey Amy,
    thanks for stopping by. i'm curious... are you out of the ER too? if not, how are you holding up?


  13. Sorry to hear about that, but glad to hear you are not beating yourself up about it. Keep up the good work, its always interesting to read what Drs in other countries get up to!