Spiders
2012; Elsevier BV; Volume: 59; Issue: 6 Linguagem: Inglês
10.1016/j.annemergmed.2011.10.009
ISSN1097-6760
Autores Tópico(s)Cardiac Arrhythmias and Treatments
Resumo[Ann Emerg Med. 2012;59:548.]I'd scoped her out before she even came back from the waiting room, actually. The place is a mess, and I've reached that point where I just want to discharge someone. Anyone. Anything to get the electronic tracking board down to just 2 screens, to reduce the problem to something I can wrap my brain around even if I can't solve it. I am in that discouraging place where I see 2 or 3 in a row, sit back down at my computer to do the “paperwork,” and while I'd been away, they've been multiplying. Sigh.I had been getting near what should have been the end of my shift, picking through the easy stuff, flipping them quickly, and I had come upon her.SPIDER BITE TO EAR. 70yo F.Smile. I absolutely love it. I've done this a while; I know this could be anything. It could be a spider bite, sure. Anything is possible. Maybe she saw the spider. Hell, maybe the spider is still in her ear. You can't get much better than that in terms of diagnostic accuracy. It's worth, like, 8 points on the TIMI score for spider bites. Better yet, maybe she's one of those people who are convinced the spider laid eggs under her skin and she believes that I will open the bump and little baby spiders will crawl out. This would be rewarding for us both, and maybe she'd let me take a picture of it to show to my incredulous friends. I bet I could get a publication out of the picture alone, and she'd probably never see an arachnid sci-fi flick again.Just as likely, this could be an anginal equivalent. She may well have been waiting for over an hour in the waiting room with her ischemia-presenting-as-spider-bite, and I'll have to hear about our department missing the ECG and cath lab benchmarks from my boss. I try to figure out under which circumstances an ECG should be done on people with ear complaints and spider bites. I am currently unaware of any practice standards, but I know there is a piece of paper for everything. I make a mental note to do a lit search on this later, so when I get that future call from Quality Assurance I'll have something to say.This could also be a high-up cervical radiculopathy, probably C2, or trauma from a human bite during a boxing match, or some ill-thought-out piercing debacle. I suppose anything is possible. And I'm absolutely positive I've seen PEs present with isolated ear symptoms, or at least heard about it in one of those terrifying CME lectures where someone talks about missing a PE presenting with a broken fingernail, resulting in the death of a young mother. I decide this is the second highest item on my differential. This is always the second highest item on my differential, regardless of the chief complaint.And it's possible, of course, and maybe even likely that this is some psychosocial disaster, with the ear being a happy coincidence. This woman may be demented or debilitated, cared for by someone who loves her but just can't do it anymore. Her steady decline may have dislodged her from all the moorings tying her in place in the world, the filaments thinning and snapping. The web of her life may be unraveling around her and there may be nowhere else for her to go. It happens. Life is beautiful and complex and ordered, except when it comes apart. Then it dumps you here.I sign up for her without reservation. It's probably just a simple cutaneous abscess, honestly. I should be able to get her out in 15 minutes. But if I can't, I know who to blame.Everybody blames the spider. [Ann Emerg Med. 2012;59:548.] I'd scoped her out before she even came back from the waiting room, actually. The place is a mess, and I've reached that point where I just want to discharge someone. Anyone. Anything to get the electronic tracking board down to just 2 screens, to reduce the problem to something I can wrap my brain around even if I can't solve it. I am in that discouraging place where I see 2 or 3 in a row, sit back down at my computer to do the “paperwork,” and while I'd been away, they've been multiplying. Sigh. I had been getting near what should have been the end of my shift, picking through the easy stuff, flipping them quickly, and I had come upon her. SPIDER BITE TO EAR. 70yo F. Smile. I absolutely love it. I've done this a while; I know this could be anything. It could be a spider bite, sure. Anything is possible. Maybe she saw the spider. Hell, maybe the spider is still in her ear. You can't get much better than that in terms of diagnostic accuracy. It's worth, like, 8 points on the TIMI score for spider bites. Better yet, maybe she's one of those people who are convinced the spider laid eggs under her skin and she believes that I will open the bump and little baby spiders will crawl out. This would be rewarding for us both, and maybe she'd let me take a picture of it to show to my incredulous friends. I bet I could get a publication out of the picture alone, and she'd probably never see an arachnid sci-fi flick again. Just as likely, this could be an anginal equivalent. She may well have been waiting for over an hour in the waiting room with her ischemia-presenting-as-spider-bite, and I'll have to hear about our department missing the ECG and cath lab benchmarks from my boss. I try to figure out under which circumstances an ECG should be done on people with ear complaints and spider bites. I am currently unaware of any practice standards, but I know there is a piece of paper for everything. I make a mental note to do a lit search on this later, so when I get that future call from Quality Assurance I'll have something to say. This could also be a high-up cervical radiculopathy, probably C2, or trauma from a human bite during a boxing match, or some ill-thought-out piercing debacle. I suppose anything is possible. And I'm absolutely positive I've seen PEs present with isolated ear symptoms, or at least heard about it in one of those terrifying CME lectures where someone talks about missing a PE presenting with a broken fingernail, resulting in the death of a young mother. I decide this is the second highest item on my differential. This is always the second highest item on my differential, regardless of the chief complaint. And it's possible, of course, and maybe even likely that this is some psychosocial disaster, with the ear being a happy coincidence. This woman may be demented or debilitated, cared for by someone who loves her but just can't do it anymore. Her steady decline may have dislodged her from all the moorings tying her in place in the world, the filaments thinning and snapping. The web of her life may be unraveling around her and there may be nowhere else for her to go. It happens. Life is beautiful and complex and ordered, except when it comes apart. Then it dumps you here. I sign up for her without reservation. It's probably just a simple cutaneous abscess, honestly. I should be able to get her out in 15 minutes. But if I can't, I know who to blame. Everybody blames the spider.
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