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Journal of the American Academy of Physician Assistants:
Mindful Practice

The fabric of freedom

Godfrey, Alexandra MS, PA‐C

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Alexandra Godfrey, MS, PA‐C, practices emergency medicine at St. Joseph's Mercy Hospital, Ypsilanti, Michigan. She is a member of the JAAPA editorial board.

My patient fell off his bicycle on a sunny summer afternoon. A 21‐year‐old college boy was riding to class when his bike hit a patch of gravel hidden in the shadows of the branches of a weeping willow. The bike tires lost friction, catapulting him into the road.

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The boy was not wearing a helmet. He preferred the breeze in his hair, the wind whipping his legs, and the spin spin of the wheels. His senses asserted his right to life, liberty, and happiness until the moment his head smacked the solid gray pavement. He lay motionless until a motorist moved him from the road, gently lifting him onto some grass. Later, the boy denied loss of consciousness, declaring he remained awake. He turned EMS away, texting his girlfriend instead. The boy's girlfriend arrived quickly, loading him into her car and bringing him to the hospital. He hobbled into the ER, complaining of head and back pain. By the time the triage nurse called, the boy had crumpled into an oversized wheelchair.

7 pm emergency department PA3 shift.

Chief complaint: fall.

Triage note: fall from bike; head and back pain: no focal deficits or LOC. Acuity 4.

I hear my patient groaning. His guttural sounds hold an element of something primeval. My skin prickles, and my gut tells me his pain cuts deep. I check the boy's vitals before walking into his room; sinus tachycardia at 123 bpm, normotensive, RR 18.

The boy is dressed in khaki shorts and a navy shirt decorated with the American flag. Blood spots bespeckle the stripes. I cut off his clothes and help him change into a gown. His injuries trouble me. His head took the brunt of the impact. His right eye bulges and glistens like the eye of a tree frog. His swollen, ecchymotic lids hint at fracture. I watch as a red stream trickles down his cheek from a ragged laceration above his brow, forming a deep, dark pool that lodges in the lower rim of the c‐collar clasping his neck; tufts of matted blonde hair spiked around the collar turn pale pink. The boy is conscious and gives me a clear history. He is unsure of the time of the accident. I suspect amnesia. I take a short history as I want to move quickly to my exam.

The boy is tough. He tries hard not to show his hurt to be strong for his girlfriend. His face is a mess. I palpate his facial bones carefully. My fingers press gently, noting step offs inferiorly and superiorly. I feel the crunch of crepitus and the bogginess of hematoma. I pry the swollen lids of his right eye apart and watch as his Crayola blue iris contracts: PERRL. His pupils match. His eyes follow the command of the otoscope beam: up, down, and across. I am satisfied his eye muscles are free from entrapment, but I see tears spilling over his right eyelid. I look to the left; no tears there. This isn't emotion.

I give the nurse a verbal order for IV pain meds. I check the boy's nose for septal hematoma and his ears for blood and fluid. Small pieces of grit nestle in his ear. His teeth look good. I count them all in. In my head questions spin: How is your vision? Is your face numb? Do your teeth fit together? Is there a bleed in your head? He passes the visual acuity test with his eye pried open. He opens then closes his jaw. His teeth align and his bite is strong. I move on.

The boy's back hurts. I roll him like a tree trunk, limbs tucked in, nerve roots protected. I palpate his spine working from thoracic to lumbar. He hurts in the thoracic midline. I see bruising and swelling. I suspect fracture. The road rash on his shoulders and flank causes him to flinch. He moves his extremities without difficulty. His abdomen is soft and nontender, and his breath sounds are equal bilaterally. I tell him I am concerned about facial fractures, head injury, spinal fracture. His eyes fill with tears. Gently, I take his hand. I reassure him that he is safe with us and young bodies mend well.

I order a CT of his head, face, neck, and thoracic spine. He does not meet the criteria for a Bravo trauma, but I let the charge nurse and my attending know about my patient's condition. The radiologist calls me with the CT results: T5 compression fracture with associated hematoma, displaced fracture superior right orbital floor of right anterior cranial fossa continuing superiorly to right frontal calvarium with small amount of intracranial air, small amount of epidural blood adjacent to the fracture site, displaced and comminuted fractures of the anterior inferior right orbital rim and anterior right maxillary sinus wall.

I call the trauma team and neurosurgery. We order CTs of his chest, abdomen, and pelvis. The boy remains on head injury and spinal precautions. Pan scanning is negative for further injuries. The boy rides to ICU with his back in a brace and head elevated to 30 degrees. The air is still. The sun has gone. The boy is restricted, vulnerable, and contained. His stars and stripes sit in the trash. I think about pulling it free but then decide freedom does not reside in the fabric of a shirt. I wonder: is the definition of freedom to do exactly as you want or is it to have some control? I question the cost of liberty. With good medical care, the boy will mend and hear the liberating spin spin of his bike wheels again. Next time, I hope he realizes that with freedom comes responsibility. Next time, I hope the boy wears a helmet.

© 2013 Lippincott Williams & Wilkins, Inc.

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