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Emergentology: The Perspective from the Other Side

Walker, Graham MD

doi: 10.1097/01.EEM.0000434483.34525.5b

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT, a number-needed-to-treat tool to communicate benefit and harm.





I'd like to recommend that everyone bite it really hard on some subway stairs. It's been the best thing to happen to me in a while.

There I was, completely sober, on my iPhone, walking down the subway stairs in New York. I missed a step, and down I went onto an inverted ankle. I felt a crunch, and stood back up. I started to vagal about five seconds later. I told myself, “Oh, no, Graham, you're not about to be that guy” (especially considering that EMS would take me to the hospital where I trained). I sat down for a few minutes, decided I had some point tenderness, and hobbled over for an x-ray. Negative.

The next week was a visit to podiatry, where my anterior talo-fibular ligament was declared to be ruptured. I was given a few-month trajectory of my ankle progress that ended with, “Yeah, you're going to feel it for six months, but you should heal up pretty well.”

Last week, physical therapy cleared me of using my ankle support wrap, and gave me some stretching, strengthening, and balance exercises. All of this has been a nice reminder of what it's like to be on the other side of the stretcher as a patient, and has really been great at motivating me to rehab and get more active.

Holy cow is emergency care expensive. My level 3 visit — x-ray, ibuprofen, ice — was a cool $2500 for the hospital charges only. Think of this the next time your uninsured patient comes in for something that seems relatively minor or straightforward. Is the lab work, x-ray, or CT scan really worth wiping out the poor guy's bank account? I'm not going to turn this column into a primer on health care economics, I certainly understand the reasons the bill was $2500, and I know the insured doesn't actually pay that amount, but still, it's worth remembering the insane degree to which our services and care are marked up for something as straightforward as a rolled ankle.

The Aircast should be the ankle sprain standard of care. I'd read good things about Aircasts compared with wraps, ice, and elevation, but I never had them to give away in an emergency department. “Here's your ibuprofen, a wrap, and a bag of ice (or occasionally crutches). Good luck.” The Aircast costs $20-30, has air padding the medial and lateral aspects of the foot and ankle, up to the lower third of your calf. It's held together with a strap that goes under your heel, and then Velcro holds the sides together. The end effect allows dorsiflexion and plantar flexion of your ankle but prevents any eversion or inversion, exactly what you need when you've injured one of the ligaments that support and stabilize those movements. It makes the wrap seem like a joke.

It was amazing how well the Aircast worked: I was able to walk with significantly less pain, and even (slowly) go up and down stairs and hills. (I live in San Francisco where hills and stairs are as omnipresent as the fog.) Now I can't imagine discharging a patient with an ankle sprain without prescribing an Aircast. Please tell everyone about them.

I appreciate my joints like I never did before. The joint is a thing of beauty and something to care for. Just seeing other people doing simple things — walking the dog, running, quickly mounting stairs, and dancing — made me want to limp up to them, and say, “Wow, you're so lucky! Appreciate that good ankle of yours!” But that would be creepy, so I kept those emotions to myself.

Sometimes patients just need a little reassurance. My podiatrist and physical therapist didn't do a whole lot: a quick exam and confirmation of what I had already suspected about my injury. But their reassurance, prognosis, and education were all extremely comforting and helpful. I have a tendency to assume the worst, so hearing that I'll probably be back to normal activities in a few months was better than any MRI or x-ray.

The injury also has been an amazing motivator to get in shape, and it's working! I find fear to be a pretty decent behavior modifier for me, so my sheer terror of being that guy who “used to be in shape but then busted an ankle and is now overweight” has driven me to the gym almost daily. I also think it's probably easier to work out when you have a specific goal (or in my case, fear) that you're working toward (or trying to avoid). Now the only question remains: how long can I convince myself that I need to keep rehabbing?

All injuries are not created equal, but I do think my ankle tear was just bad enough to scare me and remind me that I'm not 18 anymore, that I need to take care of my body, and that every pain-free step is a gift, not an expectation.

This kind of goes along with what I think makes a lot of emergency physicians such fun, humorous, and cynically positive people, namely that we see so much suffering and tragedy and hear so many terribly depressing stories that we appreciate our lives just a little bit more than the average person or even the average physician. My friends and colleagues can vouch for me; I certainly dance like nobody's watching. Who knows how much longer we have in this life before the terminal diagnosis or even the next ankle sprain?

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