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The Art of Medicine

When a discharge instruction is overlooked

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: February 2016 - Volume 29 - Issue 2 - p 58
doi: 10.1097/01.JAA.0000476225.39882.71
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Christmas has come and gone; the New Year is nearly here, formally marking another time of transition.

It's 6:15 p.m. and the after-hours care center is hopping. I've just finished up with the 18th patient of the evening—another youngster with cough and cold—when the nurse hands me the encounter form for the next patient. “He was hit in the eye with a Nerf dart,” she says. Then in a whisper she adds: “It was fired by his father.”

I step into the exam room to find a young adolescent boy sitting quietly on the exam table. His mother reclines in one of the chairs nearby.

“I understand you were hit in the eye by a Nerf dart,” I say. “How are you doing?”

“I can't see out of my eye,” the boy says. “Everything is blurry.”

“Are you in a lot of pain?”

The boy shrugs his shoulders. “It hurts,” he says.

I pull the otoscope from my pocket and pass the light across the surface of the boy's left eye. He winces a bit when the light strikes the cornea. The pupil does not react. The lower half of the anterior chamber is flooded with blood.

“Be right back,” I say, dashing out of the room to retrieve a stock bottle of proparacaine eye drops and a sodium fluorescein strip from the laboratory. In a moment I return. “Lie down on the table,” I instruct the boy. “Now make a fist, stick out your thumb and bring your hand up above your head”—I direct the boy's arm—“and focus on your thumb.”

As the boy complies with my instructions, I put a drop of the topical anesthetic into the conjunctival sac. He squeezes his eyelids shut and then blinks as the discomfort subsides. Next I place a drop of the same drug on the fluorescein strip and instill the dye. Immediately his eye turns orange. I reach for the ophthalmoscope, adjust the dial to the blue light, and flash it across the cornea. A small central abrasion fluoresces at the 11 o'clock position.

“He's got a small abrasion of the cornea and a hyphema,” I tell the mother, explaining in lay terms what that means. “I'll give you a prescription for some antibiotic eye drops, patch the eye, and have you follow up with his doctor first thing tomorrow morning. You can take acetaminophen for pain, but no aspirin or ibuprofen; and be sure not to rub your eye—you could actually make the abrasion worse.”

“Will I be able to see again?” the boy asks.

“Yes. It will take a few days, but your eye will heal up just fine.”

Hurriedly, I sketch a diagram of the boy's eye on the encounter form to document the location of the corneal abrasion and the extent of the hyphema; it will be faxed to the primary care physician of record later this evening. The next patient's encounter form already waits in the queue.

In another hour things begin to wind down. “One more kid to see,” the nurse says, handing me the clipboard. I glance at the chief complaint.

“You've got to be kidding,” I say, staring in disbelief.

“I guess it's a bad year for Nerf darts,” the nurse says. “This boy doesn't seem to be as bad as the last one.”

Thankfully, he isn't. Apart from some bulbar conjunctival injection, the boy's eye seems to be fine: no sign of hyphema, no corneal abrasion.

“He'll be okay,” I reassure the parents. “By the way, who shot the Nerf dart?”

The boy drops his gaze to the floor. “His older brother,” the mother says. “They were playing with his Christmas present.”

Suddenly, I think back to the other boy with the ocular injury I saw earlier this evening. I recall that I neglected to mention something very important in my final discharge instructions. I promise myself that this time round I won't make the same error.

“I imagine your brother feels bad about this,” I say to the boy. “He's probably sitting at home, worried about what might have happened to your eye.”

The parents remain silent. Slowly, the boy nods his head.

“So when you get home, I guess you're going to have to talk this out,” I say, purposely pacing my speech so the words sink in.

Again the boy nods his head.

“Forgiveness is a powerful thing,” I say as we step out of the exam room into the hallway.

My words are meant for all three of them—and also for myself.

Copyright © 2016 American Academy of Physician Assistants