4th Day in the ER

Something interesting happened. I saw a patient, he was in extreme pain. He said it had happened out of the blue, as he was watching TV. He had been dealing with some URI symptoms over the week prior. Checked his ears, no pain in the pinna/tragus/mastoid regions. Looked inside, the tympanic membrane looked okay but then when I peered upwards I saw what looked to me to be a tear, with blood on its edges. I went back to my supervising PA, told her the patient needed pain meds asap, and told her I believed his eardrum had ruptured. She ordered him a percocet, and went in to check him out. She looked in his ear and said, "yup, you've got a perforated eardrum." The PA still called for a Doc to check it, in case there was anything we could have missed.

The Doc didn't come to speak with us, saw the patient and re-diagnosed him with acute otitis externa/media and specifically noted that there was no perforation of the tympanic membrane. When my supervising PA saw that he had changed the diagnosis, she went off. "What is he talking about? How could he say it's involving otitis externa, he doesn't have any outer ear pain and there's no sign of infection! The guy said it hit him like a thunderbolt, how does that history say anything other than a rupture? And the student and I both saw it! Plus he had a history of ruptured eardrums as an infant!"

So, the patient was sent home with prescriptions for steroid and abx drops. Now, steroid drops are contraindicated in tympanic membrane ruptures as they can slow down healing. The abx, there's no problem there since the patient should probably have them either way. I'm just glad that the PA told the patient to see an ENT specialist asap, in order to make sure of the final diagnosis. I know that my future will be bringing these types of situations, but it was interesting to finally encounter one first-hand. All that matters to me is that the patient is treated properly. I suppose I might have mis-judged what looked to me to be a tear, but as the PA saw it also it leaves me to think 'hmmm', you know? It was on the upper right hand top edge of the drum, so what if the Doc didn't see it? Then again, what if we both mis-judged, and the patient would have gotten inadequate treatment from our side.

I think that the key point I took home was that there were two conflicting diagnoses, but it was the PA who, even when she had made her diagnosis, still told the patient that he needed to follow up with an ENT specialist. The Doc did not. I'm not saying that their different licenses had anything to do with it, it could have easily been the other way around. But I do think it's better to be safe than sorry, especially in light of any disagreement or possible discrepancy.