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  • Writer's pictureLFaits

Emergency Room STAT!

Who doesn’t like ER?

ER is where I first set eyes on George Clooney, after all.

There is a certain allure to having an ER shift at the IEI during your rotations. Anything can walk in the door and you have to be prepared for it all. This is where three years of didactic and clinical experience merge, where your skills and aptitude are put to the test, where fire meets ice, and where dreams come true.

Did you fall off your chair with excitement?!

I have the good fortune of having my ER shift with the incomparable Dr. Mothersbaugh on Monday mornings. This is notoriously the craziest shift, because as everyone knows, the most scandalous and riveting eye injuries occur on the weekend.

(An aside: Most scandalous and riveting teeth injuries occur on Tuesdays.)

total Hyphema

I admit, I thought I’d be seeing 8-ball hyphemas often enough I could start predicting the future with them. Whenever a patient checks in, my heart flutters for a second: Is this the story I bust out at dinner parties for the rest of my life?

In truth, “emergency” means something different to all of us. Waxing your entire eyebrow clean off may seem like a true emergency to you.

But when someone checks into the ER, they don’t do it lightly or with abandon. They are scared that something has happened that may permanently affect their vision, and that is a frightening thought. As much as it is their right to seek an optometric opinion, it is our responsibility to handle it with care, concern and attentiveness.

Even if it’s blepharitis.

What is the most valuable piece of equipment when it comes to ER?

Go ahead and think on it for a second. Here’s a hint, it’s probably something that has been swallowed in the depths of your briefcase and hasn’t seen the light of day in far too long. No, not your measuring tape.

pinhole occulder

It’s your pinhole occluder.

As we’ve all been trained to do since first year, we can spout out the optical magnificence of that glorious piece of plastic. “It eliminates the peripheral marginal rays and allows only the para-axial rays to penetrate and focus on the retina”, you are probably chiming. I congratulate you, and so does Dr. Goodfellow.

But in that ER room, slapping on your pinhole occluder can give you a quick idea of where the rest of your exam is headed.

For example, I saw a patient the other week that was an uncontrolled diabetic with hypertension, but usually saw 20/20 without glasses. She came to the ER because she noticed a sudden, painless loss of vision. I probably shouldn’t have been so giddy, but I really thought that I was in for a juicy emergency. Pack your umbrellas, kids–there’s blood and thunder in the forecast!

(This is also another lesson I learned. Don’t diagnose diseases based on what you wish they had).

With her reduced acuities in both eyes, I shuffled through my briefcase and found my pinhole. And sure enough, she was back to 20/20 owing purely to a refractive error. Her anterior seg and retina were pristine.

Not even blepharitis.

With an appointment in Primary Care and a request for her to follow up with her doctor to better control her blood sugar and blood pressure, she was on her way.

Happy for her, but dejected for myself, I sulked back to my room.

Second rule of ER: Don’t be sad when your patient is fine.

Don’t worry about me though. In my rotation through Urgent Care, I have been lucky enough to see almost every spectrum of ocular emergency.

I have seen a traumatic basketball accident one week and a Miami girls’ night gone too wild (with resulting corneal laceration) the next. I got to see a dreaded excavated corneal ulcer with heaped up borders. I had a mild freak out when a sweet old lady came in with an acute viral conjunctivitis and I pulled her lids in every which direction, admiring her classic follicles and serous discharge, and then touched my face. Gloves are your friends, people.

It seems like with pollen swirling in the air this summer like oxygen, everyone and their mother has come in suffering from gnarly allergic conjunctivitis, and I think our clinic is drinking up Pataday like it’s water.

My BIO skills are getting better thanks to searching for several posterior vitreal detachments.

And so are my diagnostic skills: I diagnosed a non-granulomatous anterior uveitis based on two swipes of the cornea because she was too photophobic to sit behind the slit lamp for any longer. Thank goodness for those fine keratic precipitates.

I have seen nodular episcleritis that lit up like a Christmas tree with fluorescein staining, and flipped lids to reveal more gargantuan papillae than I thought humanly possible to diagnose vernal conjunctivitis. I have seen corneal abrasions that have ranged from the most mild of discomfort to people writhing in pain so dramatically I was worried they were going to fall right off the chair.

ER blog

I have learned that pain is wildly subjective. I always ask the “on a scale of one to 10, one being very mild and 10 being debilitating pain” question, and it’s amazing the answers you get. One 16-year-old immediately answered “10!” until her mother raised an eyebrow.

Just one.

She amended her answer to five. I need to learn how to raise just one eyebrow and get pain to recede. Or perhaps the better skill would be to raise an eyebrow and get pain to elevate, depending on the person.

In truth, ocular pathology is so much better to see in real life instead of in a lecture packet. When you can picture a patient sitting in your chair and remember how a condition presents, the management and treatment plans no longer seem as impossible as when you were studying for a test.

Come visit me on Monday mornings, preferably with a coffee in hand. I’ll probably flip your lids and hand you a bottle of preservative-free artificial tears.

And if you do happen to wax off your entire eyebrow, I will happily give you an eyebrow pencil, a floppy hat, and my sincerest sympathy.


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