Doing Nothing

It can be hard to do nothing when you see someone. Nothing meaning nothing. No tests, no treatment, empiric or otherwise, or at least not change any treatment. Many, maybe most patients expect you to do something.

One of the situations where I mostly do nothing is with the late at night call about someone found on the floor, known to have fallen, banged something in a transfer, something in that category. Many times the nurse might say, "We found Mr. X on the floor. Looks like he was trying to get up by himself and slipped. Do you want us to order any Xrays?"

Uh, X-ray what?

"Well, he might have hit his head or his back."

Is there any scrape or bruise or tenderness, or...

"No."

So are we going to X-ray his whole body? Why? Unless someone has had a fall that was of itself clearly serious, you need some help in knowing what to X-ray, what to look for, what to be worried about. Furthermore, what are we going to do about it at 3am in the morning? Nothing. So you put them to bed, wait until morning to assess the patient and ask for feedback about something somewhere that's not right.

Last week I had a patient tell me that her foot got twisted during a transfer. I checked the foot. It looked Ok, had no pain with palpation, no pain with motion, so I decided to just wait, ie, do nothing. Within the next few days, the foot became tender with weight bearing, and an X-ray showed a metatarsal fracture, so now she's wearing a boot.

Do I feel bad about "missing" the fracture? No. I needed to have some indication of what to look for, and there wasn't anything lost by waiting to know what to look for and do it efficiently. And this one fracture occurred as a rarity given all the other patients with a similar story who subsequently had no problems, so in the end I've saved a lot of money on unnecessary X-rays.