Stories from the ER

Stories from the ER
Bascom Palmer Eye Institute emergency is a unique experience for any resident, fellow, or even attending physician to experience. Due to its reputation and location in a densely populated area, there can easily be over a hundred visits every day. Its geographic location enables many patients to come to the ER literally moments after passing immigrations, some of whom have not had access to ophthalmic care for decades. My favorite cases, however, were from local young men who unfortunately had poor judgment.

The first patient was a 24 year old male who had decided to do some housework at midnight. It is unclear as to the exact motivating factors which led him to perform these chores in the middle of a weekend night, but what was certain was that he was not wearing eye protection. While working with his power tools, he suddenly felt a sharp pain in his right eye that did not resolve after blinking, rubbing, or using copious Visine drops. He presented to the ER at 1AM with a metal foreign body approximately 0.5 mm in all dimensions that had penetrated his cornea full-thickness but was still partly embedded in his posterior cornea. The metal was too deep to be retrieved from an anterior approach and so the decision was made to remove it surgically. Unfortunately while the emergency room at Bascom Palmer is open 24/7, the OR does not have an in-house team and to call everyone in would take several hours. After discussion with the patient of all the options, both he and I agreed to remove it in the minor procedure room. I performed a retrobulbar block on him in the ER room and brought him to the procedure room where his eye was prepped in sterile fashion. A small paracentesis was made with #75 blade through which viscoelastic was injected. The paracentesis was then opened slightly further and grasping forceps were used to remove the foreign body, which came out easily. A 10-0 nylon suture was pre-placed and balanced saline solution was then injected via cannula to express the viscoelastic slowly. The knot was then tied and buried, and the eye was patched and shielded. The patient healed remarkably well, with no loss of visual acuity or other sequelae. Every time I saw this patient in clinic visits, and even now, I reflect on how remarkable we as ophthalmogists are at being able to save a person's sight.

My other favorite ER story is not a patient of mine but of my co-fellow at the time Dr. Pulin Shah (now practicing at Ochsner Medical Center in New Orleans). A 17-year-old male presented with pain and redness thought to be conjunctivitis, however on examination he was found to have a large corneal ulcer with perforation and uveal prolapse. Cultures performed were positive for gonorrhea and treatment was immediately started. He was also admitted for strict bed rest, fox shield, and plans for surgery in the morning when IV sedation could be administered safely. The following morning during rounds, the patient was found in bed with his girlfriend in a compromising position. This case I will never forget – it reminds me to be completely thorough in my explanations of pre- and post-op restrictions, and it taught me never assume the patient has good judgment.

I owe much of my ophthalmic knowledge to the variety of pathology I was able to see in the Bascom Palmer Eye Institute ER each and every day. While first emergency room encounters can be challenging and, at times, overwhelming for the young physician, the confidence and education garnered from each experience is tremendous.

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