A ruptured eardrum turns out to be something much more


My shift is over, and I’m ready to head out the emergency department door.  When I walked in 12 hours ago, the department had 20 waiting patients.  I look up at the monitor and after 12 hours of trying to wrestle the department under control, not only is it not under control, now we’re 25 patients deep in the weeds.  My partner Dr. Jim looks at me and says, “Get out of here.  Don’t even think about staying late.  You can’t save the world.”

With me leaving, the department will drop to single coverage with Jim taking the reins alone the rest of the night.  Despite his words, the dejected look on his face reads, “Help!”

It’s going to be a long and grueling overnight shift for Dr. Jim.

I look up at the monitor, and it says, “ruptured eardrum.”  That’s easy, I think to myself.  I’ll stay late and see at least one more patient to help out.  I walk in the room, and it’s a 16-year-old girl, in a green and white basketball uniform, with her mom and dad, who looks like he could be a retired football linebacker.

“I got hit in the ear with the ball.  I can’t hear at all, and my ear’s bleeding.  This is the second time it’s happened.  Last time I couldn’t play basketball for a week,” she says.

“OK, let’s take a look,” I say.

I put a couple of drops of peroxide in the ear to soften up the dried blood.  Hmm?  There are no bubbles.  I clean out the ear and … what is that smell?  Do I smell raspberry jelly?  I clean out the ear more and look at the ear drum.  It’s perfect.  There’s no rupture and no laceration in the canal.  Her ear is completely normal.

“I won’t be able to play this weekend, will I?” she asks.  “Just put me on the injured list this weekend, and we’re good to go,” she says with a bubbly smile.  Being that she’s 16, and still a minor I ask her parents if she and I can talk in private for a minute.  They say OK, I have a female nurse come with me, and we close the door.

“Did you put something in your ear?” I ask.  “Like raspberry jelly or something, to make it look like blood?”

“Yes,” she says, looking deflated.

She then confesses that she doesn’t want to go to the tournament and concocted the whole story to have a reason to be injured, so she could go to her boyfriend’s party, instead.  I thank her for her honesty.

“Can I go now?” she asks.

I discharge her and on the way out the dad comes back in.

“Doc, she faked it didn’t she?  I know she doesn’t want to play in the tournament.”

Without speaking, I gave a half nod.  He smiled and walked out.  Even though I was dog-tired after working 12 1/2 hours and staying late, I finished the shift a little lighter, with a simple case where no one died, no one bled out, or inappropriately demanded narcotics.

A week later prior to a shift, our ED director Dr. Bob comes to me and says, “Hey Bird, how’ve you been?  I’ve got some good news, bad news and ugly news.  Which do you want first?”

“None of it,” I answer.

“OK, the good news.”

Then, with the phrase no ER physician ever wants to hear, “Remember that kid you saw last week?  The one with the bleeding ear?”

“No.  Wait, do you mean the one with raspberry jelly coming out of the ear?” I chuckle.

“Yeah, that one.  Well, she’s alive,” he continues.

“I figured that.  I haven’t seen death by raspberry jelly, yet,” I laugh.

Then he drops this on me, “The bad news is she attempted suicide the night after you discharged her.”

“Wow, that’s terrible.  There was no sign of that at all.  It was just a simple ear complaint.  What’s the ‘ugly’ news?” I ask, half not wanting to know.

“The ‘ugly’ news is that it’s your fault, at least according to the girl’s father,” says Director Bob.

“What?” I exclaim half-shocked, half-knowing I should never be shocked by anything that happens in or around the circus that is the emergency department.

“Yeah, I know.  No good deed goes unpunished.  Plus, they filled out a Press Ganey survey, giving you the lowest scores possible then filled a formal complaint with administration,” says Director Bob, acting irritated at me.  “Now it’s my job to smooth this crap over, somehow.”

“A complaint about what?” I ask.

“Well, they’re claiming you violated EMTALA, and committed malpractice by missing the diagnosis,” says Director Bob.

“What?  She got a screening exam, and there was no inkling of depression whatsoever.  That’s a crock of #&@$,” I say, in disbelief.

“Maybe, but administration is very concerned, plus they are worried there may be a HIPAA violation, also.  You know contract renegotiations are coming up soon.  They’ve been holding the blow torch to my back over metrics, and now this.  Let’s just say they’ve made some threats,” says Bob.

“What diagnosis are they saying I missed?  The kid put jelly in her ear for Pete’s sake.  And HIPAA, I didn’t violate HIPAA?  First of all, she’s a minor, plus I didn’t tell the father anything,” I say exasperated.

“Let me see,” Director Bob says dropping his glasses, looking down at his notes.  “You may have violated HIPAA by telling the father the girl faked the injury, when that was supposed to be a private conversation between you and the girl. Then when he confronted her, and told her she couldn’t go to some party, she goes and swallows a handful of his pain pills and overdoses.  The missed diagnosis was suicidal depression, and you violated EMTALA by not doing a proper medical screening exam, specifically, a psychological screening exam.  I’m quoting the complaint now: ‘The doctor is 100% responsible for this.’”

“You’ve got to be kidding me,” I say.

“Unfortunately, I’m not.  Now, for the bad news,” he continues.

“Wait a minute, that was the ‘good’ news?  Whatever, just tell me,” I say.

“They plan to contact an attorney and are threatening to sue you, the hospital, and the group,” he says.

“Of course.  This is utterly nauseating and ridiculous.  I don’t have time for this, I have to go start my shift,” I answer, more than ready to be done with this conversation.

“Make sure you draw up a draft apology letter for me, so I can send that out to the family.  Admin requires it, you know,” says Director Bob.

“Apology, for what?” I ask.

“No, I’m not, but don’t worry about it,” says Director Bob, in a nervous hurry.  “You know how the system works.  It’s just business, Bird.  Just get back out there, keep cranking those patients through the department as fast as possible, keep the Press Ganey scores up and everything will be just fine.”

“BirdStrike” is an emergency physician who blogs at Dr. Whitecoat.


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