When Whiskey and Healthcare Collide

     As you may know from reading my blog, a few of my passions are practicing medicine (I'm a family practitioner), and discussing (and of course enjoying) the occasional cocktail or spirit.  I blog about healthcare in general, as well as drinks.  I have a patient story for you that encompasses both of these topics.
     The day after Thanksgiving I saw a female who is in her late 40's in the office.  She was accompanied by her husband.  Three days prior (on Tuesday), she was getting ready to cook something for the holiday.  She opened a cabinet that was raised, and a bottle of vinegar immediately fell out of it, onto the floor.  She bent forwards to pick it up, and then a bottle of Jameson Irish Whiskey conked her on the top of her head, then hit the floor, and shattered.  (I know the saying regarding crying over spilled milk, but I imagine there is also one regarding Irish Whiskey, somewhere.)  Of course this hurt when the bottle hit her, but she told me she never lost consciousness.
     The next day she had a slight headache, and felt somewhat dazed, but on Thanksgiving she felt like her symptoms were improving.  Unfortunately, that evening, her headache increased, and she felt like her head was in a vice.  Bright lights made her symptoms worse.  When I saw her on Friday, symptoms persisted, and were perhaps a bit more intense.
     On evaluation, her vitals were normal.  There was minimal tenderness at the site of the trauma to her skull (she has long, thick hair that likely softened the blow).  Her eyes were sensitive to light, but her pupils reacted appropriately, and her neurological exam was normal.  There was no blood seen behind her tympanic membranes.  The exam was basically normal.  Diagnosis: closed head injury (concussion without loss of consciousness).  Her symptoms of headache and photophobia were consistent with her injury, however, the worry was that despite initial improvement of symptoms, they were worsening over the past 24 hours.  This was in the setting of no exertion.  As such, I thought it was prudent to order a CT of the head to rule out an intracranial bleed.
     I placed an order for a CT scan.  I was hoping to perform this as an outpatient, in order to avoid the excess charge of an ER visit coupled with the facility fees of getting a scan in the hospital.  Unfortunately, when we called the insurance company to get the authorization, the insurance company was closed!  Nobody would answer the telephone on this holiday Friday.  So this left us with 3 options:

1. Sign a waiver and obtain the outpatient scan.  If the insurance refused to pay for this, the patient would be personally liable for the charges.
2. Go to the ER due to the worsening headaches, head pressure, and photophobia, and have a CT in the ER.  Depending on one's deductible, this can be quite expensive.
3. Continue supportive care with over the counter medication for headaches, and monitor for any change in neurological status over the weekend.  Should symptoms get more severe, or should anything worsen, she should call 911 or have her husband take her to the ER immediately.  On Monday AM, we would call the insurance company first thing, to try to obtain approval.

     The patient preferred option 3.  I don't blame her.  I again clearly explained the risks of not obtaining the scan that Friday:  should she have a slow bleed in her head, this can be life threatening, and we can't know for sure without the CT.  Because the patient and her husband seemed well educated and dependable, and expressed their understanding regarding the potential risks of each option, I was okay with her waiting until Monday (after all, vitals were stable and her exam was normal, and consistent with her concussion).

     Fortunately, Monday morning the insurance company approved the CT scan.  Even more fortunately, by then the patient's symptoms had completely resolved, and no scan was longer necessary.  I counselled the patient at her visit regarding minimizing exertion, and that symptoms may return if she exerts herself too much, too fast, or too soon.

    I think there can be a few lessons here:

1. Don't store your liquor in high places
2. If possible, get insurance from a large company, whose employees don't only work bankers hours
3. Not all head injuries require a CT scan.  However, if symptoms worsen, one should weight the need for imaging.

     The good news is that my patient was able to avoid both the ER visit, and a CT charge, with careful monitoring and clear instructions.  Not all are as fortunate, as illustrated in the cases of Natasha Richardson and Sonny Bono.

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