The Coumadin Goose-Egg

Despite the light drizzle of rainfall, she pushed the grocery cart filled with her unwashed clothes to the local laundromat. It was Tuesday and, like any other Tuesday, it was laundry day. Despite her dislike of rain, habit and her dirty clothes dictated that she make this journey.

Her apartment was just a few short blocks from the laundromat. Being elderly and recently widowed, a local laundromat, a supermarket, and a bus stop were on her short list of requirements for her new apartment's location. She had never taken the time to learn how to drive when her husband was alive. On hindsight, though, she should have insisted that he teach her. Now, she relied on public transportation and her steadfast grocery cart, given to her from the local grocer's manager when she had asked him about buying one.

She smiled to herself as she remembered that recent day. "This ones' an old one," the manager had said as he patted the cart's handlebar, refusing her money, "just take ol' Bessie and get some good use out of her, okay?" She blushed before taking Bessie, not quite sure how to deal with the random kindness of a stranger.

As she pushed her cart slowly along the sidewalk, she came to a slight decline just a half-block from her destination. Even in dry weather, she had fretted about guiding her cart down this gentle-sloping hill. Now, with the rain-slicked walks, she stopped at the top and appreciated the wet sheen of the approaching pathway. She briefly contemplated turning around and returning another day to wash her clothes.

She should have.

Slowly, after deciding to proceed to the laundromat, she guided her filled-cart down the sloping walk. One step. Another. And another. Her hands tightly gripped the cart's handlebar, her elderly, frail forearms beginning to burn from the effort it took to maintain her sliding cart.

Another step. And another. The muscles of her arms tremored. Her calves tightened. She leaned her body back, struggling to keep the cart from careening out of her control.

It was all in vain. Just a few short yards into this declining slope, she lost control of her cart. It began to slip and slide over the sidewalk, pulling her resisting body along, her hands still death-gripping the handlebar. It veered towards the left, almost jumping the curb and joining the local traffic, before she was able to over-correct the cart and steer it right.

The cart jumped the sidewalk and smacked right into a telephone pole. And, unfortunately, so did she.

I walked into Room 22 to find a very sweet-appearing elderly woman in her late seventies. She was sitting upright in her treatment cot, a hospital gown loosely draping her frail body, answering her nurse's interview questions with her matching frail, high-pitched voice. One that crackled with nervousness. On her room's counter, I noticed a pair of comfortable leather beige shoes, old and well-worn. Beside her shoes, a pair of pastel-blue pants. Polyester, of course. And on top of the pants, a blood-soaked floral shirt.

"Mrs. Taylor," I said, extending my hand as I entered, "I'm Dr. Jim. Nice to meet you, maam." She looked up at me and gave me a feeble smile, extending her hand, cold and covered in paper-tissue skin and blue-ribbon, spidery veins. I took it between both of my gloved ones.

"Maam," I continued, "what happened that brought you by ambulance to our ER, today?" Despite asking, I already knew the answer. Whether it was my nearness or the brightness of the overhead fluorescent lighting, I could now appreciate the significant cephalohematoma of her right frontal region. Othewise known as a contusion. Or, for those of you in my age group, a "goose-egg" or "goose-bump." You know, those big swollen bumps that our mothers used to hold the flat edge of a table-knife against to reduce the swelling when we were young and had just fallen off our bikes.

Anyway, Mrs. Taylor's goose-egg was quite impressive, covering most of her right forehead with the lower border extending into her upper brow and eyelid on the same side. Even her nasal bridge was swollen. Overlying the goose-bump, a superficial abrasion seeped a touch of thin, watery blood. The overall injury gave this kind woman a lopsided, deformed appearance suggesting that she just went ten rounds with Rocky.

Mrs. Taylor, in-depth, told me what happened. It was important to her that I understood two things. One, that she was a recent widow and missed her husband terribly. And two, that she had tried everything in her power to stop her cart from going out-of-control.

I patted her shoulder. "I understand, Mrs. Taylor. Thank you for sharing that with me."

What complicated Mrs. Taylor's history, besides Mrs. Taylor being elderly, was the fact that she was on coumadin, a blood-thinning medication that is used in the treatment and prevention of clots and, in Mrs. Taylor's case, for an irregular heart rhythm that otherwise increases the likelihood of stroke. I knew this, from the sheer size of her injury as well as the thin, watery blood oozing from the site.

I asked her a few more questions. Had she lost consciousness? No. Did her neck hurt? No. Did she have numbness or tingling or weakness in any of her extremities? No. Any chest pain, shortness of breath, or abdominal pain? Again, no. No arm, leg, or pelvis pain, either. On exam, outside of her impressive contusion, she didn't have any other significant findings. Well, unless you count her damaged pride.

I sent her, frail smile and all, to the CT scanner, where we imaged her head, her neck, and her facial bones. We were overly-cautious in her testing as her injury was considered a "distracting injury," meaning that with all of her attention focused on her goose-egg, she might not realize if she had neck pain. Thankfully, though, her reports came back well. No skull fractures or intracranial bleeding, just the large collection of swelling and bleeding outside of her skull cap in the frontal region. Her neck CT? Negative. Her facial bones CT? A questionable non-displaced distal tip nasal fracture. Her coumadin level had been in therapeutic range.

I discussed all of Mrs. Taylor's results with her. "Thank you, dear," she said, after I explained her next course of action. Since she was on coumadin, despite not having any significant bleeding within her intracranial space, we were going to admit her to the medical service for overnight observation. This is our hospital's protocol. Had she had a significant brain bleed, she would have been admitted to trauma and neurosurgery services and had her coumadin's effects reversed.

I never saw family or friends during the time Mrs. Taylor spent with us in our ER. Despite her frailty, though, she demonstrated a piss-and-vinegar attitude and resilience that assured our nurses and myself that she would be okay. She was one neat lady.

My one wish, though, for Mrs. Taylor? Well two, actually. One, I wished she had learned to drive at some point in her life. I meet too many elderly women who's husbands did all the driving so "I never had to learn." Of course, though, that would probably be me stuck behind her driving 15 mph in a 45 mph speed-zone. And two, I wished her husband had still been alive to hold a table-knife against her big ol' goose-egg.

Just like my mom used to do.

As always, big thanks for reading. I hope you had a great weekend. Next post will be Wednesday, June 9. See you then...