Keywords

Case Scenario

An 84-year-old Chinese woman is brought to the emergency department (ED) by ambulance. EMS was called by a friend who found the patient in her kitchen with a large head laceration . By report, a large amount of dried blood was found at the scene, and the patient had applied a poultice to her scalp following the incident.

The patient is sitting calmly in bed, alert, and looking around. She does not speak English but rather a dialect of Cantonese which the ED interpreter assists in translating: “The patient states she was cooking that morning when she slipped on the kitchen floor and fell, hitting her head on the counter. She did not lose consciousness.”

Review of Symptoms

Neurologic: Mild headache, denies loss of consciousness.

All other systems are reported negative.

Past Medical History

Non-insulin-dependent diabetes, hypertension.

Family History

Noncontributory.

Social History

The patient is retired and lives alone in senior housing in Chinatown. No family lives nearby. She denies alcohol or recreational drugs.

Physical Exam

Vital signs

Temp, 98 °F; pulse, 89; BP, 136/84; respirations, 12, O2 Sat 99% on room air.

General

Thin, petite woman appearing stated age sitting calmly on stretcher with her head in a bandage.

Cardiovascular

No murmurs, gallops, or rubs.

Respiratory

Clear breath sounds bilaterally.

ENT

Edentulous.

Abdomen

Non-distended, non-tender with normal bowel sounds.

Extremities

No cyanosis, no edema.

Skin

15 cm laceration to scalp at crown with dried brownish powder in wound, shallow abrasion to the anterior forehead.

Neuro

Grossly intact, moves all four extremities, no obvious sign of deficit.

Neck

Supple, non-tender in posterior midline, no pain on range of motion.

Questions for Discussion

  1. 1.

    Why didn’t the patient seek medical attention of her own accord?

Attitudes/Assumptions: The Physician

  1. (a)

    The poultice the patient applied to her wound will increase odds of wound infection and certainly was not beneficial.

  2. (b)

    The patient chose to not seek medical attention; therefore, she must not understand the seriousness of her condition and likely won’t comply with our recommendations.

  3. (c)

    The patient doesn’t speak English, so she must not be educated.

Attitudes/Assumptions: The Patient

  1. (a)

    I’ve treated wounds myself the same way many times in the past, and they all healed fine – Why do I need to go to the emergency room?

  2. (b)

    None of these doctors or nurses are speaking to me directly – they must not be concerned about me.

Gaps in Provider Knowledge

  1. (a)

    Lack of knowledge of health beliefs/customs: folk medicine/home remedies.

  2. (b)

    Lack of knowledge of disparities/discrimination: immigrant communities often lack insurance coverage or access to medical care. If this patient is undocumented, she may defer seeking medical care for fear of deportation [1].

  1. 2.

    What actions can be taken by the doctor to provide the optimal outcome?

Cross-Cultural Tools and Skills

  1. (a)

    Use a professional interpreter to obtain accurate information within a culturally appropriate context. Use of professional interpreters is associated with improved clinical care with respect to clinical outcomes and patient satisfaction [2, 3].

  2. (b)

    Acknowledge that the patient acted logically based on her prior knowledge and circumstances.

  3. (c)

    Understand that the patient may have limited access to medical care for follow-up of her emergency room visit.

  1. 3.

    What medical issues concern you about this case?

  1. (a)

    The physician should discuss with the patient that she is at greater risk of developing a wound infection, given delay before wound closure.

  2. (b)

    The physician should determine the patient’s ability to obtain follow-up medical care for her wound and blunt head injury.

  1. 4.

    Which components of the Emergency Medicine Milestones of the ACGME competencies [4] are incorporated in the case?

  1. (a)

    Patient-centered communication: Demonstrates interpersonal and communication skills that result in the effective exchange of information and collaboration with the patient.

  2. (b)

    Professional values : Demonstrates compassion, integrity, and respect for others, as well as adherence to the ethical principles relevant to the practice of medicine.

Case Outcome

Diagnosis

Scalp laceration, blunt head trauma.

Disposition

Home with friend.

After a history and physical is obtained, the provider discusses the next steps for her care using the interpreter. The patient undergoes a CT scan of her head, which shows no acute intracranial injury. The wound is thoroughly irrigated and closed using staples. The physician is able to determine that the patient has appropriate follow-up for wound check and staple removal at a sliding-scale community clinic in her neighborhood. Via an interpreter, the patient is given time to ask questions. The patient and provider conclude using shared decision-making to hold antibiotics, and the patient is given strict return precautions for wound infection.