Context Matters

More than one patient has come to the ER with blue, purplish, or black skin. At first glance, it appears that there is a lack of blood flow and it’s obviously very disconcerting. My colleague recently had a young lady like this who was rushed from triage to a critical care area as it appeared her legs did not have any blood flow. They were blue.

Google blue or purple skin and you will be hit with all kinds of scary information that makes you think you are on the verge of death. But it turns out, context matters.

This young lady was otherwise doing just fine. No pain, no loss of function of her legs, normal vitals. Those things cannot exist if your legs truly have no blood flow. Something else will be significantly abnormal if your legs are truly blue from lack of circulation.

In this case, she was wearing pants that had been recently tie-dyed. The bluish color wiped off on the sheets in the ER. Mystery solved.

The bigger point here is that context matters. Truly life-, limb-, or eye-threatening emergencies generally don’t present in isolation. If there is some seemingly bizarre and catastrophic symptom or finding, the lack of any other abnormality is very reassuring.

The same is true of little kiddos. A fussy baby with a fever but normal vitals and normal everything else is usually not worrisome. A toddler who bangs his forehead after tripping on the driveway but then runs around playing, laughing, eating, and smiling for the rest of the day, who then finally comes to the ER to get the goose egg on his head checked out, doesn’t need a CT scan. It’s pretty hard to have a life-threatening head bleed and act perfectly normal for an entire day no matter how bad the goose egg looks.

A subconjunctival hemorrhage occurs when a blood vessel in the white part of your eye breaks. They can look very dramatic. They can occur spontaneously or after coughing or vomiting and are more likely to happen in patients who take blood thinners. Here again, context matters. If your vision is normal, you have no pain, your eye moves normally, and you have absolutely no other symptoms, it’s not an emergency.

I see kids with pain in some part of an extremity after some minor trauma. It may hurt really bad but particularly in regard to long bones, those being your humerus (upper arm), radius and ulna (forearm), femur (upper leg), or tibia and fibula (lower leg), those generally don’t get broken without significant difficulty functioning. If there is no deformity, no impaired movement, good circulation distal to the injury, it’s probably not broken. Even with bruising and swelling, you probably just have a bruise. It may be more painful than average, but it’s not broken.

When I was a teaching faculty in an ER that trains residents, more than once a new resident or medical student would want to X-ray a femur because someone bruised their thigh. And not on a patient with major trauma. This was on a patient who walked into triage and had full function of their leg, no deformity, no loss of pulses. I can assure you that you can’t calmly walk into an ER on a broken femur.

So the next time you encounter something that seems like a medical emergency, take a breath, look around, and reassess. Is this thing accompanied by lots of other things that seem abnormal? Or is this thing isolated and everything else seems fine? One of those is concerning to me, the other is not.

And when you tie-dye clothes, wash them before wearing them.