Recently, I had a transfer patient from outside hospital with a large subdural. She had been intubated for airway protection, reportedly she was unresponsive upon arrival to the outside hospital.

The patient had a history of multiple psychiatric disorders, chronic substance abuse, had been picked up from a different state by her mother to bring her back to their home state to try to find help with substance abuse and her psychiatric illnesses. At baseline, patient had hallucinations as she did overnight the night before presentation and she had not slept all night. The patient fell asleep while in the car and slept for many hours as her mother drove. Her mother did not think anything of it since she had been awake all night. When her mother stopped to get food, patient was not able to be aroused and she was taken to the nearest hospital. There, she was intubated for airway protection and was found to have a large subdural hemorrhage with midline shift. Patient was expeditiously transferred to our facility where she was evaluated in room 9. Imaging was on a disc which was quickly uploaded and reviewed. It was a very large subdural hemorrhage. On exam, her reflexes were intact. Neurosurgery was paged twice to room 9 with no answer. Due to concern that the pt was an operative candidate, we were able to locate the cell number of the NES resident who promptly evaulated the pt in the ED. Pt was admitted to take to the OR and but coded just prior to being wheeled out of room 9. Rhythm was V. tach, ROSC was obtained. Pt was taken to the OR, within a few hours post-op was following commands, moving all 4 extremities and spontaneously opening her eyes.

The reason I bring up this case is because, as July 1 is upon us (literally minutes away) and we have new PGY-2s having a large increase in responsibility, it is a good time to remind ourselves that sometimes, the right thing to do it call NOW rather than waiting. As emergency medicine physicians we are given the opportunity to advocate for our patients. We are constantly made to feel like we cannot call until the entire workup in complete, all labs are back, all imaging done, etc. However, sometimes it is better to call “early” rather than to wait and it end up harming a pt.

Take care of each other and keep up the good work. I miss all of you all already.